All about Ayushman Bharat The good, bad and worst
Ayushman bharat is a good scheme initiated by the Government of India, particularly when it is covering upto 10 crore families which means almost 40-50 % of the population will be covered. The solution which has been proposed in the scheme is to cover all the people Below Poverty Line (BPL), rural masses and moreover it surpasses the previously introduced scheme – National Health Protection Mission (NHPM), whose primary objective was to cover BPL citizens with capacity of around 30,000.
What are the advantages of Ayushman Bharat ?
The current scheme where a family will be insured for Rs 5 lakh per annum is a huge sum and will cover most of their health issues. Additional pioneering benefit is that all the Primary health centers and the present sub-centers are being converted into wellness centers. The current scenario of primary health centers and its sub-centers were a question of talk for a very long time and its functioning is not doing well which can solely be attributed to poor Governance. Lack of better efforts from the government to improve the primary health care infrastructure has reflected in the current status of our nation’s health. With the availability of around 30,000 primary health centers, vacancies less than 2000 shows the shortage of doctors. Each Primary health center has five sub-centers and the prime idea was that the health workers there will be running the sub-centers and the doctor in-charge from the associated Primary Health Centers will make a monthly or a fortnightly visit to these sub-centers. And now the Government’s direction in the current proposed Ayushman
Bharat scheme is to convert all the sub-centers into preventive and wellness centers which is a very good initiative. This will have huge impact in the betterment of preventive illnesses and is a good move that needs to be appreciated.
The problem at hand since independence is that the health sector has been suffering as less importance was given to health. In comparison to developed countries like US and UK, over 15% of the GDP is allocated for betterment of health; India only spends around 1-1.3% on an average.
Indian healthcare scenario can only improve when these numbers are increased and health made a fundamental right to all citizens. Until and unless health is made a priority sector, the current situation is not going to change.
This scheme has many inbuilt measures which also highlights the Government’s approach and attention towards improving the primary health structure. With certain modifications in the system or infrastructure of the Primary Health care centres, things can be made better. If the villagers are covered with 5 lakh insurance, then they can get a much better treatment otherwise.
Medical education in rural India needs improvement
One medical college should be there in every three district, but according to the current medical education system, about 200 districts have only 450 medical colleges, which is very less. If we take the examples of union territory like Puducherry has 11 medical colleges. If Government makes more medical colleges particularly in tribal areas, or areas which does not have medical health care or is looking for medical education, then the overall development of that area is bound to happen with opening of such Government medical colleges and better healthcare.
The Government should also make changes in policy making in order to prohibit any further opening of medical colleges in areas that already has such colleges in abundance. Giving permission to open new medical colleges in districts with no medical colleges or remote areas will help in overall betterment.
Is there a shortage of doctors?
Government has always been pin pointing upon the dearth of doctors in the country. But imagine, in a country that produces over 90,000 MBBS doctors annually with 67,000 doctors passing out from 489 medical colleges in India and approximately 20,000 doctors who join as foreign medical graduates. This is the availability of doctors who can practice medicine in India. But the problem arises with the fact that the available post graduation seats are limited to only 30,000, and the remaining 60,000 doctors may have only 1750 vacancies to join in any of the wellness centers. If the number of seats and number of vacancies are increased, the so called dearth of doctors can easily be tackled.
If the system is made robust, these 60,000 doctors can be employed in the sub-centers on regular basis, instead of providing them contractual and adhoc appointments.
For instance, if an MBBS graduate from metro city is appointed in some far flung rural area on a contractual basis, they may hesitate to go. But if certain changes are made in the policies, in terms of incentivizing their appointments on regular basis, healthcare in rural areas is bound to improve. Moreover if the posting in rural areas is incentivized with additional weightage in PG entrance exam, the number of doctors willing to go to rural areas will increase drastically.
Being an insurance scheme –who will reimburse?
Being an insurance scheme with cashless transaction, reimbursement to hospitals remains a hidden aspect. Will the reimbursement be provided by the government or the insurance sector? Again the question remains that if the Government reimburses, then CGHS is already suffering. Payments in CGHS and ESI are not made for months together and the hospitals truthfully are not admitting patients.
A robust system should be developed by taking private sector into confidence, be it a private healthcare organization or leaderships from private sectors and involvement of the Indian Medical Association before implementing this scheme. Such Public Private Partnerships will be able to work shoulder to shoulder and to frame rules and work out efficiently as far as different rates are concerned.
What needs to be changed in policy making?
This is one of the most wonderful schemes ever thought of, but my concern is that it should not become a victim of poor governance; proper thought process has to go in. The blatant example of this poor governance is the National Rural Health Mission, which was started 10 -15 years back to improve the primary health structure. But even after investing crores and crores of money, the government had to abandon the mission due to high corruption rate. As a medical activist we do not want this scheme also to be a victim of poor governance. A lot of thought process is required to go into this scheme as such.
Involve more private players
So far in this scheme no private organizations like IMA or any other private players have been consulted. The government seems shaky and cloudy as far as the thought process is concerned, and even the methodology of implementation of this scheme seems unclear.
Participation of private sector, it will be a defining moment for this scheme. Being in no hurry, involve more and more private sector, have consultations with them, talk to IMA, and involve all possible stake holders before launching this scheme.
The rates for various medical procedures should be decided in consultation with various stakeholders including IMA. At this many unaffordable or unmanageable rates will breed corruption and make this scheme unviable.
There should be transparent, clear cut directions along with a robust reimbursement system in this scheme to be implemented. For this, awareness has to be created among MBBS doctors at sub-centers and focus should be more on improving primary healthcare. As a personal opinion the sub-centers can be run by MBBS doctors if proper employment is provided to them. Instead of spending lavishly in building super-specialty hospitals, make most of the investments in improving the primary health structure of the country, be it the primary health centers or sub-centers. It is a question of concern that why and how some of the states are doing extraordinarily well? States like Kerala has a very robust primary health structure and recently Tamil Nadu and Gujarat has also started doing well by giving a lot of attention to the Primary healthcare infrastructure.
Scheme requires a federal structure
A federal structure is required in this scheme to be successful which implies that some of the states already have their own schemes, and some are over and above this. As inbuilt in the scheme, 40% expense will be provided by the state and 60% by the central government should be implemented properly along with better participation of the states. States should be directed or requested to see that it should become one scheme where everybody is at par looking at it. The issue of empanelment of hospitals, as far as services are concerned both in government and private hospitals, not only primary, but secondary and tertiary care hospitals, neighboring nursing home, atleast maternity benefits should be properly given, accident victims should get proper attention.
Pattern of diseases is changing from communicable to non-communicable diseases. If we take a look at 25 years back lot of deaths were attributed to malaria, dengue, small pox, jaundice and other water borne communication diseases. Today diseases are much more lifestyle related and there is increase in non-communicable diseases. So this changing pattern of illnesses also needs to be taken care of as far as the preventive health is concerned.
So the point is that some kind of a quality control, along with a streamlined reimbursement process and with private sector taken in confidence, this scheme can be a great success.
the author is former President of Indian medical association (IMA)
By Dr Vinay Aggarwal