The euphoria around PMJAY vs neglect of public health schemes

The NDA government announced the Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (AB-PMJAY). The PMJAY component would give hospital coverage of up to Rs 5 lakh for about 100 million families. The costs would be shared by centre and states in a 60:40 ratio.

PMJAY is largely based on the erstwhile Rashtriya Swasthya Bima Yojana, a model which was fraught with problems and has not led to any decline in the out of pocket (OOP) expenditure for the people. A large chunk of OOP expenditure is on outpatient care that is not covered under the insurance scheme. The poor and the marginalised largely seek outpatient care because they cannot afford to lose their daily earnings.

As of now, five states — Delhi, Chhattisgarh, Odisha, Telangana and West Bengal — have opted out of the AB-PMJAY. For those states that are part of the AB-PMJAY, there are reportedly issues of central funds not being disbursed timely, giving rise to apprehensions regarding last-mile delivery of services to patients which was a major problem in RSBY also.

Even in terms of resources provided for the scheme, the implementation agency of AB-PMJAY, the National Health Agency (NHA), had reportedly demanded Rs 7,400 crore to meet the expenditure for 2019-20 but has been allocated only Rs 6,400 crore. Further, it has been made clear by the government that it would give land and other facilities to incentivise private investment in tier 2 and tier 3 cities — a clear step in favour of private commercial interests. 

Starving of NHM

This euphoria about an insurance-based healthcare can be juxtaposed with the apathetic treatment meted out to public health schemes/programmes such as the National Health Mission. The share of NHM in the total health budget has consistently declined since 2014-15 from 61 per cent to 49 per cent in 2019-20.

Despite tall claims made by the Modi government, the union government’s budgetary allocation/expenditure for the health sector has remained stagnant at about 0.3 per cent of GDP since 2014-15. To achieve the targeted health expenditure by government (both centre and states) of 2.5 per cent of GDP by 2025, of which 40 per cent should come from the centre, requires one per cent from the union budget, which remains a distant dream.

Thus, what we see over the years is a deliberate weakening of the public health system. If we compare budget allocation for PMJAY with those for National Rural Health Mission (NRHM), this becomes evident. The allocation for PMJAY increased by 167 per cent while for NRHM it increased by a mere 2 per cent, though over 2017-18, the NRHM allocation in fact declined by 1.5 per cent. Further, the allocation for the second component of Ayushman Bharat — the Health and  Wellness Centres — budgetary provisions have been put under the NHM head, which implies that allocation to HWCs would come at the cost of existing interventions under the NHM.

Increasing privatisation & no regulation

In addition to the incentives being given under the PMJAY, the private sector has been given an increasing role in managing primary healthcare. In a number of states, the operation of health facilities is being pushed into the public private partnership (PPP) mode which is being opposed by people in Chhattisgarh, Punjab and Rajasthan. To compound the problems further, regulation of private sector is negligible and only a few states have adopted the Clinical Establishment Act. In effect, what these developments indicate is a plot towards undermining public health system and promoting a privatised healthcare model.

Dilapidated infrastructure; neglected health personnel

Such stagnation in terms of budgetary resources is being witnessed at a time when overall public health system is in shambles. There is a debilitating shortage of key health personnel — 75 per cent shortfall of obstetricians and gynaecologists, 85 per cent shortfall of surgeons, 86 per cent shortfall of physicians and 83 per cent shortfall of paediatricians at community health centres. Health infrastructure across the country is in poor condition as was highlighted by the CAG report in its audit of NRHM. Nearly 25 per cent of the sub centres are without electric supply, 17 per cent without regular water supply and 10 per cent without all-weather motorable approach road.

In addition, there is increasing contractualisation of health workforce with very less remuneration but enormous work pressure. The backbone of the primary health care — the ASHA and Anganwadi workers have been demanding regularisation and status as a worker but the government has conveniently ignored the demands. 

Neglect of maternal and child health 

Even as the finance minister talked about “women-led development” in his budget speech, the programmes/schemes that are relevant for women’s health have been neglected. Allocations towards reproductive and child health (RCH), which includes schemes like Janani Suraksha Yojana (JSY), immunisation programmes and various key disease control programmes, have experienced a cut of around Rs 4,200 crore compared to the expenditure in 2017–18. Along with this, the allocation for Pradhan Mantri Matru Vandana Yojana (PMMVY), the erstwhile maternity benefit scheme, has largely remained the same as in 2018-19 (BE). It must be noted that PMMVY succeeds the erstwhile Indira Gandhi Matritva Sahyog Yojana (IGMSY). Whereas the incentive provided under IGMSY was for the first two live births, under PMMVY, this has been limited to the first living child.

Edited excerpts from a critique of the Pradhan Mantri Jan Arogya Yojana in CPI (M) organ, People’s Democracy, April 21 in New Delhi