Soham D Bhaduri
Universal health coverage (UHC) has received an unprecedented systemic push over the past decade, reinforced greatly by the Sustainable Development Goals. In India, the public health insurance (PHI) route has been strongly advanced as the prime agency for attaining UHC—founded on the experience of the multitude of state and national PHI schemes stretching since the early 2000s. The latest in line is the Pradhan Mantri Jan Arogya Yojana (PMJAY), hailed as the largest health assurance programme in the world, covering more than 50 crore poor Indians for hospital expenses upto `5 lakh per annum.
Recent policy pronouncements have clearly bespoken the present government’s intent to make PMJAY the face of UHC expansion in the country. Calls for expanding PMJAY to the remaining uncovered population have particularly picked up pace in the context of Covid-19. However, pushing this laudable purpose using incongruous representations and askew interpretations would be least warranted. It is in this respect that the Economic Survey 2021 tends to disappoint.
The Survey ends up using an array of inapposite health indicators in studying the scheme’s impact. This includes indicators that do not seem relevant to assessing any hospital insurance scheme (for e.g., sex ratio at birth, years of schooling, child vaccination), and ones that can only weakly be linked with hospital insurance (for e.g., maternal and child health care). Two relevant indicators would have been mortality rates from diseases covered under insurance, and the extent of financial risk protection afforded to beneficiaries, but they lack even a passing mention. Protection from catastrophic hospital expenses incurred due to severe illnesses has been the prime purpose behind rolling out the PMJAY and other PHI schemes. What is ironic is that one of the few somewhat-related indicators, viz. institutional births, has actually been found to be better in non-PMJAY states (like West Bengal) than states implementing PMJAY.
The very basis for using NFHS-5 data is questionable. The NFHS-5 (2019-20) phase 1 fact-sheets read explicitly that the PMJAY may not have been rolled out fully at the time of the NFHS-5 survey, and thus, may not have been reflected in its health insurance coverage estimates. It is far-fetched to think that PMJAY, which was rolled out only in September 2018, could have significantly impacted distal health indicators like infant and child mortality within such a short time. For e.g., in three PMJAY states which have been studied (Assam, Bihar, and Sikkim), the NFHS-5 fieldwork was undertaken anywhere between June 2019 and February 2020. One also finds assumptions about comparability and similarity between the studied states (West Bengal and its three neighbours mentioned earlier) to be discomforting. Their spatial contiguity has been held to imply a concomitant similarity in demographic and socio-economic profiles. The economic survey attributes the decline in health insurance coverage in West Bengal, and a concomitant increase in its neighbouring states (Assam, Bihar, and Sikkim), to PMJAY. However, one must note that the major chunk of the increase in the neighbours is accounted for by just one state: Assam, which recorded a dramatic increase in insurance coverage from 10.4% (NFHS-4) to 60% (NFHS-5). Bihar saw only a small increase (12.3% to 14.6%), while Sikkim actually registered a decline in insurance coverage (30.3% to 25.7%). Also, one cannot dismiss the likely role of the Atal Amrit Abhiyaan (AAA), the state PHI scheme of Assam, which has a larger beneficiary base than PMJAY, in majorly pushing up the insurance coverage figures for Assam. The AAA was rolled out in 2016-17, a couple of years before PMJAY, and is therefore, likely to have been better captured than the latter in the NFHS estimates.
Finally, the Survey ignores certain basics when it comes to PMJAY and hospital insurance. It shows that the highest number of insurance claims under PMJAY comes from relatively inexpensive procedures, and argues that this could indicate PMJAY being used as a delivery channel for primary care services, or even as a substitute for the latter. The fact, however, is that PMJAY covers not primary, but secondary and tertiary care (outpatient consultation is covered if it leads to hospital admission), and substituting primary care with hospitalisation is a highly undesirable end that is antithetical to the single most important goal of health systems—to halt disease progression in its early stages. Further, while fewer claims for expensive procedures could indicate fewer malpractices such as cream-skimming, it could also imply that the scheme isn’t catering adequately to its primary purpose of protecting against prohibitive hospital bills.
The PMJAY could be a useful tool for a much-needed healthcare expansion in India, but a scramble to push it shouldn’t lead to adoption of awry, indefensible ways for demonstrating its effectiveness. Besides amounting to mere self-flattery, it could seriously erode public faith in the otherwise promising programme.
Chief editor of The Indian Practitioner and a physician-researcher based in Mumbai. Views are personal