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While presenting her second Union Budget in Parliament on February 1, 2020, finance minister Nirmala Sitharaman did not announce any increase in allocation to Pradhan Mantri Jan Arogya Yojana — Ayushman Bharat (PMJAY-AB), the central government’s flagship scheme. It was Rs 6,400 crore for 2019-20, and remains so for 2020-21 as well. In fact, revised estimates were halved to Rs 3,200 crores last year.
Ayushman Bharat is an umbrella healthcare scheme that provides Rs 5 lakh insurance cover to eligible families. It also aims to create 1.5 lakh health and wellness centres by 2022. Until now, less than one-fourth such centres have been built. Budget under this head has not increased from last year’s Rs 250 crore. With only two years left to meet the target, experts wonder how the government aims to achieve the target.
K Srinath Reddy, president of non-profit Public Health Foundation of India, estimates a 10-fold increase in funds requirement from last year’s allocation if the scheme becomes fully operational. “Overall, the utilisation percentage under the scheme has remained low and there is a good amount of understanding to this effect in the government. That might have been the reason,” Shakti Selevaraj, health economist, told Down To Earth.
A policy brief paper of National Health Authority (NHA), the apex body responsible for implementing Ayushman Bharat, lays bare the fault lines in the budget utilisation, especially among the poor states.
“States with high poverty head counts have low claim volumes. Bihar, Madhya Pradesh and Uttar Pradesh have high poverty and low utilisation. Better off Kerala has the highest number of claims in India,” the paper read. The poverty level in Nagaland is low, but the claims are high. Gujarat, with relatively low poverty, has by far the highest spending per beneficiary.
This inverse relation is also true for disease burden. States with high disease burden have shown low utilisation. In principle, high uptake could cause low disease burden in the long run, but states with high disease burden are not utilising the scheme enough. Bihar, Uttar Pradesh, Assam, for instance, which have high disease burden, have recorded fewer claims than other states.
The paper clearly shows how the programme is off-track for the ones who need it the most. “In brief, both in terms of relative need for financial risk protection and improved health, PMJAY uptake among the neediest states is falling short during the first year of implementation,” the paper states.
During her speech, Sitharaman said there are many aspirational districts which do not have a single hospital empanelled under the scheme of insurance coverage. There are 115 aspirational districts in India which have poor socioeconomic indicators in comparison to others. Tapping these districts will be a priority, she said.
“It is proposed to set up viability gap funding window for setting up hospitals in the public-private partnership mode. In the first phase, those aspirational districts will be covered, where presently there are no Ayushman empanelled hospitals,” she said.
Another NHA policy brief states private hospitals are not keen to enroll under this scheme in aspirational districts. “Nine states have no private hospital empanelled in any aspirational district. For key tertiary care services, the share of hospitals empanelled to provide services in aspirational districts is less than half the share in other districts,” the paper stated.
The paper clearly states that the interest of private hospitals were lower in aspirational districts than in non-aspirational districts. “Private hospitals account for a larger share of admissions in non-aspirational districts in all states except Maharashtra and Uttarakhand. However, the average claim size is significantly small in aspirational districts in all states except Jharkhand.”