Would Ayushman Bharat make Indians healthier and health conscious? Results of a flash field survey

By Dr S Jayaprakash, Dr Arjun Kumar, Micael Ha, Dr Simi Mehta*

The Ayushman Bharat—Pradhan Mantri Jan Arogya Yojana (PM-JAY)- the signature health insurance scheme announced in the budget of 2018-19, was launched in Ranchi, the capital city of the second poorest state of India- Jharkhand. Massive preparations were done in the state with all its employees working at a war footing to welcome PM Modi on September 23, 2018 to inaugurate this program, amidst various queries and debates from various stakeholders. While much hype was created around the PM-JAY, live audience, however, felt that this program was more to bash his government’s achievements and prepare the grounds for the impending elections at the Union and State levels.

It is a progression towards promotive, preventive, curative, palliative and rehabilitative aspects of Universal Healthcare, with most of the states opting for the trust model, the operations are supposed to be backed by proven insurance claims processes that has worked so far in India.

Nevertheless, it is important to list the major features of PM-JAY launched towards the fag end of this government’s tenure:

• It is supposed to be the game changer in the healthcare industry in India towards providing accessible and affordable healthcare to the common man. It will be “world’s largest government funded healthcare program” targeting more than 50 crore beneficiaries (over 10.74 crore vulnerable entitled families based on SECC data). It is often termed as ‘MODI-CARE’, being one of the largest health assurance scheme in the world, bringing the dynamics of health economics, in general, and, health insurance, in particular, to the center of debate.
• The Yojana would provide a coverage up to ₹ 5,00,000 per family per year, for secondary and tertiary treatment through a network of Empaneled Health Care Providers (EHCP)- both private and public.
• The services would include 1350 procedures covering pre- and post- hospitalization, diagnostics, medicines. The rates for these have been prepared.
• So far 15,686 applications for hospital empanelment have been received.
• MoU has been signed with Common Service Centre (CSC) for identifying the beneficiaries through the help of over 3 lakh village level entrepreneurs. The beneficiaries would be able to avail the health services from more than 150,000 Health and Wellness Centres (HWCs) for primary care.
• The scheme would create a cadre of certified frontline health service professionals called Pradhan Mantri Aarogya Mitras (PMAMs) who would facilitate the beneficiaries to avail treatment at the hospital, thereby acting as a support system to streamline health service delivery.
• Training of PMAMs has begun and been conducted in across 27 states with around 4000 Aarogya Mitras having received the training.
• A performance-linked payment system has also been designed to incentivize hospitals to improve service quality and patient safety. States have been permitted flexibility to implement the scheme through an insurance company or directly through the Trust/Society/Implementation Support Agency or a mixed approach.

Rationale and Premise of the Research

Given the visionary step towards advancing the agenda of Universal Health Coverage (UHC), the authors conducted a swift survey between September 4-21, 2018, to observe primary inputs and awareness about the PM-JAY and health assurance schemes, building upon earlier scheme Rashtriya Swasthya Bima Yojana (RSBY). It was executed across 9 states Karnataka, Tamil Nadu, Maharashtra and Goa, Delhi, Uttarakhand, Uttar Pradesh, Bihar, Jharkhand and Assam. The age of the respondents ranged from 19-83.

The rationale behind this survey was to:

– understand the ways in which the respondents managed their medical expenses and the challenges therein.

– understand the expectations of the people from the PM-JAY.

-understand the awareness about the health insurance programs and their ability to access them.

– understand whether they put their smart phones for health purposes

It was hypothesized that telemedicine using smartphone applications could help ease the patients’ efforts in physically going to the doctors’ clinics. There was a caveat drawn from a similar Chinese experiment which revealed lack of penetration of mobile apps for healthcare. The Sino-US Center in China assisted in this evaluation exercise, which collected 43 responses from China on mobile healthcare apps and their healthcare requirements. The rationale behind studying the Chinese experience because of their experiment of ensuring delivery of telemedicine through mobile apps and in the last 2 years.

In this exercise, it is important to acknowledge the limitations in terms of its reach and responses yet underscore the rationale as an opportunity to pursue case studies and pave the way forward towards similar and wider research for the objective of ensuring a healthier India and ensuring effective health assurance coverage.

Some of the highlights of the survey in India are

Some major highlights of the survey in India is listed below:

• 7% (78) respondents have 4-6 dependents in the family
• 4% (66) were employed in Private sector while 34.2% (52) were self-employed as vendors, running petty shops, saloons in villages, flower vendors etc.
• 6% of the people sampled were lesser than Graduates with majority of them are 10th standard pass category.
• 56% of the people have visited hospital within 3 months for various reasons ranging from fever, vaccinations etc. to surgery requirements
• Out of 152, only 8 have gone for alternative medicines like AYUSH that shows the need for promoting the stream for minor ailments in India. 27 respondents were not aware about the qualification of Doctors only which is an alarming situation as there are risks associated with quack doctors spoiling the good initiative of Ayushman Bharat.
• It is also alarming to note that 120 people (80%) is taking risks by not going to qualified doctors but go to nearby pharmacies for smaller ailments to give a try before going to doctor.
• There is lot of potential for Pradhan Mantri Arogya Mitras to identify the cases before hand to put them into the main streams of monitoring. People making more than 6 visits per year contributes almost 28% (Note: 2 people did not respond back on this question).
• Two-Thirds of the respondents falls within the category of spending less than Rs.1000 per month. Some of the respondents from BPL category opined that though they go to the government hospitals for free treatment, some of the charges for registration, transport kills their pocket very much, burdening their Out of Pocket expenditure (OOP) on health.
• The awareness of insurance or government insurance schemes are very poor. Only 8 respondents have utilized government insurance in some manner. More than 85% of the respondents have managed the healthcare expenses only through savings or borrowings from friends.
• Majority of the people opined that they have hospitals or some access within 5 Kms distance. However, in the rural areas wherein the interview was conducted that constitutes around 40, most of the respondents said that the nearest medical center is more than 5 kms.
• Only 35.1% of the people told that they are aware of some state government insurance schemes. Out of that, only a few have availed the same. The reasons quoted by them for unable to avail is as below:
  • They had no idea the process to get the insurance cards
  • Some people came to know only after admitting their family members in the hospital, they were worried about the delays in getting cards and hence they decided to spend from their pocket.
  • Some respondents who availed the benefits thought that the limit is over, and they cannot claim further for the rest of their life. For example, a shopkeeper availed 1 lakh insurance in Hosur, Tamil Nadu for a surgery of his father. Father developed complications in the following year also, but he did not bother to ask if the window is still open, he himself jumped to conclusion that he has exhausted the limit and spent from his pocket.
  • One of the respondent is working in a private school as Physical Trainer. His father is in Coma for the last 18 years following a bus-accident. He does not know about insurance coverage of any kind which is surprising.
  • Some respondents from Private security agencies were not aware about the ESI coverages also.
  • The cases of migrant people working in Bangalore from Villages in Tamil Nadu is very interesting. They are aware of the schemes in Tamil Nadu that covers diseases, so far, any major ailments they will travel from Bangalore to their native village only. It is a reverse process. Schemes like Ayushman Bharat can help people to build confidence to stay put in the better city infrastructure hospitals to avail the treatments.
  • Some respondents are confident that they can get cards only when required, till then can remain silent about it, not aware any procedures involved in getting the card.
  • There were also cases reported that despite submitting all the required documents, they could not get cards. Some respondents told that Bank officials when opening Jan Dhan accounts spoke about insurance and collected documents, but nothing happened for the past 2 years, he did not receive the card so far, but came to Government hospital for free cataract surgery.
  • Out of 152, only 103 uses smart phones which is almost 2/3rd of the sample size, which shows the penetration of smart phones to depend upon it to perform any telemedicine services.

The following section highlights the Chinese responses to the survey:

• Over 60% of the respondents or their families visited a doctor or hospital 5-10 times a year.
• The average monthly expenditure for their families amounted to less than 500 Yuan (equivalent to approximately ₹ 5200).
• Out of 43 respondents, 15 utilized their savings to meet their medical expenses while a comparable 12 and 11 used their health insurance and employer benefits for the purpose.
• A whopping majority of them were not aware of the existence of digital applications for healthcare. Out of the 18 who were aware, only 10 made use of them.
• They felt that because the hospitals were within a decent proximity to their homes, the need to make use of digital applications was not dire.

If we analyze the responses on some key questions from India and China, it is seen that there isn’t much difference between the two with respect to the medical care and the adoption of telemedicine, given the high illiteracy in the two countries. However, some of the relevant opinion on mobile applications as an alternate to physical visits to the hospitals revealed that:

1. It can be more user friendly, pocket friendly.
2. Can have more features that can provide good access to the elderly.
3. But it is also important to note one important point that many felt that they have some sort of hospitals nearby which is not actually the case for India.

It requires more efficient personnel, what the researchers found in rural areas are that there is at least one or two educated persons connected with a village and has some sort of access to the internet or smart phones, he is aware of the persons in the villages also. Hence Government should introduce a window to make volunteers not restricted to the existing enrolled volunteers. These volunteers including the Arogya Mitras must be also trained for campaigns and spreading awareness at village levels, and for this they can be monetarily incentivized. They could play an instrumental role in disseminating information through exclusively developed mobile applications and in enabling the real-time status of poorer patients in Ayushman Bharat. This would enable the penetration of the scheme to the remotest regions of the country.

Policy Recommendations

• Ayushman Bharat has the potential to improve the innovations in insurance sector and help the citizens to enroll in health insurance. Therefore, it is recommended that the PM-JAY to incorporate the clauses that bridge the exclusionary clauses, the gap of the insurance sector can also be abridged. Thus, we argue that it time for insurers to design products for higher penetration leveraging Ayushman Bharat.
• Further, Ayushman Bharat can be a game-changer with respect to easing of accessibility to the network of hospitals in and around the beneficiaries’ household. This stands more pertinent and relevant for the poorer population, who could avail the benefits without over-spending in travel to the hospital far from their homes. This would also ease the tremendous patient inflow on the state government hospitals, so that they can improve their quality of treatment.
• Per the estimates of the insurance sector, fraudulent claims leads to a leakage of 10-15%. Strict control processes using claim analytics, de-duplication of customers and maintaining a strong database could help control frauds.
• We suggest that the amount remaining in unclaimed insurance ought to be redirected to trust funds by modifying existing rules as such schemes contribute to the insurance sector indirectly.
• Following the pattern of continuous mortality investigation, a process of continuous morbidity investigation must be put into place and continuously analyzed by using actuaries. This could utilize the stochastic modeling techniques in the PM-JAY to derive good asset liability models.
• Further, since Ayushman Bharat would generate real-time data in huge magnitude, these must be published on quarterly or half-yearly basis that will identify the gaps and challenges, enable beneficiary analysis and encourage for further innovation.
• As our survey in India demonstrated that majority of the participants employed in white-collared professions, were not aware of the Ayushman Bharat. Therefore, the government and the relevant ministries and departments must engage in massive awareness drives, and make use of the digital technology

When we investigate the Health Management Information System (HMIS) data with respect to the analysis and comparison of various factors like Mortality rates, Crude Birth rates, Neo natal mortality rates etc., the analysis are made in depth covering all the states and has been drilled down even till the district level. The HMIS has also marked the districts under each state has the potential dangers in various health parameters. Hence it is important for spreading awareness in the select districts based on the suggestions given in these papers on priority.

Conclusions

Given the massive scope of improving the deplorable health conditions and health service delivery systems in India, PM-JAY comes at an opportune time. Leaving the election gimmick behind, PM-JAY is important because of India’s health indicators that do not showcase a good picture. According to the National Health Profile of the Ministry of Health and Family Welfare, Government of India (2018), 1% of the GDP allocated for healthcare. With such a meagre amount, India has no other options to depend upon the probabilities to give a good coverage by creation of necessary infrastructure in place.

The Press Information Bureau’s Press Release delineating the program’s features referred to PM-JAY that would provide “accessible and affordable healthcare to the common man”. The government’s excessive concentration on ‘man’ does not reveal much of its gender sensitivity in the choice of its words.

Once the entire architecture of PM-JAY is set in place and is put into action, India would have the “world’s largest government funded healthcare program”. By targeting more than 50 crore beneficiaries (over 10.74 crore vulnerable entitled families) it will progress towards financial protection for promotive, preventive, curative, palliative and rehabilitative healthcare through HWCs. Use of digital technology and regular updates through applications would certainly invite the curiosity of the citizens and enable them to explore options of several types of health care- thereby making a Healthy India- in the true sense of the term.

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*Dr S Jayaprakash: PhD, Health Insurance;  Dr Arjun Kumar: Director, Impact and Policy Research Institute (IMPRI), New Delhi; Michael Ha: Qualified Actuary & Director, Sino US Research Center, China; Dr Simi Mehta:CEO and Editorial Director, IMPRI, New Delhi