On 29 May, the prime minister invoked Ayushman Bharat-PM-JAY after a long time. He announced that children orphaned by COVID-19 would be made beneficiaries, and therefore eligible for a Rs 5 lakh health insurance cover per annum. PM-JAY is the centrepiece of India’s public health push, currently. With the global pandemic, and especially the ferocity of the second wave of COVID-19 in India, we must examine what India means when it says public health.
The Immediate Background
In 2008, the UPA, inspired by the success and popular support for then Andhra Pradesh Chief Minister YSR Reddy’s Aarogyasri schemem — of public money subsidising secondary and tertiary private hospitalisations — started its Rashtriya Swasthya Bima Yojana. This targeted poor families and covered secondary and tertiary treatment for up to Rs 30,000. Subsequently, several state governments launched their own state-specific health scheme versions.
It was this UPA insurance yojana/plan that the Modi government refitted and (not unsurprisingly) acronymed as AB-PMJAY or Ayushman Bharat-Pradhan Mantri Jan Aarogya Yojna, and launched it in September 2018.
This remained an insurance scheme that covered 1000 treatments as well as a cashless component; the costs of certain treatments was fixed. The Modi government regarded this as a flagship scheme before the 2019 general elections and it aimed to cover the bottom 40 percent, and 10.74 crore of the 24.88 crore households in India (as per Census 2011) were identified as beneficiaries. Ayushman Bharat also claimed to take care of primary health through wellness centres, but mainly, it remained a way to offer money in order to fund hospitalisations.
How We Look at Healthcare: Let’s Do Away With the ‘Insurance Lens’
But here is the rub. An insurance lens on public health does grave injustice to the people. Just making sure that people can have some ‘cashless’ service at public and mostly private hospitals and projecting that as India’s ‘public health programme’ is creating more problems than solving it, for our 1.3 billion.
COVID-19 has surely nailed the importance of public health to mean a network of effective local healthcare workers and good local health infrastructure. The conundrum at the start of the pandemic, of high-income countries falling victim to the ravages of the virus, but medium-income countries doing better, was resolved soon.
Enabled by effective public health responses, like local frontline healthcare workers adept at prevention, investigation, contact-tracing, and therefore being able to limit the infection, countries which had invested in more and local healthcare personnel and infra were able to minimise suffering.
So, countries like Vietnam, South Korea, Thailand beat the US hands down. Countries with a healthcare system primarily centred around insurance, lost out.
Thailand’s Successful Implementation of Universal Health Coverage
The WHO noted earlier this year in its bulletin, that Thailand’s successful implementation of universal health coverage (UHC), which began in 2002, “demonstrated the value of long-term investment in health systems and primary healthcare. To accommodate the rapid increase in service utilisation required for the implementation of UHC, the Thai government more than doubled the number of qualified nurses and midwives from 84,683 (13.2 per 10,000 population) to 191,575 (27.6 per 10,000 population; 94.8 percent women) between 2002 and 2018.
In India too, this became increasingly clear as the second wave of COVID-19 consumed lives.
Oxygen fell short, as did ventilators and medicines and access to doctors; it did not matter if you had all the money and insurance, lives could just not be saved because something far more fundamental — healthcare facilities and personnel — was inadequate; the system was broken.
Evidence of Complete Collapse of India’s Primary Healthcare
The Indian government’s own figures, in its annual report ‘Rural Health Statistics’, published by the Health Ministry’s National Health Mission for 2019-20, vouches for this complete collapse of primary healthcare other than in a few states like Kerala, Tamil Nadu and Himachal Pradesh. The three-tiered centres, the sub-centres, primary health centres (PHCs) and community health centres (CHCs) have failed people woefully, with both crumbling infrastructure and inadequate personnel.
Had Ayushman (meaning ‘long life’) Bharat meant anything to those with the power to change things, the fallout of the COVID-19 crisis could have been ameliorated, somewhat.
Consider this; just about 4 percent of sub-centres, 13 percent PHCs and 9 percent CHCs conform to Indian Public Health Standards (IPHS) (these are a set of uniform standards published in January/February 2007, envisaged to improve the quality of healthcare delivery in the country). Or look at what the state of specialists in states which should have been more alert to their health status reveals — Gujarat needed 1,392 specialists, but the report records that only 13 specialists were in place. Uttar Pradesh needed 2,844 specialists but had just 816; Madhya Pradesh needed 1,236 but had a mere 46. Rajasthan needed 2,192 but had 438.
An insurance push alone, thus, is no remedy for the disease.
All in all, the issues at play here are closely tied in with our democracy.
Why Public Health Is An Index of the State of Our Democracy
Firstly, does good health for everyone rank as a priority for the ruling party? It is only when there is a genuine commitment to all lives being equal that public health as a goal can be pursued. Public health is an index of the state of our democracy, how much those in power care. As so cruelly brought into focus during the pandemic, in states run by the ruling party for decades, Bihar (15 years), Gujarat (for quarter of a century) and Madhya Pradesh (15 years), the visible absence and absolute neglect of primary healthcare is a cause for alarm.
But secondly, this is also about how vigilant people are and how demanding they’ve been of their leaderships, to deliver on public health. ASHAs, the Accredited Social Health Activists, are among the first responders in every public health crisis. How many people are enraged that the government does not even consider them as workers (the Modi government treats them as ‘volunteers’)?
As Amartya Sen and Jean Drèze point out in Uncertain Glory, of 300 articles published in a leading newspaper between January and June 2000 that they analysed, not one was about health. The authors “repeated the exercise between January and June in 2003,” and they found one.
How Big Healthcare Innovations Have Often Followed In the Wake of Crises
The pandemic has forced the conversation on health. The PM, on 30 April, in his Cabinet meeting, referred to the pandemic as a “once in a century crisis”. A crisis of such proportions must be used as an opportunity to effect big shifts. Globally, big healthcare innovations have often followed in the wake of such crises. The Spanish flu and the world wars led to the UK developing its signature National Health Service (NHS), epidemics like smallpox led to unthinkable things like the US’s Center for Disease Control (CDC) and the Soviet Union’s Institute of Virus Preparations, cooperating at a time of an intense cold war to distribute the smallpox vaccine to developing countries.
China, the closest to India in size, which had moved to emphasise private care, when it had opened up other sectors, drew the right lessons after the SARS scare and ‘re-socialised’ its public health system. AIDS galvanised South Africa to boost public health.
In India, the Bhore Committee in 1946, the High Level Expert Group on Universal Health Care in 2011 and the high level group which submitted its report to the 15th Finance Commission in 2019, have spoken eloquently on what public healthcare in India must mean.
Despite all those words and the experience of the pandemic, if we are still not able to move away from insurance and focus on meaningful Universal Health Care, treating it as a matter of national security, it will amount to inflicting great harm on Indians and its young demographic.
We have seen how public health mismanagement has had unintended consequences. It has impacted our reputation for making vaccines for the world, and consequently has hurt India’s influence in the region. Its reputation is at grave risk, so if not the lives of millions, perhaps just the pragmatism of it should lead India’s government to evolve a roadmap and follow it through with a commitment to preventive, primary healthcare — for all.
(Seema Chishti is a writer and journalist based in Delhi. Over her decades-long career, she’s been associated with organisations like BBC and The Indian Express. She tweets @seemay. This is an opinion piece and the views expressed above are the author’s own. The Quint neither endorses nor is responsible for the same)
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