By Muppidi Simir Reddy

Abstract

The Ayushman Bharat Scheme was inaugurated in 2018, to confront the mounting health challenges that were facing the people of India. The scheme sought to extend substantial health insurance coverage to over 40% of the population while concurrently enhancing healthcare infrastructure through the establishment of additional health and wellness centres. Subsequent to its launch, the scheme has undergone significant updates, including the introduction of the Ayushman Bharat Digital Mission and revisions outlined in the interim budget for the 2024 fiscal year. This article endeavours to evaluate the efficacy of these initiatives and assess the ramifications of the ensuing updates on the healthcare landscape.

Introduction

The Indian healthcare system grapples with a multitude of challenges, including escalating healthcare expenses, the growing demand for long-term nursing care for senior citizens amid a societal shift from extended to nuclear family structures, and the complex burden of addressing both communicable and non-communicable diseases alongside injuries. Compounding these issues is the chronic underfunding of the public healthcare sector.

India’s healthcare landscape inherently perpetuates inequities, particularly for individuals in lower-income brackets. Despite comprising a significant portion of the population, over 70 percent of healthcare consultations occur in the private sector, which encompasses roughly 50 percent of available beds. However, these private facilities often vary in quality and size due to a lack of regulation, predominantly catering to higher-income segments of society. Conversely, the public sector struggles with overwhelming demand, exacerbated by insufficient funding, a scarcity of trained healthcare personnel, and inadequate medical supplies. Furthermore, the pervasive absence of comprehensive health insurance coverage further exacerbates these disparities, with only an estimated 37% of Indians currently enrolled in health insurance schemes.

The Ayushman Bharat Scheme was first introduced in 2018, as a response to the healthcare inequality that was proving to be a large problem in the country. It aimed to reduce this health inequality by solving two key problems – the underutilization of the public healthcare sector and the high out-of-pocket expenditure.

What is the Ayushman Bharat Scheme?

The Ayushman Bharat scheme comprises two key components: Health and Wellness Centres (HWCs) and the Pradhan Mantri Jan Arogya Yojana (PM-JAY). Introduced in February 2018, the Health and Wellness Centres initiative aimed to establish 150,000 HWCs nationwide, enhancing access to primary healthcare services. These centres offered a range of essential services including maternal and child healthcare, management of non-communicable diseases, and provision of free essential medications and diagnostic facilities. The second component, the Pradhan Mantri Jan Arogya Yojana (PM-JAY), was launched on September 23, 2018. This component seeks to provide health coverage of up to Rupees five lakhs annually per family for secondary and tertiary care hospitalisation. It targets over 12 crore economically disadvantaged families, constituting the bottom 40% of the Indian population. Eligibility for coverage is determined based on the deprivation and occupational criteria outlined in the Socio-Economic Caste Census 2011 (SECC 2011) for rural and urban areas respectively.

What is the Efficacy of the Ayushman Bharat Scheme?

The continued utilisation of the 2011 Socio-Economic and Caste Census within the Ayushman Bharat Scheme presents a systemic challenge. This issue extends beyond Ayushman Bharat, reflecting the dynamic nature of India’s demographic landscape characterised by ongoing population shifts and migration patterns. Consequently, schemes relying on outdated census data are prone to inaccuracies in identifying beneficiaries, thereby posing a minor hurdle to effective implementation.

The Oxford Policy Management conducted a comprehensive study on the Ayushman Bharat Scheme to assess its effectiveness in reaching its intended beneficiaries. Utilising both qualitative and quantitative methods, the study was conducted across two states, Uttarakhand and Haryana. Results indicated a low level of exclusion among the intended beneficiaries registered under the Pradhan Mantri Jan Arogya Yojana (PMJAY) in both states, suggesting a commendable accessibility level and successful identification of the targeted beneficiaries by the scheme.

However, notable flaws within the program were identified. The inclusion error through design was found to be prevalent, indicating avoidable mistakes. For instance, in Uttarakhand, individuals eligible for the National Food Security Act (NFSA) typically belong to the bottom 40% of the population, with minimal overlap observed among those holding government jobs. Leveraging such insights could facilitate the exclusion of households with government employment from eligibility criteria, thereby enhancing the efficiency of Ayushman Bharat and similar subsequent schemes.

Moreover, the study illuminated the dynamic nature of India’s demographic landscape, underscoring the importance of periodic reassessment and adaptation of eligibility criteria to ensure accuracy in targeting beneficiaries. Additionally, the research highlighted the need for enhanced coordination between different welfare schemes to minimise duplication of benefits and streamline service delivery. By leveraging advancements in data analytics and technology, policymakers can refine the targeting mechanisms of Ayushman Bharat to improve its effectiveness in reaching vulnerable populations and addressing their healthcare needs comprehensively.

The study also highlighted the issue of exclusion errors in implementation. Unlike design errors, these arise during the execution phase, resulting in individuals being inadvertently excluded from the program. This underscores a disparity between the program’s effective design structure and its deficient implementation, which is a common challenge encountered in many Indian policies due to bureaucratic hurdles, information gaps, corruption, and various other factors.

Ayushman Bharat Digital Mission

It’s crucial to recognize that the Ayushman Bharat Scheme extends beyond the policies previously mentioned. The National Health Authority (NHA), the apex body responsible for implementing the Pradhan Mantri Jan Arogya Yojana (PM-JAY), also spearheaded the Ayushman Bharat Digital Mission. This initiative aims to establish a National Digital Health Ecosystem, revolutionising healthcare delivery in India.

The Ayushman Bharat Digital Mission encompasses various components designed to bolster the digital infrastructure within the medical field. These components include:

1. Healthcare Professionals Registry (HPR): This serves as a comprehensive database containing information on all healthcare professionals engaged in delivering healthcare services, spanning both modern and traditional systems of medicine.
2. ABHA Mobile App (PHR): The Personal Health Record (PHR) app enables individuals to maintain electronic records of their health-related information. These records adhere to nationally recognized interoperability standards and can be sourced from multiple platforms, empowering individuals to manage, share, and control their health data.
3. Health Facility Registry (HFR): This repository catalogues health facilities across the nation, encompassing various systems of medicine, thereby facilitating accessibility to healthcare services.
4. Unified Health Interface (UHI): Envisioned as an open protocol, the UHI facilitates various digital health services. The UHI Network functions as an open platform connecting End User Applications (EUAs) and participating Health Service Provider (HSP) applications.
5. Ayushman Bharat Health Account Number (ABHA): The ABHA Number serves as a unique identifier for individuals. It facilitates authentication and enables the integration of health records (with the patient’s informed consent) across diverse systems and stakeholders, enhancing continuity of care and data management.

By leveraging these digital innovations, the Ayushman Bharat Digital Mission aims to enhance healthcare accessibility, efficiency, and quality, ultimately contributing to improved health outcomes for all citizens.

Subsequent developments to Ayushman Bharat

In the 2024 budget, the Ayushman Bharat scheme received significant updates, reflecting the government’s ongoing commitment to healthcare reform. Notably, the scheme saw a notable year-over-year increase of 10%, bringing the total allocation to Rs. 7500 crores. This augmentation underscores the government’s prioritisation of expanding healthcare coverage and improving accessibility for the populace. Additionally, Finance Minister Nirmala Sitharaman announced a noteworthy expansion of healthcare coverage under Ayushman Bharat, extending benefits to all ASHA workers, Anganwadi workers, and helpers. This move not only acknowledges the crucial role played by these frontline healthcare workers but also aims to enhance their well-being, ultimately strengthening India’s healthcare infrastructure.

Delving into the budget allocation details, out of the total Rs. 7500 crores earmarked for the Ayushman Bharat scheme, approximately Rs. 411 crores are designated for capital expenses. These funds are intended for investment in infrastructure or assets, laying the foundation for bolstering healthcare facilities and services across the country. The remaining Rs. 7,089 crores are allocated for operational expenses, covering essential aspects such as salaries, maintenance, and day-to-day operational costs. This balanced allocation strategy ensures that both the immediate operational needs and the long-term infrastructure requirements of the healthcare system are adequately addressed.

Upon closer examination of the budget allocation and expenditure figures, a critical analysis reveals several noteworthy insights. While the 10% year-over-year increase in the Ayushman Bharat scheme’s budget allocation signals the government’s purported commitment to healthcare reform, discrepancies between the budget estimates and actual expenditure raise questions about the efficacy of resource utilisation. Despite the substantial allocation of Rs. 7,500 crores, the revised expenditure for FY24 stood at Rs. 6,800 crores, indicating a considerable variance and potential inefficiencies in spending.

The discrepancy between budget estimates and actual expenditure suggests possible challenges or bottlenecks in the implementation of the Ayushman Bharat scheme. Factors such as bureaucratic red tape, administrative inefficiencies, or delays in project execution may have contributed to underspending or cost-saving measures. Furthermore, the gap between allocated funds and actual expenditure raises concerns about the scheme’s ability to effectively utilise resources to achieve its stated objectives of expanding healthcare coverage and improving accessibility.

Moreover, while the allocation of Rs. 411 crores for capital expenses demonstrates an intention to invest in healthcare infrastructure, the extent to which these investments translate into tangible improvements in healthcare delivery remains uncertain. Without adequate monitoring and evaluation mechanisms in place, there is a risk that capital investments may not yield the desired outcomes or fail to address critical gaps in healthcare infrastructure.

This trend becomes even more concerning upon closer examination of the healthcare budget for 2024. While there appears to be a nominal increase of 0.34% in the health budget’s share of GDP, It is crucial to consider whether this rise adequately accounts for inflation. When inflation is factored in, the budget allocation actually shows a decline in real terms. This discrepancy underscores a concerning pattern: the government’s healthcare spending continues to fall short of the recommended threshold of 2.5% of GDP, as outlined in the National Health Policy of 2017. This persistent underinvestment poses significant challenges to achieving Universal Health Coverage (UHC) and addressing the healthcare needs of the population effectively.

While the Ayushman Bharat Scheme has witnessed an increase in funding, several critical subsequent schemes have experienced budget cuts, signalling a concerning trend in healthcare allocation. The National Health Mission (NHM), an essential pillar of the healthcare system, has seen a notable reduction of Rs.375 crores compared to the previous year. This decline in funding threatens to undermine the structural integrity of essential services, particularly those dedicated to supporting the health needs of pregnant women and children.

Furthermore, key initiatives such as the Pradhan Mantri Matru Vandana Yojana have faced a decrease in allocation by Rs. 41 crores. This program plays a pivotal role in providing crucial financial assistance to pregnant and lactating mothers, emphasising the potential adverse effects of reduced funding on maternal and child health services.

Similarly, Mission Shakti, aimed at empowering and ensuring the security of women, has experienced a reduction in allocation by Rs. 40 crores. This decline, from Rs. 3,184 crores to Rs. 3,144 crores, underscores the considerable challenges in sustaining efforts to promote gender equality and women’s safety amidst financial constraints within the budgetary framework.

Conclusion

While the Ayushman Bharat Scheme has undoubtedly provided significant benefits to many individuals, its existence highlights a broader healthcare challenge within the country. While Ayushman Bharat represents a crucial step towards addressing this issue, it cannot serve as a one-size-fits-all solution. Complex problems such as underfunded public healthcare sectors, the spread of diseases, and underlying health issues require systematic solutions implemented at the grassroots level. Therefore, while Ayushman Bharat is an important initiative, a comprehensive and multifaceted approach is necessary to tackle the underlying healthcare issues plaguing the nation.

Author’s Bio

Muppidi Simir Reddy is a first-year BA (Hons) Economics student at Jindal Global University, with a keen interest in developmental economics. Outside of his academic pursuits, he dedicates his free time to researching social issues both globally and, more specifically, within India.

Image Source: https://health.economictimes.indiatimes.com/news/policy/transforming-rural-healthcare-in-india/95567034