Increasingly, nations are being judged on the quality of health security they provide to their citizens, in addition to the economic momentum. This is a paradigm shift in perspective and it is a matter of pride that India took a giant leap ahead with the launch of the landmark Ayushman Bharat. PMJAY- the world’s largest public-funded heath financing scheme, could well eliminate a major reason of indebtedness in the country, in time, by supporting 10.74 crore families with an annual cover of INR 5 lakhs per family for secondary and tertiary care hospitalisation.
Since the launch of PMJAY on September 23, 2018, the numbers pouring in from NHA are impressive and the average number of beneficiaries admitted to hospitals increased to 10,000 per day in December from around 2,000- 5,000 per day in October. States such as UP, Bihar and Jharkhand where health indicators have been poor, show a significant jump in number of hospitalisations. So far, nearly 7 lakh beneficiaries have been treated under the scheme and claims of Rs 700 crore raised, where about 65 per cent services were delivered by private hospitals. 33 states and union territories are a part of the scheme. Over 16,000 hospitals have been empanelled to provide services under the scheme with 69 per cent hospitals being multi-specialty hospitals. However, implementation of the scheme in all states is not uniform with states like Uttar Pradesh and Bihar that have the highest number of families identified as PMJAY beneficiaries lagging behind others. States which were already implementing their state-funded health insurance programmes- like Gujarat and Tamil Nadu are amongst the front runners in terms of performance.
Since before the launch, Ministry of Health and Family Welfare, NITI Aayog and National Health Agency (NHA) have held several rounds of consultation meetings across the country with various stakeholders from the public and private healthcare sector. Key anomalies in the existing public health assurance schemes surfaced as glitches in the procedure for empanelment, unscientific determination of package rates, inordinate delay in reimbursement to providers, shortage of trained manpower and fraudulent claims. Most of these challenges can be tackled with effective public private collaborations and by harnessing technology.
Considering the scheme has a coverage almost equal to population of the EU, we need to substantially expand the network of hospitals. It is essential to empanel credible hospitals of all types– from small hospitals serving patients in tier III or IV towns to multi-specialty and specialist tertiary care centres located predominantly in the metro cities. But, empanelment criteria as well as reimbursement rates also need to be linked to level and quality of care.
Private healthcare providers- a crucial partner for PMJAY, have rising concerns related to inadequate package rates for the procedures covered under the scheme and have been demanding for scientific derivation of package rates. An objective understanding of cost of providing healthcare services should be the bedrock for derivation of rational package rates. To demystify the ambiguity around the costing of care, FICCI undertook a scientific study for determining cost of select procedures across a diverse set of hospitals from both private and public sector. The study reveals that package rates proposed under AB-PMJAY are inadequate even to cover the cost incurred by both private and public hospitals. It has also been found that the providers operating in the non-metro cities incur higher manpower costs owing to higher salary packages and benefits demanded by the workforce, while the providers in metro cities, incur higher land and facilities cost.
These are fairly complex challenges that require concerted efforts to work towards an appropriate reimbursement model that is not only viable but also accounts for enhanced quality and clinical outcomes. There is need for a rationalised reimbursement system that defines differential rates for stratified provider groups, based on factors like location of operation, quality of services, qualification and experience of manpower, deployment of cutting-edge technology as well as the provision of best-in-class service by the provider.
Another major concern of national importance is the availability of skilled health workforce to meet the demands of Ayushman Bharat. As per FICCI estimates, in addition to the current deficiencies we would need, additional 10 lakh MBBS doctors, 1 lakh specialists, 20 lakh nurses and 30 lakh paramedics and healthcare technicians. Around 1 lakh Arogya Mitras will also be deployed at empanelled hospitals. Immediate innovative and strategic interventions for training and recruitment of required healthcare workforce across the continuum of care will play a pivotal role in revamping the healthcare cadre for the nation.
In brief, Ayushman Bharat epitomises a potent will to build a truly healthy nation, a commitment to harness the benefit of our demographic dividend to make India realise its full potential. This can be achieved with collaborative efforts and innovative partnerships between various stakeholders.
Sangita Reddy is Senior Vice President, FICCI & Joint MD, Apollo Hospitals Enterprise Ltd.
Brig (Hony.) Dr Arvind Lal is Chair, FICCI Health Services Committee and CMD, Dr Lal PathLabs
Shobha Mishra Ghosh is Assistant Secretary General, FICCI.