Ayushman Bharat: A two-month scorecard

January 14, 2019 0 By FM

I had written about the Ayushman Bharat (AB) scheme just around the time when it was being launched nationally by the Prime Minister in September. The article had attempted to analyse and comment on the preparedness of the centre and the states, and what would matter for the success of the programme.
At the time, much of the analysis was based on conjectures, in the absence of any tangible data points to assess our readiness to launch a scheme of such magnitude. While it was my conviction then, and now, that the timing of the launch had less to do with preparedness and more to do with political exigencies, a certain degree of performance must be ensured even if the eye is primarily on reaping political benefits from the launch.

Now, we have the first set of data points on the actual performance of the scheme after two months of launch. These are as follows:

1) Total number of beneficiaries – 2,32,592
2) Share of care provided through public health facilities – 32%
3) Top five specialities by claim — oral and maxillofacial surgery, general surgery, general medicine, ophthalmology, obstetrics and gynaecology.
4) Top five states by usage: Gujarat, Tamil Nadu, Maharashtra, Chhattisgarh and West Bengal.
Before offering a critical analysis of this data, I must clarify that I am acutely aware that two months are too short a period for any definitive evaluation of a scheme of this magnitude. It is also very heartening to see that the programme has been set in motion, unlike many other well-meaning schemes of this kind that get mired in endless intellectual/bureaucratic muddle, either to die a quiet death or be subjected to significant delays. Having said that, it is important to highlight what needs to be corrected with an utmost sense of urgency to ensure that the scale-up happens in the most efficient manner for a scheme that has life-changing implications for its beneficiaries.

With the aforesaid background, my views on the aspects of Ayushman Bharat that need correction are as follows:

1. Improve communication and outreach: An analysis of the number of beneficiaries reveals that only 20% of the actual hospitalisation cases occurring in the target population is currently under the scheme. That is to say, out of every 10 people actually getting hospitalised in the target group eligible for AB, only 2 or fewer are availing the benefits of the scheme. This can be derived by comparing the actual hospitalisation rate of the target population group before the launch of the scheme in the 18 states where the scheme is being piloted and the number of beneficiaries hospitalized under AB in the first two months of the scheme. It should be noted that the actual number of states where the pilots are running is reported to be 22, but only 18 have been mentioned on the AB website. Hence, this is a conservative estimate. Even if it’s just a two-month-old scheme, a figure of less than 20% is too low. Given that it is an entitlement based scheme, the propensity to avail by the beneficiary is extremely high and typically such schemes are expected to result in a rise in hospitalisation rates in the first year. This is also corroborated, anecdotally, in my conversations with the target group population in multiple states where the pilots are on. In fact, the states that have emerged as leaders had a history of well-entrenched state-sponsored schemes targeting at least 50% of the target group which got subsumed under AB. The beneficiary numbers under AB would have been much lower without the cannibalisation.

2. Focus on improving the share of public health facilities: What is surprising are comments from senior authorities managing the programme, highlighting the 68% share of private healthcare providers as a positive aspect, indicative of their adoption of scheme. Indeed, support of private healthcare is crucial for the programme, but the planned economics of this scheme necessitates significantly improving the share of public health facilities to at least to 50% to make it sustainable. Hence, the deterioration in the public share to 32% from 34%, which is the current national average, is not good news.

3. Speed up empanelment of the tertiary care players: The specialities that have come up on top are not typically found to be so in a normal situation, particularly ophthalmology and obstetrics/gynaecology. At the same time, cardiac ailments, that account for 10% of hospitalisations in India, does not find a mention. This is possibly owing to insufficient empanelment of high-end tertiary care private hospitals (given the paucity of sufficient capability in public health) which needs to be ramped up. The good news is that oral and maxillofacial surgery coming on top is perhaps indicative of accident/trauma care getting the benefit.
In conclusion, it must be emphasized that what have been commented upon as areas of improvement are based on the very limited data that has come into public view. A more comprehensive view can be taken after six months of implementation and when more details are available, but the government may not have the luxury of time in this case. With the elections coming up in six months, it is imperative for the government to do everything it can to ramp up effective usage of the scheme as soon as possible.

The author has long-standing association with EY India but the views are strictly personal.