Context: India enters the second week of a national lockdown imposed in response to COVID-19, it is still unclear how well prepared the healthcare system is in dealing with the pandemic. 

Challenges for the govt:

  • The resource constraints: Government hospitals alone will not be able to manage the fallout of severe cases of COVID-19 that would require hospitalisation. 
    • Moreover, even within the government system, tertiary care and public health are the weakest links.. 
  • Costly diagnosis: At present, the government has put a cap on the cost at ₹4,500 per test, which is a burden for even a middle class patient. 
    • The National Health Authority has recommended that the testing and treatment of COVID-19 be included in the PM-Jan Arogya Yojana (PM-JAY) but this proposal is still awaiting clearance. 
  • Fragmented governance of the health service system: There is lack of a visible central command, which should be created under the supervision of the Union Health Minister, aided by a team of experts. 
  • Ignoring the middle class: So far the govt. has offered packages to the poor but the large, middle class, of which many are employees in the services sector is being ignored. They do not have secure employment, nor do they have insurance cover. 
  • The government’s silence on involving the private healthcare system: Faced with a serious health emergency, the silence of the government on the expected role of the private sector is questionable.

Ayushman Bharat

Ayushman Bharat is a two pronged approach towards Universal Healthcare. 

  • Health and Wellness centres - They will provide comprehensive Primary Health Care, free essential drugs and follow up of hospitalization cases. They will also conduct yoga sessions to promote wellness and have a much wider range of free drugs and diagnostics. 
    • The HWCs serve as the awareness, screening and referral link between patients and PMJAY. 
  • Pradhan Mantri Jan Arogya Yojana (PMJAY) - It provides a health protection cover of rupees 5 lakh per family per year to the bottom 40% of poor and vulnerable population for hospitalization expenses towards the treatment of serious illnesses. 

Ayushman Bharat aims to offer financial risk protection to the beneficiary families through a system of demand led Healthcare initiative that meets their immediate hospitalization needs in a cashless manner. 

Key features of Pradhan Mantri Jan Arogya Yojana 

  • It provides cashless cover upto rupees 5 lakh to each eligible family per annum for listed secondary and tertiary care conditions. 
  • The cover under the scheme includes all the expenses including non-intensive and Intensive Care Services, medicine and Medical consumables and post-hospitalization follow up care upto 15 days. 
  • There is no cap on family size and age of members. 
  • All pre-existing diseases are covered from the very first day unlike private insurance schemes. 
  • Benefits covered under PM-JAY are portable across the country and any eligible beneficiary can visit any empanelled Hospital across the country. 

The stated aims of the insurance portion of the programme include to cushion poor families against the financial shock that a health emergency can trigger, as well as to bring the private sector to small cities. 

Support Mechanisms

  • A National Health Authority (NHA) has been mandated to roll out and coordinate the programme.
  • A cadre of frontline health service professionals called Pradhan Mantri Arogya Mitras (PMAMs) are trained to facilitate provision of treatment to beneficiaries at hospitals. 
  • The scheme is supported by a strong IT backbone that facilitates the identification of beneficiaries, records treatments, processes claims, receives feedback, and addresses grievances. 
  • A live dashboard helps in monitoring and improving performance, based on real-time data and regular analysis. This platform also helps states to compare their performance. 
  • A strong and sophisticated fraud prevention, detection and control system at the national and state level has proved to be critical for PM-JAY to ensure that frauds are largely prevented. If attempted, they are quickly detected and strong action is taken.

Implementation Model 

Considering the fact that states are at different levels of preparedness and have varying capacities the PM-JAY provides them with the flexibility to choose their implementation model which can be through Insurance, Trust or Mix mode. 

  • Insurance Mode - The state government appoints an insurer at a defined rate for taking over the financial risk of the beneficiaries. 
  • Trust Mode - The state government creates an agency which pays the claims of the hospitals as per actual utilisation. The risk of health protection lies with the state. 
  • Mixed Mode - The state uses a combination of insurance and trust modes generally where low-cost common procedure (secondary care) is managed by the insurer and high cost specialised procedures managed by the state trust.

PMJAY, being a centrally sponsored scheme is fully funded from the consolidated fund of India. The expenditure is shared between Central Government and state government as per the sharing instructions issued by the Ministry of Finance. 

PMJAY embodies a policy shift where the government now assumes the role of a purchaser of services from that of the provider and also is surely a giant Leap forward towards the achievement of the sustainable development goals specially SDG 3.8 achieving Universal health coverage.

Significance of involving the private sector: 

  • In India, private corporate hospitals have, in the past, received government subsidies in various forms and it makes them responsible towards the general public.
  • They are also well poised to provide specialised care and have the expertise and infrastructure to do so. 

Recent initiatives to rope in private sector

  • Some individual private sector companies have come forward with offers of creating capacity and making it available to COVID-19 patients.
  • Some States like Chhattisgarh, Rajasthan, Madhya Pradesh and Andhra Pradesh have already roped in the private sector to provide free treatment.
  • There have been some tentative measures taken by States to allow individuals seeking testing for COVID-19 to access private laboratories at subsidised rates. 
  • The Central government has already taken over some private hotels to accommodate persons quarantined for COVID-19.
  • The treatment for COVID-19 has been included under Ayushman Bharat.

Way forward: There is a need for a comprehensive national policy to ensure that private healthcare capacity is made available to the public. 

  • Creating adequate testing and quarantine facilities: the government should ‘take over’ private corporate laboratories and hospitals for a limited period. 
    • A graduated approach to this is possible by asking tertiary private hospitals to create ICU facilities and isolation wards to care for the moderate and severe cases under the supervision of the government. 
    • The political directive for such a move needs to come from the Central government while ensuring that the Ministry of Health provides standard treatment protocols for health personnel.
  • Niti Aayog's 'Model Concession Agreement for Setting Up Medical Colleges Under the Public Private Partnership' guideline document: To address shortage of qualified doctors and bridge gap in medical education, the Niti Aayog has come out with the public-private partnership model to link new or existing private medical colleges with functional district hospital to augment medical seats.

Universal public healthcare is essential not only to curb outbreaks, but also to ensure crisis preparedness and the realisation of the promise of right to health.

Spanish Example

  • The Spanish government issued an order bringing hospitals in the large private corporate sector under public control for a limited period. 
  • This tough decision was taken with the understanding that existing public healthcare facilities would not be able to cope with the sudden, if short-term, rise in COVID-19 cases.
Source: The Economic Times