Launched a year ago on 23 September, the Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) scheme remains one of India’s most ambitious health schemes ever. While it may be too early to comprehensively evaluate the scheme’s impact, the early trends suggest that the scheme risks sharpening the inequalities in public health, built on the edifice on a healthcare system skewed against the poor.

The scheme built on the more limited Rashtriya Swasthya Bima Yojana (RSBY), a UPA-era scheme that provided some groups, including people below the poverty line people, health insurance coverage up to 30,000, and also subsumed some state-level insurance schemes. 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. The claims limit is a big step up from the RSBY, at 5 lakh per beneficiary annually. The government claims that 4.46 million beneficiaries have used the scheme thus far.

The data that the government has so far put in the public domain centres largely around the numbers of beneficiaries, hospitalisations, and reimbursement claims. Relatively little is known about the nature of treatments sought by beneficiaries. Yet, the data available thus far points to worrying inclusion and exclusion errors, both stacked against the poor.

The poor in India systematically report lower rates of reported illness, medical attention-seeking and hospitalisation than the rich, as these pages have pointed out earlier.

This occurs at both the individual/ household level, and the state-level. This is not because the poor are healthier than the rich; the per-person disease burden, measured by “disability-adjusted life years" was the highest in Assam, Uttar Pradesh, and Chhattisgarh in 2017, and the lowest in Kerala and Goa, according to the latest edition of the Global Burden of Disease database.

The difference between the lower reported rates of illness in poorer but high-burden states arise from lower health awareness and from limited ability to access healthcare. For the same reasons, richer states have higher reported illnesses and higher hospitalization rates.

From AB-PMJAY data, it would appear that this pattern is being replicated, and the scheme has not yet been able to substantially alter inter-state patterns in medical attention-seeking behaviour.

Until June 2019, the most recent month for which data was submitted to Parliament, Madhya Pradesh had enrolled the most beneficiaries for the scheme, followed by Uttar Pradesh, Bihar, and Maharashtra.

However, it was Chhattisgarh, followed by Gujarat, Kerala and Tamil Nadu which submitted the most claims; and in terms of value of the claims, Gujarat had by far the most expensive treatments reimbursed. If the scheme intends to push up the share of people in poorer states who seek hospitalisation, the numbers thus far indicate that the medical attention-seeking behaviour in the poorest states remains low, and there is little data to tell us if it has increased.

In addition to such exclusion errors, there is some evidence of inclusion errors.

Early news reports indicated that the scheme was being most widely used for procedures including dialysis, cataract, and caesarean deliveries that were in many cases covered by other existing government schemes.

Among other issues, this raised the concern that the scheme might not yet be pushing up treatment for under-treated non-communicable diseases. A study conducted in Haryana and Gujarat, and published earlier this year, found that “the unmet need for treatment, as reported in illness data, was found to be highest for cardiovascular conditions, followed by other non-communicable conditions and respiratory infections".

A study commissioned by AB-PMJAY found that one-third of all claims involved high-value claims. Compared to overall patterns, high-value claims were skewed in favour of male beneficiaries and private hospitals, and just 20 hospitals accounted for 17% of high-value claims and 5% of total outlays, a skew that should trigger investigation.

The high rate of hysterectomies conducted under the scheme has also raised red flags. AB-PMJAY-commissioned study found that six states generated three-quarters of all hysterectomy claims (but these were also states with higher rates of all claims). The study indicates that the use of hysterectomies for relatively benign conditions is a public health issue, and insurance schemes could exacerbate the issue.

Other studies do show higher incidence of more expensive intervention in private than in public hospitals, but how much of this is on account of patients choosing private hospital for higher-risk procedures and better quality infrastructure, and what proportion arises from private hospitals squeezing extra expenses from patients is not entirely clear yet. A study commissioned by AB-PMJAY found that private hospitals were raising the most claims for more expensive neo-natal packages with a longer hospital stay, but the quality of care provided was also higher.

There is little doubt that the scheme has improved access to hospitalisation across the country, with large numbers of beneficiaries enrolled and a high insurance cover. However, it is not yet clear that scheme is helping the most vulnerable cross existing barriers to access medical help and be protected from excess interventions. Given the large public spending on the program, greater transparency and more data is sorely needed to evaluate these issues.

Rukmini S. is a Chennai-based journalist

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