By Soham D Bhaduri
The Ayushman BharaT Pradhan Mantri Jan Arogya Yojana (AB-PMJAY)—India’s flagship publicly financed health insurance (PFHI) scheme—celebrated its fifth anniversary this September. A CAG report on the performance audit of the AB-PMJAY preceded this important milestone. It observed many of the same issues that have traditionally bedeviled PFHIs in India, such as inclusion and exclusion errors, duplication and fraud, poor provider engagement, and persistent out-of-pocket expenses. Even before the roll-out of AB-PMJAY, PFHIs attracted considerable academic opprobrium on the ground that they lacked strong indigenous evidence, and some suggested rolling back this expedient measure in favour of public provisioning of healthcare as the predominant means. Does the CAG report reinforce this argument? Does the AB-PMJAY route merit a rethink?
Despite the ‘messiness’ of complex health systems, linear thinking continues to preside over much of academic and policy discourse and feeds the fallacy that elegant, unilateral solutions can sustainably plug health system gaps. The state of the UK and Canadian health systems smash the commonly held notion that overarching public involvement is the sole, eternal panacea for UHC. While many experts have contested that the challenges with the UK and Canadian healthcare are attributable not to poor design but to inadequate funding, it is the latter that is the problem. Any solution that naively presumes the governments’ endless ability to fund public health care amid other competing sectors and priorities will be foredoomed. This is not to argue against public healthcare provisioning, but to emphasise that in a messy system such as healthcare, one can’t expect new solutions not to beget newer problems in a perpetual problem-solution cycle.
Grint has described wicked problems as those which admit to no straightforward and rational solutions, lack past precedents, have no definitive end, and are inseparable from their context. These are to be addressed through ‘clumsy’ solutions that are syncretic, creative, expedient, and often ad hoc and imperfect. Accordingly, the pragmatic answer to UHC in a diverse landscape like India lies not in a single policy elixir, but is destined to be an evolving mishmash of different approaches. This requires a careful balancing of three major approaches: hierarchist (centralised governmental control), egalitarian (decentralisation), and individualist (private initiative and innovation).
At least for the near future, the contours of AB-PMJAY are rather easily foreseeable. Being poorly positioned to receive or absorb dramatic increases in funding quickly, it is poised to continue offering thin health care coverage, even as ambitious expansions of the beneficiary pool occur driven by populist motives. This warrants that it is complemented by parallel avenues to improve healthcare access, while the imperfections of the AB-PMJAY are steadily and simultaneously addressed.
Much of these will have to do with reducing costs and increasing efficiencies in private health care. For example, while private health insurance is inequitable by nature, allowing more affordable, simplified, and attractive commercial insurance options can not only benefit a chunk of citizens but also have salutary effects on the private care free market. Same goes for contributory health insurance, currently being planned by the Union government for the middle-income population, despite its many glaring drawbacks. Policy incentives for gainful consolidation of private healthcare providers will need to be looked at beyond the purview of PFHIs.
Economic theory tells that besides driving up the demand for care, generous health insurance contributes to overall healthcare inflation through inducing technological innovations. Tech innovations, particularly in the advanced care space, are important drivers of healthcare costs today, and this relentless march of technology has more or less to be reconciled with. Rather, greater attention is now warranted to making routine primary and secondary care as cost-effective as possible through cost-reducing innovations. Highly protocol-driven primary care featuring task shifting from doctors to mid-level health care providers and strongly aided by digital technologies are an apt example. Similarly, indigenous models of home-based care and self-care need to be increasingly explored. Evidence available globally shows that home-based care can be cost-effective without impinging on quality and patient satisfaction.
Very often, AB-PMJAY has been posited as an alternative to investing directly in public hospitals. This is a dangerous paralogism, and rather, the AB-PMJAY merits a whole new way of looking at public sector reform. Much like strategic purchasing in health has found widespread credence, strategic public sector strengthening, particularly in the secondary care space and in under-resourced regions, is the need of the hour under AB-PMJAY. Impending health care reorganisation under universal health insurance is also likely to warrant strong decentralised administrative capacities. Particular attention is merited on strengthening district level organs which remain hobbled by human resource shortages.
Many of the issues highlighted in the CAG report can be redressed with a robust, well-functioning digital health and data system. There is a need for a whole new perspective from where to view the current digital health movement. A robust digital infrastructure, first and foremost, needs to be seen as an instrument for effectively managing the ineluctable messiness of the health system, through its integrative, economising, and analytical functions.
Soham D Bhaduri, Healthcare policy specialist and chief editor, The Indian Practitioner. Views are personal.