Dr Rajneesh Kumar
With the rolling out of Pradhan Mantri Jan Arogya Yojna/National Health Protection Scheme (PMJAY/NHPS) from 1st December in the state, the scheme has become active in the state. J& K was among the initial states in the country to implement the scheme. Activities to create awareness among the masses about the Pradhan Mantri Jan Arogya Yojna (PMJAY) have already been undertaken at the district level with District administrations flagging off Ayushman Bharat Raths from their district headquarters. Ayushman Bharat has two components one is Pradhan Mantri Jan Arogya Yojna (PMJAY/NHPS) and the other is Health and Wellness Centers (H&WCs). PMJAY is a health insurance scheme wherein the eligible beneficiaries would get free treatment up to Rs 5 lakhs per family per annum for secondary and tertiary illnesses in all government as well as empanelled private hospitals. This is certainly a good move for the poor patients of the state who need secondary and tertiary care and cannot afford it. PMJAY would therefore be a boon for such poor patients of the state. Providing financial assistance to the poor for healthcare is a welcome step but achieving Ayushman Bharat through PMJAY would be questionable.
It is worthwhile to note that 90% of the healthcare in our state is provided by public health system. While majority of the population of our state resides in the rural areas and thus their healthcare needs are catered entirely by public health system. The role of private players is thus limited and is concentrated in the two major cities and a few big towns of the state only. Moreover the private healthcare is a costly affair and is thus a luxury; meant for privileged class only. It has been argued that PMJAY will foster the growth of private hospitals in tier-2 and tier-3 cities providing healthcare to more people and relieving the burden on public hospitals to some extent. But it has also been observed that at any given time less than 10% of the population would be in need of secondary and tertiary healthcare. OPD services are the ones which are more sought than IPD services. Since OPD services will not be catered under PMJAY therefore growth of private hospitals and sharing the patient burden is thus questionable. Another reason for this would be the scattered rural population and accessibility keeping in view the geography of the state. Since the goal of private healthcare providers is to maximize the profits therefore, there is a limited role for the private players to provide healthcare in the state at a low cost.
Also we have examples of economies like USA with much more per capita expenditure on healthcare and healthcare financed through health insurance programs. The life expectancy of USA is similar to that of Cuba and Cuba has achieved it at a much lesser per capita healthcare expenditure than USA. Also health insurance has never been seen as a good mode of financing healthcare by health economists. The healthcare financing mechanism in USA is predominantly, insurance based while that of Cuba is publicly funded and govt. bears the responsibility of universal access to health with emphasis on prevention and public participation. Cuba has been able to achieve this despite of four decades of economic sanctions by America because of their heavy investment in education, health and social sectors. On the other hand we have countries in our neighborhood like Thailand to learn lessons from how they have been able to achieve Universal health care (UHC) for all.
The lesser talked about component of Ayushman Bharat are Health and Wellness centers. The reason for lesser weightage of H&WCs over PMJAY by the government is that with elections nearing, government would certainly like to invest where returns are immediate and visible. The problem with investing in public health is that returns of investment are not immediate and therefore could be seen only after a long period of time. Therefore, there is less or no incentive for the government at this point of time to focus and invest on H&WCs as much as it is focusing on insurance component of scheme. Under Ayushman Bharat about 1.5 lakh sub centers would be converted to H&WCs taking the healthcare closer to the communities. H&WCs would be providing all the components of healthcare provided at primary health centers in addition the services for non- communicable diseases like hypertension, diabetes and mental health would also be provided. H&WCs certainly can be the game changers in achieving Ayushman Bharat provided they are translated in the field as they are stated on the papers. But this is unlikely to happen as the government has not been able to retain doctors and adequate human and other material resources at the primary health centers.
With the entire burden of providing preventive, curative as well as palliative care to the masses of the state resting on the shoulders of the public health system which is already strained by burden of patient load, long working hours for doctors, lack of trained human resources for health and other issues like accessibility, the need would be to invest in public health system especially in trained human resources for health who would provide healthcare to the people of state.
Ayushman Bharat cannot be created through cure based health programs and services rather it has to be achieved through preventive and primary healthcare services. No doubt that, curative services are essential and are required to recuperate health but the number of persons requiring curative secondary and tertiary healthcare services would be much more less when we have an efficient preventive and primary healthcare system at place. The financial burden of arranging and providing primary and preventive healthcare services is much less than that for secondary and tertiary care. The way forward in achieving ayushman bharat in true sense would be strengthening the primary healthcare system in the state. Strengthening primary health care essentially means providing preventive and curative care, ensuring the availability of required drugs and medical materials and human resources for health. Retaining human resources especially doctors in the peripheral health centers is a challenge which needs to be addressed. Engaging the highly motivated Public Health Professionals and managers could go a long way in ensuring the smooth functioning of primary health centers and sub centers. One such public health manager at district or more preferably at block level would be made accountable for ensuring the proper functioning of peripheral health centers and improving the health indicators like IMR, MMR, and Vaccination in the block. In any society Literacy, employment and women empowerment are the determinants to achieve good health. We simultaneously need to work on these areas as well, especially on women empowerment.
(The author is pursing Masters of Public Health in Soical Epidemiology from TISS, Mumbai)
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