LEAD STORY. Needed: a more inclusive definition of ‘healthy Bharat’

Away from the public eye and media focus on the high-profile roll-out of Ayushman Bharat, another gathering under the banner of the National Health Assembly (NHA) saw community-level health workers and advocacy groups get into a huddle at Raipur, Chhattisgarh.

About 2,000 of them gathered at the NHA organised by the Jan Swasthya Abhiyan (JSA) last weekend to assess national health policies and their impact on people at the grass roots, in local communities across urban and rural areas.

“Health is first and foremost a fundamental human right,” says Amit Sengupta, global coordinator with the People’s Health Movement, calling for different movements to converge and fight for better health.

The discussions at the gathering extended beyond the limited framework of health as meaning “the absence of disease” to include, instead, issues like nutrition, gender and social inclusion, all contributory factors to physical, mental and social well-being.

Even as this congregation was under way, Ayushman Bharat or the National Health Protection Mission was launched, powered by the entire might of the Government machinery, starting with Prime Minister Narendra Modi. The scheme has been through many iterations over the years and, in its present avatar, expects to cover 10 crore families with a ₹5-lakh health-insurance cover.

‘Based on flawed model’

But an insurance-based model is not the right method to deliver universal healthcare, say JSA representatives. “The Ayushman Bharat campaign raises expectations, when its very model is flawed,” says Sengupta, pointing out that the scheme is skewed towards secondary and tertiary (large) hospitals.

And though the money gets paid only on hospitalisation, people are getting misguided that the entire amount is coming to them, he explains. Many ailments are treated in out-patient departments that don’t get covered under insurance and this has been borne out by global and State-level insurance models, he adds.

Not adding up

Not only does the country’s health allocation stand at less than 1 per cent of GDP, says Sengupta, the shortfall in the allocation of funds for Ayushman Bharat also raises the concern that it is with an eye on the 2019 elections.

By Government estimates, the scheme requires ₹12,000 crore, independent estimates peg it at ₹50,000 crore and the Government’s actual budgetary allocation is ₹2,000 crore, he points out. “This raises the suspicion that the announcement regarding the scheme has more to do with attempts to score a political point rather than a real intent in addressing urgent healthcare needs of the Indian people,” says the JSA, which reportedly has participation from 1,000 domestic healthcare-oriented organisations. Reflecting another stakeholder view, Dr KK Aggarwal, former President of the Indian Medical Association, agrees that Ayushman Bharat is not entirely new and it is a scaled-up version of health insurance running in the country and States. And since health is a State subject, the onus to make this work will fall on them, he says, adding it will be viable but only many years down the line.

Citing the RSBY (Rashtriya Swasthya Bima Yojana) example, he says there is an insurance cap and the entire money will not be given to the patient. Ayushman Bharat will score, as the “hype” will push people to start demanding services in private hospitals and the system will “auto-correct”, he says.

Raising a larger concern on public-private partnerships, Sulakshana Nandi, co-ordinator, JSA-Chhattisgarh, says it could make a Government-run primary health centre (PHC) become out of bounds for marginal communities in remote areas where the PHC is their only refuge.

Photos credit: Amitava Guha

Serious under-funding

JSA notes that “successive budgets — especially over the last four 4 years — have contributed to the serious under-funding of the National Health Mission, tasked essentially with strengthening public services.” In fact, the infant deaths at Gorakhpur last year, says Sarojini N, JSA national co-convenor, reflect the dilapidated condition of health services in India.

Removing eggs from mid-day meals, not including non-vegetarian food in pregnant women’s diet, rising prices of food grains, cow vigilantism are all contributing to the public health crisis, she adds.

As the People’s Health Movement preps for its global Assembly in Bangladesh (November), the question is whether its call for a broader, more inclusive definition of health finds a willing listener back home among authorities spearheading Ayushman Bharat.