The Economic Survey 2020-21, pivoted around the Covid-19 pandemic, like most things in 2020. Volume I of the survey had three of ten chapters dedicated to the impact of the pandemic and the country’s response to it, as well as the healthcare system. While Chapter 1 and Chapter 5 discussed and dealt with India’s policy of short term losses for long term gains and public health care, Chapter 9 was all about the apparent brilliant performance of the PM-JAY Ayushman Bharat scheme.
In a nutshell, “JAY Ho: Ayushman Bharat’s Jan Arogya Yojana (JAY) and Health Outcomes”, highlights the positive impact of the Pradhan Mantri Jan Arogya Yojana (PM-JAY), which was launched in 2018 with the objective of providing financial aid for hospitalization, to around 50 crore beneficiaries, who made up the lower 40% of the population from an income point of view.
The survey undertook the difference-in-difference method of analysis, wherein they compared the health indicators of National Family Health Surveys (NFHS) in states that had implemented PM-JAY to those of states that had not. Overall, the survey found that the scheme had boosted health insurance coverage which is believed to have an impact on rising mother and child care and reduction in infant and child mortality rates, amongst other positive trends. The analysis was carried out in two parts- first, where the NFHS indicators of Bihar, Assam and Sikkim, who implemented PM-JAY were compared to that of WestBengal, who did not implement PM-JAY. The same method was undertaken in the second part, but for all states that had implemented PM-JAY against all states that had not. Both results echoed each other- PM-JAY has been a huge success.
The Economic survey argues that since the Nation Health Mission (NHM) has been a champion when it comes to closing the health inequity prevalent for the longest time, it would be rather impactful when implemented in conjunction with PM-JAY.
A reality check would perhaps shed light on facts that are not in sync with the Survey’s bright thoughts on PM-JAY. A National Health Authority report from June 2020: PM-JAY Under Lockdown: Evidence on Utilization Trends reports a 51% fall in the PM-JAY average weekly claim volume in the 10 week lock-down period, compared to the 12 week period immediately before it. This could perhaps be attributed to the curfews in part, but the numbers didn’t show a significant rise once the restrictions were eased, while the cases and the cost of treatment remained high, perhaps a consequence of PM-JAY being too slow in offering Covid-specific coverage.
The survey compares NFHS 4 and 5 numbers for a ‘before-after’ analysis in the states that had implemented the scheme. Phase 1 of NFHS 5 was carried out in 2019-20. Since the PM-JAY scheme was implemented in 2018 and the NFHS-5 fieldwork in Bihar, Assam and Sikkim have probably happened sometime between June 2019 and June 2020, enough time has not elapsed to conclusively comment on the impact of PM-JAY. And, the full figures of NFHS 5 have not been reported yet.
As a matter of fact, the NFHS-5 data reflects the harsh reality of malnutrition. While few states show improved indicators, the nation as a whole has worsened in most nutrition and growth indicators, such as childhood stunting and underweight children. There has also been a significant rise in anaemia, which can be directly attributed to inaccessibility to nutrition. Since the NFHS-5 will only be completed in a Covid-ridden world, one can only expect further dips in these indicators. The entire Survey, quite conveniently, makes no mention of these facts.
The indicators actually quoted for the chapter don’t strike as one that would have strong direct relations to the assessment of any kind of insurance scheme that covers hospitalization. The indicators quoted include years of schooling, rates of child vaccination, sex ratio at birth, and as mentioned before, rising mother and child care. Mortality rates of diseases and conditions covered by the scheme, or the protection from the financial burden posed by hospital bills could have been some of the more relevant indicators, but nothing as such is mentioned, not even in passing.
The assumptions about the compatibility of the studied states- West Bengals, Bihar, Assam and Sikkim- are that they have similar socio-economic and demographic profiles. The results interpreted by the Survey are that the former showed a decline and latter three showed improvement in health insurance coverage. Interestingly enough, most of this improvement was shown in Assam where the state government’s Atal Amrit Abhiyaan (AAA) health insurance scheme was rolled out in 2016-17, and Sikkim showed a clear decline.
When it comes to PM-JAY and hospital insurance, the survey lacks some basic fundamentals. It shows that the largest number of PM-JAY insurance claims comes from procedures that are typically inexpensive, and argues that this may mean that PM-JAY is used as a primary care service delivery channel, or even as a replacement for it. However, PM-JAY includes not primary, but secondary and tertiary care. Replacing primary care with hospitalisation is something that is to be avoided at all costs, since it is in direct contradiction of health systems’ most significant aim of preventing the worsening of an illness in its earlier stages, where it can be easily treated. One could definitely argue that the low uptake of claims indicates fewer expensive procedures and therefore a decline in cream-skimming. The counterargument to that could be that the scheme is not as efficient as is being told when it comes to its objective of taking on the burden of hospital bills.
The Economic Survey is unimaginative and just harps on about PM-JAY as being the miracle cure for all ills in terms of providing ways to boost the health sector in India. The Economic Survey is a classic case of manipulating data to glorify and encourage a specific narrative that is dangerously far off from the ground reality. The pandemic presented an impetus for health policy to be reoriented in order to improve public health care coverage and ensure fair and sustainable access to health for all. How the Union Budget plays out remains to be seen tomorrow, but, if the Economic Survey is an indicator in any way, it is not looking as great as the honorable Finance Minister would want India to believe.