Discuss universal health coverage and the Ayushman Bharat programme.

Universal Health Coverage and the Three Dimensions

• The UHC cube illustrates the three dimensions along which coverage can be extended, and using it structures the whole topic:
• 1. WHO is covered (population) — extending coverage to more people
• 2. What services are covered (services) — extending the range of services included
• 3. How much of the cost is covered (financial protection) — reducing the proportion paid directly by the user
• The value of the cube is that it shows every country must make trade-offs between these three, since no country can maximise all three at once
• The trade-off that matters most is between covering more people for fewer services and covering fewer people for more, and the equity argument favours the first
• The INDIAN problem that UHC addresses:
• Out-OF-pocket expenditure has been among the highest in the world as a share of total health spending
• Its consequences are catastrophic health expenditure, defined as spending exceeding a threshold share of household consumption; and impoverishment, with a large number of Indians pushed below the poverty line each year by medical costs alone
• The deeper harm is forgone care — households that do not seek treatment at all because they cannot afford it, which does not appear in expenditure statistics precisely because no money was spent
• That invisibility is important, since a fall in out-of-pocket spending could reflect better protection OR greater abandonment of care, and the two look identical in the statistics
• The largest components of out-of-pocket spending are medicines and diagnostics in outpatient care, not hospitalisation
• This IS the most important analytical point in the topic, because it means that an insurance scheme covering only hospitalisation addresses the minority of the problem
• Outpatient costs are smaller individually but far more frequent, and they accumulate relentlessly in chronic disease — where a patient with diabetes or hypertension pays every month for life
• Hence free drugs and free diagnostics initiatives may do more for financial protection than hospital insurance, and the two are complementary rather than alternative

Ayushman Bharat and its Two Components

• Ayushman BHARAT (2018) has two components, and the relationship between them is the substance of the answer:
• Component 1 — health and wellness centres (now ayushman AROGYA mandirs)
• These upgrade existing sub-centres and primary health centres to deliver comprehensive primary health care
• The expansion of the mandate is the key point — from the selective package of maternal, child and communicable disease services to a twelve-part package adding care of the elderly and palliative care; emergency care and trauma; mental health; ophthalmic and ENT care; oral health; screening and management of non-communicable disease; and screening for common cancers — oral, breast and cervical
• They are staffed by a community health officer — a nurse or AYUSH practitioner with a bridge course — supported by the ANM and ASHAs
• They provide free essential drugs and diagnostics, teleconsultation and wellness activities including YOGA
• The rationale for the mid-level provider deserves stating — there are not enough doctors willing to work at this level, and a nurse with additional training can competently manage the common conditions that constitute most of the workload
• Component 2 — pradhan MANTRI JAN AROGYA YOJANA (PM-JAY), the world’s largest publicly funded health assurance scheme
• Its features — cover of Rs 5 lakh per family per year for secondary and tertiary hospitalisation; covering the bottom 40% of the population identified by deprivation criteria from the socio-economic caste census; with NO cap on family size, age or gender; cashless and paperless treatment at empanelled public and private hospitals; portability across states; coverage of pre-existing conditions from day one; and defined packages with fixed rates
• The NO cap on family size and the coverage of pre-existing conditions are genuine departures from commercial insurance practice, and both were deliberate equity choices
• Portability matters specifically for migrants, who are otherwise excluded by schemes tied to a place
• Recent extension has brought all citizens aged 70 and above within the scheme irrespective of income
• The strengths — protection against the catastrophic cost of hospitalisation; use of existing private capacity where public capacity is absent; portability; and standardised package rates that constrain what can be charged
• The criticisms, which should be given because they are substantial:
• It covers hospitalisation but not outpatient care, medicines or diagnostics, which are the larger share of out-of-pocket spending
• Purchasing care from the private sector may strengthen private provision at the expense of building public capacity, which is a strategic question rather than a technical one
• Risk of supplier-induced demand and unnecessary procedures where hospitals are paid per package — a documented problem requiring audit and fraud control
• Package rates considered too low by private hospitals, leading to non-participation or to informal extra charging of patients
• Awareness and enrolment gaps, so that eligible people do not know they are covered
• Exclusion of the near-poor just above the eligibility line
• Uneven availability of empanelled hospitals in exactly the districts with the greatest need
• The relationship between the two components is what makes the design coherent — the Health and Wellness Centres are meant to prevent and detect disease early so that hospitalisation is not needed, while PM-JAY protects against the cost when it is
• A scheme with only the insurance component would pay ever-increasing amounts for disease it made no attempt to prevent, which is the argument for judging the two together
• The other elements of the UHC effort — the ayushman BHARAT digital mission with the health account and registries; free drugs and diagnostics; Jan Aushadhi generic medicine stores; price capping of essential medicines, stents and implants; and e-Sanjeevani teleconsultation
• Outpatient medicines and diagnostics dominate out-of-pocket spending, not hospitalisation, which changes what a scheme should cover
• Falling out-of-pocket spending is ambiguous, meaning better protection or abandoned care, and the two look alike
• Forgone care leaves no trace in the statistics, precisely because no money was spent on it
• Chronic disease costs accumulate monthly for life, which is why outpatient protection matters more than it appears
• All three UHC elements must hold together; free care that fails and good care that bankrupts are both not coverage
• The cube shows the trade-offs are unavoidable, since no country maximises population, services and protection at once
• Equity favours covering more people for fewer services rather than the reverse
• No cap on family size was an equity choice, as was covering pre-existing conditions from the first day
• Portability matters specifically for migrants, who are otherwise excluded by any scheme tied to a place
• Package payment invites unnecessary procedures, which is a documented problem requiring audit and fraud control
• Low package rates cause informal extra charging, which quietly defeats the cashless promise
• Purchasing from private hospitals is a strategic choice, and may build private capacity at the expense of public
• The two components are designed to work together, one preventing disease and the other paying when prevention fails
• Insurance alone pays forever for preventable disease, which is the argument for judging both halves together
• Wellness centres screen for oral, breast and cervical cancer, which is a genuine expansion beyond maternal and child services
• A nurse with bridge training manages most of the load, which is the rationale for the mid-level provider
• Empanelled hospitals are scarcest where need is greatest, which blunts the scheme exactly where it should bite
• The near-poor above the line are excluded, and are among the most vulnerable to a single hospital admission
• People do not know they are covered, which makes awareness as important as entitlement
• Price capping of stents and implants is a separate and effective lever on out-of-pocket cost
• Jan Aushadhi stores supply generics, addressing the medicine component of household spending directly
• Cover now extends to everyone over seventy, irrespective of income, which is a recent and significant widening