The Union government has recently announced that it will extend the benefits of the publicly funded national health insurance programme, Pradhan Mantri Jan Arogya Yojana (PMJAY), to all Indians aged 70 years and above. This programme, which enables cashless access to hospital services worth Rs 5 lakh a year, will also be available to the elderly already covered under private health insurance policies or Employees’ State Insurance Scheme. Those availing benefits of other public health insurance schemes such as the Central Government Health Scheme may either choose their existing scheme or opt for PMJAY.
This is indeed a much needed addition to the ongoing efforts to create the architecture of universal health coverage (UHC) in India by 2030—a target set under the UN’s Sustainable Development Goals (SDGs). The target calls for provision of health services to every Indian, without imposing any financial hardship on those who avail the services. PMJAY and a number of separate but complementary state government-financed health insurance programmes endeavour to do this.
Though India is a demographically young nation, it is the world’s most populous country and has a large number of persons aged 60 years or older (estimated at 149 million in 2022). This number will grow to 347 million by 2050, as the population swells and life expectancy increases. Many of them will be living on their own, as joint family structures yield place to nuclear families and members are often physically distanced. The elderly are often retirees or have lost wage earning capacity. Their financial vulnerability increases, as they grow older and savings melt away. Extending PMJAY coverage to those aged 70 years and above is projected to benefit about 60 million persons who presently need assured healthcare.
Healthcare needs of the elderly are numerous, wide ranging and often require chronic outpatient care or frequent hospitalisation for acute events. These are expensive, because of the number and nature of diagnostic procedures and the array of technology-intensive treatments involved. While hypertension, diabetes, lung disease, mental heath disorders and arthritis require prolonged care, mostly out of hospital, cardiovascular diseases, cancers, genitourinary disorders, gastrointestinal and liver maladies, fractures and dysfunctional joints need hospitalised care with medical therapeutics, surgery, radiotherapy or even a combination of those. Vision disorders and dental problems are also frequent among the elderly. Will PMJAY be able to address all these needs, whenever and wherever needed, without imposing financial hardship on the elderly?
The World Health Organization (WHO) and the World Bank recommend two measures to monitor the implementation of UHC—the extent of financial protection and the level of service coverage. The former is assessed by out-of-pocket expenditure, catastrophic health expenditure and healthcare-induced impoverishment. The latter is assessed by a service coverage index, which encompasses 14 tracer conditions inclusive of varied health conditions and health system capacity measures. PMJAY, even in its present form, has not demonstrated high levels of performance on either of these indicators. Service coverage is restricted to some health conditions that require hospitalisation; a large list of health conditions, which can and should be managed in primary care, are not covered—whether for outpatient or inpatient care at that level. Outpatient care and medicines are the largest contributors to out-of-pocket expenditure, which creates a chronic strain on those who are not rich.
Even in secondary and tertiary care facilities, frequently utilised outpatient care is not covered. Such care is needed not only for initial consultation but also for several follow-up visits. The degree of financial protection is also incomplete in those institutions, with frequent co-payments demanded by hospitals (for genuinely needed care or additional procedural interventions, which are generated by induced demand or imposed as “essential” for better health outcomes).
The Comptroller and Auditor General of India (CAG) in its 2023 report points out several deficiencies in the performance of PMJAY. Apart from concerns over fraud in patient registration, partly clarified by the government later, the report points to areas of quality deficit in the accredited healthcare providers in several states. These include non-functioning equipment, deficient bed strength, lack of blood bank and emergency transport services. Instances of co-payments by patients, beyond the amount covered by insurance, were also noted.
Paucity of accreditation-eligible hospitals in tier-2 and tier-3 cities has curtailed the penetration of PMJAY in some states and has limited its population coverage. The fact that smaller cities and towns are not served by well-equipped private hospitals was evident during the novel coronavirus (COVID-19) pandemic. Even when the government permitted and encouraged private hospitals to administer approved COVID-19 vaccines, there were low rates of uptake and utilisation by private hospitals, especially in smaller cities and towns. Hospital care for serious COVID-19 illness was also limited by inadequate hospital capacity in these areas.
Private hospitals have also been less than enthusiastic about the payment rates of PMJAY and are particularly aggrieved about payment delays. In case of the elderly, the claims are likely to be complicated because of coexisting medical conditions that require care from several speciality departments. Private hospitals may be reluctant to deal with that cumbersome process. If PMJAY is going to depend on extensive and enthusiastic participation of private hospitals, that hope maybe belied when the scheme is extended to cover the elderly.
Sections of the private healthcare sector do engage with PMJAY and will continue to do so as the scheme provides a steady and substantial stream of revenue. It has been estimated that two-thirds of the money spent under PMJAY, since its launch, has streamed to the private healthcare sector. Leaders of the sector are keen to demonstrate that they are staunch believers in the value of public-private partnerships in healthcare delivery. However, they will do so on their preferred terms and in their preferred locales. A countrywide programme for UHC cannot therefore overly rely on the private sector’s presence, capacity and motivation for its success.
The solution lies in strengthening the capacity of public sector health services—all across the country. In India’s mixed health system, the private sector can be engaged to deliver some of the healthcare services but overdependence on that sector will hold UHC hostage to the priorities and demands of private healthcare providers. Only when there is a country-wide presence of well-resourced and well-governed public sector health services, can the proper terms of engagement with the private sector be set to protect public interest and advance UHC in an efficient, equitable and economically efficient manner.
However, we are witnessing moves to privatise district hospitals and hearing proposals to create private “managed care” enterprises where the private sector will provide services across the board—from primary to tertiary—for a fee. What we need is “integrated care” with public sector-led delivery of comprehensive healthcare services which are seamlessly connected across all levels of care. Abandonment of the public sector in any redesign of UHC will come at a high price—both in terms of health outcomes and financial expenditure. The US is a cautionary example. It has the highest health expenditure and the lowest life expectancy among all OECD (the Organisation for Economic Co-operation and Development) countries, a forum of high-income economies. Indeed, life expectancy has declined in the US over the past decade—from 79 years in 2019 to 76 years in 2021.
In the Union Budget 2024-25, the government had announced that coverage under PMJAY would be extended to include ASHA workers (accredited social health activists), their helpers and anganwadi workers. This is again a welcome decision. However, budgetary allocation to PMJAY in this financial year has fallen short of the ambition—it has increased only by 1.4 per cent compared to the budgetary allocation for the previous financial year. Unless PMJAY continues to underperform in its utilisation rates, this marginal increase will not meet the healthcare needs of all the intended beneficiaries, which will now include persons aged 70 years and above.
Unless India spends at least 2.5 per cent of GDP (gross domestic product) on health services, we cannot envisage UHC gaining momentum. While investments are needed both for infrastructure expansion and bridging skilled human resource gaps in the health sector, considerably higher investments are needed to meet operational expenses of service delivery through flagship programmes of the National Health Mission. Elderly persons are likely to have lower levels of digital literacy and insurance literacy than younger adults. Their ability to recognise insurance-linked entitlements and access care accordingly, while participating in informed decision-making through dialogue with healthcare providers, may be relatively constrained. Therefore, fully assured and easily accessible health care, suitable for their needs at any point of time, should be provided through an insurance-free model of UHC.
Otherwise, we will add stress-induced mental health disturbances to their physical ailments. PMJAY does indeed provide helpful access to secondary and tertiary healthcare for many who need it. But it should fit well into a well-designed, predominantly tax-funded, model of healthcare which is insurance-assisted—not insurance-driven. It cannot become the engine of UHC in India; it can only be one of the compartments. The elderly need special assistance to get onto that train easily but not with multiple insurance gates to negotiate.
(K Srinath Reddy is a Distinguished Professor of Public Health, Public Health Foundation of India, New Delhi, and author of Pulse to Planet)
This was first published in the 1-15 October, 2024 print edition of Down To Earth