Less than a month after a sweeping electoral win in Chhattisgarh, the Congress government in the state has announced its plans to replace the Modi government’s national health scheme, the Pradhan Mantri Jan Aarogya Yojana or PMJAY, with a new scheme for universal healthcare.

Instead of using insurance to cover hospitalisation expenses of poor patients, the state government says it will bolster primary and preventive healthcare by strengthening public health facilities, as promised in its election manifesto.

“We are looking at universal health coverage and PMJAY offers only patchy coverage,” said Chhattisgarh health minister TS Singh Deo. The central scheme will be gradually phased out over two years while the state draws up its own universal healthcare plans.

The PMJAY covers hospitalisation expenses of Rs 5 lakh per family for the poorest 40% of India’s population or approximately 10 crore beneficiaries. It is based on an insurance model but each state can choose whether to partner with an insurance company or to set up a trust to run the scheme.

The Centre contributes 60% of the scheme’s costs while the rest of the funds come from the states. Delhi, Odisha and Telangana have not opted to implement the PMJAY so far, which means that these states will not receive funding from the centre to provide health cover.

In Chhattisgarh, Singh Deo said the electoral mandate showed support for a withdrawal from the Modi government’s insurance-based scheme. “We fought this election with the knowledge that PMJAY was already being implemented and we positioned ourselves against the Rs 5 lakh scheme,” he said. “The people voted for us.”

The Congress election manifesto promised to deliver “quality healthcare free of cost” by hiring highly qualified doctors for the treatment of serious diseases and upgrading public hospitals with modern facilities.

The Chhattisgarh government is now in the initial stages of drawing up new healthcare plans. It is setting up consultations with public health experts to discuss ways of giving patients access to free drugs and diagnostics, to strengthen primary and community health centres and to ensure that all public health facilities are well-staffed. An advisor to the government said that 86% of posts for specialist doctors in Chhattisgarh are currently vacant.

As of now, the state government intends to use funds from the Centre available under both the PMJAY and the National Health Mission to start upgrading primary health facilities in Chhattisgarh. When the state launches its own scheme, it will not be able to avail PMJAY funds but will have to approach the Centre separately for assistance. However, the state government hopes that there will be a Congress-led government at the Centre in a few months and that the new government will abandon PMJAY to adopt a similar approach to healthcare nationwide.

Reservations about PMJAY

Chhattisgarh has been implementing two health schemes so far: the Rashtriya Swasthya Bima Yojana or RSBY, which was the existing national health insurance scheme before PMJAY for below poverty line families, and the state-level Mukhyamantri Swasthya Bima Yojana for families above the poverty line. Both schemes were to be subsumed under the PMJAY.

Explaining why the Chhattisgarh government was going to move away from PMJAY, Singh Deo said that doctors were unhappy with the package rates for the 500 new schemes in the PMJAY and were unlikely to treat patients with these conditions. The PMJAY covers about 1,300 medical and surgical procedures of which about 800 had already been covered under RSBY.

He said that the RSBY experience has shown that many hospitals refuse to treat patients who are eligible under the scheme and reimbursements to patients are refused.

He also expressed reservations patients becoming eligible for the PMJAY only if they are hospitalised, leaving them to bear the burden of the costs of diagnostics and medicines before hospitalisation.

The state government is considering launching a programme to provide free diagnostics and medicines to poor families even before it rolls out its new health scheme and while PMJAY is still running in the state.

“Providing 100% free diagnostics and medication is easily doable,” said Singh Deo. The budget for this is not large and will be about Rs 300 crore.”

Support from public health activists

Ever since the announcement of the PMJAY in the 2018 budget, public health activists have lambasted the idea on the grounds that it will divert taxpayer money meant for the public health system into the private sector.

They say it will lead to over-medicalisation of health without addressing the problems of fradulent claims and unnecessary procedures being performed to access insurance money, as seen in existing schemes.

The Jan Swasthya Abhiyan released a people’s health manifesto in December in which it has called for the PMJAY to be abandoned nationally and existing publicly funded health insurance schemes to be absorbed into an expanded and strengthened public health system.

“We found that a lot of the research an experience of such schemes shows that the government is putting more and more money into the private sector while people who need it are not getting services or continue to have high levels of out-of-pocket expenditure,” said Sulakshana Nandi, joint national convenor of the Jan Swasthya Abhiyan.

Nandi said that insurance schemes had also incentivised government doctors carrying out their private practices and unethically referring insurance scheme beneficiaries to their private clinics to benefit from payouts instead of treating them in the public sector. She said it was important for the state and national government to ban private practice by government doctors but also ensure that they are remunerated better.

“We are glad that the Chhattisgarh government is reconsidering the PMJAY,” she said, pointing out that models for providing free diagnostics and medicines already exist, with similar schemes being implemented in Tamil Nadu, Delhi and Rajasthan.