Announced earlier this year, India’s ambitious health-care scheme ‘Ayushman Bharat,’ has a lot of gaps to plug before it gets functional. CEO of Ayushman Bharat, also formerly with the World Bank, Indu Bhushan gives a low down on how the scheme which stands to benefit as many as ten crore families going to work. Bhushan talks about identification of beneficiaries, safeguards to prevent frauds, whether there are enough private hospitals mapped for empanellment, problems that states will face in implementing the scheme as also phenomenal costs involved in seeking services of the private sector for rolling it out.

1. How far is socio-economic caste census (SECC) data efficient in tracking beneficiaries for enrolment in Ayushman Bharat, especially when residential addresses were not linked to SECC data?

A - While in rural areas we have been able to track 85 per cent beneficiaries, in urban areas we have not enrolled more than 50 to 60 per cent people. In villages, it is not much of a problem because people know where others live. In urban areas however, there are street numbers to be tracked. Also occupation in urban areas is a volatile concept, one day you are a hawker, next day you are working in some one’s home, so tracking people is difficult.

2. Then why were better methods of data collection and enrolment for beneficiaries not used? The census data is as old as collected in 2011.

A - There was a conscious decision taken to not update the data because if you do that in election year, it will open up a pandora’s box. How are you going to ensure that when you open up this number, only eligible and needy people get in? As Prime Minister Narendra Modi has said any census or survey done with pre-decided benefit associated with it it is not going to be objective. Also, none of the systems are fool-proof, and may be in the hind sight, National Food Security Act (NFSA) data which is collected through ration cards could have been the best way because ration card data is already seeded with AADHAR, so that would have been better. Therefore, so long as the states agree not to turn down any SECC beneficiary we are allowing other data-sets to be included to in enrolling beneficiaries.

3. How will a beneficiary be able to avail of the scheme?

We have identified people and give them a QR code. When they come for first time to any empanelled hospital they will get a card. Hospitals will have a software and hardware to vet if that the person is from SECC and is the same person that s/he is claiming to be. Beneficiaries can can go to hospitals and find out if they are eligible, before or during the time they want services. Once our software is ready, we will make a website, which will help find out whether a person is eligible or not. We are also thinking of developing a system where beneficiaries will get a mobile confirmation number on their phones.

4. What safe guards will be put in place to prevent fraud?

We have to ensure that hospitals don't go one step further and enrol a non-eligible person as a beneficiary. Therefore for a person to be eligible his/her AADHAR and biometrics have to be matched. We have to be careful in empanelling hospitals that have the requisite hardware, space, as well as adequate number of personnel. Also there will be provision of audits for a select sample for beneficiaries however we need to work on frequency of these audits.

5. Do you have a distribution map of sorts to figure out where there are dearth of hospitals because while having an insurance scheme is a good thing, what matters later on is if beneficiaries will be able to avail these schemes or not…?

Union Ministry of Health is trying to map public hospitals across India. In private hospitals, they have not started the process. While we do not have the numbers, we have a fairly good idea of where the gaps are. In which districts and blocks are the gaps as that goes with socio-economic status as also with supply of services. Every district will have a medical college and good tertiary level hospitals, thats the future plan. Different states are also having various schemes to increase supply of hospitals in Tier 2 and Tier 3 cities. Uttar Pradesh has a scheme to encourage public-private partnership model. We have to do something but my own hypotheses is that this scheme itself is going to encourage private sector to come up in poor areas. Why we don't have good services in poor areas, one reason is that there is no paying capacity. If private sector is motivated by profit then why would they open hospitals where people cannot pay, but now they can, now they don't pay themselves but can make the government pay.

6. There is a bit of conundrum there too as private hospitals are saying that the package rates are not good enough for them to be a part of this scheme?

You are listening to those hospitals that are one extreme. These are hospitals where you and I cannot afford to go. They have very high costs. I have a feeling that they will also join this scheme as they cannot afford to not be a part of a scheme that is covering 40% of the country. I have come across a lot of hospitals who are very keen to join. Suppose we start the scheme of having healthy food, are we going to look at five stars hotel to begin with, I think we would be looking at some thing like a Sarvana Bhavan. In fact, Dr Devi Shetty from Narayana Hrudalaya has met all the health care providers in Karnataka and they are keen on joining us. Rashtriya Swasthya Bima Yojana (RSBY) which had a coverage of Rs 30,000 had close to 10,000 hospitals empanelled, now we are having a coverage of Rs 5 lakhs, so hospitals will show interest.

7. What lessons have we learnt from RSBY, and mistakes that must not be repeated?

We have learnt how to prevent delay in payment as well as fraud prevention. All the rates have come out of RSBY, a base on which we have built this case. Also in RSBY, insurance agency was doing enrolment, they were keen to enrol more people to get more premium but were not promoting use of services. If people use more services, companies would have to pay out more. There was a conflict of interest, with more enrolment and less demand generation less. So now instead of insurance companies enrolling people, we already have a list of entitled beneficiaries.

8. Which states will face a problem in implementing the scheme?

There is a list of aspirational districts that we have drawn out. In general, supply in these districts is lower. If you have hospitals in those districts, you can get 10 per cent more. In northern states of UP, Bihar, Chattisgarh, Jharkhand, North-East there is a huge gap. We are talking of establishing a medical college in each district but it will take longer than one or two years for that to happen.

9. What all services do you have to pay for running the scheme? Which companies are in board to provide services and how much will all of it cost?

We have to pay for Information and Education activity in place, audits, maintaining IT systems, monitoring and evaluation research etc. Nandan Nilekani has been quite involved right from beginning on IT development. He has given us a couple of people to work with. Tata Consultancy Services was selected to put in place the initial IT platform because of Telangana model developed and maintained by TCS. It is the easiest for us to expand by asking them. They will create a system and then we will put out open tenders for inviting companies to maintain it. We are considering a cost of Rs 50 per family to put in place services. For 10 crore families, the costs will rise to Rs 500 crores. Additionally, an approximate Rs 1000 for premium per family, and we are looking at paying a premium of nearly Rs 10,000 crores.

10. Also, punned as world’s largest health care scheme when you unpack it you realise that there are so many sub-sets which are not covered, and so many exclusions, so how is it a world’s largest health care scheme when its not even universal?

Well, come to look at it this way, China has three schemes which covers one third of each of their rural, urban and informal sectors. Now that covers more people in separate schemes as compared to what India is planning through Ayushman Bharat. We are then the second-largest scheme. But, India is one of it’s kind, because China has co-payments involved. But China started it’s scheme in 2008 and also has Out-patient Department care services included in the scheme. So the models are different.