At 5 pm on 29 March the union health ministry’s website said that India had 869 positive COVID-19 cases, spread over 26 states and union territories. Seven days earlier, Prime Minister Narendra Modi had announced his main attempt to halt the spread of the pandemic: an unanticipated 21-day nationwide lockdown. Amid rising concerns of shortage of essential equipment and services in public hospitals for front-line staff dealing with the epidemic, the sudden lockdown exposed other faultlines. It forced thousands of migrant labourers to walk hundreds of kilometres back to their hometowns and villages. In the preceding days, several reports had emerged of private hospitals having turned away patients showing symptoms of COVID-19, including the first victim of the disease in the country. Though the union health ministry issued an advisory that no suspected COVID-19 patient could be refused, such reports, of private hospitals denying patients care, continued to emerge. Experts I spoke to have raised concerns about another worrying aspect: India’s shift towards a privatised model of health insurance in the past few decades, they said, could mean that many, especially the poor, will be left without access to free healthcare in the pandemic.
Dr T Sundararaman is a former dean of the School of Health Systems Studies at the Tata Institute of Social Sciences and a global coordinator of the Peoples’ Health Movement—a global network of grassroots health activists. He said, “India’s weakened public health infrastructure is unprepared for the COVID-19 pandemic.” Sundararaman said that the lack of supplies illustrates how “the neglect of a robust public-health system in favour of privatised, insurance-led healthcare has weakened India’s ability to deal with a national health emergency.”
In September 2018, the Modi government launched the Pradhan Mantri Jan Arogya Yojana—also known as Ayushman Bharat—the world’s largest state-sponsored health assurance scheme. Ayushman Bharat covers forty percent of the country’s population, focusing on those who are poor and most vulnerable. The official website of the scheme claims to provide medical cover to 10.74 crore rural and urban households. It provides medical cover of Rs 5 lakh per family per annum for medical treatment in empanelled hospitals, both public and private. The PM-JAY website itself notes that public sector hospitals in India “face shortage of workers, physicians and other medical staff and also the issue of deficient supply of drugs and equipment which adversely impacts their functioning.” The reason for this, it notes, is that India’s government expenditure on health has remained stagnant over the last two decades at close to 1.2 per cent of gross domestic product. The rationale for an insurance scheme is that while demand for healthcare services has exploded, the supply of public health infrastructure has not kept pace.
In theory, the coverage of Ayushman Bharat is extensive in terms of both the population and services it covers. The beneficiaries of Ayushman Bharat are identified using data from the Socio-Economic and Caste census. Additionally, the scheme also has criteria-based deprivation points that include or exclude individuals from the purview of insurance. For instance, in rural areas, landless households, manual scavengers or those from Scheduled Caste or Scheduled Tribe communities are included. Urban areas have a different set of criteria under the scheme.