OCTOBER 05, 2018

By Naresh Minocha, Consulting Editor

Dr. Manmohan Singh and P Chidambaram "destroyed" the country with their "intelligence and bookish knowledge", stated Narendra Modi on 30th November 2013 at a political rally in Delhi.

After becoming Prime Minister, Mr. Modi has been undoing the so-called destruction with clinical disruption. Free from disadvantage of bookish knowledge, he has used his political pragmatism to peddle hard his model of disruptive development.

He, for instance, rocked the economy in 2016 through demonetization. He has transformed goods and service tax (GST) into a forms-filling, burdensome tax, which shows no signs of stabilization.

He pushed Aadhar from a mere identity for delivery of welfare benefits to the poor citizens into a big-brother tool to monitor almost everything and anything citizens do. No wonder, the Supreme Court had to rein in his Aadhar web's intrusion into privacy domain.

NDA Government's obsession to link one identity number with another one has created ripples of disruption. A case in point is several entities deducting income tax at source (TDS) from the Railways' income. Mind you, Railways is a Government Department. And Government does not pay income tax.

The Railways Ministry got PAN for the first time 2017 to get GST registration with central and state authorities. PAN is a pre-requisite for good and simple tax/GST registration.

As put by Railways in an internal memo issued last month on what it considers as "a serious anomaly" in "erroneous deduction made in receivables of Indian Railways" during 2017-18.

The Memo explains that Railways' customers such as Konkan Railway, State Bank of India, Power Grid Corporation, etc. have deducted income tax at source, while releasing the amount due to the Railways.

It adds: "This has apparently happened due to erroneously quoting Ministry of Railways' Income Tax Permanent Account Number (ITPAN), which was procured solely for registering under the GST regime. It is really incomprehensible as to how and why the ITPAN number has been given by any Department for any other purpose other than GST".

The web of link-ups of different identities of an entity has, however, not led to timely deduction of potential defaults/ business troubles of all sorts - the latest case being IL&FS. This non-banking financial services giant kept raising money from capital markets with ease to roll over previous loans during last 2 years. Why no inserted asked what was IL&FS doing?

Modi Government has disrupted many development & welfare schemes by renaming and revising them. All major schemes now thus come with Pradhan Mantri tag. All of them are marketed with his photograph embedded on the top the advertisements. All formats of media are flooded with such advertisements.

The icing on disruptive development agenda is the recent re-launch of Ayushman Bharat in Jharkhand within a span of five months. It was first launched in Chhattisgarh during April.

The scheme is being marketed to over 10.74 crore Below Poverty Line (BPL) families, comprising about 50 crore beneficiaries, in a unique way. The technique involves mailing of a two-page customized/personalized letter from Prime Minister, expounding the importance and benefits of the project.

How many voters deem it as a lifeline from Modi Ji would be known after 2019 Lok Sabha polls.

The potential beneficiaries might take several years to realize that AB-PMJAY is nothing but old wine in new bottle. It, no doubt, offers scaled up insurance cover of up to Rs 5 lakh per poor family with no limit on size of the family.

This is 100 times the average actual claim payout (Rs 5000 in 2013-14) under an existing scheme with insurance cover of Rs 30,000/poor family/yr. The 5 lakh cover is needed for very few medical challenges such as bone cancer.

This shows how skillfully Mr. Modi practices the art of political disruption. He might well go down in the history as uncrowned Guru of disruptive development, assuming his initiatives benefit the economy substantially in the long run.

Right now, a big question hangs over his penchant to rework schemes, scale them in many instances, rename them and market them as something never or hardly done earlier. He dislikes open feedback, which he considers as negative news. He only wants to see, hear and feel positive news about his disruptive model of development.

And AB-PMJAY fits the bill very well here. Mainstream media has lapped it up well and dubbed it as #Modicare. It was first announced as National Health Protection Scheme (NHPS) under 2016-17 Budget on 29th February 2016. It had proposed insurance cover of Rs one lakh per poor family with top-up of Rs 30,000 for senior citizen-member of the family.

NHPS was re-announced by Mr. Modi himself on 14th August 2016 in his Independence Day speech. This time too, the announcement made no reference to existing Rashtriya Swasthya Bima Yojana (RSBY). This provides for Rs 30,000 insurance cover per poor family with top-up of Rs 30,000 for senior citizens per year.

On 17th August 2016, the Government issued a memorandum on restructuring of 66 centrally sponsored schemes (CSS) into 28. The memorandum mentioned NHPS as "Rashtriya Swasthya Suraksha Yojna (erstwhile RSBY)".

The renamed scheme or NHPS remained on the backburner till 1 st February 2018. NHPS got rebirth in the budget speech for 2018-19 without any reference to previous 2016 announcement or the 2-yr delay.

Finance Minister Arun Jaitley stated: "Government is seriously concerned about such impoverishment of poor and vulnerable families. Present Rashtriya Swasthya Bima Yojana (RSBY) provide annual coverage of only Rs 30,000 to poor families. Several State Governments have also implemented/supplemented health protection schemes providing varying coverage. My Government has now decided to take health protection to more aspirational level".

Mr. Jaitley added: "We will launch a flagship National Health Protection Scheme to cover over 10 crore poor and vulnerable families (approximately 50 crore beneficiaries) providing coverage upto 5 lakh rupees per family per year for secondary and tertiary care hospitalization. This will be the world's largest government funded health care programme. Adequate funds will be provided for smooth implementation of this programme".

What stopped the Government from phased scale-up and extension of enrollment to all BPL families under RSBY? The insurance cover, for instance, could have been doubled to 60,000 per poor family every year beginning 2014-15, the year when NDA came to power.

Alternatively, RSBY could have been made holistic by providing for insurance sub-component cover of say Rs 10,000 per family for outpatient services and medicines.

By excluding diseases and medical procedures that do not require hospitalization, Modi Government has made AB-PMJAY a white elephant for the poor. BPL families would thus continue to pay through their nose for health issues that do not require secondary or tertiary medical care (STMC) through hospitalization.

What percentage of BPL citizens requires STMC hospitalization in a year? Going by past official estimates, one can guesstimate it at below 4%. How many BPL families spend their own money to buy medicines or services from outpatient department (OPD) in a year? The unanimous answer would be: a great majority.

If Modi Government is indeed concerned about unattended health woes of poor and the resulting accentuation of poverty, should it not first take full care where the shoe pinches the poor most?

Out of pocket (OOP) expenses on doctors' fee and purchase of medicines and diagnostics are what hurt the poor most. RSBY Review Committee thus strongly pitched for provision of OPD services.

In its report submitted to Modi Government during September 2014, the Committee recommended: "OPD services under RSBY can be introduced as a separate package with a fixed package cost in the range of Rs 7500 per family per annum to be utilized @ Rs 100 per incidence, within the existing sum insured. An incidence may be defined as an illness for which the beneficiary has approached the doctor for consultation and may include more than one consultation visits".

The concern over exclusion of OPD also finds echo in several research studies and submissions made by different stakeholders of public health.

According to a research paper (RP) published last year by Social Science & Medicine, "Overall our analysis shows that RSBY has not provided any significant financial protection for poor households. Drug expenditures do not provide the full story on why these impacts are small. The burden of outpatient expenditures that account for the bulk of OOP healthcare spending is mostly unaffected and utilization of outpatient care may even have increased on account of RSBY".

Launched as RSBY, the scheme has been gradually improved through experience and criticism from various quarters including Comptroller and Auditor General (CAG).

The beneficiaries under RSBY are entitled to hospitalization coverage up to Rs. 30,000/- per annum on family floater basis, for most of the diseases that require hospitalization. The coverage extends to maximum five members of the family.

As many as 3.63 crore out of total 5.91 crore BPL families in 278 districts of 15 states had been enrolled as on 31 st March 2017. Total Hospitalization Cases under the scheme since its launch in 2008 aggregated to 1.40 crore.

The smart cards issued to BPL families would turn into waste after RSBY is subsumed into AB-PMJAY. The medical staff and other stakeholders would have re-learn the nitty-gritty of new scheme, which is different from RSBY.

Unlike RSBY which allows hospitalization for most of the diseases, AB-PMJAY limits coverage to only STMC. Put simply, patients eligible for hospitalization under RSBY for certain ailments, say for Vitamin A deficiency, would become ineligible for hospitalization under the new scheme.

The devil lies in the fine print - the list of exclusions for hospitalization and actual cases of denial of hospitalization remove "that" would be known once AB-PMJAY gets going full blast.

Some of the exclusions already notified under AB-PMJAY are: 1) Any dental treatment or surgery which is corrective, cosmetic or of aesthetic procedure, filling of cavity, root canal including wear and tear etc. unless arising from disease or injury and which requires hospitalization for treatment 2) Congenital external diseases, 3) intentional self-injury/suicide and 4) persistent vegetative state of the patient.

"Surgical and Medical packages will also not be allowed to be availed at the same time", says a Model Tender document for selection of implementation support agency for providing support services for AB-PMJAY.

It is thus clear that Modi Government has exercised its wisdom to minimize its financial commitment while offering super-mega-freebie to BPL strata of the society. Wisdom is also reflected in its decision to roll out AB-PMJAY with 60% funding by the Centre & 40% by the States.

RSBY, on the other hand, has 75: 25 Centre-States funding ratio. The financial burden on States is thus bound to increase under the new centrally sponsored scheme.

Thus, both States and patients have been short-changed under AB-PMJAY. The only immediate beneficiary with no financial burden of the new scheme is Mr. Modi. He stands to derive mileage from disruptive welfare reforms that no predecessor ever thought of.

Goodies would, of course, flow to insurance companies, private hospitals and other service providers.

The unadulterated truth is that AB-PMJAY, other existing or erstwhile Government-sponsored health insurance schemes are a far cry from universal health coverage (UHC).

There are no takers in the Governments for the working definition of UHC prepared by the High Level Expert Group (HLEG) Report on Universal Health Coverage that gave its report to erstwhile Planning Commission in November 2011.

HLEG defined UHC as "Ensuring equitable access for all Indian citizens, resident in any part of the country, regardless of income level, social status, gender, caste or religion, to affordable, accountable, appropriate health services of assured quality (promotive, preventive, curative and rehabilitative) as well as public health services addressing the wider determinants of health delivered to individuals and populations, with the government being the guarantor and enabler, although not necessarily the only provider, of health and related services".