Indu Bhushan, a 1983-batch Rajasthan cadre IAS officer, had taken voluntary retirement in 1994 to join the World Bank as senior economist. An alumnus of prestigious institutes like IIT-Delhi and John Hopkins University, USA, Bhushan later joined Asian Development Bank. He was brought back by the Narendra Modi government this year as chief executive officer of the Centre’s ambitious Pradhan Mantri Jan Arogya Yojana, to launch the mega health insurance scheme. In an interview to Sumi Sukanya Dutta, he says the new scheme will revolutionise healthcare in the country as it will create paying capacity in non-metros and small towns, thereby attracting private players to go to those centres.
The Rs 5 lakh health insurance scheme for about 50 crore Indians is touted to be largest social welfare programme globally. How do you think it will change the healthcare scenario in India and prove to be a game changer?
It’s a game changer because our strategy is completely different from what we have done over the last 70 years. In the past, our focus was to provide services, build hospitals, provide human resources and equipment. But here, instead of providing services, we are making payments to service providers based on service delivery to the last man in the line.
So, it’s a totally different approach and this will do three things that earlier policies did not do. Earlier, we had this assumption that if we provide services, poor people will benefit automatically — sometimes they did, sometimes they did not. Here, we will pay money only if poor people use services, so we will reuse the expenditure of the poor people on the health services. Secondly, this is first time we are involving public and private hospitals both, but we will promote public hospitals. Thirdly, we will also help the private sector in a big way.
If you look at the distribution of health services, most healthcare providers are in urban areas and very few in rural areas or tier II or III cities. The reason is that the private players feel there is no paying capacity in smaller places. With this scheme, we are creating paying capacity in non-metros and small towns. We are providing incentives to private sector to go to those centres. Because of these reasons, the scheme will revolutionise the healthcare scene in India.
What are the biggest challenges in implementing the scheme and how is the government trying to overcome them?
The biggest challenge is the size of the scheme as it covers 50 crore Indians. For this, we need capacity in the government as well as on the supply side. Also, health is a state subject and convincing the states to come on board has been quite a task. Other big issue has been putting the IT backbone together to ensure we have a seamless, cashless service. We also have to ensure that State has the capacity — hardware as well as enough trained people — to manage the systems to implement the scheme.
Some states like Odisha, Telangana and Delhi have not joined the scheme, which means it can’t be rolled out everywhere. How do you see that situation?
These states will take some more time but negotiations are on with all three of them. I am confident they will come on board; it’s just a matter of time. There is no reason why they should not be part of it because it’s a win-win situation for everybody. It provides resources to states. As it is good for people, it is also good for politics. Some states are looking at financial implications; sooner or later, they will be convinced about it. Though Odisha has launched a similar scheme, the Central scheme is better and far more comprehensive because we have more diseases and conditions covered. We are also offering a national portability which a state scheme cannot provide.
Who or what do you think are the most important pillars for successful implementation of the scheme?
The most important pillar is a robust IT structure. Second is the flexibility that we have given to states to choose their favoured model-insurance, trust or mixed mode of implementation or the discretion to choose the packages they want. There are core packages that they have to take, but states are free to add more packages. We have also paid a lot of attention to prevention of fraud and abuse and to privacy and security of data.
The previous Rashtriya Swasthya Bima Yojana which provided cashless hospitalisation facility up to Rs 30,000 was often associated with fraud and misuse. What steps are you taking to prevent a repeat?
We have many design features in the new programme to ensure that. One, we have a very rigorous system of beneficiary identification and verification based on Aadhaar (it is not mandatory but preferable in order to avail the scheme). We have also made sure that all the packages which are prone to fraud or misuse, such as Caesarean-Section or hysterectomy, can be availed only in public sector hospitals. So, about 40 per cent of all packages can be carried out only in government hospitals.
In many other packages, there is a provision for pre-authorisation wherein evidence needs to be provided by the state government if that particularly surgery or procedure is required. Our IT system also has an in-built feature that can detect frauds or potential frauds. We will also be taking feedback from the beneficiaries and find out whether they availed the services. We will also do frequent medical audits. We have a very clear mandate on what we will do when we find out any instances of fraud. So, have a number of checks and balances in place.
Most big and corporate hospitals are unhappy with package rates offered and want the government to set up a cost analysis committee. Do you think the government can provide tertiary care facilities without wholehearted involvement of private hospitals?
Some big hospitals are coming forward to join the scheme. For example, Medanta in the NCR is now empanelled with us. Majority of the corporate hospitals are interested. We are open to discussing and doing further work on costs. As and when we have more data on evidence that the rates we are offering now to hospitals are not sufficient, we will revise them.
Many public health experts and health economists are saying the government does not have sufficient funds earmarked for the scheme and there seems to be some degree of opaqueness in the financial aspect of the programme. What will you say about that?
The government is committed to implementing the scheme successfully, whatever it takes. Currently our allocation for the programme is `2,000 crore. It is right that this is not sufficient as the Centre-state share is 60:40. We will need more money, depending on how the scheme rolls out, what premium has to be paid per person in every state. We are discussing this with the finance ministry and will soon get additional allocation.
Which states are the best prepared to implement the scheme and which states might lag behind?
Haryana, Chhattisgarh, Jharkhand, Assam, West Bengal, Maharashtra and most southern states like Tamil Nadu are all set to launch the scheme in a big way. Some like Bihar, however, will need to work hard. The difference is largely due to leadership and administrative capacity.