Decoding Ayushman Bharat

The challenges before the components of Ayushman Bharat, the (ir)rationality behind raising the insurance coverage manifold are highlighted, a political economy narrative of the changing health financing scenario is drawn, and how the design of Ayushman Bharat will feed into executing the proposed public–private partnership model in public facilities and facilitate the strategic purchasing agenda of the National Health Policy is examined. Ayushman Bharat is a step towards creating a system that would facilitate in relinquishing public funds and public institutions to already dominant private players, which will have serious implications for the healthcare delivery system in India.

The world has observed “transitions in health financing and policies” for achieving universal health coverage (UHC). UHC is a system in which everyone in a society can get the healthcare services they need without incurring financial hardship (WHO 2005). This argues for creating a system that expands access to care, improves equity, and pools financial risks. Despite having heterogeneous approaches to achieve UHC, developing a risk pooling mechanism is central to it. The pooled share is sometimes mobilised as taxes and channelled through governments that provide or subsidise care; in other cases, it is mobilised in the form of contributions to mandatory insurance schemes (Savedoff et al 2012). Some countries have sought for insurance cover for the poor and underprivileged through fully subsidised insurance premiums, while the non-poor have the option of voluntary (or compulsory) enrolment (GoI 2011).

The strengthening of essential primary, secondary and tertiary healthcare in the public system has always been a half-hearted priority in India, but the focus has now been shifted towards promoting an insurance-based system. The country has witnessed a plethora of central- and state-level pro-poor health insurance schemes since over a decade. The funding nature of most of these schemes is rather different from the resource pooling mechanism of other countries, as they are mostly funded from government (tax) sources with minimal to no contribution from beneficiaries. Until recently, public investment in health was mostly used for financing the public health system for service provisioning, and now the (tax) funds will be diverted to finance the insurance-based system. This will lead to an important shift in the fundamental nature of healthcare financing in the country.