• India
  • Jan 21
  • Oommen C. Kurian

Playing politics over Ayushman Bharat

On September 23, the Union government launched the Pradhan Mantri Jan Arogya Yojana aka Ayushman Bharat, a centrally sponsored scheme for providing hospitalisation cover to more than 10 crore poor and deprived families (around 50 crore people) in empanelled public and private hospitals across the country. With 33 states and Union territories already agreeing to be part of the scheme, the news that West Bengal and Chhattisgarh have decided to pull out has come as a surprise to many. According to latest data, West Bengal was among the states with the highest number of families covered, and Chhattisgarh was among the top three states in terms of hospitalisations made under the scheme.

As an expanded version of the UPA-era Rashtriya Swasthya Bima Yojana, which enhanced insurance coverage from Rs 30,000 to a very impressive Rs 5 lakh per family per year, Ayushman Bharat has a great potential to improve health care access, both physical as well as financial. At the time of launch, around 19 states were governed by the BJP directly or through a coalition, and with the same party in power at the Centre, there was also an opportunity to streamline India’s health care policymaking.

The scheme started off well, and despite some initial hiccups, every state and Union territory barring three - Odisha, Telangana and Delhi - came on board the most ambitious health insurance programme in the country. Understandably, these states were not ruled by the BJP or its allies, but many states ruled by Opposition parties were part of the scheme and it was hoped that eventually all states will join the scheme.

However, analysis by Observer Research Foundation had warned at the time that political factors may undermine the true potential of the scheme. Many non-BJP states, whether contributing 10 per cent or 40 per cent to the scheme, will want their own political signature on it rather than giving full credit to the Centre. The danger identified was that the semantics of ‘Modicare’ could prevent the success of the scheme in the seven states where the BJP is not part of the governing coalition.

Several Assembly elections have followed the launch where the BJP did not do too well, and as the general election looms, a few other states are having a serious rethink about the scheme. Given the fact that health is a state subject, Ayushman Bharat needs the support of the states for its success. In an election year, pushing the Modi name, even in the states where the BJP or its coalition is in the majority, will be exhausting for political parties, BJP’s allies and the electorate alike.

For example, state leaders in Punjab and West Bengal had alleged that the Centre wants the states to carry the scheme’s financial burden while it reaps the potential political benefit in the coming general election. It was suspected that such bickering can cloud an otherwise potentially transformative scheme. As the Lok Sabha polls inch closer, this is exactly what is happening.

Chhattisgarh, where the BJP was defeated in the Assembly polls after its 15-year rule, has suddenly decided to pull out of the scheme. This is a big setback as Ayushman Bharat itself was launched in 2018 from Chhattisgarh, and also because the state has health outcomes that are relatively low and could have benefited from the scheme.

Chhattisgarh health minister is on record stating that the government is simply implementing a manifesto promise - that of a universal health care scheme - and there is no political reason. The government believes that universal health care can be provided using government-owned health infrastructure.

On the contrary, West Bengal pulled out for overtly political reasons. What irked the West Bengal chief minister was the fact that in the scheme-related communication, the Centre was putting only the photograph of Prime Minister Narendra Modi and the BJP election symbol lotus without any mention of Mamata Banerjee or the Trinamool Congress. As suspected earlier, West Bengal’s more than 1 crore families who were to be covered under the scheme have become victims of a branding-related tussle between the Centre and the state; it is possible that the coverage will have to be narrowed down if it goes back to the earlier Swasthya Sahi scheme.

Interestingly, reports suggest that some compromise was already reached between the Centre and the state earlier in this 60:40 partnership, and it was decided to run both Ayushman Bharat and Swasthya Sathi together, renaming it as Jan Arogya Yojana, removing Pradhan Mantri from the name of the joint scheme. Thus, the real reason for the pullout seem to be about the parties failing to fulfil the promises agreed upon during the negotiations. It is likely that as polls approach, many states starting with Punjab, Andhra Pradesh and Kerala will have serious rethink about being part of Ayushman Bharat.

Thus, the path to implementation of this promising scheme is, as expected, going to be full of challenges. In an election year, Ayushman Bharat could be the NDA’s social sector answer to what the UPA’s Mahatma Gandhi National Rural Employment Guarantee Act was in the 2009 polls. The political stakes are high. However, political parties must put poor patients’ interest above partisan interests for the smooth implementation of the scheme.

For the success of Ayushman Bharat, the Centre has to find flexibility to dovetail existing state insurance schemes, to allow state governments to take credit for a scheme in which they commit substantial resources, and to not cause worry among state-level leadership.

Oommen C. Kurian is fellow and head, Health Initiative, Observer Research Foundation, New Delhi. The views expressed here are personal.

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