Ayushman Bharat: Service Adoption Challenges in Universal Healthcare System

Marketing of Ayushman Bharat Scheme

Many of the target population did not know about the Ayushman Bharat scheme. Rajeev ⁴ is the District Coordinator at Nagpur in the Maharashtra state of India for insurance providing company, that is, MD India Health Insurance TPA Private Limited. He was working on the advertisement of the Ayushman Bharat scheme in Lata Mangeshkar Hospital, Nagpur. Rajeev mentioned: ‘The lack of proper training to the personnel about the Ayushman Bharat scheme was causing problems for patients at the hospitals’.

There was a need to have a proper advertisement about the Ayushman Bharat scheme and its proposed benefits to the target population. This will help the hospital staff and Arogya Mitra ⁵ to work effectively as well as more patients can avail of the cashless treatment under this mass healthcare government scheme.

The marketing of the Ayushman Bharat scheme is a major challenge, especially in states where English or Hindi is not a common language with the native population as in states of Assam and Sikkim. Maligaon in Guwahati, Assam, is a town where the majority of population thrive on agriculture. The hospital in Maligaon is an example of poor marketing where population around the hospital did not know about Ayushman Bharat scheme as they are tribal population and not aware of Hindi or English language. Since they were not aware, the hospital which was fully equipped for providing healthcare services to a large number of patients, including Ayushman Bharat scheme patients, remained underutilized. Pradeep, a paramedic staff at Maligaon hospital, stated: ‘Many people and families in the vicinity of the hospital were not aware of the Ayushman Bharat scheme. As a result, a lesser number of patients are admitted in the hospital under this scheme’.

Ayushman Bharat Portal

The Ayushman Bharat scheme portal, in its current form, does not provide patient data portability facility between the states (Exhibit 2). This creates a problem for patients travelling from one state to another, especially migrant labourers. Suresh, one of the construction site labourers, shared: ‘I recently moved from construction site in Uttar Pradesh to a new construction site in Delhi. I cannot use my Ayushman Bharat card in Delhi. I have to go to Uttar Pradesh if I want to use Ayushman Bharat facility’.

Dr Shriram is a physician at the General Surgery ward in Subhash Chandra Bose Medical College and Hospital, Jabalpur. He directly deals with different patients, whether it is general ward patient or Ayushman Bharat cardholder patient. He had been providing his services to Ayushman Bharat patients in this hospital since the last nine months. He mentioned several issues regarding the implementation of Ayushman Bharat. He stated that when a patient is sent to the ward, and physicians diagnose the patient’s problem. Treatment is selected for the patient and that treatment code in Ayushman Bharat website has been allotted a particular amount. After providing treatment, the hospital can claim only that much amount for that patient’s treatment. But a few times, the patient’s initial diagnosis and the actual problem when the treatment begins are found to be different. It might require a treatment for which the code is not available in the Ayushman Bharat website. In this case, the patient must pay the treatment cost out of his/her pocket. Also, at times, the actual disease may fall in a different code available on the Ayushman Bharat website. This code is different from the treatment code at the time when the patient was registered in the hospital. The physician and staff must provide a detailed explanation to Ayushman Bharat authorities for this change of treatment.

Dr Tiwari is a government official who works as Medical Superintendent at Jabalpur Medical College. Previously, he was incharge of the Ayushman Bharat scheme in the same hospital. Ayushman Bharat is a national scheme which aims to provide cashless (free) health facilities to the poor population of India for their medical treatments. Since the scheme is new and is implemented throughout the nation, shortcomings were bound to appear. Dr Tiwari mentioned:

The Ayushman Bharat packages that are provided to hospital in PMJAY are so rigid that they do not allow hospital to update during the treatment process. When a patient visits the hospital in distress, he explains the problem to the physician. Generally, the explanation given by patient is in layman terms. Physician has to determine the actual medical problem which is causing the patient distress. And based on physicians’ initial observation the case is generated and package is selected from Ayushman Bharat website. When surgeons had to perform more than one procedure and those treatments are covered in different packages which are necessary to save patient’s life. It requires to be conducted immediately and thus surgeon operates the patient and provides complete treatment to that patient. But since the patient was an Ayushman Bharat empanelled patient who belongs to money deprived class, the excess money incurred during the operation will be asked from the trust handling the scheme in that state. But since the package was already selected which was much less than the actual treatment cost incurred by the hospital, there are many formalities that will be required to be submitted. Some of them are very unreasonable like, photographic evidence that the procedure had to be enhanced.

There were cases where, while treating patients, doctors have to perform multiple treatments, but selecting multiple packages is not available in Ayushman Bharat scheme website. For example, a patient visited a hospital with the problem of stomach ache and bleeding while passing stool. Doctors diagnosed that he had intestinal bleeding and treatment had to be performed on an emergency basis. While operating the patient, surgeons found out that due to bleeding there was an infection grown in appendix and surgery had to be performed there as well. But the package which was selected was only for intestinal treatment. The hospital treated the patient, but when administrative personnel tried to enhance the package, they were asked for photographic evidence of patient getting treated for appendix surgery.

Dr Shriram, who had treated many Ayushman Bharat patients, opined:

There is rigidity in treatment packages offered under Ayushman Bharat scheme. It wastes physician’s critical time which he had to consume in writing explanation to Ayushman Bharat authorities why he asked to change the treatment where his time could have been utilised to treat another patient.

Shakuntla Devi is a 68-year-old woman with knee pain. She also had hypertension. In earlier diagnosis, she was diagnosed with a knee injury and was prescribed with knee surgery. After the treatment started, surgeons faced problems while treatment, and thus the budget for treatment that was registered under Ayushman Bharat with ₹27,600 increased to ₹68,400.

Ayushman Bharat scheme works on a package basis where, if a patient requires certain treatment, he had to register under certain package which is fixed by the administration of Ayushman Bharat. Now, to begin the treatment, physicians prescribed treatment, and then the administrative section registers the patient into that particular package, and then the whole treatment is conducted, and the patient is discharged after doctor’s evaluation and satisfactory treatment. But Shakuntla Devi’s blood pressure could not be controlled during treatment and due to which infection was developing, which resulted in knee replacement to be the only possible treatment. After the treatment, the total cost which, according to the selected package, was ₹27,600, increased to ₹68,400 due to modifications made during the treatment.

In Ayushman Bharat, a patient coming for emergency procedure used to get Ayushman Bharat card in approximately 2 hours which in general procedure was very time consuming. There are two different procedures by which government provides Ayushman Bharat card to people; first, the general procedure in which, in urban areas, Parshads of local areas collect evidences by which a person can be determined eligible for enrolling for the benefits of this policy, and in rural area same is done by Panchayat. Necessary data is collected and given to the respected authorities for verifying its authenticity. Later on, after satisfactory verification, the respected department send the Ayushman Bharat card along with information brochure about the card to respective individuals. This general procedure takes from 20 days to 1 month. Second, the emergency procedure in which, in case of emergency, the person who is poor can avail the benefit of this policy by submitting their relevant documents in Ayushman Bharat Desk and within 2 hours the card is generated and the patient is directly registered in hospital as Ayushman Bharat policy beneficiary. The problem was observed in cases when patient visited hospital in emergency when he/she had already applied for Ayushman Bharat card and now the Ayushman Bharat registration officer cannot register the patient in emergency procedure because his/her unique ID numbers are already registered in Ayushman Bharat database but the card is yet to be generated. This resulted in patient paying from their pocket for the emergency procedure.

Archana Chauhan is a student of second-year graduation. She hails from Prayagraj, Uttar Pradesh. She lives in a hostel and is in Delhi for studying purposes. She had an infection in her left eye and went to get it checked in Northern Railway Central Hospital. She couldn’t get admitted in the hospital with Ayushman Bharat scheme as her Aadhar Card and the identity in Ayushman Bharat database wasn’t available. She fulfilled the eligibility criteria laid down in the Ayushman Bharat scheme. She had the problem of infection since the last 3–4 days. She visited the hospital with her friend as the pain was continuously increasing. She consulted the physician and physician advised her to get admitted as the infection was severe, and her eye had to be operated to prevent further damage. She discussed the financial problem with the doctor and doctor advised Ayushman Bharat for the treatment if she was eligible. She consulted with the Ayushman desk person, and since she didn’t have the necessary documents, she couldn’t be admitted under Ayushman Bharat scheme. The documents which are necessary to enrol under the Ayushman Bharat scheme are Ration Card and Aadhar Card which should be registered with a mobile number. While registering the Aadhar Card, a one-time password is sent from UIDAI to the registered mobile number, after correctly entering the OTP only then the Aadhar Card is registered. Since the mobile number of Archana’s Aadhar Card was not with her or with anyone in contact, she couldn’t provide the OTP which was necessary to register. Hence, she couldn’t register under the Ayushman Bharat scheme and had to pay for the medicine and treatment from her own pocket.

Dr T. Lepcha is a physician at Neo STNM Hospital, Gangtok. He is also nodal officer of Ayushman Bharat scheme in that hospital. His responsibilities involve resolving issues which hospital staff, patients or administrative staff faced at the hospital while implementing Ayushman Bharat. Dr Lepcha stated:

There is lack of guidelines from Ayushman Bharat. There was an old lady who had severe burn and was admitted to my hospital with proper documentation. However, her name in Aadhar Card was spelt differently from her Ration Card and other identification. It was very difficult for her to receive benefits under Ayushman Bharat scheme. In another case a person who had applied for Ayushman Bharat card and process was still pending and the patient had to pay for the medicines which were used for the treatment. Also, the server crashes in hilly area due to which whole work gets stopped because entire Ayushman Bharat scheme processing is online. There should be an alternative offline solution or wireless connection which is more reliable than wired ones, because due to landslides, many times the wired connections broke down.

Such incidents created a negative word of mouth for the Ayushman Bharat scheme. It also created apprehension in the minds of users regarding the assurance of service delivery and impacted the service adoption of Ayushman Bharat scheme among the masses. The target population lived in close communities and word of mouth had higher credibility than the official promotion of the scheme.

Adequate Manpower

Salim Khan is a 31-year-old Indian who was suffering from gangrene. He belonged to Kareli, Narsinghpur District in state of Madhya Pradesh, India. His financial capacity included a bicycle and a small hut in a village near Kareli city. He used to work as a peasant in others’ land. He came to Narsinghpur Government Hospital, where he received the treatment with the help of district programme coordinator of Ayushman Bharat. In Narsinghpur Hospital, he was asked to leave too as the hospital staff denied providing him with the treatment. He was told to visit Jabalpur Hospital to receive treatment. But after district coordinator’s interventions, he was able to receive treatment at the same hospital from where he was denied earlier. This may be due to the improper training and unawareness about rules and regulations by the general staff of hospital at Narsinghpur District as opposed to the awareness of district coordinator who was there luckily for this patient and the patient was able to receive the treatment.

Smriti Singh is a mother and housewife. She belonged to Haldwani town of Nainital District., Uttarakhand. She has been feeling abdominal ache since past 3 months and was consulting with a local doctor for it. Since the pain got severe, the local doctor advised her to visit the hospital and get the problem diagnosed. She arrived at the hospital early morning, and her family member stood in the line while she was agonising with pain and sat on the bench outside the emergency ward. As the family member reached the administration desk, she mentioned Smriti’s situation and explained the urgency. The hospital staff apologized for the situation and mentioned that today it was a Dussehra holiday, the staff other than emergency ward was on holiday and because of it, the Ayushman Bharat card verification couldn’t be done that day. Even after many requests, the hospital staff did not consider Smriti for free treatment as the necessary staff was not available to verify the eligibility of patient under Ayushman Bharat scheme. She felt frustrated. Smriti stated:

The Ayushman Bharat officials have made such rules without thinking of festivals and holidays, people still have problems on holidays as well and they visit hospital on festivals as well. We cannot afford treatment from a private hospital. When we heard of Ayushman Bharat, we thought, finally a government is thinking about poor people like us, but now I think Ayushman Bharat is also just like many other schemes which only sound good but has no benefit for people like us.

There are more than 60 festivals celebrated in India throughout the year in different parts of the country. This impacted availability of medical staff on these holidays. The shortage of human resource, including physicians was a major issue in most of the hospitals in India. The Arogya Mitra, which is the dedicated staff for Ayushman Bharat scheme, is appointed on contract or one of the existing hospital staff is allotted this position.

Process Efficiency

Suman Patel is a farmer living in the outskirts of Jabalpur city. He visited Medical College, Jabalpur as he was having loose motions and felt nauseous. He was diagnosed with diarrhoea and was admitted in general medicine ward. Since the medicine was not available in the ward and store of the hospital, the process of bringing medicine through Ayushman Bharat took so long that the diarrhoea got subsided by then.

In Ayushman Bharat, the process of ordering medicines is as follows: The physician attending the patient writes a prescription of medicines which are required for the treatment of that disease. In case the medicine is not available in the hospital, the information is sent to the medical superintendent regarding non-availability of required medicines in the hospital store. This process of acquiring indents from ward and hospital store is a time-consuming task. Then, the medical superintendent approves the purchase of medicine from Ayushman Bharat recognized stores only. The PMJAY recognized store, subject to the availability, delivers the medicine to the store, which is then issued to requisite wards. However, in case the PMJAY recognized store did not have the medicines, then the hospital generates an order, and the supplier provides them with the medicines and then, the above-mentioned process follows:

Dr Shriram, a physician in a medical college, Jabalpur opined:

There should be for a special clause in Ayushman Bharat scheme which will have provision for ‘express delivery’ system in which whatever medicine is asked by nurse or physician will be delivered to them within an hour. This way the purpose of Ayushman Bharat can be fulfilled effectively and efficiently. There should be sufficient number of medicines in the hospital store besides a few essential medicines in the ward.

Himanshu Patel is a 13-year-old boy who occasionally gets acute ischemic strokes. He is suffering from this problem since he was 5–6 years old. He was admitted to the hospital on 13 May 2019. His treatment was of emergency nature; thus, the case was registered in auto approval basis, and the amount of ₹3,600 was approved. Later, after the treatment the total expenditure incurred was more than the approved one, that is, ₹21,600. The Ayushman Bharat portal kept rejecting the enhancement for more than three weeks and finally the enhancement was rejected. Since Himanshu was an emergency patient, the hospital staff could not capture the photographic evidence of the patient being operated in an intensive care unit (ICU) and hence could not submit it in the Ayushman Bharat portal. The hospital which treated Himanshu as an Ayushman Bharat scheme patient had to bear the difference.

Detection and Prevention of Medical Fraud

There were several cases of fraud in Ayushman Bharat scheme. In Surat, there was a mismatch in the address of a hospital given in PMJAY (Ayushman Bharat scheme) website and actual location of the hospital. The data of PMJAY needs to be rechecked and update of errors. Also, it was seen that the few hospitals which were enrolled under PMJAY had not started implementing the Ayushman Bharat scheme. One of the hospital administrators mentioned:

Few Ayushman Bharat empanelled private hospitals are conducting medical procedures on Ayushman Bharat patients which are permitted only at government hospitals. This is a medical fraud as such hospitals are showing a different procedure code on paper and claiming the amount.

National Health Authority (NHA) has delisted 171 hospitals due to Ayushman Bharat medical fraud cases. There has also been besides cases of ghost patients and non-eligible beneficiaries.

Crowd Management

The hospital crowd management needs improvement. In Medical College at Ahmedabad, there were long queues of Ayushman Bharat scheme patients in peak hours. The hospital staff required training to handle such situations. Another issue was observed from a private hospital, where the hospital had treated a few patients under Ayushman Bharat scheme, but it had a poor experience with the reimbursement. Hence, it had stopped providing treatment under Ayushman Bharat scheme. However, the hospital name was still there on the PMJAY website under the Ayushman Bharat scheme.

Hospitals with poor infrastructure, which were not hygienic as well as inadequate for treatment, especially in lower-tier towns, were empanelled under Ayushman Bharat scheme. The hospital staff found it tough to handle the large inflow of Ayushman Bharat patients. One of the physicians in Ahmedabad Medical College mentioned:

The hospitals should use token system to manage the patients in peak hours. There are chances of infections to the seriously ill patients due to the crowding at registration desks. The hospital can also make the prior appoint of doctor compulsory except for the emergency cases.

Integration with Existing Schemes

There were cashless healthcare insurance schemes running in several states of India. Most of them were subsided fully or partially by respective state governments. The Ayushman Bharat scheme, after its launch, subsumed national policies and few state policies like RSBY and Mukhyamantri Swasthya Bima Yojana (MSBY). A few state-run policies offered more benefits, due to which PMJAY (Ayushman Bharat scheme) had a rough start.

Dr Sarathak, a medical officer in South Eastern Railway Central Hospital, Kolkata, shared his views:

State government is not supporting central policy. Since West Bengal had an existing health insurance policy called Swasth Sathi in working, they have not promoted Ayushman Bharat in their state-run hospitals. The railway hospital has the infrastructure ready for Ayushman Bharat patients. The government should give advertisement for generating awareness stating that all railway hospitals can provide free treatments to Ayushman Bharat enrolled and eligible patients.

In the state of Chhattisgarh, a lot of people enrolled for the Ayushman Bharat scheme. The main reason for the success of Ayushman Bharat scheme in the state of Chhattisgarh was that the only healthcare policy runs in the state of Chhattisgarh before Ayushman Bharat was RSBY. The RSBY offered ₹30,000 per family per year, which is only 6% of the total amount covered for free treatment in Ayushman Bharat scheme (secondary and tertiary treatment). Another reason for the success of PMJAY/Ayushman Bharat scheme in Chhattisgarh was that RSBY was subsumed in PMJAY as both were centrally governed policies. The individual and families, who were already registered in RSBY, can use their RSBY card to receive benefits from PMJAY. The data of RSBY was shared and subsumed with PMJAY. Hence, the transition process was smooth compared to PMJAY’s implementation in Maharashtra where Mahatma Jyotiba Phule Jan Arogya Yojana (MJPJAY) was a state-run scheme.

The hospitals in Sikkim were found to be the cleanest and hygienic. All the facilities were available, including a separate area in registration counter for Ayushman Bharat scheme patients with a preinstalled fingerprint scanner. The Ayushman Bharat scheme patients were prompted attended, and there was a very high satisfaction level among patients and their family members. The hospitals at Delhi were also providing the healthcare services under Ayushman Bharat scheme. The registration process of Ayushman Bharat scheme patients was a smooth process. There were cleanliness issues in a few hospitals. Ayushman Bharat scheme started late in Delhi as there was almost a one-year delay in its implementation in the national capital.

The state healthcare schemes of West Bengal and Delhi were prima facie more advantageous than Ayushman Bharat scheme. However, at a deeper analysis, Ayushman Bharat scheme had multiple advantages. The multiplicity of healthcare schemes for the same target population may lead to cannibalization of one scheme against the other.

Meeting Performance Expectancy

The citizens need to be educated about the wellness and health aspects and its linkages with individual productivity. The performance expectancy would be reinforced by success stories of free quality healthcare services to Ayushman Bharat patients. The outcome in terms of the number of enrolments in Ayushman Bharat scheme, the number of surgeries performed and success stories of poor getting free quality healthcare services in the local popular press would build the people’s confidence in this government-sponsored cashless health coverage programme. The conviction that there is a strong correlation between good health and better individual performance at the workplace would enhance the adoption of Ayushman Bharat scheme in India.

Ease of Delivery of Services

The Ayushman Bharat scheme authorities have to take various initiatives to further increase the ease in delivery of its services. There is a need for digitalization of entire hospital records across the country. Once the database of all the available medicines is created, there should be a provision of generating an alert whenever any medicine stock reduces below a given threshold in a specific ward and the hospital store. This would ensure enough availability of all medicines to the needy patients and lead to better healthcare experience of the visiting patients to the hospitals.

There is a need to address the issue of rigidity in Ayushman Bharat scheme package selection. The lack of flexibility in the Ayushman Bharat package is making genuine patients suffer. There is an urgent need for simplification of this process so that the physicians do not have to invest their time in non-medico procedures such as writing a lengthy justification for the change in patient’s package. The physicians in these hospitals are already overburdened with a large number of new patients daily and follow-up cases. The highest-level administrative staff in the respective hospital may be authorized to change the package type after due diligence at his/her level. This problem led to payment by the patient himself, which defeated the very purpose of Ayushman Bharat policy.

Positive Social Influence

India is a conglomeration of various interconnected societies. The people are influenced by other’s options and recommendations. Therefore, in order to enhance adoption, the Ayushman Bharat scheme has to gain more positive word of mouth and thus gain positive social influence about this healthcare programme. The Ayushman Bharat scheme can integrate Mohalla Clinics in their programme. The community health centres (CHCs) can cater to the healthcare needs of the population in the outskirts of the city. This arrangement will help to solve the problem of overcrowding of Ayushman Bharat scheme patients in city hospitals. Hence, the integration of Mohalla Clinics and CHCs would help to not only manage the patient footfalls in city hospitals but also help Ayushman Bharat scheme patients receive their treatments in a much faster and convenient manner. These steps would cumulatively increase the Ayushman Bharat scheme’s social influence and increase its adoption by the masses.

Better Facilitating Conditions

The government-driven programme had issues with facilitating conditions. In the past, it has been marred by red-tapism, lack of technology, ambiguity in the scheme, etc. However, the Ayushman Bharat scheme has been well planned and rolled out pan India with adequate organizational and technological infrastructure by the Ministry of Health and Family Welfare, Government of India. However, there are teething issues like any large government programme. There was a problem of treatment package rigidity being faced by hospitals in different states. This problem of rigidity not only delays the process of treatment but many times when the patient is incapable of paying the difference amount, the cases are rejected after the package amount is finished, and the patient has to vacate the bed. There is a need to develop a proper medicine supply chain for the Ayushman Bharat scheme. It would have cascading benefits for patients, physicians, and hospitals. This is also an issue with technology. The Ayushman Bharat scheme portal had two different procedures to generate Ayushman Card: (a) general procedure which may take up to a month or more to provide Ayushman Card and (b) emergency procedure which can generate Ayushman Bharat card in about 2 hours. The emergency procedures can be utilized only by hospital staff authorized for providing cards when the patient is in distress, and urgent treatment is required. But the emergency procedure does not have the capacity to overwrite a general procedure. As a result, many times an emergency patient, who has already applied for the card under the general procedure, cannot avail the services under Ayushman Bharat scheme as his card status is pending and yet to be issued. The system does not allow to overwrite general procedure and issue the patient card under the emergency procedure. This rigidity in the Ayushman Bharat scheme system needs to be addressed so as to improve the service facilitation process for patients, who fall in this category.