Pradhan Mantri Jan Arogya Yojana Abhiyan through a political lens

Pradhan Mantri Jan Arogya Yojana Abhiyan (PMJAY) that entitles nearly 106 million poor households to Rs 5 lakh per household worth of hospital care every year can be good economics. For it not only aims to provide financial protection to the poor against hospitalisation costs but also has a potential to address some of the glaring gaps in the Indian health system by strengthening of district and sub-district hospitals, improving efficiencies of public hospitals, focusing on affordable care through the promotion of low-cost technologies, reducing disparities in the geographical distribution of health infrastructure and human resources and so forth.

But is PMJAY good politics too? Well, PMJAY has all the attributes to appeal to the political class: the advantage of speed, scale and the target population — majority of whom would be eligible voters too! By purchasing care from private hospitals that already have a significant presence in this space, the scheme can quickly expand the availability of hospital care to the target population — the advantage hardly enjoyed by the primary healthcare whose strengthening is a medium-term play.

It’s these attributes that made health insurance so popular among the Centre and states. Once Karnataka showed the way in mid-2000 in successfully implementing a scheme — Yeshasvini — that covered the state cooperative farmers. Slowly but surely the word spread and other states, notably Andhra Pradesh and Tamil Nadu, followed suit. The Central government was not far behind either. It too designed a template under its scheme called Rashtriya Swasthya Bima Yojana (RSBY) and incentivised states through co-financing of premiums to adopt it. Of course, the central template did provide flexibility to states to tweak the design, and many states did so to suit their context. These large-scale experiments that ran for a number of years, yielded wealth of lessons.

PMJAAY has the advantage of the lessons that came from the previous efforts. For example, one of the key factors contributing to the rapid scale-up of PMJAY now is the automatic inclusion of the target population identified through a national-level survey. This insight must have come from the RSBY in which the enrolment-based membership was a drag on its rapid scale-up. The need to maintain a fine balance between the “pulls of populism” and keeping it financially sustainable, and the need to give flexibility to states on the choice of the implementing agency were some of the other key lessons.

PMJAY also has the advantage of support from most states — governed as they are by the same political party or its allies as at the Centre — who are better aligned to the Centre and therefore can contribute to its rapid roll out.

Another area where the Narendra Modi government has demonstrable advantage is in having the necessary administrative and techno-managerial bandwidth to design the scheme and have it implemented. The basic idea embodied in PMJAY is not new. It has been around in India for a while. Yet how it gets designed and implemented is all that makes the difference. In this sense PMJAY can be called “the mother of all health insurance schemes in India” as the ambitions have soared in several aspects: population coverage, financial coverage, coverage of surgical procedures, use of digital/IT technology and so forth.

On the implementation front too, the government has been quick to constitute the National Health Authority to move things forward. The scheme is being implemented in a fast-paced mode, as there are tight timelines to get the scheme functional. Prime Minister Modi himself is reviewing the progress being made in its implementation. It may turn out to be the world’s fastest implemented health insurance programme.

That a revised health insurance scheme has been in work is a known fact. Both the PM and the FM have spoken about it on a few occasions in the past. But it is not until recently that Mr Modi actually announced it. Now that only a few months are left before the current term of the Modi government ends, his government is racing against time to have the scheme rolled-out. Even so, not many beneficiaries will be able to actually derive benefit from the scheme before they are called upon to exercise their vote in the next general election. If the launch of PMJAY is timed with an eye on the forthcoming elections, can it be said that the government didn’t time it well?

Well, far from it. The timing of the scheme seems to be a carefully thought-out strategy. True, that most beneficiaries will not be able to derive benefit anytime soon. But what matters from the election perspective is the government winning the confidence of beneficiaries. The government plans to achieve this by connecting with each beneficiary household — through a personalised letter informing them of their entitlement — and giving them a reasonable assurance that their entitlement shall be honoured when in need. This assurance is to be reinforced by giving visibility to the beneficiaries who actually avail the benefits early on. It’s a smart thinking at work!

The reality of facing the electorates necessitates a strategic approach to wooing voters. There is nothing wrong in it. All parties in power do it. But the political astuteness displayed by the Modi government is simply unmatched. No other party comes even half as close to it!

The writer is a development economist, formerly with the Bill & Melinda Gates Foundation and the World Bank