After a landslide victory in the Lok Sabha elections, the BJP has shifted its focus to Delhi, which goes to polls in a year. Riding on a saffron surge across the Hindi heartland, the BJP has decided to combat its biggest adversary in the state, the Aam Aadmi Party (AAP), with its development policies. Surprisingly, health is expected to take the electoral centre stage. A battle of one-upmanship is brewing between two health models: Prime Minister Narendra Modi’s flagship scheme Ayushman Bharat versus Delhi Chief Minister Arvind Kejriwal’s pet project Mohalla Clinics.
The Indian Express reports that, at a recently convened Delhi BJP monthly meeting, it was decided that Ayushman Bharat will be party’s poll plank for Delhi Assembly election. Hundreds of BJP workers will be engaged in mobilising the Delhi electorate in favour of Ayushman Bharat and how its non-implementation by the Kejriwal government is costing the state.
There has been a stalemate regarding the non-implementation of the central government’s mega health insurance scheme in the national capital ever since its launch. Delhi recently rejected a proposal by newly appointed Health Minister, Dr Harsh Vardhan, asking the state to implement the health insurance scheme. This came after a legal challenge sought to compel the implementation of Ayushman Bharat in the UT, only to be rejected by the Delhi High Court.
So why is Delhi government unwilling to launch Ayushman Bharat? Political considerations aside, Kejriwal has been advocating his mohalla clinics as India’s answer to universal healthcare since their launch in 2014.
The name has also been a bone of contention. The AAP government wants National Health Authority to rename Ayushman Bharat from its official title of Pradhan Mantri Jan Aarogya Yojana (PMJAY) to the Aam Admi Mukhya Mantri Aam Aadmi Swasthya Bima Yojana. It also wanted to add fifty lakh beneficiaries to the list. The Centre rejected the former stipulation. Clearly, a political narrative is being set: who is a better healthcare provider, Modi or Kejriwal?
Delhi Health Minister, Satyendra Jain, has another concern. The scheme only covers a small percentage of the Delhi population. “Delhi has a population of over two crore and this scheme [PMJAY] can only benefit ten lakh; what is the point of implementing it here? We are not going to implement the scheme, and will rather provide treatment to every patient visiting hospitals. We will not pick and choose,” Jain said.
Despite the Delhi government’s apprehension, sixteen Delhi hospitals run by the central government are successfully running the scheme and 2360 patients have benefited. Al Jazeera recently covered the story of India’s first Ayushman Bharat beneficiary: Vinod Jaiswal, a 57-year-old scrap dealer suffering from oesophagal stricture – a condition wherein the oesophagus narrows and makes swallowing food difficult. Priced out of surgery in his home state of Jharkhand, Jaiswal travelled a thousand kilometres to Delhi and was operated upon at the world-renowned Ram Manohar Lohia Hospital, using his Ayushman card. He could afford this only because of the scheme.
Despite initial gains, Ayushman Bharat’s implementation has irked critics, who feel the government is shying away from its responsibility of being a healthcare provider. Ayushman Bharat provides for tertiary care, but not for primary and preventative healthcare. Even the budget meant for schemes like the National Rural Health Mission to strengthen healthcare infrastructure in areas afflicted with shortfalls was slashed to accommodate the increased expenditure for Ayushman Bharat in this year’s Union Budget – to say nothing of other government departments related to health.
Since inception, the central government has focused on the insurance component of Ayushman Bharat and over one million beneficiaries have successfully availed its benefits. The aim is to provide 5 lakh annual health cover to ten crore underprivileged Indians. However, not much work has been done towards empowering primary healthcare, which will be provided through Healthcare and Wellness Centres (HWCs). To date, only 8000 such centres are operational across the country; however, the BJP’s election manifesto promises to launch 1.5 lakh more in the next four years.
This is where Kejriwal’s health policy has a competitive advantage. The Delhi government has been providing accessible and quality healthcare services through primary, secondary and tertiary facilities. Primary care is delivered through dispensaries and free mohalla clinics; secondary health care through multispeciality hospitals; and tertiary health care services through super-speciality hospitals.
With an aim to bring down the ever-increasing burden on big government hospitals, mohalla clinics were set up in 2015 to take free-of-cost primary healthcare to people’s doorstep, at every five-kilometre radius. The physical infrastructure is made up of pre-engineered insulated box type movable structures, manufactured and installed through the Public Works Department. The state government even allocated over Rs 300 crore, making healthcare budget twelve percent of their total expenditure. This is against the central government’s one percent budget for healthcare, with Ayushman Bharat allocated Rs 6,400 crore.
Despite the considerable fiscal allocation, the Delhi state government has witnessed difficulties in implementing its own scheme, as promised four years back. Out of the total target of 1,000 mohalla clinics, so far only 189 have been set up and 333 more are expected to be operational by June-end. Kejriwal’s party blames the Centre for non-cooperation in providing land and clearances. In a petition to the Delhi High Court, the state government alleged that the Delhi Development Authority is not handing over sites for the scheme, claiming it is impermissible under the master plan and the government should wait till 2021. Several other departments under the central government are not cooperating.
The scheme is facing other hurdles as well. There has also been an apparent reduction in footfall at these clinics, from the eighty lakh reported in the last budget to forty lakh in the current financial year. This forced the AAP government to reduce allocation from Rs 403 crore in 2018-2019 to Rs 375 crore in this budget.
The AAP’s Mohalla Clinic initiative has certainly improved the healthcare scenario in Delhi. They have made primary healthcare affordable and accessible and reduced the burden on government hospitals. The scheme continues to battle infrastructure investments, something where the central government can contribute by collaborating with the state government and using its novel idea for strengthening the healthcare and wellness centres model under the Ayushman Bharat scheme.
Both schemes complement each other, with an aim to accomplish the universal healthcare target. Political complications and a tug-of-war over credit stand in the way of consolidating the two models. For now, both parties will take their models to the electorate and let them decide which one wins. If the AAP is voted back into power it will continue to halt Ayushman Bharat. The BJP’s victory, on the other hand, would be ominous for the future of mohalla clinics. Unless the impasse is resolved, it will be for the people of Delhi to keep their health in mind when they cast their precious vote in next year’s election.