Patients in India spend around 80 per cent of their out-of-pocket (OOP) cost for treatment, which primarily comes from their household income or savings. According to a report by the National Sample Survey Office (NSSO), over 80 per cent of the Indian households were not covered by any health scheme and most of the cost was met by OOP in 2015. The report also shows that around six million families were pushed into poverty due to high hospitalisation expenditure. The proportion of population reporting any OOP expenditure increased to 80 per cent in 2011-12 from 60 per cent in 1993-94. In situation like these, only a universal health insurance programme or provision for healthcare at subsidised rates can ensure that people are not pushed into poverty by catastrophic medical expenses. 
However, India’s public healthcare budget remained low at just 1.3 per cent of the GDP, which is far less than the global average of six per cent. Also, Government contribution to health insurance stands at about 32 per cent, compared to 84 per cent in a developed nation, such as the UK. 
In this context, the new flagship health initiative, ‘Ayushman Bharat’, announced by the Government recently holds lot of promises and has two main objectives: First, to strengthen primary healthcare which has been lacking in the country. Second, to offer financial protection from catastrophic expenditure, often encountered once a family member is sick and needs long-term healthcare. 
The programme seeks to provide a coverage of five lakh rupees per family, annually to 10 crore families chosen through the Socio Economic Caste Census, mainly rural poor and identified urban workers. The expenditure incurred in premium payment will be shared by the Union and State Governments in the ratio of 60:40. Till now, 31 States and Union territories (UTs) have signed Memorandum of understandings (MoUs) with the Centre for the implementation of the programme.
However, the most critical issue for the success of the programme is its limited scope, uneven distribution of manpower and lack of infrastructure to cater to the health service. Around 40 per cent of the sanctioned posts are lying vacant in some States. Most of the primary health care centres and district hospitals are facing shortage of doctors and specialists. The country has severe shortage of registered medical practitioners as per the World Health Organistaion (WHO) norms, particularly in rural and remote areas, where they refuse to serve even after several efforts by the Government. 
According to a recent national health profile 2018, one allopathic doctor in a Government hospital, on an average, serves a population of 11,082, which is 10 times more than the WHO norms of one doctor per 1,000 population. The situation is worst in Bihar, where one doctor serves a population of 28,391 people, followed by Uttar Pradesh (19,962), Jharkhand (18,518), Madhya Pradesh (16,996), Chhattisgarh (15,916) and Karnataka (13,556), while some States have relatively better status, such as Delhi (2,203) and Goa (3,883). 
Further, health infrastructure shortage reflected with one Government hospital bed for every 1,844 people and one State-run hospital for every 55,591 people. Across States, Bihar has the highest congestion with 8,645 people served by one Government hospital bed followed by Andhra Pradesh (3,819), Jharkhand (3,079), Uttar Pradesh (2,905), Madhya Pradesh (2,661), and Chhattisgarh (2,647). On the other hand, Himachal Pradesh (577), Goa(671), Delhi(824), Tamil Nadu (899) and Kerala (939) have relatively less burden. The situation is worse in rural areas when compared to urban areas, where nearly 70 per cent of the people reside, while more than 60 per cent of the registered doctors are concentrated in urban areas, thus creating a highly skewed distribution and accessibility of basic health facilities. Situation differs across the States with acute shortage in some poor regions.   
In order to make any health scheme a success, besides the cost of medicines, both the Centre and States must work together to address the wide shortage of healthcare manpower and other necessary infrastructure. Above analysis shows that although India has a public healthcare network ranging from primary healthcare centres all the way to super-speciality hospitals, basic network is poorly equipped, under-staffed and overcrowded, forcing the people to look for private providers. 
Effective implementation of the ‘Ayushman Bharat’ scheme may have a positive impact on reducing OOP expenditure but with a condition that the Government will ensure the right infrastructure to meet the new infrastructure and manpower demand. This can have a cumulative positive effect on increased access to quality health and medication. In addition, unmet needs of the population will be catered, which remained hidden due to lack of financial resources.
If human resource and infrastructure problems in public health services are not timely addressed, patients will be forced to go to the private sector. In this case, the ‘Ayushman Bharat’ scheme is likely to benefit the private sector more than the public health services. There will be a huge scope to generate fake bills, as happened in previous health insurance schemes, where insurance companies found this to be a costly proposition and most of them refused to pay. 
Hence, it is important to place more emphasis on improving public health services and implementation of proper health insurance regulations. Otherwise, this ambitious scheme will ultimately be unsustainable and even detrimental for the poor for whom the scheme is intended like other schemes in the past.
(The writer is Fellow at Institute for Human Development, Delhi)