Navigating The Healthcare Maze: A Rural Surgeon’s Struggle With Ayushman Bharat’s Promises

With most surgical infrastructure concentrated in urban areas, seeking surgical treatment for people in rural areas is a nightmare. Poorly equipped and overburdened public health centers make things worse by pushing people requiring urgent care to private health centers that are known to leave patients with huge financial burdens.

Ayushman Bharat PMJAY, the government’s flagship program, was offered as a bandaid for the fractured Indian health system.  AB PMJAY is a health insurance scheme that offers needy families free treatment up to 5 lakh rupees per annum in impaneled hospitals. However, enrolling in this scheme is often more difficult than fighting the disease itself. 

Seeking treatment for a painful neck swelling, Sohan Lal, a 68-year-old farmer from eastern Madhya Pradesh, arrived at Jan Swasthya Sahyog, a hospital in rural central India. The search for a diagnosis - multiple consultations with doctors, and the tests they ordered - had already drained Sohan’s savings. 

Following a thorough clinical examination and some basic tests, the doctor diagnosed him with cancer of the parotid gland (a salivary gland located over the cheek). The cancer had spread to the lymph nodes in the neck. The treatment was however not the only struggle that he had to go through.

Besides low hemoglobin that prevented him from getting treatment, just like most people from rural India, Sohan was also low on finances. Even though the treatment costs at JSS are highly subsidised, poor people seeking care there often struggle to pay even the smallest of amounts. To continue further treatment, for the poor, enrolling into the Ayushman Bharat PMJAY scheme is the only option. 

To enroll in the scheme and get an AB PMJAY card, a patient needs to prove that they fit the inclusion criteria of being socioeconomically backward by showing multiple documents like the Samagra ID Card, Ration Card, and Aadhar Card.

As Sohan was unaware of this scheme, he lacked the required documents. For most people in remote and rural areas returning home to get the documents is also not an option as they often travel hundreds of kilometres for treatment. 

For some people like Mukesh, another farmer seeking treatment at JSS, even having all the correct documents prevented him from receiving the scheme's benefits. A mismatch in his name’s spelling in the Ration and Aadhar card meant that the digitized and empowered India could not identify that “Mukesh” and “Mukes” were the same person who was desperately seeking treatment for his suffering.

The doctors found donors for his treatment as they feared that the duration taken in correcting the spellings, a herculean task in itself, would outlast the time Mukesh was left with. Similarly, a mismatch in age also denies people an AB PMJAY card till the discrepancy is corrected.

Manju, a 70-year-old lady with tongue cancer, was facing a struggle not so unique in remote areas. Having worked in the field all her life, her hardened fingers had lost the fingerprints needed to prove her existence.  She too was denied an AB PMJAY card. Was her suffering, not only from the disease but also from poverty and social isolation, not enough to qualify her for a PMJAY card? Just like Manju, many other people have also lost their right to health after losing their fingerprints due to chronic undernutrition, long hours of manual labor, or to disease process itself.

The mandatory OTP verification further adds to the problems. The PMJAY card is denied even after dealing with all the hurdles mentioned above if the OTP can not be shared for verification. Most of the time people in need of the benefits of the scheme are migrant laborers. Due to their financial constraints and high risk of theft, they often do not use the same number for a long duration of time. Frequently updating the number in government documents is practically impossible considering the slow functioning of government offices. People living in tribal areas often even lack a phone. The need for OTP therefore denies them the care they need.

If by chance, everything goes well and the patient is enrolled in the scheme, the reimbursement can still be denied to the hospital because of the stringent criteria set for reimbursement. For example, an infection needs to be proved using a positive culture test to get the reimbursement. Not all infections always yield a positive culture and often the limitations of the labs in resource-limited settings fail to provide the necessary test results needed to prove a clinically apparent disease. 

In Sohan Lal’s case, somehow we were able to manage all these hurdles and he underwent a successful surgery. As per plan, he was referred for radiation therapy to another center which was situated 350 km from his home and 150 km from our centre.

Over the years, my experience with PMJAY has raised several questions in my mind. Why is a health insurance scheme and not public health infrastructure our government’s main priority to address people’s healthcare needs? Why is the scheme designed to be so difficult for patients? Is our health system and its policies really designed keeping the people in mind?

Sohan was lucky. However, countless people are struggling to access the most basic healthcare services. It’s been 78 years since independence. How many more years will it take till the government realizes the importance of maintaining good health and providing access to a good public healthcare system?

(The views are personal and do not reflect the views of the organization the author works with.)

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Edited by Parth Sharma

Image by Gayatri Sharma