Media on Ayushman Bharat.

On September 12th, 2018, international medical journal

Lancet published an article 'The new politics of health in
India
[https://www.thelancet.com/journals/lancet/article/PIIS0140-
6736(18)32211-6/fulltext?rss=yes].' Richard Horton's article
using Rahul Gandhi's remarks on "job crisis" as a jumping
board talked about India's "health crisis" and the findings
of the new Lancet papers, he said:

"The five Lancet papers reveal a dangerously rapid

epidemiological transition. Ischaemic heart disease is the
leading individual cause of disease burden in India. The
contribution of cardiovascular diseases to total deaths has
almost doubled since 1990. The number of Indians living with
diabetes has grown from 26 million in 1990 to 65 million in
2016. The incidence of all cancers increased by 28% between
1990 and 2016, with new cases of cancer reaching 1·1
million. Those who suffer with chronic obstructive pulmonary
disease have risen from 28 million (1990) to 55 million
(2016). And while India is engulfed in this swirling
epidemic of non-communicable diseases, the country is also
in the grip of a mental health emergency. India could claim
18% of the world's population in 2016, yet it accounted for
37% of global suicide deaths among women and 24% among men.
The death rates from suicide in India were 2·1 times higher
among women and 1·4 times higher among men than global
averages in 2016. Suicide is the leading cause of death
among 15-39-year-olds".

He talked about the health crisis in its political context,

as evident from the title of the piece. He said, that "in
April, 2019, Indian voters will go to the polls in the most
important general election since India achieved independence
in 1947. The new government will not only set a fresh course
for health policy. It will also have the opportunity to
redefine the idea of India for a new generation". And while
emphasizing the value of the apparent steps Modi government
has taken towards two healthcare programmes, "first, the
creation of 150000 health and wellness centres across the
country. These centres [will] provide a spine of primary
care facilities to deliver universal health coverage.
Second, the National Health Protection Mission (NHPM)-a
system of health insurance [that intends to] cover 500
million people. The financial risk protection offered by the
NHPM is equivalent to €6265 per person annually. It covers
secondary and tertiary care for the poorest and most
vulnerable families. Together, these twin programmes
[should improve] access to quality health services and
reduce out-of-pocket health expenditures." (My emphasis.)

Beyond this recognition and hope his article was pretty much
neutral about the next general elections prospects for both
the parties. For example:

"Narendra Modi is India's current Prime Minister and leads

the centre-right Bharatiya Janata Party (BJP). His main
rival is Rahul Gandhi who, since December, 2017, has led the
Congress Party. In 2014, Modi won a landslide victory
against Rahul Gandhi-the Modi wave. A centre-right
coalition, the National Democratic Alliance, won 336 seats
in India's Parliament, the Lok Sabha. The centre-left United
Progressive Alliance, dominated by Congress, won only 60
seats (44 by Congress). Rahul Gandhi led his party to the
worst electoral defeat in its history. He is now seeking to
resurrect Congress and to prove that India's greatest
political dynasty still has something to offer. [He might
be hopeful. Recent by-elections suggest discontent with the
BJP. Indian voters are questioning Modi's success in
delivering economic growth and job creation]".

And, "Modi's stated goal is to build a new India by 2022.

Rahul Gandhi has spoken about a “modernising impulse” in
India and the possibility of “a transformation of 1·3
billion people”. Modi has grasped the importance of health
not only as a natural right for India's citizens, but also
as a political instrument to meet the growing expectations
of India's emerging middle class. Modi is the first Indian
Prime Minister to prioritise universal health coverage as
part of his political platform. Rahul Gandhi, despite his
promises to help lower castes, tribal communities, and the
rural poor, has yet to match Modicare. There is now every
prospect that as the BJP and Congress set out competing and
contrasting visions for India's future, health will rightly
become a decisive issue in next year's general election".

I emphasized these lines because they are unequivocally

missing from 100% of media coverage. Almost all coverage was
based on a PTI cable, with exception of one or two
independent coverage. Here are some of the headlines given:

1. "Lancet Praises PM Modi for Prioritising Universal Health

Coverage, Takes Potshot at Rahul Gandhi" (News18)

2. "Lancet: Modi 1st Indian PM to prioritise UHC" (Tribune)

3. "British medical journal Lancet gives thumbs up to

Narendra Modi's Ayushman Bharat, takes a dig at Rahul
Gandhi" (Buisness Today)

4. "Modi first Indian PM to prioritise universal health

coverage: Lancet" (Times of India, PTI)

While the original article was a health-crisis report and

it's political implication in next elections the coverage
was a Pro-"Modi First" whitewash - missing the "He (Rahul)
might be hopeful. Recent by-elections suggest discontent
with the BJP. Indian voters are questioning Modi's success
in delivering economic growth and job creation" sentence.

Moreover, most reports gave 10-20% of the space to actual

health data. None suggested strengths of the programmes.
While the original article said that, "[n]ow is the right
moment to be debating the future health of the world's
largest democracy," coverage was a pro-programmes verdict.

What is the current status of "Modicare," especially

Ayushman Bharat (AB)?

Down To Earth's Kundan Pandey has been covering the scheme

for quite some time and has interview it's first
beneficiaries. [downtoearth.org.in/news/ayushman-bharat-
what-pm-did-not-tell-in-the-last-i-day-speech-of-his-tenure-
61398] He reports that:
"As per the estimate, the programme will have to empanel
more than 20,000 hospitals and close to 200,000 personnel
will be needed to implement it across the country. All these
personnel need to be trained for rolling out the programme.

“In terms of the scale, there is just a beginning on the

ground. Even Indian Medical Association (IMA), the biggest
association of private doctors in India, has to meet
policymakers over the package rates in the scheme. Earlier,
they registered their dismay against the low price of
package rates. They agreed to join the programme only after
government’s assurance to look into the issue and there is a
meeting proposed before rolling out the scheme.

“These facts indicate that huge preparation is needed to

rollout the programme and it won’t be possible on September
25 as Prime Minister announced from the ramparts of Red
Fort".

“In addition to the lack of planning there are serious

financial issues. Kundan reports: "In his last full-fledged
budget speech, Arun Jaitley announced the scheme without
doing any homework and allocated a meager Rs 2,050 crore.
When experts criticized the government’s claim and
allocation, MoHFW confirmed that it will cost Rs 10,000
crore."

“On August 15, a family in Karnal, Haryana became the first

benefiary of Ayushman Bharat. Dinesh Arora, Dept. CEO of the
scheme tweeted: "First claim raised under #AyushmanBharat.
A baby girl is born through caesarean section at Kalpana
Chawla Hospital in Haryana. Claim of RS 9000 paid to the
hospital by Ayushman Bharat- Haryana".

Kundan writes that[downtoearth.org.in/news/health/in-poor-

health-thanks-to-ayushman-bharat-free-institutional-
delivery-now-costs-rs-9-000-61597], "in the midst of the
euphoria over the ‘First Ayushman Bharat Baby’, are we
becoming oblivious to the fact that the woman was supposed
to get all the facility free of cost in the government
hospital under Janani Suraksha Yojna (JSY)?
"Vandana Prasad says that there is fear that budget
allocated to government hospital may be slashed with the
government putting forward an argument that these hospitals
are now earning through the insurance scheme. Under such
circumstances, government hospitals will be forced to
compete with private hospitals and may start pushing for
caesarian section because it will fetch them more money
under the insurance scheme".

How can a healthcare programme and system function if it is

not reported on critically and fairly. But here emerges
another big problem with all social programmes in India.
Kundan on a phone interview mentioned that all social
schemes in India are associated with a party and a
government, which makes it hard to monitor and criticize the
policies fairly for the political actors and the media. And
without such criticism and scrutiny, no social scheme can
achieve its desired objectives. Hence, it is doubtful the
Horton's advocacy of "health coverage as part of his
political platform" is at all productive.

Broader Health-Crisis.

The India health crisis, that the Lancet articles put some
light on, is not emerging in isolation but is rooted in
socio-economic realities. Realities of unprecedented
inequality
[https://stokemagazine.wordpress.com/2018/09/15/demanding-
more-misery/]. For almost half a century the relationship
between social, economic inequalities and its impact of
health has been understood.

Vicente Navarro, Professor of Policy Studies at the Johns

Hopkins Bloomberg School of Public Health and Professor of
Political and Social Science at Pompeii Fabra University 15
years ago wrote:
[https://monthlyreview.org/2004/06/01/inequalities-are-
unhealthy/]

"[T]he distance among social groups and individuals and the

lack of social cohesion that this distance creates is bad
for people’s health and quality of life. Studies performed
among civil servants in Great Britain have shown, for
example, that life expectancy (the years that people can
expect to live) among the top civil servants, grade 32, is
longer than the life expectancy of civil servants of grade
31, who have longer life expectancy than civil servants of
grade 30, and so on, reaching the lowest life expectancy at
grade 1. There is no poverty among British civil servants,
but there are significant differences in their life
expectancies. The same finding has been replicated in other
countries. In Spain, for example, we performed a similar
study, looking at life expectancy by social class, and we
found that the members of the bourgeoisie (the European term
to define the corporate class) live an average of two years
longer than the petit bourgeoisie (the term to define the
upper middle class), who live two years longer than the
middle class, who live two years longer than the skilled
working class, who live two years longer than the members of
the unskilled working class, who live two years longer than
the unskilled working class that has been chronically
unemployed. The difference between the two poles-the
corporate class and the chronically unemployed-is ten years.
This average distance in the European Union is seven years.
In the United States, it is 14 years.

"Why these differences in life expectancy? A lot of research

has been done in the attempt to answer that question. And we
have enough evidence to provide an answer: social distance
and how that distance is perceived by people, in addition to
the lack of social cohesion that it produces, is at the root
of the problem. This situation appears clearly when we
compare the life expectancy of a poor person in the United
States (who makes $12,000 a year) with the life expectancy
of a middle-class person in Ghana. The poor person in the
United States is likely to have more material resources than
the middle-class person of Ghana (who makes the equivalent
of $9,000). The U.S. resident may have a car, a TV set, a
larger apartment and other amenities that the middle-class
person in Ghana does not. As a matter of fact, if the world
were considered a single society, then the poor in the
United States would be a member of the worldwide middle
class and the middle-class person of Ghana would be part of
the worldwide poor-certainly poorer than the poor in the
United States. And yet, I repeat, the poor citizen of the
United States (although of the worldwide middle class) has a
shorter life expectancy than the middle-class person
(although of the worldwide poor) in Ghana (two years less,
to be precise).

"Why? The answer is simple. It is more difficult to be a

poor person in the United States than a middle-class person
in Ghana. For the poor person in the United States, the
worst component of his or her existence is not primarily the
absence of material resources, but rather his or her social
distance from the rest of society. He or she feels
frustrated, a failure, unable to fulfill the expectation of
becoming a successful member of the “mainstream” and
attaining its standard of living, which incidentally, for
those depicted in the media as mainstream (and very much in
particular in the broadcast industry), is higher than the
national average. Indeed, the image of the “mainstream” does
not correspond with the reality of the average person in our
society. Most TV program characters, for example, are
professionals in the upper middle class. Very rarely are
blue-collar workers, nurse’s aides, carpenters, or taxi
drivers, for example, the main characters in TV programs.
The establishment’s media has, in general, a wrong view of
how average U.S. citizens live and work. In the United
States, the “American Dream” imparts an idealized vision of
what Americans really are. The frustrations of those who do
not see themselves a part of that mainstream in America are
indeed a source of pathology. It is very difficult-
emotionally as well as materially-to be outside of what the
U.S. establishment defines as “mainstream,” which, I repeat,
has a much higher than average pattern and standard of
living. Moreover, the massive poverty that exists in terms
of political and collective resources available to defend
the interests of the majority of working people in the
United States explains their enormous feeling of
powerlessness and lack of social cohesion, both of which
give rise to disease".
Inequality in India adds a new dimension to the health
crisis and, the crisis, urgency to the need to do something
about the inequality. But as the current state of Indian
health care system - or the lack of it, the radical
shortcomings (and harms) of Ayushman Bharat, worsening
situation of labour laws and inadequate and lack of fair
media coverage are not signs of development in the correct
direction.