The monogrammed shirt cuffs may be the first thing you notice, reminiscent of a not-so-distant past, but Indu Bhushan knows when to roll up his sleeves and jump into the epicentre of mass healthcare programmes — from Thailand and Mongolia to our very own Rajasthan.The career bureaucrat-turned development banker was lured away this March from a 21-year stint with the Asian Development Bank to be the chief executive of Ayushman Bharat When, as an IAS officer, he was tasked with eradicating guinea worm disease in the state in the late eighties, a “fascinated” Bhushan would keep a glass jar of the parasites on his desk — a reminder of both what he had achieved and what he was yet to accomplish. “I should have probably kept the jar as a memento,” he chuckles decades later, sitting in his new office at the health ministry in New Delhi.But occupying his desk and mindspace today is a large, poster-size checklist of states and Union Territories that the Centre is targeting for Ayushman Bharat — National Health Protection Mission ( AB-NHPM ) – the world’s largest sponsored healthcare insurance scheme that aims to provide 10 crore of India’s poorest families with health insurance of Rs 5 lakh each per year for secondary and tertiary care hospitalisation.For the world’s largest democracy of 1.3 billion, where over 70% of the population has had no significant insurance coverage and has been spending out of pocket for medical care, the sheer ambition and audacity of AB-NHPM, or Modicare, will eclipse all social welfare programmes, as well as subsume the existing Rashtriya Swasthya Bima Yojana (RSBY), launched in 2008 by the UPA government.“The poor in the country will not have to struggle with trouble of illness, not take money on loan from money-lenders and family will not go bankrupt,” claimed an emphatic Prime Minister Modi, during his Independence Day speech, while announcing its September 25 launch date, the birth anniversary of the RSS ideologue Pandit Deen Dayal Upadhyaya.“In tier II-III cities, hospitals will open, new jobs will be created. This is such a big scheme — the 50 crore beneficiaries under it are almost equal to the population of entire Europe or the combined population of US, Canada and Mexico.”As its CEO, though, Bhushan has to dexterously manoeuvre the labyrinthine state bureaucracies and entrenched private sector interests while carrying along stakeholders of the country’s fractured body politic.Being an IAS man himself, he knows where to retract, give in diplomatically and where to hard sell. “I knew I could add value to this programme,” says the man with a Master’s degree in health sciences and a PhD in Economics from John Hopkins University.Till date, Bhushan has managed to bring on board 28 of the total 36 states and UTs, including some ruled by the opposition. The likes of TDP-led Andhra Pradesh or Trinamool Congress-led West Bengal had initially declined participation, claiming it would be a “waste” of state resources.The scheme is as much a vote magnet ahead of elections 2019 as it is socially relevant. Naturally, the stakes are high in the politically important states of Uttar Pradesh and Bihar, where BJP is in power and beneficiaries are the highest. Uttar Pradesh, for example, has verified nearly 1.18 crore families who will be a part of the programme. A seamless rollout here is a crucial poll plank for the BJP.“Apart from Bhushan and his team, a lot of credit also goes to Niti Aayog,” says Sidharth Nath Singh, health minister, Uttar Pradesh, who feels it has been able to structure a common template for states.Yet, not everything may have gone as planned. Bhushan earlier announced August 15 as his team’s personal deadline to complete preparations, but both Uttar Pradesh and Bihar are both planning on a September launch.Some states are yet to complete the tendering process for insurance companies and hospital empanelment while BJP-ruled Maharashtra sent a letter declaring “inprinciple” agreement to participate in the scheme, just hours before Independence Day. An official memorandum of understanding (MoU) is expected in a week’s time, say government sources.Seven states, including Tamil Nadu and Kerala, are yet to agree to implement ABNHPM, and Odisha is its fiercest critic.Most already have existing health cover schemes for a much larger universe of beneficiaries than what the Centre is willing to provide under Ayushman Bharat.Even their annual cover is far higher than what has been envisaged under Modicare. Integrating them with the Centre’s will, therefore, burden the state exchequers even more as costs may rise significantly to cover those beneficiaries left out of their own scheme.Under the Ayushman Bharat MoU, the Centre is required to pick up only 60% of the tab; the rest is borne by the states. In June, Odisha reportedly decided not to implement the scheme because signing up would “deprive” nine lakh families of free health services, according to its health minister.The state runs its own health scheme – Biju Swasthya Kalyan Yojana — offering a similar Rs 5 lakh coverage per family in all government-run hospitals and feels it’s a superior initiative. Pratap Jena, Odisha health minister, could not be reached for comment.Delhi, led by AAP’s Arvind Kejriwal, is in talks with the Centre and is even willing to foot a bigger share of the cost if the Centre agrees to increase the ceiling of covered population, AAP spokesperson Nagendar Sharma told ET.The Delhi government has expressed concerns that using Socio-Economic Caste Census to identify beneficiaries would cover just 10% of the National Capital’s population.“We have been working on our own health insurance scheme for last two years which will cover far more people in Delhi,” says Sharma. “We are not in favour of the Centre’s scheme in the present form. But talks are on. If we fail to reach an agreement, Delhi government will launch its own scheme.”Senior government officials remain hopeful that at least five states that are holding out — Telengana, Punjab, Kerala, Tamil Nadu and Karnataka — will sign agreements in the next 30 days.Their inputs have already been implemented on ground. Telengana’s IT architecture for its Arogyashree health scheme is getting replicated nationally under AB-NHPM. A senior official in the Punjab health minister’s office acknowledges the Centre’s outreach after state health minister Brahm Mohindra stormed out of a Shimla meeting this May, minutes before signing an MoU, over differences in the scheme’s financial models.“While our political opponent, Shiromani Akali Dal, questioned us on political grounds, the Ayushman Bharat team and health minister JP Nadda addressed our concerns through letters and presentations. We had some reservations but we are convinced now,” the official adds. Even the vitriolic Mamata Banerjee government will be part of pilots starting from Wednesday. For most, it’s a political tightrope.While the opposition remains circumspect of the vote bank impl ic at ions of launching a scheme so closely associated with the Prime Minister, staying out of Ayushman Bharat may also not be politically prudent ahead of the 2019 elections.“People of the state could question their government on why they are being deprived of the big Modicare scheme which people from other states are benefitting from,” a senior central government functionary says on condition of anonymity.Like so many of Modi’s flagship initiatives, this one too has completely polarised the narrative, with several public health practitioners find it a rushed job. Some link this entirely to BJP’s 2014 manifesto promises of universal healthcare access.“It’s great to see the government’s intent, but a scheme like this that can revolutionise a significant proportion of the healthcare delivery mechanism and therefore the national economy, cannot be properly implemented without adequate preparation,” points out a Delhi-based public policy lawyer who works closely with state governments.“Memories of the post GST roll-out botch ups are still fresh… Even economic peers like Thailand where Bhushan worked extensively spent years in preparation.” “Given the timeline, the entire process seems to have been rushed. They may not have had time enough to iron out details at state level, where it has been implemented,” adds Anuska Kalita, specialist, Indian health systems, Harvard TH Chan School of Public Health.AB-NHPM’s design looks very similar to previous health financing schemes — like the UPA’s RSBY, the first attempt at near-universal healthcare for the poor. Health financing cannot work isolated from a “comprehensive” healthcare system that links primary, secondary and tertiary care and it’s the former that should ideally act as the bedrock of affordable healthcare for all, says Kalita.Currently, the primary care system is skewed towards mother and childcare, she feels, and lacks a “strong referral system” that will take years to develop, even with creation of health and wellness centres the government has conceptualised to take Modicare to the grassroots.As per the government’s own admission in March, inpatient hospitalisation costs have risen 300% over the past 10 years and an estimated six million families are knocked back into poverty every year by a medical crisis.Over 50% of households either don’t use or don’t have access to government facilities, says Crisil research, as India only has 0.8 physicians per 1,000 people, one of the lowest ratios in the world. India is at least 75% short of the number of qualified doctors it needs.So, even when the government raised its health budget by 11.5% in 2018-19 to `52,800 crore, it is still a paltry 2.16% of its total expenditure of Rs 24.42 trillion for the year. No surprise then, that around 80% of the poor’s acute medical needs at the primary level are “overwhelmingly” met by unqualified medical practitioners, highlights Shailaja Chandra, former secretary in the health ministry.“Patients often run from pillar to post, from one doctor to another, for a year or more before getting diagnosed for a specific condition requiring hospital intervention.”Insurance would give a much-needed sense of security to the poor, but seems far too confined to hospitalisation coverage only. “Who will see that the patient gets into the right hospital without avoidable loss of time?” asks Chandra. A diagnosis and referral to an empanelled hospital would be needed as would a layer of licensed, medically-trained medical auxiliaries who function at the tehsil or Gram Sabha level, to act as a bridge between patient and facility.It would perhaps be naïve to hope for supply response after scheme introduction, heightening prospects of bottlenecks and inefficiencies. A recent PwC-CII study lists the need for a proper monitoring structure, challenges in empanelling hospitals, identifying beneficiaries and potential for fraud as risks.More importantly, in order for ABNHPM to be successful, the government would also have to pump in at least Rs 2.5-3 lakh crore, compared to the Rs 10,000 crore allocated to it, says a health economist on condition of anonymity. “This (amount) is not going to achieve any health goals or financial protection goals,” he adds, since even this allocation is much less than total out-of-pocket expenditure on healthcare.Resources are hardly a challenge, assures Bhushan. “There is no cap on funding. We will get whatever is needed. Already, we have doubled initial allocation to Rs 4,000 crore in the supplementary budget,” he is reported to have said. His own estimate puts the requirement at Rs 20,000-Rs 30,000 crore, 60% of which will come from the Centre.The low reimbursement rates –20-25% lower than even Central government health schemes — for hospitals for some critical procedures has also irked service providers. AB-NHPM is expected to contribute 30-40% of the actual cost of hospital operations and, in its present form, may not encourage private hospitals to expand to underserved areas, according to the Association of Healthcare Providers India (AHPI).“It is obvious that the package rates have not been set scientifically,” laments Alex Thomas, president, AHPI. Writing in ET on Monday, Naresh Trehan, chairman, Medanta, also sought incentives for private players already bogged down by receivables and collections from existing government schemes.“It is important that policy makers understand that there is a cost of quality, and that rates need to be sufficient to make participation in the scheme viable for private providers,” Suneeta Reddy, managing director, Apollo, India’s largest hospital chain, had told ET.With even BJP-ruled states like Maharashtra earlier raising concerns on financial viability, Bhushan’s solution has been to al low them flexibility to match ABNHPM package rates with rates under their existing schemes. “In India, we have not seen a scheme of this scale yet, so it is bound to evolve,” he says. “If we’re wrong, we’ll change it, but we have to start somewhere.”A big personal victory for Bhushan was to win over the Indian Medical Association (IMA), India’s largest body of doctors that, until June, alleged Modicare would be a “non-starter” for its “abysmal” package rates.IMA last month even partnered the government to encourage hospitals to apply for empanelment, with president Ravi Wankhedkar calling it a “visionary” mission after it was clarified the body would play a more “active” role in the scheme’s implementation and costing committee.Since the portal to empanel hospitals in these states launched last month, over 1,200 applications have been submitted and over 6,000 are currently in the process of being filled out, according to the health ministry.With over 20 states planning to implement AB-NHPM through the trust model or a mixture of trust and private insurance — to keep a check on expenses while keeping the process simple —31 general insurers also stand the risk of their products being left out of the reckoning from the largest health insurance drive in the world.For a segment that reportedly lost money on group health insurance schemes for nearly two decades, this was expected to be new fertile ground for bumping up premium incomes, growth and valuations.Some are still hopeful of a transition back to them to check frauds and control costs. “States are taking a decision that suits them at the moment and, as experience grows, there could be a shift from trust to insurance,” feels Sanjay Datta, head of underwriting, ICICI Lombard. “There are lot of implementation issues that need to be put in place. The entire model continues to evolve to make it sustainable.”In the trust model, the claims would be settled from a corpus to be created by contributions from the central and state governments, with the latter responsible for settling claims, monitoring risks and building infrastructure.Insurance companies have quoted aggressively while bidding. Nagaland has chosen Apollo Munich, whose managing director Antony Jacob claims, “We are familiar with their healthcare ecosystem and it gives us an edge to understand their challenges better.” But are they as familiar as they say?A Crisil analysis indicates a national average premium of Rs 1,765 per family, based on the average total medical expenditure for treatment per hospital, says its director, Binaifer Jehani. So even the government’s prescribed per family cover seems woefully low.Bhushan needs AB-NHPM to be a success because he hopes it will be the stepping stone towards something bigger — universal health coverage. “There are massive challenges in setting up such a health system in a country as large and diverse as India, but if anybody can manage this, it is Indu,” says Erik A Bloom, senior economist and colleague from ADB. “He has the management experience and technical knowledge.More importantly, he has the commitment and the heart.” Bhushan says, “My personal vision is that, one day, all government healthcare schemes like CGHS, defence and railways can be merged with AB-NHPM, or at least brought under one umbrella, to ensure efficiency…and cover everyone.” While he waits for that day, Bhushan has more worms to defeat.