TAJ - Is it working?

The "TAJ" in the title is just an attempt to come up with something as interesting and trendy as "JAM" for an abbreviation.....don't know if you like it but its the best I could think of.

In case....it doesn't work for you...will try to make up for it with some better quality writing below. 😊
Hopefully it will be worthwhile for everybody reading.

So to start....TAJ....

T - Toilets
A - Ayushman Bharat (National Health Protection Mission)
J - Jan Aushadhi

It is no secret that out-of-pocket (OOP) health expenses are one the biggest reasons for people remaining poor....and some slipping from not being poor to becoming poor.

Govts have come and gone..... allocated some budgetary resources...spent some money....but that has not improved the ground situation much.
Economic growth has helped families come above the poverty line....but that still leaves them vulnerable to OOP expenses, which keep rising every passing year. All that is gained from growth can be lost to OOP medical expenses.
Back to square one.
Some estimates suggest that about 5 cr Indians are pushed below the poverty line EVERY YEAR because of OOP medical expenses.

Is TAJ any different from previous Govt schemes?

As a layman....approach towards reducing an expense can be looked at in 2 ways I think.

- How can the expense be prevented?
- When it has to be borne, how can it be minimised?

The way I see it .... TAJ follows that simple thought process.

TOILETS (T from TAJ):

Open defecation has multiple horrible effects on health of all, particularly kids, who are surrounded by or live in that environment.
Effects are both short term and long term.
I am not a medical professional...but a simple Google search will give enough insights on how open defecation is a horrible practise for the society to be following.
As the name itself suggests..... since its about defecation.... solution is obviously usage of decent toilets.

But this simple solution, while finding fleeting mention from all previous govts and ministers....hardly had enough focus from the same people.
No wonder.... more than 65 years after independence, household toilet coverage in rural India was only around 38%. More than 50 cr people (maybe 60 cr, almost half the population) were defecating in the open in 2014.

Since 2nd October 2014....when PM Narendra Modi sounded the bugle for Swachh Bharat.... toilet building has been under intense focus.
There has hardly been a forum from where PM does not talk about it.... state machinery till the Panchayat level has been included in the whole process.

Almost 4 years now.... more than 8 cr toilets have been built.... household toilet coverage has now gone to 92%. Another few weeks should see it reaching 100%.
Surveys have suggested that usage of the toilets is upwards of 90%....and as result more than 4 lac villages have been declared as Open Defecation Free (ODF). Verification and audit of the ODF status is a continuous process.
More than 50 cr people would have given up open defecation by the time we come to 2nd October 2019. It will have a positive impact on 50 cr+ human lives.

Essentially..... "prevention".... the first attempt at reducing any expense.... is at work when building toilets. Swachh Bharat itself can be called a big disease prevention program (probably biggest ever), toilets being a big part of it.

Ujjwala scheme, under which poor households are given LPG connections
(5.5 cr till now).... and Mission Indradhanush, for large scale kids immunisation.... are also part of the "prevention" mechanism.
(They are subjects of big write ups individually.)


JAN AUSHADHI (J from TAJ):

If Toilets and other programs are part of the prevention strategy.... Jan Aushadhi kendras are part of "minimising the expense" strategy.

India's pharma market has branded generics as big part of it. Medicine prices have big markups and margins.... increasing the medicine cost for people.
Medicine costs are estimated to form 60-70% of OOP medical expenses.

Jan Aushadhi program is to bring the generic medicine to the people at very low markups....and thus very low prices. Not all medicines maybe available through this Jan Aushadhi network.... but around 1000 of them are. Savings on buying these generic medicines are anywhere between 50-95% over the prices of branded generics.
There are over 4000 Jan Aushadhi stores as of now..... probably will touch 5000 by March 2019. All this has happened over last 3 years..... previous govt had tried the same program.... but never progressed to anything meaningful. It was a big flop then.

But has Jan Aushadhi started making a big impact?   No. Not yet.
But we do have seeds of something big..... most stores have opened in the last 2 years.... word of mouth and trust factors may take a little time.

Turnover is picking up exponentially..... albeit on a very very low base.
FY19 till 31st August...it has already crossed 100 cr.
So maybe we will see 300 cr type of number in FY19.
(There could be some issues of stock availability at shops and range of medicines etc.... but those can be ironed out with time.)

If program can be sustained and scaled up to Rs. 1000 cr+.... we are talking big numbers...because 1000 cr of Jan Aushadhi turnover here could mean 
Rs 4000-5000 cr of branded generic turnover.
That is not small for a branded generic market size of ~Rs 80000 cr.
(Please correct me if this wrong.... this is my understanding of what the size is) 
Its 3000-4000 cr saving per annum....potentially more in future years.

Ayushman Bharat (A from TAJ):

Firstly.... Ayushman Bharat will start soon.... so part of the title "is it working" does not apply.
But it essentially forms a big part of the "minimising the expense" strategy.
Providing insurance cover for hospital expenses.
More than 10 cr families....around 50 cr families are supposed to be covered as per the plan. Some selective trials are going on.


Coming to second part - "Is it working?"

Two legs of "TAJ" have been in works for 3 or more years now.
Since it is still work-in-progress.... tough to conclude whether it is successful or not. But do we have some initial signs which may indicate some trend?

Just sharing some indicators....not concluding on any direct "cause and effect" correlation. (I have neither the capacity nor enough data to do it)

- Disease outbreaks - under Integrated Disease Surveillance Program (IDSP) weekly disease outbreaks are reported. If we look at sanitation/cleanliness related disease outbreaks like cholera/diarrhoea etc.
Average number of weekly outbreaks reported in various years:
                 2014: 24.9
                 2015: 29.6
                 2016: 37.3
                 2017: 24.2
                 2018: 19.6 (first 24 weeks)

The number of outbreaks were on uptrend from calendar year 2014 to 2016. 
Toilet building after starting in 2015, picked up pace in 2016 and 2017.
At same time, other parts of Swachh Bharat also picked up. 
So yeah... all our cities have not become spick and span.... but some have done very well.... others have lot to learn and cover up. Its a continuous process.

Disease outbreaks reported a decline in 2017 and first part of 2018.
(Outbreaks numbers do not give number of cases reported....but clustered break out of a disease. Individual cases will be far more. Here I am just using it as a rough indicator.
The website... idsp.nic.in .... is unfortunately not working last few weeks.)
Lesser outbreaks, lesser diseases....lesser medical expenses obviously.

- Indian Pharma Market Growth (Medicines only, FY) - 
                        2012  15%

                   2013  10%

                   2014  10%

                   2015  12%

                   2016  14%

                   2017  9%

                   2018  6%

Pharma market growth has shown a downturn.... somewhat in sync with disease outbreak decline.

Small news item from Indore.... which has been ranked the cleanest city 2 years in a row. (More related to broader Swachh Bharat than toilets)

This says last year medicine sales in Indore fell by 25 cr!!

 - Hospital Occupancy -

Am using Apollo Hospitals data.... listed for a long time.... so data also available for a longer term.

From 2006 to 2014.... Apollo reported occupancy of 70-75%+ even as it kept adding bed numbers throughout the period.

But since then...occupancy has dropped off and stabilised around 65%.

This may have more to do with demand-supply equation of hospitals beds itself.... and lesser with Swachh Bharat or related things.

But has had positive side effect of hospital charges having stagnated for few quarters.

This inflation in hospital charges had been 7-8% per annum for more than a decade.

From.... disease outbreaks to medicine sales.... there are some signs which are pointing in the right direction. If the momentum and focus on the programs continue....impact could be bigger.... and a stronger case for the "cause and effect" correlation could be made.

Some localised anecdotes of "prevention" having a positive impact....

- Result after UP Govt ran a big sanitation and immunisation campaign

- Effect in a district in Jharkhand

- Village in Adilabad

- Effect of efforts of Municipal Corp on Indore

To add to all this.... If Ayushman Bharat is implemented well... we could be watching the most significant positive change in public health as it unfolds.

And with that... it will also be a big help in reducing the number of people who slip into poverty due to health related expenses.

That it will add to productivity of those, who otherwise would suffer from diseases, is positive economic side effect.

I am neither a medical professional nor public health expert, so article is numerical type with data.... and not philosophical type with nuances.

Obviously it cannot be comprehensive either. There is lot more to the subject than I can even start to comprehend.

Its just a layman attempt to collate few things that came to notice.... in the form of a blog.

Thank you for reading through!!