Pradhan Mantri Jan Arogya Yojana

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TOPIC: General Studies 2

• Issues relating to development and management of Social Sector/Services relating to Health
• Development processes and the development industry the role of NGOs, SHGs, various groups and associations, donors, charities, institutional and other stakeholders

In News: The ambitious Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (PMJAY) completes a year on Monday, with impressive numbers to show but it still faces challenges of sustainability, synchronization and financial fulfilment.

According to the ministry of health and family welfare, in the last one year, around 46.4 lakh hospital treatments worth ₹7,500 crore have been carried out, and 60% of the amount spent was on tertiary care. As on date, the scheme has been implemented in 32 states and union territories. Various states are using different models for implementing their own health insurance/assurance schemes.

Ayushman Bharat – Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) is a Centrally Sponsored Scheme having central sector component under Ayushman Bharat Mission anchored in the Ministry of Health and Family Welfare (MoHFW). 

Implementation by: National Health Authority (NHA)

Ayushman Bharat is a conscious attempt to holistically address health, encompassing prevention, promotion and ambulatory care at the primary, secondary and tertiary levels. It promises to bring healthcare to the poorest through two components: Health and Wellness Centres (HWCs) delivering comprehensive primary healthcare through the development of 1.5 lakh HWCs, and PM-JAY, the health assurance scheme delivering secondary and tertiary care to 55-crore people through a health cover of Rs 5 lakh per family per year. 

Ayushman Bharat has been designed on the fundamental precepts that prevention is better than cure, and that no one should fall into poverty because of expenditure on healthcare, or die, because they cannot afford treatment.

Health and Wellness Centres: These centres will provide comprehensive health care, including for non-communicable diseases and maternal and child health services.

National Health Protection Mission (AB-PMJAY)

• AB-PMJAY provides a defined benefit cover of Rs. 5 lakh per family per year. This cover will take care of almost all secondary care and most of tertiary care procedures.
• To ensure that nobody is left out (especially women, children and elderly) there will be no cap on family size and age in the scheme.
• The benefit cover will also include pre and post-hospitalisation expenses. All pre-existing conditions will be covered from day one of the policy. A defined transport allowance per hospitalization will also be paid to the beneficiary.
• Benefits of the scheme are portable across the country and a beneficiary covered under the scheme will be allowed to take cashless benefits from any public/private empanelled hospitals across the country.
• The beneficiaries can avail benefits in both public and empanelled private facilities. All public hospitals in the States implementing AB-PMJAY, will be deemed empanelled for the Scheme. Hospitals belonging to Employee State Insurance Corporation (ESIC) may also be empanelled based on the bed occupancy ratio parameter. As for private hospitals, they will be empanelled online based on defined criteria.
• To control costs, the payments for treatment will be done on package rate (to be defined by the Government in advance) basis. The package rates will include all the costs associated with treatment. For beneficiaries, it will be a cashless, paper less transaction. Keeping in view the State specific requirements, States/ UTs will have the flexibility to modify these rates within a limited bandwidth.

What has Ayushman Bharat Scheme done till now?

Ayushman Bharat has provided a platform and framework for the country to accelerate its progress towards comprehensive universal healthcare.

Integration of Schemes: 

• Eleven states/UTs have expanded the coverage to include almost all families. 
• In addition, 23 states/UTs have expanded the beneficiary base with the same benefit cover as under PMJAY or lower in some cases. 
• Several states have merged their many ongoing schemes with PMJAY to make implementation simpler for both beneficiaries and participating hospitals. They don’t need to deal with different target groups, rates and reporting systems.

Creation of Job opportunities: 

• With the setting up of 1.5 lakh HWCs by 2022, an expected 1.5 lakh jobs will be created for community health officers, including 50,000 multi-purpose health workers. 
• It has generated an estimated 50,000-60,000 jobs in the first year itself and is expected to add over 12.5 lakh jobs in both public and private sectors over the next three to five years, with 90 per cent of them in the healthcare sector and the remaining in allied sectors such as insurance and implementation support. 
• As more people seek in-patient care, 1.5 lakh beds will be added in existing and new hospitals. This, in turn, will lead to the creation of around 7.5 lakh new opportunities for doctors, nurses, technicians, pharmacists and frontline healthcare workers such as Pradhan Mantri Arogya Mitras (functionaries who are the key interface between beneficiaries and the scheme).

Participation of Private Hospitals: PM-JAY has created a massive demand for private (and public) sector services by making hospital facilities accessible to 55 crore people. 

• In tier II and tier III cities, private sector hospitals are already witnessing an almost 20 per cent increase in footfall. 
• Some hospital chains are already contemplating plans for expanding their capacity or opening new facilities in underserved areas. 
• Public sector facilities have streamlined their processes so as to improve service quality and amenities with funds from PMJAY.

Strong IT backbone: Facilitates the identification of beneficiaries, records treatments, processes claims, receives feedback, and addresses grievances. 

• A live dashboard helps in monitoring and improving performance, based on real-time data and regular analysis. 
• This platform also helps states to compare their performance. 
• A strong and sophisticated fraud prevention, detection and control system at the national and state level has proved to be critical for PM-JAY to ensure that frauds are largely prevented. If attempted, they are quickly detected and strong action is taken.

Challenges the Scheme faces

A good beginning has been made, but a lot needs to be achieved before we reach our goals. Opportunities that lie ahead need to be effectively harnessed. By the government’s own admission, the uneven geographic distribution of poor families makes it difficult to find out the real targeted beneficiaries given the uneven geographic distribution of poor families. Inspite of many people having been treated under the scheme, many remain unaware of the programme.

• Exploiting the potential of collective bargaining and leveraging economies of scale – this could deliver more affordable and quality healthcare by negotiating better prices for various devices, implants and supplies, and also leveraging other policies such as Make in India. 
• Ensuring quality treatment of patients by prescribing and ensuring adherence to standard treatment protocols is another opportunity waiting to be fully harnessed. 
• Strengthening the linkage between HWCs and PMJAY will improve the backward and forward referrals and enhance overall healthcare services, especially to the poor. Expansion of coverage to include the lower-middle and middle class needs to be a priority.
• “Green field” states with no past experience of implementing healthcare schemes have to work harder to scale up their progress. All states will need to make sincere efforts towards providing seamless health services to the last mile.
• Lacks in rational pricing and health insurance for all as it covers only a section of the population: There is a need to scale up this programme with quality and sustainability for all stakeholders. We need to strengthen delivery mechanism which includes expansion of private providers’ network, shift towards organized care delivery, innovations, speciality, low cost, and value-based care
• Along with delivery and quality, the government will need to adopt innovative funding models for long-term sustainability. India needs to attract strategic funding through various other internal and external sources to sustain Ayushman Bharat. With adequate financing and funding to the sector, rural-urban gaps in quality and delivery systems can also be bridged.
• Ensuring seamless connectivity in regions of turmoil like Kashmir or empanelling hospitals in remote areas like the north-east and Leh remains a challenge.

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Connecting the Dots:

1. Ayushman Bharat is one of the most ambitious health schemes ever launched in India. What can be the key challenges in proper implementation of this scheme?
2. Examine the status of insurance coverage in India. What is your assessment of the potential of Ayushman Bharat in this regard?