Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY)

Ministry of Health and Family Welfare

Context:

Ayushaman Bharat progress data release by the Government of India

About Ayushman Bharat:

• Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB PM-JAY), also referred to as Ayushman Bharat National Health Protection Scheme  (NHPS) of the Government of India is a national health insurance scheme of the state that aims to provide free access to healthcare for low income earners in the country.
• Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) was launched on 23^rd September 2018.
• It was by the Ministry of Health and Family Welfare
• The scheme launched to address health issues at all levels – primary, secondary, and tertiary. It has two components:
  • Pradhan Mantri Jan Arogya Yojana (PM-JAY), earlier known as the National Health Protection Scheme (NHPS)
  • Health and Wellness Centres (HWCs)
• Roughly, the bottom 50% of the country qualifies for this scheme. People using the program access their own primary care services from a family doctor.
• When anyone needs additional care, then PM-JAY provides free secondary health care for those needing specialist treatment and tertiary health care for those requiring hospitalization
• The scheme is an integrated approach comprising health insurance and primary, secondary and tertiary healthcare.
• The HWCs are aimed at improving access to cheap and quality healthcare services at the primary level. PM-JAY will cover the financial protection for availing healthcare services at the secondary and tertiary levels.
• The programme is part of the Indian government’s National Health Policy and is means-tested
• It is a centrally sponsored scheme and is jointly funded by both the federal government and the states.
•  By offering services to 50 crore (500 million) people it is the world’s largest government sponsored healthcare program. The program is a means-tested as its users are people with low income in India.

Key Features

• The government-sponsored health insurance scheme will provide free coverage of up to Rs 5 lakh per family per year at any government or even empanelled private hospitals all over India for secondary and tertiary medical care facilities.
• Modicare will be available for 74 crore beneficiary families and about 50 crore Indian citizens. Under the process, 80 percent of beneficiaries, based on the Socio-Economic Caste Census (SECC) data in the rural and the urban areas, have been identified.  
• There is no restriction on the basis of family size, age or gender.
• Ayushman Bharat is unlike other medical insurance schemes where there is a waiting period for pre-existing diseases. All kinds of diseases are covered from day one of the Ayushman Bharat policy. The benefit cover includes both pre and post hospitalization expenses.
• The expenditure incurred in premium payment will be shared between Central and State Governments in a specified ratio. The funding for the scheme will be shared – 60:40 for all states and UTs with their own legislature, 90:10 in Northeast states and three Himalayan states of Jammu and Kashmir, Himachal and Uttarakhand and 100% Central funding for UTs without legislature.
• The NHPS will draw additional resources from the Health and Education Cess and also depend on funding from States to boost the Central allocation. The premiums are expected to be in the range of `Rs 1,000 – ` 1,200 per annum.
• The NHPM (National Health Protection Mission) will pay for the hospitalisation costs of its beneficiaries through strategic purchasing from public and private hospitals.

PM-JAY Benefits

PM-JAY is a visionary scheme that aims at the fulfilment of the concept of Universal Health Coverage (UHC). It offers many benefits, which are discussed below.

• It will reduce medical expenditure for many families, which is currently, mostly out-of-the-pocket expense. Eligible families can avail of quality medical services without getting into debt.
• The insurance cover provided by this scheme includes items that are generally excluded from standard medi-claims (for example, pre-existing conditions, internal congenital diseases, and mental health conditions).
• The scheme requires hospitals to maintain a certain minimum standard.
• Insurers and third-party administrators will have access to the large new market that opens up because of the scheme.
• The scheme has the potential to initiate wide reforms in India’s healthcare system.
• After one year of the scheme’s beginning, beneficiary families are said to have saved over Rs.13000 crores.
• Over 60% of the treatments have been done by private hospitals. The private sector has played an active role in this scheme and they have also benefitted from it. In many tier II and III cities, private hospitals have observed increased footfall. 
• Economically weaker sections of society can have access to quality healthcare services without financial hardships.
• The scheme has also resulted in the creation of more jobs. In 2018, it generated more than 50000 jobs. This number is expected to increase as the government is planning to build 1.5 lakh HWCs by 2022.
  • 90% of the jobs are in the health sector and the remaining in allied sectors like insurance.
• The scheme is supported by a robust IT framework.
  • IT supports beneficiary identification, maintaining treatment records, processes claims, addresses grievances, etc.
  • There is fraud detection, prevention, and control system at both the central and state levels, which is critical for preventing fraud.

Why such scheme needed

• The 71st round of the National Sample Survey Office (NSSO) revealed many grim numbers about the country’s healthcare system.
  • About 86% of rural households and 82% of urban households do not have access to healthcare insurance.
  • Over 17% of the country’s population spend a minimum of 1/10th of their household budgets on availing health services.
  • Unexpected and serious healthcare problems often lead families to debt.
  • Over 19% and over 24% of the urban and rural households respectively meet their healthcare financial needs through borrowings.
• To address these grave concerns, the government, under the National Health Policy 2017, launched the Ayushman Bharat programme along with its two sub-missions, PMJAY and HWCs.

Challenges

• When Ayushman Bharat Yojana began there were questions of how to reconcile its plans with other existing health development recommendations, such as from NITI Aayog. A major challenge of implementing a national health care scheme would be starting with infrastructure in need of development to be part of a modern national system. 
• While Ayushman Bharat Yojana seeks to provide excellent healthcare, India still has some basic healthcare challenges including:
  • Relatively few doctors,
  • more cases of infectious disease, and
  • a national budget with a comparatively low central government investment in health care.
  • Not well organized transport system.
  • Many private hospitals have no will to join the scheme. The private hospitals report that they would be unable to offer their special services at the government low price, even with a government subsidy.
  • The scheme has faced challenges in form of fraudulent bills. In response, National Health Authority has revoked empanelment of 171 hospitals and imposed a penalty of ₹4.6 crore (US$640,000). Another 390 hospitals have been issued show cause notice.
• However, unlike the earlier RSBY (Rashtriya Swasthya Bima Yojana) era, plagued by lax monitoring of insurance fraud, AB-PMJAY involves a robust information technology infrastructure overseeing transactions and locating suspicious surges across the country.
• Despite all efforts to curb foul-play, the risk of unscrupulous private entities profiteering from gaming the system is clearly present in AB-PMJAY.

PM-JAY Criticisms

There are certain criticisms in the implementation of PM-JAY. They are briefly described below.

• There has been a criticism that while the allocation of funds for PM-JAY has increased exponentially, the fund for the National Rural Health Mission (NRHM) has gone up only by 2%. So, the scheme has been eating into the funds for NRHM.
• Under this scheme, the private sector has been given a large role in offering primary health care to the people. This has been protested by many people in various states, as regulation of the private sector is marginal.
• The scheme excludes those economically weaker sections that fall under the organized sector and have no access to health insurance.

Health and Wellness Centers (HWCs)

In February 2018, the Government of India announced the creation of 1,50,000 Health and Wellness Centres (HWCs) by transforming the existing Sub Centres and Primary Health Centres. These centres are to deliver Comprehensive Primary Health Care (CPHC) bringing healthcare closer to the homes of people. They cover both, maternal and child health services and non-communicable diseases, including free essential drugs and diagnostic services.

List of Services to be provided at Health & Wellness Centre

• Pregnancy care and maternal health services
• Neonatal and infant health services
• Child health
• Chronic communicable diseases
• Non-communicable diseases
• Management of mental illness
• Dental care
• Eye care
• Geriatric care Emergency medicine

“It is health that is real wealth and not pieces of gold and silver”

Mahatma Gandhi.

Recent data for AB-PMJAY: PIB

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