Ayushyman-Bharat---PM-JAY-IASToppers-2020
Mains Article

Ayushman Bharat – Pradhan Mantri Jan Arogya Yojana (AB-PMJAY): One Year Review [Mains Article]

Indeed, PMJAY has the potential to institute reforms to India’s healthcare and health insurance systems at a lower cost to the exchequer, if health information and monitoring systems can arrest the possibility of over-provisioning and cost-inflation.
By IT's Mains Articles Team
September 26, 2019

Contents

  • About Ayushman Bharat Scheme
  • Success of PM-JAY
  • Criticism
  • Suggestions
  • Conclusion

Ayushman Bharat – Pradhan Mantri Jan Arogya Yojana (AB-PMJAY): One Year Review

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About Ayushman Bharat Scheme

Ayushman-Bharat-Scheme-IASToppers2-IASToppers

  • Ayushman Bharat aims to undertake interventions to address health at primary, secondary and tertiary level.
  • It adopts a continuum of care approach, comprising of two inter-related components, which are:
  1. Health and Wellness Centres (HWCs)
  2. Pradhan Mantri Jan Arogya Yojana (PM-JAY)

Health and Wellness Centres (HWCs)

Health-and-Wellness-Centres-IASToppers

  • In February 2018, the Government of India announced the creation of Health and Wellness Centres (HWCs) by converting existing Sub Centres and Primary Health Centres.
  • These centres deliver Comprehensive Primary Health Care (CPHC) covering both maternal and child health services and non-communicable diseases, including free essential drugs and diagnostic services.

Pradhan Mantri Jan Arogya Yojana (PM-JAY)

Pradhan Mantri Jan Arogya Yojana (PM-JAY) IASToppers

  • PM-JAY is the world’s largest health insurance/assurance scheme fully financed by the government targeting more than 50 crore beneficiaries.
  • Launched in September 2018, this scheme was earlier known as National Health Protection Scheme (NHPS) before it was rechristened to PM-JAY.

Key Features of PM-JAY

  • Provides cover of Rs. 5 lakhs per family per year, for secondary and tertiary care hospitalization across public and private empaneled hospitals in India.
  • Provides cashless access to health care services for the beneficiary at the point of service, that is, the hospital.
  • Covers up to 3 days of pre-hospitalization and 15 days’ post-hospitalization expenses such as diagnostics and medicines

 

  • Benefits of the scheme are portable across the countrye. a beneficiary can visit any empanelled public or private hospital for cashless treatment.

Significance

  • It will help reduce catastrophic expenditure for hospitalizations for poorest 55 crore people in India, which pushes 6 crore people into poverty each year, and will help mitigate the financial risk arising out of catastrophic health episodes.

The cover under the scheme includes all the expenses incurred for the following components of the treatment.

  • Medical examination, treatment, and consultation
  • Medicine and medical consumables
  • Non-intensive and intensive care services
  • Diagnostic and laboratory investigations
  • Medical implant services (where necessary)
  • Accommodation benefits & Food services
  • Complications arising during treatment

Eligibility

  • Families who are identified by the government on the basis of deprivation and occupational criteria using the Socio-Economic and Caste Census (SECC) 2011 both in rural and urban areas.

Success of PM-JAY

ayushman-bharat-scheme-3-IASToppers

  • More than five crore people have been screened for a whole range of common non-communicable diseases.
  • More than 45 lakh hospital admissions have taken place for cashless treatment in more than 18,000 hospitals, resulting in savings of more than Rs 13,000 crore for the beneficiary families.

ayushman-bharat-scheme1-IASToppers

Extended benefits

  • Several states and UTs have extend the benefits under PM-JAY to far larger numbers. For instance, 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. Karnataka has merged seven different existing schemes into one, while Kerala has merged three different schemes.

Role of Private Sector

  • The private sector has played an active role in the early pick up of the scheme as over 60 per cent of the treatments have been done by private hospitals.
  • PM-JAY has created a massive demand for private (and public) sector services by making hospital facilities accessible to poor 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.

Job Creation

  • With the setting up of 1.5 lakh HWCs by 2022, an expected 5 lakh jobs will be created for community health officers, including multi-purpose health workers.
  • PM-JAY has already generated over 50,000 jobs in 2018 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.
  • As more people seek in-patient care, more beds will be added in hospitals. This will lead to the creation of new opportunities for doctors, nurses, pharmacists and frontline healthcare workers such as Pradhan Mantri Arogya Mitras (functionaries who are the key interface between beneficiaries and the scheme).

Strong IT Framework

  • This scheme is supported by a strong IT framework that facilitates the identification of beneficiaries, records treatments, processes claims, receives feedback, and addresses grievances.
  • A live dashboard helps in improving performance, based on real-time data which helps states to compare their performance.
  • A 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.

Criticism

Starving of NHM

  • The share of National Health Mission (NHM) in the total health budget has consistently declined since 2014-15 from 61% to 49% in 2019-20.
  • On the other hand, the allocation for PMJAY increased by 167 per cent while for National Rural Health Mission (NRHM) is increased by a mere 2 per cent. In fact, in 2017-18, the NRHM allocation declined by 1.5 %.
  • Further, the fund allocation for the Health and Wellness Centres have been put under the NHM, which implies that allocation to HWCs would come at the cost of existing interventions under the NHM.

Increasing privatization & no regulation

  • Under the PMJAY, the private sector has been given an increasing role in managing primary healthcare.
  • In a number of states, the operation of health facilities is being pushed into the public private partnership (PPP) mode which is being opposed by people in Chhattisgarh, Punjab and Rajasthan.
  • Moreover, regulation of private sector is negligible and only a few states have adopted the Clinical Establishment Act.

Neglected health personnel and infrastructure

  • Under this scheme, there is a shortage of key health personnel: 75 per cent shortfall of obstetricians and gynaecologists, and over 80% shortfall of surgeons, physicians and paediatricians at community health centres.
  • Nearly 25 per cent of the HWCs are without electric supply, 17 per cent without regular water supply and 10 per cent without all-weather motorable approach road.
  • In addition, there is increasing contractualisation of health workforce with very less remuneration but enormous work pressure.

Other Challenges

  • Possibility of inaccurate implementation and the right execution of the plan.
  • Since the scheme protects 40% of the poor, it fails to secure those individuals, who depend on the organized sector with no access to health insurance.
  • Possibility that private hospitals might not push the higher expenses under the Statutory Health Insurance (SHI).
  • Challenge of Communicating the benefits of the scheme to the beneficiaries.
  • States that are part of the PMJAY are complaining issues of central funds not being disbursed timely and giving rise to apprehensions regarding last-mile delivery of services to patients

Suggestions

  • Harnessing the potential of collective bargaining which could deliver more affordable 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.
  • Strengthening the linkage between HWCs and PMJAY will improve the backward and forward referrals and enhance overall healthcare services, especially to the poor.
  • States with no past experience of implementing healthcare schemes need to work harder to scale up their progress.

Conclusion

  • 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.
  • PM-JAY has sought to cover a population larger than that of Canada, the United States and Mexico put together.
  • However, PMJAY needs to take lessons from ongoing 4 schemes: Rashtriya Swasthya Bima Yojana, Employment State Insurance Scheme, Central Government Health Scheme, and Aam Aadmi Bima Yojana and should focus on efficiency of administration. Otherwise, there is a danger of this idea becoming only a little more than a political band-aid, only to fall by the wayside.
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