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- Approval by Union Cabinet (September 2024):
- Health Coverage Expansion: As per the Union Cabinet announcement in September 2024, the government extended health coverage under AB PM-JAY to all senior citizens aged 70 and above, benefitting around 6 crore senior citizens and 4.5 crore families.
- Insurance Coverage: Each senior citizen will receive health insurance cover worth ₹5 lakh annually under this new provision.
- Distinct Health Cards: Eligible citizens will receive separate AB PM-JAY health cards for easy identification and service delivery.
- Top-Up for Existing Beneficiaries:
- Senior citizens already covered under AB PM-JAY will receive an additional top-up of ₹5 lakh, providing exclusive health coverage for themselves.
- Choice of Scheme: Senior citizens already benefiting from other schemes like Central Government Health Scheme (CGHS), Ex-Servicemen Contributory Health Scheme (ECHS), and Ayushman CAPF will have the flexibility to choose between these schemes or AB PM-JAY.
About Ayushman Bharat : It is a flagship scheme of Government of India, was launched as recommended by the National Health Policy 2017, to achieve the vision of Universal Health Coverage (UHC). This initiative has been designed to meet Sustainable Development Goals (SDGs) and its underlining commitment, which is to "leave no one behind."
- Ayushman Bharat adopts a continuum of care approach, comprising two inter-related components, which are –
- 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.
- Pradhan Mantri Jan Arogya Yojana (PM-JAY): The second component under Ayushman Bharat is PM-JAY, the largest health assurance scheme in the world, which aims at providing a health cover of Rs. 5 lakhs per family per year for secondary and tertiary care hospitalization across public and private empanelled hospitals in India.
Significance of Ayushman Bharat
(i) The increasing life expectancy rate over 68.3 years has improved the quality of health care in India.
(ii) Health care is an essential factor, along with other variants like income, hygiene, and nutrition.
(iii) According to the World Health Organization, every country must invest at least 4% of the Gross Domestic Product (GDP) on their health.
(iv) The out-of-pocket expenditure on healthcare is 40% in India.
(v) The Government Scheme not only covers for expensive treatments but also provides quality services to all the people eligible under the plan.
Provisions of Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PM-JAY):
1. Largest Public Health Assurance Scheme: The scheme is the world’s largest publicly funded health assurance program.
- Launched in 2018, the Ayushman Bharat scheme covers 55 crore individuals or 12.34 crore families, offering health insurance worth ₹5 lakh per year for secondary and tertiary care hospitalisation.
2. Coverage of Pre and Post-Hospitalization Costs: Costs of diagnostics and medicines are covered for:
- Up to 3 days before hospitalization (pre-hospitalization).
- 15 days after hospitalization (post-hospitalization).
- All pre-existing medical conditions are also covered.
3. Ayushman Card: The Ayushman Card acts like a pre-paid card worth ₹5 lakh.
- Can be used to avail free treatment at more than 27,000 empanelled hospitals across India.
- Every hospital must have Pradhan Mantri Arogya Mitras (PMAMs) to assist the beneficiaries.
4. Interstate Portability: The scheme offers interstate portability, allowing beneficiaries to access treatment at empanelled hospitals across different states.
5. Aadhaar-Based Authentication: Aadhaar-based authentication is required for:
- Card creation.
- Registration for treatment under the scheme.
6. Administration by the National Health Authority (NHA): The scheme is administered by the National Health Authority (NHA) under the Ministry of Health and Family Welfare.
- NHA has a governing board with representatives from the central government, domain experts, and state authorities.
- Post-Discharge Follow-up:
- NHA’s call center contacts beneficiaries 48 hours post-discharge to assess treatment quality.
- A second follow-up call is made 15 days post-discharge to check the patient’s prognosis.
7. Inclusivity: PM-JAY is an inclusive scheme, covering transgender individuals among its beneficiaries.
- 50 special packages were designed for transgender healthcare needs, including Sex Reassignment Surgery (SRS).
8. Anti-Fraud Mechanism: The National Anti-Fraud Unit (NAFU) designs, implements, and oversees anti-fraud initiatives within the scheme.
- Anti-Fraud Units also operate at the state level to prevent misuse and fraud in the healthcare system.
Achievements of Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PM-JAY):
1. Nudging of State Governments: The scheme has encouraged states and Union Territories, responsible for public health under India's federal structure, to expand healthcare coverage to more beneficiaries.
- National Sample Survey Organization (NSSO) 71st round: It was found that 85.9% of rural and 82% of urban households lacked healthcare insurance. PM-JAY specifically targets deprived and poor families, addressing this critical gap.
2. Effective fiscal management: AB-PMJAY has reduced Out-of-Pocket Expenditure (OOPE), which has been a significant financial burden for Indian households.
- Over 17% of Indians previously spent more than 10% of their household budget on healthcare, leading many into debt. The scheme mitigates these financial risks by providing coverage for secondary and tertiary care.
3. Bridge the gap: PM-JAY has effectively connected healthcare providers with service users by uniting them through government channels, thereby addressing the shortfall in access to healthcare services for marginalized populations.
4. Spirit of Inclusiveness: The scheme promotes inclusivity, with 48% of treatments being availed by women, and also covers transgender individuals.
- Beneficiaries can access services even if they do not possess an Ayushman card at the time of treatment, ensuring no one is left out.
5. Regularisation of process: In order to engage private healthcare providers effectively, Health Benefit Packages (HBPs), covering in-patient treatment, have been revised five times in the last five years to stay relevant and comprehensive.
6. Early Claim settlement: To ensure smooth and timely financial management, efforts are being made to settle claims within a 15-day standard. States like Uttarakhand have managed to reduce the settlement time to under seven days, setting an example for others.
7. Reward to Hospitals: To encourage trustworthy and efficient hospital service, hospitals with a good record receive 50% of the claim amount as an upfront payment immediately after submitting their claims, without the need for adjudication.
8. Interoperability: The scheme is particularly beneficial for migrants, providing interoperability across states and ensuring that the poor and marginalized can access healthcare services even when they move across borders. This has proven vital in emergencies.
9. Effective Monitoring: The end-to-end digital service delivery system eliminates bias, ensuring transparency. The National Health Authority (NHA) monitors the scheme's implementation through internal checks and a public dashboard, enabling real-time tracking.
10. Fraud management: The establishment of institutions like the National Anti-Fraud Unit (NAFU) has significantly reduced fraud in the registration, verification, and insurance claims processes, ensuring accountability and integrity within the system.
11. Use of technology: Leveraging Artificial Intelligence (AI) and Machine Learning (ML), the NHA uses advanced technology to detect suspicious transactions and potential fraud, ensuring efficient monitoring and reducing misuse of the scheme.
Issues
1. Exclusion Error: One of the most significant challenges is the Socio-Economic Caste Census (SECC) data, which has been criticized for non-transparent methods of data collection and outdated population figures.
- These errors can lead to eligible beneficiaries being left out, and hence, there is a need to update and improve the estimates for better targeting.
2. Asymmetric Federalism: Several states have increased the coverage of the scheme via state schemes. This entails increased expenditure by states which choose to expand coverage, such as Kerala. However, this may be particularly hard for cash-strapped states like Bihar which depend on Union government funding more than their own resources.
3. Ghost Beneficiaries: Unrelated ineligible beneficiaries are admitted based on forging a relationship with the head of the beneficiary family. The challenge that lies ahead for National Health Authority is to strengthen artificial intelligence to pick up all such instances of fraud.
4. Future Fiscal Burden: As insurance coverage grows, there is a possibility of a rise in hospitalization rates, leading to increased claim ratios and higher premiums, which may strain government finances.
- Insurers, needing to run a profitable business, may demand higher premiums, creating fiscal stress on the program.
5. Infrastructural and man-power issues: Public health infrastructure faces severe deficiencies:
- 10% of Primary Health Centers (PHCs) lack doctors.
- 56% of sub-centers (SCs) lack staff washrooms, 73% lack separate washrooms, and 36% of PHCs do not have gender-segregated facilities.
These infrastructural gaps undermine the scheme's effectiveness.
6. Compliance Burden: In rural India, beneficiaries face a significant compliance burden due to long distances to hospitals, which makes access to care difficult. This often results in a lower than expected usage of health services.
7. Double Charging: Publicly Funded Health Insurance Schemes (PFHIS) are prone to double charging, where the hospital makes the patient pay for some or all services/medicines/diagnostics which are covered under the PFHI and also claim the reimbursement from the PFHI.
8. Information Asymmetry: There is a lack of awareness among beneficiaries about their entitlements under the scheme.
- The hierarchical structure of the healthcare system and the complexity of the scheme exacerbate this issue, leading to low utilization of the available benefits.
9. Outpatient Care: AB-PMJAY does not cover outpatient care, which constitutes between 40% and 80% of Out-of-Pocket Health Expenditure (OOPHE). This is a significant gap, as outpatient care is a major contributor to rising health expenses.
10. Upcoding: Upcoding is the practice of fraudulent medical billing in which the bill for a medical service is more expensive than it should have been based on the service that was performed.
11. Cost: The rates provided by PM-JAY serve as guidelines and have not been strictly followed by states, which has either kept big hospitals at bay or resulted in disparities in service costs across states.
12. Empanelment: Empaneling hospitals in remote areas, such as in the northeast and Leh, has been difficult, creating significant gaps in healthcare access for people living in these regions.
13. Inequity in access: There is inequity in access to healthcare, especially for the poor. Many patients suffering from serious illnesses find that their conditions are not listed among the medical packages covered under AB-PMJAY, leaving them without adequate support.
14. Implementation: The scheme faces several implementation issues:
- Improper procedures for empanelment and cost fixation mechanisms.
- Inordinate delays in reimbursement to hospitals.
- Lack of standardization in services across hospitals, with the National Accreditation Board for Hospitals (NABH) certification covering only some hospitals.
- Budgetary constraints are also a major issue, as the AB budget, while substantial, may not be sufficient to cover the growing costs of the scheme. This has resulted in payment backlogs to hospitals, which has led some hospitals to limit the number of patients they accept under the scheme.
- Beneficiaries often prefer private hospitals over public ones due to perceived better quality care and fewer capacity constraints in private institutions.
15. Low Monitoring and Grievance Redressal: Monitoring of the scheme is suboptimal, with several states yet to form State Health Authorities (SHAs) or establish Anti-Fraud Cells and Claim Review Committees.
- For example, a CAG report revealed the fraudulent registration of 7.5 lakh beneficiaries under a single phone number.
- Additionally, the Public Financial Management System (PFMS) guidelines for tracking expenditure flows have not been fully complied with.
16. Parallel Systems and Beneficiary Overlap: Some states operate parallel transaction management systems, leading to the overlap of beneficiaries between Ayushman Bharat and state-specific health schemes. This creates confusion and may result in inefficiencies in service delivery.
Suggestions for improvement
- Improve the public health sector by dealing with limited resources and creating systems that encourage healthcare providers and patients to support universal health coverage.
- There is a need to consolidate government healthcare spending and clear payment backlogs owed to hospitals by the government.
- To realise the scheme’s full potential, the National Health Authority (NHA) along with its counterparts in the states should aim to provide every possible beneficiary with an Ayushman Card.
- State governments which have not formed the SHAs, Fraud cells etc. should consult and through dialogue the bodies should be constituted to improve the interoperability of the scheme.
- The issue of upcoding, dead patients availing benefits, double charging should be addressed by reducing information asymmetries and increasing the awareness of the people.
- Parallel transactions management system creates ambiguities in management and ensuring accountability, states and Centre should come up with a unified and transparent system.
- Recommendations by Indian Medical Association (IMA):
i. Government hospitals, which already provide services free of charge, should be excluded from the scope of the scheme. Instead, public hospitals should receive direct funding from the government.
ii. India should move away from utilizing insurance-based healthcare delivery due to high administrative costs and problematic ties with insurance companies, which often prioritize profits over quality care.
The goal of 'Swasth Bharat' should be to embrace a holistic approach to health, which will naturally progress towards a 'Sampann Bharat' or a prosperous India. To realize this vision, there is a need for effective implementation of this scheme.