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5 Years of Ayushman Bharat

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September 28, 2023

Why in news?

The Ministry of Health and Family Welfare is organising Arogya Manthan to celebrate 5 years of Ayushman Bharat - Pradhan Mantri Jan Arogya Yojana (PMJAY).

What is Ayushman Bharat Scheme?

  • It is the world’s largest health assurance scheme.
  • Year of Launch2018 as recommended by the National Health Policy, 2017
  • Ministry - Ministry of Health and Family Welfare (MoHFW)
  • Aim – To achieve the vision of Universal Health Coverage (UHC) which encompasses promotive, preventive, curative, palliative and rehabilitative care.
  • FundingCentrally Sponsored Scheme  (expenditure incurred in premium payment will be shared between Central and State governments)
  • Coverage - Targets over 10 crore families (approximately 50 crore beneficiaries) based on SECC (Socio-Economic Caste Census)
  • Implementing Agency National Health Authority (NHA)
  • Components - It has 2 components covering all 3 types of care to the people.
    • Health and wellness Centres (HWC) – It covers primary care hospitalisation by providing comprehensive health care, including for non-communicable diseases and maternal and child health services.
    • Pradhan Mantri Jan Arogya Yojana (PM-JAY) – To provide a health cover of Rs. 5 lakhs per family per year for secondary and tertiary care hospitalization.
    • It covers up to 3 days of pre-hospitalization and 15 days post-hospitalization expenses such as diagnostics and medicines.
    • There is no restriction on the family size, age or gender.
    • Benefits of the scheme are portable across the country i.e. a beneficiary can visit any empanelled public or private hospital in India to avail cashless treatment.
  • Ayushman Bharat Digital Mission (ABDM) – It was launched in 2021 to provide Unique Digital Health IDs (UHID) for all Indian citizens to help hospitals, insurance firms, and citizens access health records electronically when required.

Public Health is a State Subject so states are responsible for providing effective public health to the people.

Status of Ayushman Bharat Scheme

  • About 15.5 crore families are covered.
  • It amounts to potential coverage of 50% of India’s population.
  • 11 states/UTs have pushed for 100% coverage of their respective population.
  • 48% of treatments under the scheme have been availed by women.
  • More than 24 crore Ayushman Cards have been created.
  • It has resulted in savings of more than Rs 1 lakh crore for the beneficiaries which is often cited as Out of Pocket Expenditure (OOPE).
  • According to the World Bank, proportion of out-of-pocket expenditure on healthcare in India, at 50.59 %, is the highest among emerging economies.

What attributes to the success of AB-PMJAY scheme?

  • Private sector participation – To elicit the participation of private service providers, health benefit packages (HBPs) are given.
  • Quicker settlement of claims – Efforts are being made to settle the claims within a defined standard of 15 days.
    • A few states like Uttarakhand have brought down the claims settlement time to less than 7 days.
  • Rewarding service providers – Reward to hospitals with a trustworthy record with an upfront payment of 50% of the claim without adjudication.
  • Guidance mechanism – Every hospital is mandated to have dedicated Pradhan Mantri Arogya Mitras (PMAMs) who guide the beneficiaries.

Ayushman Mitra initiative is a part of PM-JAY where any citizen of India can voluntarily enrol themselves as Ayushman Mitra to assist patients and to coordinate with beneficiaries and the hospital.

  • Interstate portability – A patient registered in one state is entitled to receive care in any other state that has an AB-PMJAY programme.
  • This has proved helpful to migrants, especially in emergencies.
  • Digitalised service delivery – NHA has deployed a public dashboard that tracks implementation on a day-to-day basis.
  • Ensures privacy – Beneficiary details are published without compromising their privacy and has faceless claim processing.
  • Real-time monitoring – The National Anti-Fraud Unit (NAFU) and state level Anti-Fraud Units oversee anti-fraud incidences.
  • Artificial Intelligence (AI) and Machine Learning (ML) technologies are used to detect suspicious transactions/potential frauds.
    • Aadhaar-based authentication for card creation and registration for treatment has been mandated.
  • Feedback mechanism – The NHA’s call centre makes calls to every beneficiary within 48 hrs of discharge to verify the quantity and quality of the treatment.
  • Inclusive treatment –Around 50 packages were designed specifically for the transgender community, including packages on Sex Reassignment Surgery (SRS).
  • Holistic treatment – It provides cashless secondary and tertiary inpatient care for almost all health conditions to its beneficiaries.

The scheme has taken the country closer to Sustainable Development Goal 3.8, which envisions universal health coverage.

What issues were noted by the CAG report for 2018 to 2021?

  • Registration of beneficiaries - The identification of beneficiaries based on the SECC could be irrelevant by now.
  • The CAG audit shows that matching of beneficiaries with the SECC in the online portal was not done and registrations and rejections of applications was done in an arbitrary manner.
  • The audit brought to light that there were large numbers of beneficiaries registered against the same mobile number or Aadhar.
  • Malpractices - The auditors found large scale corruption in insurance claims settlement.
  • Hospital empanelment done without checks - An Empanelled Healthcare Provider (EHCP) has to fulfil criteria like the presence of round-the-clock support systems like pharmacy, blood bank, laboratory, dialysis unit, ICU care etc.
  • Many hospitals after being empanelled for a certain set of fixed services, failed in providing them.
  • Missing hospitals - The existence of hospitals in the empanelled list did not necessarily translate into even their existence in the scheme
  • Shortage of infrastructure & personnel - Shortage of healthcare infrastructure, doctors and equipment in many States and UTs.

Public healthcare expenditure as a percentage of GDP at around 2%, places India among the underdeveloped economies.

What lies ahead?

  • NHA along with its counterparts in the states should aim to provide every possible beneficiary with an Ayushman Card.
  • Encouraging many private hospitals to join as empanelled hospitals under Ayushman Bharat Scheme.

 

References

  1. IE| Five years of Ayushman Bharat
  2. PMJAY web| Jan Arogya Yojana
  3. NHA web| National Health Authority
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