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Ayushman Bharat
About the Scheme :
Flagship scheme of Government of India launched in 2018 as recommended by the National Health Policy, 2017, to achieve the vision of Universal Health Coverage (UHC).
Universal Health Coverage (UHC)As per WHO, UHC means all people have access to quality health services they need, any time without financial hardship. It covers a full continuum of essential health services, like health promotion to prevention, treatment, rehabilitation and palliative care. SDG 3 aims to provide good health and well being to all. |
The Scheme Has 2 components –
- Health and Wellness Centres (HWCs) and Pradhan Mantri Jan Arogya Yojana (PM-JAY)
Health and Wellness Centres(HWCs) :
- Creation of 1,50,000 Health and Wellness Centres (HWCs) by transforming the existing Sub Centres and Primary Health Centres to deliver Comprehensive Primary Health Care (CPHC).
- Covers both, maternal and child health services and non-communicable diseases, free essential drugs and diagnostic services.
Pradhan Mantri Jan Arogya Yojana(PM-JAY) :
Largest health assurance scheme in the world and aims at providing a health cover of Rs. 5 lakhs per family per year for secondary and tertiary care hospitalisation across public and private empanelled hospitals in India.
Features of PM-JAY:
- Cashless access to health care services for the beneficiary at the point of service.
- Mitigate catastrophic expenditure on medical treatment.
- Covers up to 3 days of pre-hospitalisation and 15 days of post-hospitalisation expenses such as diagnostics and medicines.
- No restriction on the family size, age or gender
- Benefits of the scheme are portable across the country
- Covers all the costs related to treatment, including drugs, supplies, diagnostic services, physician’s fees, room charges, surgeon charges, OT and ICU charges etc.
- Public hospitals are reimbursed for the healthcare services at par with the private hospitals.
- Fully funded by the Government and cost of implementation is shared between the Central and State Governments.
Eligibility :
- The households chosen are determined by the levels of deprivation and occupation outlined in the Socio-Economic Caste Census 2011 (SECC 2011) for rural and urban areas.”
- Beneficiaries under the Rashtriya Swasthya Bima Yojana (RSBY).
- Eligibility Criteria for Rural Households:
- Families living in one room with kucha walls and roof.
- Households with no adult member within the age group of 16-59 years.
- Households with a disabled member.
- SC/ST households.
- Landless households earning a major part of their family income from manual casual labour
- Eligibility Criteria for Urban Households:
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- Domestic worker
- Beggar
- Ragpicker
- Home-based workers/ artisans/ tailors/ handicrafts workers.
- Sanitation workers/ sweepers/ mali
- Construction worker/ labour/ painter/ welder/ security guard/ plumber/ coolie/ mason and other head-load workers
- Chowkidar/ washer-man
- Electrician/ mechanic/ assembler/ repair worker
- Transport worker/ rickshaw puller/ conductor/ cart puller/ driver/ helper to drivers and conductors
- Waiter/ shop worker/ assistant/ attendant/ helper/ peon in small establishment/ delivery assistant
- Street vendors/ hawkers/ cobbler/ other service providers on the street.
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Challenges:
- Low Public expenditure: PM-JAY expenditure is 2.5% of total health expenditure as actual spending is less than allocated.
- High Out of Pocket expenditure:India ranks 67 out of 189 countries in terms of out-of-pocket expenditure.
- Low QualityPrimary Healthcare Centres (PHCs): PHCs are underutilised and have high wastage and inefficiency like hospital checking whether a person is authorised to receive PM-JAY or not.
- Private Better Public: A belief among people that private hospital services are better than government ones leads to more demand for private hospitals despite having government hospitals closer to them.
- Empanelled Private Hospitals Syndrome:
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- Number of people per empanelled healthcare provider (EHCP) is very high in some states. For example : Bihar having 10,000 families per EHCP.
- Delays in claiming payments despite having clear guidelines about turnaround time.
- Claim rejects by insurance companies after operation of patients due to documentation or technical errors.
- Cap on the amount by the government that can be charged by private hospitals for different treatments.
- Inactive Empanelled Hospitals: In states like UP, around 39% of empanelled hospitals are inactive and only 50% were active in the last 6 months.
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Impact of PMJAY :
Solutions :
- An insurance model where the money isn’t given directly to healthcare providers in advance but on a performance basis.
- Leveraging Healthcare Cooperatives: Pooling of health professionals and users to reconcile misalignments between healthcare supply and demand. Singapore has developed this cooperative model and has one of the best health services in the world.
- PLI Scheme for Medical Devices: Indigenous production of medical devices should be there to bring down overall cost of treatment.
