Healthcare has been a big challenge for India since independence. The rapidly growing population worsens the situation. It was also on top of the agenda of NDA government ever since they came to power in 2014.National Health Policy-2017 was announced having vision-Swasth Bharat, Samriddh Bharat. The aim is to build New India by 2022 and ensure enhanced productivity, Well being, Avert wage loss and impoverishment, generate lakhs of jobs especially for women.
On 1 Feb 2018, Sri Arun Jaitley, Finance Minister announced in his budget speech about the ambitious health care plan of his government, Ayushman Bharat-National Health Protection Mission(AB-NHPM).A budget of Rs 10500 Crs was allocated for the scheme.
He proposed two pronged strategy:
1.Setting up of Health and Wellness Centers(HWC).He proposed to open 150000 centers closer to homes of people. It will provide comprehensive health care including non communicable diseases, maternal and child care. It will also provide free essential drugs and diagnostic services. The budget of Rs 1200 Crore was allocated, besides contribution from private sectors was contemplated through Corporate Social Responsibility(CSR) activities. First Health and Wellness Centre was opened on 14 April 18 in Bijapur,Chhattisgarh.
2.The second flagship programme was National Health Protection Scheme(NHPS) under Ayushman Bharat.Under the scheme 10 Cr vulnerable families(50 Cr people approx..) will be provided with cover of Rs 5 lacs per family per year for secondary and tertiary care hospitalization. The scheme was going to be a biggest health care scheme in the world funded by the government. He promised to provide adequate funds for the successful implementation of the scheme.
PM in his Independence Day speech of 2018 announced that Health Insurance Scheme will be rolled out soon in some states on pilot basis.
On 23 Sept 18, in Ranchi, PM announced Ayushman Bharat-PM Jan Arogya Yojana (AB-PMJAY).The scheme was to become operational from 25 Sept 18 the birth anniversary of Pt Deendayal Upadhyaya.
SALIENT FEATURES OF THE PMJAY SCHEME:
1.The aim of the scheme to provide universal Health Care.
2.Primary health care to be provided through Health & Wellness Centers.
3.Secondary and Tertiary care to be provided through Empaneled Health Care Providers(EHCP) under PMJAY Scheme. It will provide cover upto Rs 5 lacs per family, per year towards hospitalization.
4.Scheme expected to cover 10.74 Crore vulnerable families comprising of 50 Crore family members.
5.Scheme will provide Cashless and paperless services at the point of service i.e. EHCP hospitals.
6.It will save the people from the exorbitant expenditure on hospitalization and will improve financial health of the people.
7.The scheme is going to be the largest government funded scheme in the world. It is a step towards the vision of Universal Health Coverage of GOI.
8.The scheme will be implemented both in Rural and Urban areas.
9.Existing Rashtriya Swasthya Bima Yojana(RSBY) and Senior Citizen Health Insurance Scheme(SCHIS) will be subsumed in PMJAY scheme.
Socio-economic Caste Census(SECC) data,2011 will be the base for identifying the eligible beneficiaries for both rural and urban areas. Scheme primarily targets the poor and deprived rural families and identified urban families. Beneficiaries already identified under Rashtriya Swasthya Bima Yojana(RSBY) will be eligible in the scheme in both rural and urban areas. In rural area identification of beneficiaries will be on the basis of Deprivation Categories (D1,D2,D3,D4,D5 & D7).Whereas in urban area it will be based on 11 Occupational categories as per SECC data.
Entire working of the scheme has been digitalized and sophisticated software has been developed to keep the process paperless and have less manual intervention. The Beneficiary Identification System(BIS) has been created to find and validate the beneficiaries at Common Service Centre(CSC) and point of care.NHA has already tested the system in 80 districts across 10 states. System will be further modified based on feedback received.
COVERAGE OF THE PMJAY:
The Scheme will be implemented in all States and Union Territories. States have to opt for the implementation of the scheme. In NSSO survey it has been found that 86% of rural and 82% urban population have no access to healthcare insurance. Huge expenditure on healthcare pushes the families into debt as they meet the expenditure on healthcare through personal borrowings. This has serious implication on financial conditions of the families. At present 67% of expenditure on health comes from out of pocket (OOP) of households,22% is funded by Govt,7% by local bodies and 4% private insurance companies. There is a big gap in government contribution in Health welfare.
IMPLEMENTATION OF PMJAY SCHEME:
For focused and effective implementation of the scheme a separate entity called National Health Agency (NHA) has been formed.NHA will provide vision and directions for effective implementation of the scheme. States also have to set up similar State Health Agency(SHA) for implementation in their state. For overall monitoring of the scheme a National Health council has been formed. Health Minister is ex-officio chairman of the council.
Presently 33 States and UTs have joined the scheme and Odisha, Delhi and Telengana have not joined the scheme so far.
Expenditure on premium will be shared in a specified ratio by Central and state governments as per the Ministry of Finance guidelines. For transfer of funds in time an Escrow a/c is to be opened and SHA has to contribute their matching share within defined time.
CORE BENEFITS OF THE SCHEME:
The following are the major benefits to the beneficiaries:
1.Provides coverage up to Rs 5 lacs per year per family irrespective size and age of family members. Priority is given to Girl Child, Women and Senior Citizens.
2.Provides Cashless and Paperless facilities in Empanelled hospitals.
3.Covers cost of Medicines, Surgeries, Diagnostics and other treatments.
4.Facilities could be availed throughout India.
5.Existing diseases are also covered from the day one.
PRADHANMANTRI AROGYA MITRA(PMAM):
For an effective and smooth implementation of the scheme, a facilitator has been created called as PM Arogya Mitra. He will be professionally trained and will act as a facilitator between the beneficiary and hospital to avail the benefits under PMJAY scheme. PMAM is posted at the empaneled hospitals and will have a help desk. PMAM will verify the eligibility and will ensure enrolment in the scheme.
PMAM are being trained in the institute empaneled by National Skill Development Corporation(NSDC).A total of around 4000 personnel have trained as PMAM in 27 states.
FLOW CHART OF SCHEME
The above flow chart shows that the entire process is cashless and beneficiary is not required to pay any amount to the empaneled hospital.
The present data has revealed that the scheme has taken a flying start since its launch and gaining popularity day by day.
1.PMO has sent beneficiary card with family card to 1.70 Crore identified beneficiaries.
2.Total 23287 claims amounting to Rs 38.10 Crore have been settled.
3.Total 23297 claims amount to Rs 45 Crore are pending for settlement.
4.Total 32814 hospitals have applied for enrolment under the scheme. Total 13865 hospitals have been enrolled so far.
5.33 states and UTs have implemented the schemes.
6.Around 4000 Arogya Mitra (PMAM) have been appointed.
Whenever such large scale welfare schemes are floated it faces some inherent challenges and PMJAY is not an exception. The following are major challenges:
1.Selection of eligible beneficiary will be a big challenge as some ineligible persons will also try to sneak into the list.
2.There may be misutilization of the scheme with the connivance of cardholder and hospital.
3.OPD patients may be converted into IPD deliberately by hospitals in order to get undue advantage of the scheme.
- Hospitals may quote higher package than the eligible package.
5.Hospitals may treat the disease for which they are not equipped.
6.Doctors may perform unnecessary procedures in order to get higher claim amount.
7.Hospital may coerce the patient to pay same extra amount inspite of cashless scheme.
Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana(AB_PMJAY) is a paradigm shift in Health care in India. Scheme has been touted as one of its kind and biggest in the world. The scheme is in nascent stage and has been rolled out in right earnest. The success of the scheme much depends upon its implementation by States & UTs. National Health Agency (NHA) will have to periodically review the performance of the scheme and take corrective steps. They will also have to plug the loop holes of the scheme to prevent the misuse.