Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (PM-JAY)

IN NEWS:

• Recently, CAG report has highlighted several irregularities in the implementation of the Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (PM-JAY) scheme.

PRADHAN MANTRI JAN AROGYA YOJANA (PM-JAY):

•  Ayushman Bharat, 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).
• It has two inter-related components
  • Health and Wellness Centres (HWCs) and
  • Pradhan Mantri Jan Arogya Yojana (PM-JAY).

• PM-JAY is the world’s largest health insurance/ assurance scheme fully financed by the government.
• Launched in 2018, it offers a sum insured of Rs.5 lakh per family for secondary care as well as tertiary care.
• It provides cashless and paperless access to services for the beneficiary at the point of service in any (both public and private) empanelled hospitals across India.
• The scheme is portable, and a beneficiary can avail medical treatment at any PM-JAY empanelled hospital outside their state and anywhere in the country.
• Coverage:

• It covers 3 days of pre-hospitalisation and 15 days of post-hospitalisation, including diagnostic care and expenses on medicines.
• There is no restriction on the family size, age or gender.
• All pre–existing conditions are covered from day one.
• Beneficiaries:

• It is an entitlement-based scheme that targets the beneficiaries as identified by Socio-Economic Caste Census (SECC) data.
• Funding:

• The funding for the scheme is shared – 60:40 for all states and UTs with their own legislature, 90:10 in Northeast states and Jammu and Kashmir, Himachal and Uttarakhand and 100% Central funding for UTs without legislature.
• Nodal Agency:

• The National Health Authority (NHA) has been constituted as an autonomous entity under the Society Registration Act, 1860 for effective implementation of PM-JAY in alliance with state governments.
• The State Health Agency (SHA) is the apex body of the State Government responsible for the implementation of AB PM-JAY in the State.

ACHIEVEMENTS OF THE SCHEME:

• Vast coverage of the scheme:

• Since its inception in 2018, Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) has provided a health cover of Rs 5 lakh per family per year for secondary and tertiary care hospitalisation to about 15.5 crore families (more than 50 crore beneficiaries), making it the world’s largest health assurance scheme.
• Convergence with state schemes:
  • The scheme’s success prompted the states and UTs to extend it to more beneficiaries, and states’ schemes are being implemented in convergence with AB-PMJAY.
  • For instance, eleven states and UTs have already taken steps to ensure 100 percent coverage of their respective populations.
• Interstate portability:
  • Interstate portability is a key component of AB-PMJAY. The patient is entitled to get care in any other state that offers the AB-PMJAY programme if they are registered in one state.
  • Migrants have found this to be useful, especially during emergencies. For instance, amid the COVID-19-induced lockdown in 2020, the scheme was widely used by migrant workers.
• Out-of-pocket health expenditures:
  • The scheme has catered to more than 5.39 crore admission events worth Rs 66,284 crore in the last five years.
  • If the beneficiaries had availed themselves of the same care outside AB-PMJAY’s ambit, the total cost of treatment would have been nearly two times higher. This has resulted in savings of more than Rs. 1 lakh crore.
  • This contributes directly to reducing the out-of-pocket health expenditures of the public.
  • For instance, as per Health financing profile 2017 by World Health Organisation, the healthcare out-of-pocket expenditure (OOPE) in India was estimated at around 67 percent of the total health expenditure, higher than the world average of around 18 percent, indicating high expenditure, which leads to a high incidence of catastrophic expenditures and inequality.
• Supports vulnerable sections of population:
  • The AB-PMJAY includes vulnerable sections in its coverage by adding people from the transgender community to its list of beneficiaries.
  • For instance, around 50 packages were designed specifically for the community, including packages on Sex Reassignment Surgery (SRS).
  • Also, as per the reports, 48 percent of treatments under the scheme have been availed of by women.
• Claim settlement in a short period:
  • Efforts are being made in the scheme to settle the claims within a defined period of 15 days. A few states, like Uttarakhand, have brought down the claim settlement time to less than seven days.
  • Also, efforts are being made to reward hospitals with a trustworthy record with an upfront payment of 50 percent of the claim amount immediately after submission of claims, without adjudication.
  • Service delivery is end-to-end digitised, and the claim processing is completely faceless.
• Pradhan Mantri Arogya Mitras:
  • The scheme ensures that the difficulties of people from poor and underprivileged sections in accessing healthcare services are mitigated.
  • Every hospital is mandated to have dedicated Pradhan Mantri Arogya Mitras (PMAMs) who guide the beneficiaries.
• Use of technology:
  • The scheme introduced, Ayushman Card, is like a pre-paid card worth Rs 5 lakh that can be used to avail free treatment at more than 27,000 empanelled hospitals. So far, more than 24 crore Ayushman Cards have been created. It should be noted that a person on the beneficiary list is not denied service if she does not have a card.
  • Also, the Ayushman Bharat Digital Mission (ABDM) was launched, which aims to develop the backbone necessary to support the integrated digital health infrastructure of the country.
  • For extra reading: https://ilearncana.com/details/Ayushman-Bharat-Digital-Mission-ABDM/2555

CHALLENGES FACED BY THE SCHEME AND DISCREPANCIES POINTED OUT BY THE CAG REPORT:

The following issues or irregularities were raised by the CAG report:

• Errors in beneficiary databases:
  • According to the CAG report, in the absence of adequate validation controls, errors were noticed in beneficiary databases, such as invalid names, unrealistic date of birth, duplicate PMJAY IDs, and an unrealistic number of family members in a household.
  • For instance, report said that there were cases of multiple beneficiaries being linked to a single Aadhaar number.
  • The CAG report also said that patients earlier shown as "dead" continued to avail treatment under the scheme.
• Ineligible Beneficiaries:
  • According to the CAG report, ineligible households enrolled as PMJAY beneficiaries in six States and UTs and took advantage of the benefits.
  • Ineligible beneficiaries received payments ranging from 12,000 in Chandigarh to 22.44 crore in Tamil Nadu.
• Bogus numbers:
  • As per the CAG report, almost 7.5 lakh people in the scheme’s beneficiary database were linked with a single cellphone number: 9999999999. Almost 1.4 lakh were linked to the number 8888888888, while another 96,000 were linked to another obviously bogus number.
  • However, the central government made a clarification that the CAG finding that one mobile number is associated with multiple beneficiaries has no operational or financial implications as the beneficiary identification process under Ayushman Bharat PM-JAY is not linked with the mobile number.
  • The government also said that since there was a field for collecting mobile numbers, it is possible that some random ten-digit number was entered by the field-level workers in some cases in the earlier stages of the scheme's implementation.
• Shortages of infrastructure:
  • The CAG report raises issues such as shortages of infrastructure, equipment, and doctors at empanelled hospitals, as well as cases of medical malpractice.
  • Also, in several States and UTs, the available equipment in empanelled hospitals were found to be non-functional.
• Systemic issues:
  • The CAG report found issues, including private hospitals performing procedures reserved for public hospitals and hospitals with pending penalties amounting to multiple crores of rupees.

Other challenges:

• Fragmented Health Information System:
  • There is no unified database with information about patients, doctors, hospitals, services offered, etc.
  • This affects the quality of healthcare as well as the mobility of social security measures like PM-JAY. The Ayushman Bharat Digital Mission (ABDM) is a welcome step in this regard.
• Shortfalls in infrastructure:
  • The healthcare ecosystem in India lacks basic infrastructure to cater to the demands of a large population which would affect the smooth functioning of PM-JAY. For example, India has only 8.5 beds for every 10,000 citizens.
• Human resource deficit:
  • In India, doctor to patient (1 per 1456 patients) and nurse to patient (1.7 per 1000 patients) ratios are much lower than the WHO standards of 1/1000 in the case of doctor and 3/1000 in the case of nurses.

CONCLUSION:

• The PM-JAY is five years old, and it has not had proper scrutiny till now. The CAG report should prompt the government to address its shortcomings and improve its working.
• The National Health Authority and Ministry of Health and Family Welfare should examine in detail the recommendations of the CAG performance audit report and take necessary action to make the system more robust, efficient, and prudent by strengthening the existing IT platform and processes.

PRACTICE QUESTION:

Q. Discuss the achievements of PM-JAY and also examine the challenges faced by the scheme.