Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (AB-PMJAY)

Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) India has been able to wipe out the scourge of diseases such as polio, guinea worm disease, yaws and maternal and neonatal tetanus and control the incidence of HIV/AIDS that crippled people and their ability to build better lives for themselves.

• However, challenges remain in the health system in India and it is currently facing the unique situation of a 'triple burden of disease'.
  • Estimation of eradicating major communicable diseases remains unfinished, the population is also bearing the high burden of non-communicable diseases and injuries.
• Delivery of Healthcare services in India remains inadequate and fragmented.
• Public sector hospitals in India are overburdened, underfunded and their utilisation varies widely.
• More than half of health services are provided by the private sector which is not effectively regulated.
• Health sector continues to be characterized by high out of pocket expenditure, low financial protection, low health insurance coverage among both rural and urban population.
• India's general government expenditure on health has remained stagnant over the last two decades at close to2% of its GDP.
  • The World Health Organization recommends that a country should spend at least 4% of its gross domestic product (GDP) on health. Canada and the United Kingdom allocate 8 percent of their GDP to provide comprehensive social health insurance.
  • Less than a quarter of India’s meagre public health expenditure is allocated to preventive care.
• At the national level, India only has 62 doctors for every 1,000 population, as opposed to the World Health Organization standard of 1 doctor per 1,000 population.

Approach Adopted

• The focus of public policy on health since Independence has been on building and strengthening Public Health Care delivery with the government assuming the role of a provider of services.
• in the last decade the government introduced new initiatives to strengthen demand-side financing and address gaps in equity and affordability of Healthcare. For example, Rashtriya Swasthya Bima Yojana was launched in 2008. It did not have a strong linkage with Primary Health Care as a result healthcare in India remained fragmented and operated in silos.
• Ayushman Bharat represents a significant transition from a sectoral segmented approach to comprehensive holistic approach bringing together preventive, promotive, curative, rehabilitative aspects of care along with a continuum of care.

The ambitious Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (PMJAY) completes a year with impressive numbers to show but it still faces challenges of sustainability, synchronization and financial fulfilment.

• It has recorded 46.4 lakh hospital treatments worth ₹7,500 crore with 60% of the amount being spent on tertiary care. This has resulted in saving of over ₹12,000 crore to the beneficiary families.
• More than 18,236 hospitals have been empanelled across India to ensure optimal accessibility to the eligible families. Out of the total hospitals empanelled, 53% are private, especially multi-specialty.
• Currently, 32 States and Union Territories are implementing the scheme and more than 10 crore beneficiary cards have been issued.

Ayushman Bharat Ayushman Bharat is a two pronged approach towards Universal Healthcare. Health and Wellness centres - They will provide comprehensive Primary Health Care, free essential drugs and follow up of hospitalization cases. They will also conduct yoga sessions to promote wellness and have a much wider range of free drugs and diagnostics. The HWCs serve as the awareness, screening and referral link between patients and PMJAY. Pradhan Mantri Jan Arogya Yojana (PMJAY) - It provides a health protection cover of rupees 5 lakh per family per year to the bottom 40% of poor and vulnerable population for hospitalization expenses towards the treatment of serious illnesses. Ayushman Bharat aims to offer financial risk protection to the beneficiary families through a system of demand led Healthcare initiative that meets their immediate hospitalization needs in a cashless manner. Key features of Pradhan Mantri Jan Arogya Yojana It provides cashless cover upto rupees 5 lakh to each eligible family per annum for listed secondary and tertiary care conditions. The cover under the scheme includes all the expenses including non-intensive and Intensive Care Services, medicine and Medical consumables and post-hospitalization follow up care upto 15 days. There is no cap on family size and age of members.  All pre-existing diseases are covered from the very first day unlike private insurance schemes. Benefits covered under PM-JAY are portable across the country and any eligible beneficiary can visit any empanelled Hospital across the country. The stated aims of the insurance portion of the programme include to cushion poor families against the financial shock that a health emergency can trigger, as well as to bring the private sector to small cities Support Mechanisms  A National Health Authority (NHA) has been mandated to roll out and coordinate the programme. A cadre of frontline health service professionals called Pradhan Mantri Aarogya Mitras (PMAMs) are trained to facilitate provision of treatment to beneficiaries at hospitals. The scheme is supported by a strong IT backbone that facilitates the identification of beneficiaries, records treatments, processes claims, receives feedback, and addresses grievances. A live dashboard helps in monitoring and improving performance, based on real-time data and regular analysis. This platform also helps states to compare their performance. A strong and sophisticated fraud prevention, detection and control system at the national and state level has proved to be critical for PM-JAY to ensure that frauds are largely prevented. If attempted, they are quickly detected and strong action is taken. Implementation Model Considering the fact that states are at different levels of preparedness and have varying capacities the PM-JAY provides them with the flexibility to choose their implementation model which can be through Insurance, Trust or Mix mode. Insurance Mode - The state government appoints an insurer at a defined rate for taking over the financial risk of the beneficiaries. Trust Mode - The state government creates an agency which pays the claims of the hospitals as per actual utilisation. The risk of health protection lies with the state. Mixed Mode - The state uses a combination of insurance and trust modes generally where low-cost common procedure (secondary care) is managed by the insurer and high cost specialised procedures managed by the state trust. PMJAY, being a centrally sponsored scheme is fully funded from the consolidated fund of India. The expenditure is shared between Central Government and state government as per the sharing instructions issued by the Ministry of Finance. PMJAY embodies a policy shift where the government now assumes the role of a purchaser of services from that of the provider and also is surely a giant Leap forward towards the achievement of the sustainable development goals specially SDG 3.8 achieving Universal health coverage.

The data that the government has so far put in the public domain centres largely around the numbers of beneficiaries, hospitalisations, and reimbursement claims, points to the worrying inclusion and exclusion errors, both stacked against the poor.

Exclusion Errors

• The poor in India systematically report lower rates of reported illness, medical attention-seeking and hospitalisation than the rich. This occurs at both the individual/ household level, and the state-level.
  • This arise from lower health awareness and from limited ability to access healthcare.
  • For the same reasons, richer states have higher reported illnesses and higher hospitalization rates.
• Per-person disease burden, measured by “disability-adjusted life years" was the highest in Assam, Uttar Pradesh, and Chhattisgarh in 2017, and the lowest in Kerala and Goa, according to the latest edition of the Global Burden of Disease database.
  • From AB-PMJAY data, it would appear that this pattern is being replicated, and the scheme has not yet been able to substantially alter inter-state patterns in medical attention-seeking behaviour.
• Until June 2019, the most recent month for which data was submitted to Parliament, Madhya Pradesh had enrolled the most beneficiaries for the scheme, followed by Uttar Pradesh, Bihar, and Maharashtra.
  • However, it was Chhattisgarh, followed by Gujarat, Kerala and Tamil Nadu which submitted the most claims; and in terms of value of the claims, Gujarat had by far the most expensive treatments reimbursed.

Inclusion Errors

• Early reports indicated that the scheme was being most widely used for procedures including dialysis, cataract, and cesarean deliveries that were in many cases covered by other existing government schemes. The high rate of hysterectomies conducted under the scheme has also raised red flags.
  • The use of hysterectomies for relatively benign conditions is a public health issue, and insurance schemes could exacerbate the issue.
  • This has raised the concern that the scheme might not yet be pushing up treatment for under-treated non-communicable diseases.
  • A study conducted in Haryana and Gujarat, and published earlier this year, found that the unmet need for treatment, was found to be highest for cardiovascular conditions, followed by other non-communicable conditions and respiratory infections.
• A study commissioned by AB-PMJAY found that one-third of all claims involved high-value claims.
• Compared to overall patterns, high-value claims were skewed in favour of male beneficiaries and private hospitals, and just 20 hospitals accounted for 17% of high-value claims and 5% of total outlays.
• Higher incidence of more expensive intervention in private than in public hospitals. Private hospitals were raising most claims for more expensive neonatal packages with a longer hospital stay, however the quality of care provided was also higher.
• According to the public health experts Ayushman Bharat lacks in rational pricing and health insurance for all as it covers only a section of the population.
  • Uneven geographic distribution of poor families makes it difficult to find out the real targeted beneficiaries.

Other Concerns/Limitations

• Relatively better infrastructure for health in the top-performing states is expected to cause an influx of patients there. This can lead to two potential scenarios.
  • The burden on the infrastructure in these states would increase. This may negatively affect their service-providing capability.
  • Even if the states are able to develop infrastructure commensurate to demand, the expenditure would be borne by the lower-performing states. This implies a transfer of wealth or policy premium from the states down in the ladder to the ones at the top.
  • This is because the funds provided by state A (say, Bihar) for its residents to insure themselves, would be spent by the person at the healthcare facilities in state B (say, Gujarat).
• States’ participation in the scheme mandates them to contribute funds for insurance, which naturally diverts funds allocated to building healthcare infrastructure within the state.
• Under the 7th schedule of the Indian Constitution, health is a state subject. In such a scenario, a nationwide scheme of health insurance to supply healthcare facilities at the state level leads to a dilution of the state responsibility in the provisioning of the same.
• Diversion of resources from preventive measures of disease management, towards curative measures which would not be efficient in the long run.

Other factors pushing the programme to its limits include increasing population, disease burden, concentration of health services in urban areas, and lack of awareness of the scheme among a major chunk of entitled beneficiaries.

Way-Forward

• There is a need to scale up this programme with quality and sustainability for all stakeholders.
• The focus needs to be on coverage of those who are outside the ambit of healthcare. Expansion of coverage to include the lower-middle and middle class needs to be a priority.
• Strengthen delivery mechanism which includes expansion of private providers’ network, shift towards organized care delivery, innovations, speciality, low cost, and value-based care.
• Along with delivery and quality, the government should adopt innovative funding models for long-term sustainability. For example, attract strategic funding through various other internal and external sources.
• Given the state of primary healthcare in India, we need more schemes such as the Swacch Bharat Abhiyan to take care of the actual spread of diseases and not merely of their treatment.
• Recommendations made by the Finance Commission panel earlier this month of declaring healthcare a right and shifting health to the Concurrent List are inherently linked and are favourable to the success of Ayushman Bharat.
• The success of the programme will rely on a reformed and adequately resourced public sector to lead implementation, delivery, and monitoring of the scheme.

There is little doubt that the scheme has improved access to hospitalisation across the country, with large numbers of beneficiaries enrolled and a high insurance cover. However, it is not yet clear that scheme is helping the most vulnerable cross existing barriers to access medical help and be protected from excess interventions.

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