Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana

• 12 Aug 2023

For Prelims: Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana, Comptroller and Auditor-General of India (CAG), Socio-Economic Caste Census (SECC), Health Insurance Scheme.

For Mains: Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana, Issues with it and Way forward.

Source: TH

Why in News?

Recently, The Comptroller and Auditor-General of India’s (CAG) performance audit report flagged irregularities in the Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (PMJAY).

What are the Issues Highlighted By CAG?

• Treatment of Dead Patients:
  • The patients earlier shown as “dead” continued to avail treatment under the scheme.
    • The maximum number of such cases were in Chhattisgarh, Haryana, Jharkhand and minimum number of such cases were from Andaman & Nicobar Islands, Assam and Chandigarh.
  • 88,760 patients died during treatment specified under the Scheme. A total of 2,14,923 claims shown as paid in the system, related to fresh treatment in respect of these patients.
• Unrealistic Household Sizes:
  • There are instances where the registered household sizes were unrealistically large, ranging from 11 to 201 members.
    • Such discrepancies suggest a lack of proper validation controls during the beneficiary registration process.
• Pensioners Availing Benefits:
  • Pensioners in certain states were found to possess PMJAY cards and were availing treatment under the scheme.
    • Delayed actions to remove ineligible beneficiaries from the scheme led to ineligible individuals receiving benefits under the PMJAY.
• Bogus Mobile Number and Aadhaar:
  • It revealed that some beneficiaries were registered with a single bogus mobile number, potentially compromising the verification process.
  • Similarly, some Aadhaar numbers were linked to multiple beneficiaries, raising questions about proper verification.
• Systemic Failures:
  • CAG's report unearthed systemic issues, including private hospitals performing public hospital-reserved procedures, infrastructural inadequacies, equipment shortages, and medical malpractice cases.
    • Absence of adequate validation controls, invalid names, unrealistic date of birth, duplicate PMJAY IDs.
  • In several States and UTs, the available equipment in empanelled hospitals were found to be non-functional.
• Pending Penalties:
  • The report flagged pending penalties of Rs 12.32 crore from 100 hospitals across nine states.
• Issue of data collection in the Scheme:
  • It is possible that some random ten-digit number was entered by the field level workers in some cases.
    • Further, necessary changes have been made in the current IT portal used by the National Health Authority (NHA) to capture only valid mobile numbers, in case the same is possessed by the beneficiary.

What are the Clarifications Provided by the Government?

• Mobile Numbers and Verification:
  • The Ministry of Health clarified that mobile numbers were not used for beneficiary verification.
    • The scheme primarily identifies beneficiaries through Aadhaar-based e-KYC, and the mobile numbers were used for communication and feedback purposes rather than for verification.
• Authentication Options:
  • NHA provided multiple options for beneficiary verification, including fingerprint, iris scan, face authentication, and OTP.
    • Fingerprint-based authentication is commonly used and helps ensure the accuracy of beneficiary verification.

What is Ayushman Bharat-PMJAY?

• About:
  • PM-JAY is the world’s largest health insurance scheme fully financed by the government.
  • Launched in February 2018, it offers a sum insured of Rs.5 lakh per family for secondary care and tertiary care.
    • Health Benefit Packages covers surgery, medical and day care treatments, cost of medicines and diagnostics.
• Beneficiaries:
  • It is an entitlement-based scheme that targets the beneficiaries as identified by latest Socio-Economic Caste Census (SECC) data.
    • The National Health Authority (NHA) has provided flexibility to States/UTs to use non- Socio-Economic Caste Census (SECC) beneficiary family databases with similar socio-economic profiles for tagging against the leftover (unauthenticated) SECC families.
• 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.

Way Forward

• The PMJAY's irregularities demand corrective measures, including stringent beneficiary verification, hospital oversight, and a robust grievance redressal mechanism to ensure the scheme's intended effectiveness.