Sansad TV Special - Decoding Ayushman Bharat: A Beacon of Health & Hope | 11 Nov 2024

Why in News?

Recently, the Union Cabinet decided to extend health coverage under the Ayushman Bharat- Pradhan Mantri Jan Arogya Yojana (PM-JAY) to all senior citizens aged 70 and above, and is expected to benefit over 6 crore elderly individuals across India.

• Senior citizens aged 70 and above will now receive free hospital treatment along with the issuance of the Ayushman Vaya Vandana Card.

What is the PM-JAY Scheme?

• About Ayushman Bharat: Launched in September 2018, Ayushman Bharat is India’s flagship health initiative aimed at achieving Universal Health Coverage (UHC).
  • It focuses on providing financial protection for healthcare services to vulnerable populations.
• Components of Ayushman Bharat: It includes two primary components: Health and Wellness Centres (HWCs) and Pradhan Mantri Jan Arogya Yojana (PM-JAY).
  • Health and Wellness Centres (HWCs): HWCs aim to provide Comprehensive Primary Health Care (CPHC) services to communities.
    • Ayushman Arogya Mandirs (AAMs), formerly Ayushman Bharat Health and Wellness Centres (AB-HWCs), aim to provide comprehensive healthcare, including preventive, promotive, curative, rehabilitative, and palliative care.
    • 1,50,000 AAMs will offer universal, free primary healthcare.
    • These centers are designed to address preventive, promotive, and curative care needs by offering free consultations, medicines, and diagnostic services for maternal and child health, non-communicable diseases (NCDs), and other health concerns.
    • The initiative focuses on bringing healthcare closer to the people, ensuring equity and accessibility for all.
  • Pradhan Mantri Jan Arogya Yojana (PM-JAY): It provides Rs. 5 lakh per family per year for secondary and tertiary care hospitalization.
    • It is targeted at 12 crore vulnerable families (approximately 55 crore beneficiaries), covering the poorest 40% of the population.
    • The scheme is designed to address catastrophic health expenditure and prevent families from falling into poverty due to high medical costs.
    • PM-JAY is fully government-funded, with costs shared between the Central and State Governments. It allows beneficiaries to access care at both public and private empanelled hospitals across India.

What Benefits does PM-JAY Provide to Individuals and Families?

• Reducing Financial Vulnerability: PM-JAY has been availed by around 7.8 crore beneficiaries in the past 6 years, thus preventing millions from being pushed into poverty due to catastrophic health expenditures.
  • With Rs 5 lakh coverage, the scheme meets most families’ annual hospitalization needs, ensuring access to critical care without the risk of debt.
  • The share of Out-of-Pocket Expenditure (OOPE) in total health expenditure decreased from 62.6% to 47.1% in 2019-20, indicating progress toward financial protection and Universal Health Coverage for citizens.
• Empowering the Elderly: A major expansion of PM-JAY in 2024 extended coverage to all citizens aged 70 and above, addressing the specific healthcare needs of the elderly, who often face chronic diseases and disabilities.
  • Unlike private insurers, PM-JAY does not impose waiting periods or exclusions for pre-existing conditions.
• Increasing Access to Quality Healthcare: PM-JAY connects over 29,000 empanelled hospitals (including 13,000 private hospitals) across Tier 2 and Tier 3 cities, ensuring that even those in remote areas have access to quality healthcare.
  • Over 57% of hospital admissions occur in private hospitals, showing the significant role the private sector plays in the scheme.
• Gender Equity: The scheme has positively impacted gender equity, with 49% of Ayushman cards issued to women, and over 3.61 crore hospital admissions utilized by women. This ensures that women have equal access to life-saving healthcare services.
• Strengthening Healthcare Delivery: The Health Benefit Package (HBP) has been expanded and rationalized, increasing from 1,393 procedures in 2018 to 1,949 procedures in 2022.
  • Differential pricing allows states to adjust for regional variations in healthcare costs.
• Scientific Studies Backing PM-JAY's Impact: A study based on data from the Household Consumption Expenditure Survey 2022-23 shows that PM-JAY has significantly reduced financial shocks related to medical expenses for the bottom 50% of India’s population, improving economic resilience.

What are the Major Challenges of PM-JAY?

• Fraudulent Claims and Data Management Issues: The Comptroller and Auditor General (CAG) in 2023 reported irregularities such as patients receiving treatment after being declared dead, multiple beneficiaries linked to a single mobile number (e.g., 7.5 lakh beneficiaries linked to the single phone number 9999999999), and Aadhaar duplication.
  • The CAG reported that Rs 12.32 crore in penalties from 100 hospitals across nine states remain pending.
  • In six States and UTs, ineligible households were registered as PMJAY beneficiaries, with expenses ranging from Rs 12,000 in Chandigarh to Rs 22.44 crore in Tamil Nadu. Additionally, in nine States and UTs, delays in processing of rejection cases ranged from 1 to 404 days.
  • These data points to lapses in the system toward fraud and misuse in the PM-JAY.
• Healthcare Infrastructure Shortfalls: Many public hospitals, particularly in rural areas, lack proper infrastructure, equipment, and trained personnel.
  • In several states, empanelled hospitals had non-functional equipment and insufficient medical professionals, undermining the quality of healthcare delivery.
• State Non-Participation and Regional Disparities: Key states such as West Bengal, Odisha, and Delhi have opted out of the scheme, citing their own health insurance programs.
  • This creates regional disparities, where citizens in these states do not benefit from Ayushman Bharat, limiting the scheme’s nationwide impact.
• Unaddressed Indirect Costs for the Poor: Ayushman Bharat focuses on direct healthcare costs, but indirect costs like transportation, loss of income, and post-hospitalization expenses are not covered, leaving poor beneficiaries still financially vulnerable.
• Inadequate Primary Healthcare Support: The scheme focuses more on secondary and tertiary healthcare, while primary healthcare remains underdeveloped.
  • Health and Wellness Centres (HWCs), intended to address primary care, are often under-resourced, needing more investment to strengthen preventive and basic healthcare services.
• Limited Outreach and Awareness: Many eligible beneficiaries are not well-informed about the scheme or face hurdles during enrollment due to limited administrative infrastructure.
  • This results in millions of deserving citizens being excluded from the benefits, especially in remote areas.
• Weak Monitoring and Control Mechanisms: There is insufficient monitoring of private hospitals, some of which demand upfront payments, defeating the cashless nature of the scheme.
  • Additionally, overuse of drugs and fraudulent claims necessitate better surveillance and checks to curb misuse.

Way Forward

• Strengthening IT Systems and Fraud Prevention: Implement advanced data validation tools to detect anomalies like duplicate Aadhaar entries and invalid mobile numbers.
  • Enforce penalties for fraudulent claims and enhance multi-factor authentication (e.g., Aadhaar, biometrics) for beneficiary verification.
  • Establish a fraud detection unit within the National Health Authority (NHA) to monitor irregularities and ensure swift corrective actions.
  • The Ayushman Bharat Digital Mission which aims at providing digital health IDs, enabling seamless access to health records for hospitals and insurance firms, streamlining healthcare delivery and claims processing can help in enhancing benefits of the PM-JAY scheme.
• Enhancing Healthcare Infrastructure and Capacity: Prioritize rural healthcare infrastructure upgrades, including equipment, services, and recruitment of skilled professionals.
  • Promote public-private partnerships (PPPs) to address gaps in healthcare access while ensuring accountability.
• Bridging State Non-Participation and Regional Disparities: Engage non-participating states (e.g., West Bengal, Odisha) through dialogue and offer incentives to integrate their health programs with PM-JAY.
  • Adjust policies to meet state-specific needs, making the scheme more flexible and appealing.
• Addressing Indirect Costs for the Poor: Introduce provisions to cover indirect costs like transportation, income loss, and post-hospitalization expenses.
  • Create community health funds or micro-insurance schemes to assist poor beneficiaries in managing these costs.
  • The National Health Claims Exchange (NHCX) should be strengthened to improve fraud detection and streamline claims settlements.
• Strengthening Primary Healthcare Support: Boost funding for Health and Wellness Centres (HWCs) to improve infrastructure, supply essential medicines, and strengthen preventive care and early diagnosis services.
• Expanding Outreach and Awareness: Launch awareness campaigns in underserved areas using technology, mobile apps, and door-to-door outreach to inform eligible beneficiaries.
  • Simplify enrollment processes and enhance administrative capacity for better scheme access.
• Improving Monitoring and Control Mechanisms: Conduct regular audits of empanelled hospitals to prevent fraud and ensure compliance with the scheme's guidelines.
  • Strengthen real-time fraud detection systems and improve grievance redressal to address beneficiaries' issues efficiently.