Ayushman Bharat

The editorial is primarily based on the article “The Primary Anchor of a Health-Care Road Map” which appeared in The Hindu on 24th September 2018. It suggests steps that can be taken to ensure better implementation of the recently launched scheme, Pradhan Mantri Jan Arogya Yojana (PMJAY).

Ayushman Bharat is a flagship initiative that attempts to move away from the sectoral and segmented approach of service delivery to a comprehensive need-based health care service. It has been launched by the government with an aim to move towards a provision of universal healthcare in the country. Quality healthcare is the one which is affordable and inclusive. It holds the providers accountable for cost and quality and it translates into a reduction in disease burden. Ayushman Bharat adopts a two-pronged approach:

  • Firstly, the creation of health and wellness centres to bring health care closer to homes.
  • Secondly, the formulation of a Pradhan Mantri Jan Arogya Yojana (PMJAY) to protect poor and vulnerable families against financial risk arising out of catastrophic health episodes.

Wellness Centres

  • These centres will provide Comprehensive Primary Health Care (CPHC), covering both maternal and child health services and non-communicable diseases, including free essential drugs and diagnostic services.
  • The Health and Wellness Centres will play a critical role in creating awareness about PMJAY, screening for non-communicable diseases, follow-up of hospitalisation cases among others.
  • The health and wellness centres can play a valuable role to reduce the pressure on secondary and tertiary hospitals for expensive treatments by investing in preventive and primary care facilities.

Challenges

  • Upgrading wellness centres and broadening the scope of services they offer will be a big task. It starts with fixing infrastructure problems that range from lack of power to inadequate equipment.
  • The inadequate functionality of this infrastructure and the fact that it’s concentrated in the metropolis is another major challenge in the implementation of this part of the scheme.
  • There is no clarity on the funding for this project. Most of the centres suffer from the manpower shortages often making do with less than half the trained personnel they need.

Pradhan Mantri Jan Arogya Yojana (PMJAY)

  • PMJAY offers a sum insured of ? 5 lakh per family for secondary care (which doesn’t involve a super specialist) as well as tertiary care (which does). For the beneficiaries, this is a free scheme.
  • It is an entitlement-based scheme that targets the beneficiaries as identified by latest Socio-Economic Caste Census (SECC) data.
  • Individuals can walk into any empanelled hospital that can process cashless payments.
  • Once identified by the database, the beneficiary is considered insured.
  • The insurance cost is shared by the centre and the state mostly in the ratio of 60:40.
  • Empanelled hospitals agree to the packaged rates under PMJAY—there are about 1,400 packaged rates for various medical procedures under the scheme.
    • These packaged rates also mention the number of average days of hospitalization for a medical procedure and supporting documents that are needed.
    • These rates are flexible, but once fixed hospitals can’t change it and under no circumstances can they charge the beneficiary. The scheme also has prescribed a daily limit for medical management.
  • National Health Agency has been constituted as an autonomous entity under the Society Registration Act, 1860 for effective implementation of PMJAY in alliance with state governments.
    • Inter-alia, this will include, formulation of PMJAY policies, development of operational guidelines, implementation mechanisms, coordination with state governments, monitoring and oversight of PMJAY amongst other.

Benefits of PMJAY

  • The PM-JAY is one significant step towards the achievement of Universal Health Coverage (UHC) and Sustainable Development Goal - 3 (Good Health And Well-Being).
  • PMJAY is portable, which means the beneficiary can avail treatment in any of the states that have implemented the scheme.
  • It will leverage capacities available in both public and private sector hospitals, while providing standardised high-quality care, with strong fraud protection mechanisms.
  • It can ensure improved access and affordability, of quality secondary and tertiary care services through a combination of public hospitals and well measured strategic purchasing of services in health care deficit areas, from private care providers, especially the not-for profit providers.
  • It can significantly reduces out of pocket expenditure for hospitalization.
  • It will align the growth of private sector with public health goals.
  • It will strengthen public health care systems through infusion of insurance revenues.
  • It will enable creation of new health infrastructure in rural, remote and under-served areas.
  • It will help India capitalize its demographic dividend, ensure enhanced productivity, well-being and avert wage loss and impoverishment.
  • The scheme will also enrich the database of hospitals registered with the Registry of Hospitals in Network of Insurance (ROHINI) System and the human capital captured under the National Health Resource Repository (NHRR) project.
  • Moreover, the scheme will have a multiplier effect on hospitals and allied sectors like pharmaceuticals, medical devices and diagnostics. Companies will be encouraged to invest more, and this will create jobs.

Challenges

  • Since health is a State subject and States are expected to contribute 40% funding for the scheme, it will be critical to streamline and harmonise the existing State health insurance schemes to PMJAY. Telangana, Odisha, Delhi, Kerala, and Punjab have already refused to implement the scheme.
  • Costs are a contested area between the care-providers and the Centre, and many for-profit hospitals see the government’s proposals as unviable.
  • Accountability of the Private Sector: The ill-equipped public sector health capacities calls for necessary partnerships and coalitions with private sector providers.
    In such circumstances, the provision of services can be ensured only if the providers are held accountable for their services.
  • The National Health Policy 2017 proposed “strategic purchasing” of services from secondary and tertiary hospitals for a fee. The contracts with the healthcare providers who will receive the financial compensation package should clearly spell out the strict following of notified guidelines and standard treatment protocols in order to keep a check on potential for unnecessary treatment.

Way Forward

  • The first-order priority should be to draw up a roadmap for universal health coverage, through continuous upgradation of the public sector infrastructure.
  • All relevant inter-sectoral action linking health and development should be brought together in order to bring down the disease burden by providing access to clean drinking water, sanitation, garbage disposal, waste management, food security, nutrition, and vector control. Incorporation of Swachh Bharat programme into Ayushman Bharat can be one step towards it.
  • Upgrading district hospitals to government medical colleges and teaching hospitals will enhance capacities at the district level. Roping in the service providers to follow the practice of good governance can maintain accountability for cost and quality on their end.
  • Making good use of technology and innovation can further reduce the overall cost of the healthcare. AI-powered mobile applications can provide high-quality, low-cost, patient-centric, smart wellness solutions. The scaleable and inter-operable IT platform for the Ayushman Bharat is a positive step in this direction.