Syllabus: UPSC GS-2– Health

Context:
The Pradhan Mantri Ayushman Bharat Health Infrastructure Mission, an additional scheme component, is also the subject of an MoU between the Delhi government and the Centre. This initiative is designed to enhance the capabilities of health systems and institutions at the primary, secondary, and tertiary levels.

What is the PM-JAY scheme?

Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PM-JAY) is a centrally sponsored scheme introduced in September 2018 by the Ministry of Health and Family Welfare as part of the bigger Ayushman Bharat effort. It is one of the world's largest government-funded health insurance programs, with the goal of providing financial security and quality healthcare to more than 10 crore poor and vulnerable families (about 50 crore beneficiaries) in India. 

The major goal of PM-JAY is to lessen the financial burden associated with hospitalisation and promote universal health care. The policy provides health insurance coverage of up to ₹5 lakh per family per year for secondary and tertiary care hospitalisation, with services available at accredited public and private hospitals. It runs on a paperless and cashless model and is wholly sponsored by the federal and provincial governments. PM-JAY is an important step in India's road to achieve the Sustainable Development Goal of "Health for All."

About PM-JAY

• PMJAY is the largest government-funded health insurance program globally.
• Initiated in 2018, it provides a coverage amount of Rs. 5 lakh per household for secondary and tertiary care.
• Health Benefits Packages encompass surgical procedures, medical treatments, outpatient care, pharmaceutical expenses, and diagnostic services.
• On September 23, 2018, Hon. Prime Minister Shri Narendra Modi of India launched the Pradhan Mantri Jan Arogya Yojana (AB PM-JAY) in Ranchi, Jharkhand.

Components of the Pradhan Mantri Jan Arogya Yojana 

• (PMJAY) is the largest health insurance system globally, entirely funded by the government.
• It offers coverage of Rs. 5 lakhs per family annually for secondary and tertiary care hospitalization in both public and private empanelled hospitals in India.
• More than 120 million impoverished and at-risk families (roughly 550 million people) qualify for these payments.
• PM-JAY offers cashless access to healthcare services for beneficiaries at the point of service, namely within hospitals.
• PM-JAY aims to alleviate catastrophic medical expenses that drive around 6 crore Indians into poverty annually.
• It encompasses up to 3 days of pre-hospitalisation and 15 days of post-hospitalisation charges, including tests and medications.
• No limitations exist regarding family size, age, or gender.
• All pre-existing conditions are covered from the outset.
• The system's advantages are transferable nationwide; a recipient may access cashless treatment at any empaneled public or private hospital in India.
• Services encompass roughly 1,929 procedures that cover all treatment-related expenses, including but not limited to pharmaceuticals, supplies, diagnostic services, physician fees, lodging charges, surgeon fees, and charges for operating and intensive care units.
• Public hospitals receive reimbursement for healthcare services equivalent to that of private hospitals.

Other schemes

• Phase-II (ECRP-II package) of the India COVID-19 Emergency Response & Health System Preparedness Package: This program is a centrally sponsored program that includes elements from the central sector. 
• With an emphasis on developing health infrastructure, including for pediatric care, and achieving quantifiable results, it was recently introduced with the goal of accelerating health system readiness for prompt responsiveness for early prevention, identification, and management.

PMJAY Scheme Eligibility

The eligibility criteria are based on the Socio-Economic Caste Census (SECC) 2011 data.

Who Can Apply?

Rural Beneficiaries

• Families without a male member aged 16 to 59.
• Households that include impaired individuals.
• Families classified as Scheduled Caste (SC) or Scheduled Tribe (ST).
• Landless households rely on day labor.

Urban Beneficiaries

• Street sellers, housekeepers, rickshaw drivers, and construction workers.
• Plumbers, electricians, and sanitation personnel.
• Small business entrepreneurs and other low-income individuals.

Impact of AB-PMJAY on Healthcare Access

Mitigating Financial Obstacles and Guaranteeing Access to Healthcare

• Before the introduction of PMJAY, numerous low-income families were at considerable risk of descending into poverty due to exorbitant out-of-pocket healthcare payments.
• Even seemingly modest medical treatments can precipitate financial devastation for a family.
• PMJAY has given families financial protection by subsidizing hospitalization expenses, allowing them to seek treatment free from the weight of initial costs.
• Those with chronic or acute conditions needing frequent or protracted hospitalizations especially benefit from this.
• For many, our program has shown the difference between skipping treatment due to financial restraints and getting life-saving care debt-free.

Enhancing Health Equity and Engaging Underserved Populations

• A notable accomplishment of PMJAY has been its contribution to enhancing health equity throughout India.
• The initiative primarily aims at economically disadvantaged segments of society, guaranteeing that those most need financial safeguarding can obtain critical healthcare treatments.
• This is especially significant in rural regions, where access to adequate healthcare has historically been constrained.
• Before the implementation of the system, residents in these regions frequently encountered the dual obstacles of insufficient medical facilities in proximity and the inability to purchase care, even when traveling to larger urban centers.

Broadening the Spectrum of Therapeutic Options

• The influence of PMJAY beyond mere financial assistance has also broadened the range of medical therapies accessible to recipients.
• Since its inception, the Health Benefit Package (HBP) has undergone revisions and expansions, augmenting the number of covered operations from 1,393 in 2018 to 1,949 by 2022.
• This expansion encompasses a diverse array of treatments and procedures for severe diseases, including cardiac surgery, cancer therapies, and orthopedic interventions, which are generally prohibitively expensive for the uninsured.
• This indicates that PMJAY beneficiaries can now have more sophisticated and life-saving therapies without the concern of exorbitant expenses.

What is HBP? According to the HBP health card, eligible individuals can use the Ayushman card to receive cashless healthcare benefits totaling up to INR 5 lakhs per family per year at empanelled hospitals and healthcare providers nationwide.

Empowering Families via Cashless Healthcare

• A distinctive aspect of PMJAY is its emphasis on cashless treatment, essential for enhancing healthcare accessibility.
• Numerous individuals from low-income families refrain from pursuing medical assistance due to the necessity of advance payments.
• The cashless aspect of PMJAY signifies that patients do not need to make any out-of-pocket payments during admission or treatment.
• This is especially advantageous in emergencies, where medical delays caused by insufficient urgent funding could be fatal.
• PMJAY enables families to prioritize the health of their loved ones without the burden of securing cash on short notice.

Beneficiaries Under Pradhan Mantri Jan Arogya Yojana (PMJAY)

• The scheme provides health insurance coverage under several government-funded plans in India, which have historically been limited by an upper cap ranging from INR 30,000 to INR 300,000 per family across different states, resulting in a fragmented system.
• PM-JAY offers cashless coverage of up to INR 5,00,000 for each qualified family annually for specified secondary and tertiary medical conditions.
• The coverage under the scheme encompasses all costs associated with the following treatment components.
• Medical evaluation, therapy, and consultation
• Pre-hospitalization
• Pharmaceuticals and medical supplies
• Non-intensive and intensive healthcare services
• Diagnostic and laboratory assessments
• Medical implantation services, when required
• Advantages of lodging
• Culinary services
• Complications occurring during therapy
• Post-hospitalization follow-up care for a duration of up to 15 days
• Any or all family members can use the benefits of INR 5,00,000 on a family floater basis.
• The RSBY imposed a family limit of five people. Nonetheless, drawing from insights gained from earlier programs, PM-JAY has been structured to impose no limitations on family size or the age of its members. Moreover, pre-existing conditions are covered from the initial day.
• The change indicates that any qualified individual with a pre-existing medical condition will now receive treatment for all such conditions under the PM-JAY scheme from the day of enrolment.

Reduction in Medical Vulnerability According to a study based on the Household Consumption Expenditure Survey 2022-23, the lower 50% of India's population is now less vulnerable to healthcare-related financial shocks, thanks mainly to PMJAY.

Concerns and challenges with AB PM-JAY (as per CAG Report, 2023)

1. Issues: 

Several problems were discovered in the beneficiary database due to a lack of proper validation procedures, including erroneous names, unrealistic dates of birth, duplicate PMJAY IDs and an unreasonable number of family members per household.

For example, in Tamil Nadu, 4761 registrations were registered against seven Aadhaar IDs.

2. Poor infrastructure: 

Some Empanelled Health Care Providers (EHCPs) did not meet the minimal criteria for the support system and infrastructure and did not adhere to the mandated quality standards and criteria.

3. Financial irregularities:

• Inadequate validation checks, such as admittance before preauthorization, transactions before the Scheme's inception, surgery after patient discharge, payment before claim submission, non-availability/invalid dates, and other entries.
• Revenue obtained from PMJAY was not used by public/government hospitals for the purposes specified in the PMJAY system.

4. Delays in implementation:

• For example, hospital claim submission, pre-authorization approval, grievance settlement, etc.

• The absence of master data is due to the lack of a uniform format for data maintenance.

Way Forward

• The following steps for PMJAY include expanding beneficiary coverage, building healthcare infrastructure, improving fraud detection, integrating digital health data, and increasing private sector participation.  
• Greater awareness, seamless mobility, and long-term funding will ensure the organization can provide quality, inexpensive healthcare to India's poor people.

Conclusion

AB PM-JAY has substantially altered the healthcare landscape, offering critical coverage to millions while lowering financial burdens connected with medical bills.   NHA must take more proactive measures to guarantee that initiatives such as efficient validation processes, enhanced infrastructure, geotagging of hospitals, regular verification, and so on are carried out in full.

Practice Question 1. How can PMJAY help provide better healthcare facilities to the underprivileged sectors of society? Throw light on the scope and impact

FAQs

1. What is the Ayushman Bharat Yojana?

Ayushman Bharat Yojna is a government healthcare initiative that offers complimentary health insurance coverage of ₹5 lakh per family year for economically disadvantaged and vulnerable populations.

2. What is the Ayushman Bharat Digital Mission?

The Ayushman Bharat Digital Mission is a project that offers a unique health ID for every person to store and access digital medical records securely.