Coverage, utilization and impact of Ayushman Bharat Scheme on access to medicines and healthcare in India

 Shafiqa Rasool, Mohammad Ishaq Geer*

Department of Pharmaceutical Sciences, 

University of Kashmir, Hazratbal, Srinagar-190006, J&K

*For Correspondence: Prof. Mohammad Ishaq Geer (migeer@uok.edu.in)

Abstract

Ayushman Bharat (AB) is a government sponsored health insurance scheme that is aimed to cover about 100 million poor and vulnerable people in India. It provides benefit cover of Rs. 5 lakh per family per year with no cap on family size and the services are portable across the country. This scheme was launched by the Govt. of India in the year 2018 as a progressive step towards achieving Universal Health Coverage (UHC). It has two interlinked components, namely Health and Wellness Centres (HWCs) and the Pradhan Mantri Jan Arogya Yojana (PMJAY). The former aims to upgrade sub-centres and primary health centres to deliver comprehensive primary healthcare to the population whereas the latter is a national, publicly-funded health insurance (PFHI) scheme covering secondary and tertiary care hospitalization for the most deprived 40 percent population of the country. Around 1350 medical and surgical packages are covered under this scheme which include about all secondary and most of the tertiary care procedures. As a result of Ayushman Bharat scheme access including availability and affordability of medicines in India has drastically improved.

Introduction

Out-of-pocket expenditure (OOPE) on health in India is 62.6% of total health expenditure which is one of the highest in the world and nearly thrice of global average of 20.5%. More than two-third of this OOPE is paid on consultation fees and medicines followed by diagnostic tests. In India more than 300 million people face catastrophic expenditures and around 50 million people are pushed into poverty every year on account of out-of-pocket expenditures (OOPE) on health. One of the main reasons for this is the limited access to healthcare services in public sector. The average cost per hospitalization is Rs. 20,000 which is more than annual consumer expenditure of nearly half of our population (1). OOP expenditure on medicines alone is high and accounts for 70% of total out-of-pocket expenditure which is more than twice that of consultation fees and diagnostic services (2).

Ayushman Bharat-PMJAY was launched with an aim to protect the population against these very financial hardships and has successfully averted these disastrous consequences for more than 1.3 crore population of India. As per WHO-World Medicines Situation Report of 2004, 65% of Indian population lacked access to medicines at that time (3) but as a result of AB-PMJAY scheme the access to medicines has considerable improved in India.

Coverage and utilization of health services under AB-PMJAY

Ayushman Bharat Mission has been advanced as the prime instrument for achieving Universal Health Coverage (UHC). Unlike previous schemes like Rashtriya Swasthya Bima Yojana (RSBY) and the Senior Citizen Health Insurance Scheme, the AB-PMJAY has no cap on family size and age (4). The identification of the beneficiaries under this scheme is being done on the basis of the Socio-economic and caste census (SECC), 2011. The centre–state financing mode is same as in the National Health Mission. Indian states running similar schemes have been given an option to merge with PMJAY or run it in a parallel manner.

AB-PMJAY covers larger population, provides more comprehensive benefit package and incorporates a wider hospital network for healthcare delivery. The HWCs are committed to provide wider range of preventive, promotive, curative and rehabilitative healthcare services including treatment and services for non-communicable diseases and chronic communicable diseases like tuberculosis. These services were expanded keeping in view India’s high OOP expenditure. Government of India has allocated Rs. 3,200 crore and also envisages contribution of private sector in the form of corporate social responsibility (5,6). As of 21 March 2022, a total of 74,947 AB-HWCs were operational which is set to reach the target of 1.5 lakh by December 2022.

The other component of Ayushman Bharat covers larger number of population. The number of people benefited are double the number benefited from previously launched health schemes. Once fully functional the benefits of HWCs are expected to be available to 100% of population in India. HWCs together with AB-NHPS will be synergistic in providing healthcare needs across all three levels of care and will also help in increasing accessibility, availability and affordability of healthcare and medicines (7).

Impact of AB PMJAY on access to health services

Various studies on AB-PMJAY have reported mixed responses on financial risk protection. High value of greater than Rs. 30,000 and very high value claim of greater than Rs. 1,00,000 make up 32% and 9% of PMJAY claim payouts respectively. This is indicative of the fact that this scheme has enabled access to services that would otherwise be OOP or catastrophic to the individual. However, PMJAY does not cover out-patient services that account for around 60% to 70% of the total OOPE in India (8).

In a retrospective study conducted among 160 patients registered at Ayushman Bharat cell of a Srinagar-based tertiary care hospital namely SKIMS between 26th December, 2020 and 20th February, 2021, every patient was found to have received the benefits of the scheme as a result which they had to pay nothing for their hospitalization and there was no need for them to sell their assets or borrow money for treatment thus bringing the prevalence of distress financing to zero level. This was found to be quite contrary to studies conducted by the same authors at the same centre before the launch of the scheme wherein prevalence of distress financing among cancer and chronic kidney disease patients was found to be more than 70% (9,10,11).

Discussion

India, the sixth largest economy and largest democracy of the world has been improving its health-care facilities slowly since last few decades. India has made considerable progress in reducing maternal and child mortality under the national health mission. Ten to fifteen years ago communicable diseases alongwith maternal and nutritional disorders contributed to the major disease burden. Doubling the life expectancy from 31 years in 1947, when India got its independence from the British rule to 68.3 years in 2017, the Indian government has been doing a fairly good job; however, it is still quite less as compared to the western world. In terms of health-care access and quality India still stands at 145th position among 195 countries, lagging way behind than most of the countries like its neighbour Bangladesh which stands at 133rd position (12).

Conclusion

As India moves towards the path of UHC, the focus should be on reduction of burden due to non-hospitalization care. High OOP spending on medicine needs to be addressed. Use of medicines should be rationalized and rational prescribing encouraged. To significantly reduce OOPE, the provision for free medicines should be increased (The Indian Express, 2021). The utilization of manpower under Ayushman Bharat has been proved to be successful by way of engagement and potential usage of nearly 1 million ASHA workers under the National Health Mission (NHM). The programme provides an innovative initiative of building a highly impactful health model with low cost alongwith the utilization of skilled workforce. All these facts prove that Ayushman Bharat is a boon for the country (13).

References

1.Bhardwaj S. A study of Ayushman Bharat PM-JAY as an enabler of social upliftment. International Journal of Research in Humanities, Arts and Literature 2019: 7(3); 559-564.
2.  The long road to Universal health coverage. The Indian Express dated April 24, 2022. (Available at: https://indianexpress.com/article/opinion/the-long-road-to-universal-health-coverage/) (Accessed on 24.04.2022).
3.    World Health Organization. (‎2004)‎. The world medicines situation, 2nd ed. World Health Organization. WHO/EDM/PAR/2004.5. Available at: https://apps.who.int/iris/bitstream/handle/10665/68735/WHO_EDM_PAR_2004.5.pdf?sequence=1&isAllowed=y (Accessed on 24.04.2022).
4.   Indrani Gupta, Samik Chowdhury, Abhijit Roy, Ramandeep. Ayushman Bharat: Costs and Finances of the Prime Minister’s Jan Arogya Yojana. Economics and Political Weekly 2020 (4): 36; 56-64.
5. Bajpai N, Wadhwa M. Health and wellness centers: expanding access to comprehensive primary healthcare in India, ICT Indian Working Paper No. 13 dated July, 2019. (Available at: https://csd.columbia.edu/sites/default/files/content/docs/ICT%20India/Papers/ICT_India_Working_Paper_13.pdf) (Accessed on 24.04.2022).
6. Vitsupakorn S, Bharali I, Kumar P, Yamey G, Mao W. Early experiences of PM-JAY in India: A narrative review. Duke Global Working Paper: 30 march 2021. (Available at: https://centerforpolicyimpact.org/wp-content/uploads/sites/18/2021/02/PMJAY_FINAL.pdf) (Accessed on 24.04.2022)
7. Lahariya C. ‘Ayushman Bharat’ Program and Universal Health Coverage in India. Indian Pediatrics 2018:55;495-506.
8. Garg S, Bebarta KK, Tripathi N. Performance of India’s national publicly funded health insurance scheme, Pradhan Mantri Jan Arogaya Yojana (PMJAY), in improving access and financial protection for hospital care: findings from household surveys in Chhattisgarh state. BMC Public Health (2020) 20:949 (https://doi.org/10.1186/s12889-020-09107-4).
9. Abas Khan, Farooq Jan, Haroon Rashid. Prevalence of distress financing and catastrophic health expenditure among end stage renal disease patients attending a tertiary care teaching hospital of north India. Biomedical Journal of Scientific & Technical Research 2020: 32(4); 25133-35.
10. Abas Khan, Farooq A Jan, Haroon Rashid, Arshad Manzoor Najmi, Imtiyaz Ahmed Wani. Prevalence of distress financing and catastrophic health expenditure in cancer patients: a study from India. European Journal of Pharmaceutical and Medical Research 2020;7(12); 384-386.
11. Abas Khan, Yatoo, G. H., Mohd Sarwar Mir. Impact of Ayushman Bharat scheme on the prevalence of distress financing and catastrophic health expenditure among patients attending a tertiary care teaching hospital. Rivista Medicine 2021:1;11-15.
12. Mehta V. Ayushman Bharat Initiative: India’s answer to provide Universal Health Care. Journal of Medical Research and Innovation 2019;3(1):e000148
13. Venkatesh U, Mogan KA, Mukesh Kumar, Preety Doley, Jugal Kishore. Ayushman Bharat is a boon for the country. Motion International Journal of Preventive, Curative & Community Medicine 2019:5(3);31-35.