With more than 18 crore golden cards having been issued nationwide so far, Ayushman Bharat-PMJAY scheme has considerably improved accessibility, availability and affordability of healthcare and medicines in India
Ayushman
Bharat – Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) is a health insurance
scheme launched by the Govt. of India with an aim of moving closer towards
achieving Universal Health Coverage (UHC) and providing health insurance cover
to about 100 million poor and vulnerable citizens of India. This flagship
scheme provides an insurance cover of Rs. 5 lakhs per family per year for
secondary and tertiary care hospitalizations, with no cap on family size and
the services are portable all across the country. This scheme was launched by the
Prime Minister, Sh. Narendra Modi on September 23rd, 2018 as a
progressive step towards achieving UHC in India. So far more than 18 crore
Ayushman cards have been issued nationwide under this scheme. Union Health
Minister Dr. Mansukh Mandaviya tweeted on May 13th, 2022 that under this
scheme, more than 3.2 crore people have availed the benefits of free hospitalization
and free medicines worth an amount of Rs. 37,398 crores. This scheme has two
interlinked components viz., Health and Wellness Centres (HWCs) and the Pradhan
Mantri Jan Arogya Yojana (PMJAY). While on one hand HWCs are intended to
progressively expand access to comprehensive primary health care, free
essential medicines as well as diagnostics services, on the other hand, PM-JAY
aims to provide financial risk protection for secondary and tertiary care to
bottom 40% of India’s population besides ensuring improved access to good
quality healthcare services through a combination of public and private
empaneled providers for everyone without facing any financial hardships. Around
1350 medical and surgical packages are covered under this scheme which include
almost all secondary and most of the tertiary care procedures. As a result of Ayushman
Bharat scheme access including availability and affordability of medicines and
healthcare in India has drastically improved.
As
per WHO-World Medicines Situation Reports of 2004 and 2011, almost 65% of
Indian population lacked access to medicines during that period. The average
cost per hospitalization at present in our country is Rs. 20,000 which is more
than annual consumer expenditure of nearly half of our population. Out-of-pocket
expenditure (OOPE) on health in India is believed to be 62.6% of total healthcare
expenditure which is one of the highest in the world and nearly thrice the
global average of 20%. OOPE on medicines alone accounts for 70% of total
out-of-pocket expenditure on health which is more than twice that of
consultation fees and diagnostic services. In India more than 300 million
people face catastrophic expenditures and around 50 million people (nearly 4%
of total population) are pushed below poverty line every year on account of these
out-of-pocket expenditures on health. One of the main reasons for this has been
the limited access to healthcare services in public sector which means that the
medicines and other healthcare services were either not available or not
affordable to 65% of Indian population. Ayushman Bharat-PMJAY was launched with
an aim to protect the population against these very financial hardships and catastrophic
expenditures on healthcare and medicines. This scheme has successfully averted
these disastrous consequences for a large segment of more than 1.3 crore
population of India. As a result of AB-PMJAY scheme the access to healthcare
and medicines has considerable improved in India now that has been duly
acknowledged by reputed, scientific, international journals like Lancet, BMJ
etc.
Unlike
previous UHC schemes like Rashtriya Swasthya Bima Yojana (RSBY), Employees
Health Insurance Scheme (EHIS) and the Senior Citizens Health Insurance Scheme
(SCHIC), the AB-PMJAY has no cap on family size and age. The identification of
beneficiaries under this scheme is being done on the basis of socio-economic
and caste census (SECC) of 2011. The centre–state financing mode is same as that
of the National Health Mission. Various states running similar schemes have
been given an option to either merge with PMJAY or run it in a parallel mode. Unlike
previous UHC schemes, AB-PMJAY covers larger population, provides more
comprehensive benefit package and incorporates a wider network of hospitals for
healthcare delivery. HWCs have been upgraded to provide wider range of pre-emptive,
preventive, promotive, curative and rehabilitative healthcare services
including treatment and services for non-communicable diseases as well as
chronic communicable diseases like tuberculosis. These services have been
expanded in view of India’s high out-of-pocket expenditures. The union budget
of 2022-2023 has allocated Rs. 6412 crores for AB-PMJAY whereas an amount of
Rupees 6400 crores was allocated last year. Further an allocation of Rs. 5156
crores has been made for the newly announced PM-AB Health Infrastructure
Mission (PM-ABHIM) in October 2021 with a view to strengthen the health
infrastructure of the country in a mission mode and improve primary, secondary
and tertiary healthcare services. This way AB-PMJAY is receiving a substantial
financial package by the Govt. of India for its successful implementation. As on
21st March 2022, a total of 74,947 AB-HWCs were operational which is set to
reach a target of 1.5 lakh by December, 2022.
AB-PMJAY
was introduced in the UT of Jammu and Kashmir on December 1, 2018, by the Govt.
of India. Earlier this scheme was meant to provide health coverage of about 5
lakh rupees per year to each family member of the eligible household that was
below poverty line for tertiary and secondary care hospitalization. However, on
December 26, 2020 Govt. of India made this scheme universal in J&K under
the revised title of Ayushman Bharat Jan Arogya Yojana Sehat. As per the data
obtained from State Health Agency (SHA) of J&K, number of eligible families
covered under this scheme as on September, 2021 were 5,97,801 besides
additional families numbering 14, 56,497, thus providing coverage to about 98%
of eligible families in J&K. As per official figures under this scheme
33.70 lakh golden or sehat cards have been issued in J&K among 9.57 lakh
families out of a total of 14.56 lakh families that are eligible to be covered
under this scheme. Since the launch of this scheme in J&K, around 60,594
patients have been treated through 218 empaneled hospitals and an amount of Rs.
60.12 crores has been paid against a total of 123986 claims made. The State
Health Agency of J&K has also started an initiative by the name of ‘Gaon
Gaon Ayushman’ to reach out to the last mile villages that remain cut off from
the rest of the world due to inclement weather conditions so as to percolate
the benefits of the scheme down to every beneficiary. In order to ensure
hassle-free registration of all eligible beneficiaries under the scheme, the
State Health Agency has set up a network of more than 8000 Common Service
Centres (CSCs) and virtual learning environment (VLE) Centres in villages for
ensuring 100% registration besides awareness activities at the grassroots level
in association with PRI representatives and ASHA workers.
Various
scientific studies on AB-PMJAY have reported mixed responses on financial risk protection
by this scheme. It has been observed that high value claims of greater than Rs.
30,000 and very high value claims 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 out-of-pocket
or catastrophic to the individuals. However, PMJAY does not cover out-patient
services that account for around 60% to 70% of the total OOPE in India that
needs to be considered in future after its successful coverage among all hospitalized
patients. In a retrospective study by Khan A et al (2020, 2021) 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 opposite
to the observations made by the same authors at the same centre before the
launch of this scheme wherein prevalence of distress financing among cancer and
chronic kidney disease patients was found to be more than 70%. Similarly,
several other studies from different parts of the country have reported findings
in appreciation of this scheme though several concerns like the number of
hassles/formalities involved for patients and delays in expediting payments to service
providers have been expressed as well.
One
of the major objectives of the AB PM-JAY is to reduce OOPE and provide
financial risk protection against catastrophic health expenditures (CHE) to all
its citizens. Secondary and tertiary care accounts for nearly one-third of
total OOPE. Therefore, OOPE cannot be reduced only by covering secondary and
tertiary services, although, reduction in the incidence of CHE due to sudden
hospitalization can be achieved. As India moves on its path towards Universal
Health Coverage, emphasis needs to be laid upon reduction of financial burden
as a result of OOPE in ambulatory or outpatient care by extending the insurance
cover under PM-JAY to out-patients too in due course of time. Further in order
to make this scheme long-lasting and sustainable for all times to come, govt.
needs to pool available funds from all sources including budgetary allocations,
employers, households, individuals, insurance companies and NGOs and thereby
derive a suitable mix of trade-off between the extent of population to be
covered, extent of services to be provided and the extent of costs to be borne
by the govt. though extreme care should be taken not to surrender it to private
insurance companies or profit making organizations since that will kill the
basic essence and spirit of this scheme. A nominal cess of 2 or 3 percent on
total taxable income on account of services to be provided under this scheme
could also be helpful in making this scheme sustainable and successful in
future, whose ultimate aim is to enforce social solidarity and ensure social
security to all citizens of the country by enhancing their access to quality
medicines and healthcare services.
(Author teaches at the Dept. of Pharmaceutical Sciences, University of Kashmir)
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