Ayushyaman Bharat – National Health Protection Mission / Pradhanmantri Jana Arogya Yojana

GS 2 -Government policies and interventions for development in various sectors and issues arising out of their design and implementation.

Issues relating to development and management of Social Sector/Services relating to Health, Education, Human Resources.

GS 3 – Indigenization of technology and developing new technology.

Background –

India has achieved significant public health gains and improvements in health care access and quality over the last three decades. The health sector is amongst the largest and fasting growing sectors, expected to reach US$ 280 billion by 2020.  At the same time, India’s health sector faces immense challenges. It continues to be characterized by high out-of-pocket expenditure, low financial protection, low health insurance coverage amongst both rural and urban population.

It is a matter of grave concern that we incur a high out-of-pocket expenditure on account of health and medical costs. 62.58% of our population has to pay for their own health and hospitalization expenses and are not covered through any form of health protection. Besides using their income and savings, people borrow money or sell their assets to meet their healthcare needs, thereby pushing 4.6% of the population below the poverty line.  

Commitment –

The Government of India is committed to ensuring that its population has universal access to good quality health care services without anyone having to face financial hardship as a consequence. PM-JAY seeks to accelerate India’s progress towards achievement of Universal Health Coverage (UHC) and Sustainable Development Goal – 3 (SDG3). When fully implemented, the PM-JAY will become the world’s largest government funded health protection mission.

Aim –

  1. The scheme is targeted at poor, deprived rural families and identified occupational category of urban workers’ So, if we were to go by the Socio-Economic Caste Census (SECC) 2011 data, 8.03 crore families in rural and 2.33 crore in urban areas will be entitled to be covered under these scheme, i.e., it will cover around 50 crore people.
  1. AB-NHPS will have a defined benefit cover of Rs 5 lakh per family (on a family floater basis) per year for secondary and tertiary care hospitalisation. It will offer a benefit cover of Rs 5 lakh per family per year. It will subsume the existing Rashtriya Swasthya Bima Yojana (RSBY), launched in 2008 by the UPA government.
  1. To ensure that nobody is left out (especially women, children and the elderly), there will be no cap on the family size and age under the AB-NHPS. The scheme will be cashless and paperless at public hospitals and empanelled private hospitals. 

Eligibility Criteria for the beneficiaries – 

  1. There is no enrolment process in AB-NHPM as it is an entitlement-based mission. Families who are identified by the government on the basis of deprivation and occupational criteria using the SECC database, both in rural and urban areas, are entitled for AB-NHPM. Currently the database is based on census for the year 2011.
  1. A list of eligible families has been shared with the respective state governments as well as state level departments like the ANMs, BMO, and BDOs of relevant areas. A dedicated AB-NHPM family identification number will be allotted to eligible families. Only families whose name is on the list are entitled for the benefits of AB-NHPM.
  1. Additionally, families with an active RSBY cards as of 28 February 2018 will covered. No additional new families can be added under AB-NHPM. However, names of additional family members can be added for those families whose names are already on the SECC list.
  1. The scheme will be cashless & paperless at public hospitals and empanelled private hospitals. The beneficiaries will not be required to pay any charges for the hospitalization expenses. The benefit also includes pre and post-hospitalization expenses. 

Ultimate accomplishments aspired –

  • Help India progressively achieve Universal Health Coverage (UHC) and Sustainable Development Goals (SDG).
  • 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.
  • Significantly reduce out of pocket expenditure for hospitalization. Mitigate financial risk arising out of catastrophic health episodes and consequent impoverishment for poor and vulnerable families.
  • Acting as a steward, align the growth of private sector with public health goals.
  • Strengthen public health care systems through infusion of insurance revenues.
  • Enable creation of new health infrastructure in rural, remote and under-served areas.
  • Increase health expenditure by Government as a percentage of GDP.
  • Improvement in population-level productivity and efficiency. Improved quality of life for the population.

Challenges to the implementation of the scheme –

  1. Implementation of such scale and benefit is bound to face obstacles, the most substantial of which is for it to be economically sustainable. At the moment, hospitals are unhappy because, in their view, package rates fixed by the government are loss-making. For example, the proposed cost of a coronary artery bypass graft (CABG) is about Rs. 90,000. The Central Government Health Scheme (CGHS) rates for this in Delhi are above ₹1 lakh and private hospitals routinely charge above ₹3 lakh.
  2. Insurers worry that they will be left out because states have the option to select a “Trust” model that does not require insurers to participate. In fact, this is the preferred model for many states. Where insurers participate, the auction may push premiums to unviable, low levels. The insurer model has an in-built conflict of interest. The organisational committees that will deal with grievances of hospitals and insurers consist primarily of government representatives. Their chief focus will be to have patients’ claims paid and they have less incentive to solve the problems of hospitals or insurers.
  3. Hospitals will build considerable capacity to meet the demand for beds. There are about 1.5 million hospital beds in the country. These cannot support the 500 million people who will have insurance. As hospitals see an increasing patient inflow, they will build capacity.
  4. Pricing of health packages is another problem. The Indian Medical Association has questioned the viability of providing healthcare at the proposed low costs and this has been a ‘bone of contention’ as well.
  5. Lack of uniformity of hospital procedures and protocols for doctors are among the other challenges.
  6. The success of the scheme would also depend on how supply-deficient Uttar Pradesh, Bihar and the north-eastern states implement the scheme,
  7. The government proposed a 40% participation of states in contributing towards premium and implementation of Ayushman Bharat. However, till date, there has been no communication to states and it’s very much possible that states which are not governed by ruling party may not be on board. Besides some of the states might already be having similar schemes implemented. For example, Karnataka government has plans to roll out Universal Health Coverage (UHC) which intend to provide health coverage of approximate Rs. 1.5 Lacs to 1.4 crore households living in BPL category.
  8. A merger with the Centre’s scheme, thus, is bound to pose administrative challenges—shifting to the national software, and then, ensuring that all eligible beneficiaries are covered, too.

Technology helpful to realise the goal of such schemes – 

  1. Telemedicine has taken the benefits of the healthcare into the remotest corners of the country. Telemedicine is the remote delivery of healthcare services, such as health assessments or consultations, over the telecommunications It allows healthcare providers to evaluate, diagnose and treat patients using common technology, such as video conferencing and smartphones, without the need for an in-person visit.
  1. Use of Artificial Intelligence for preventive and predictive health analytics can strongly support clinical diagnosis with an evidence-based guidance and also prevent disease.
  1. Augmented Reality and 3-D Printing can eliminate every nodule of malignant melanoma, preventing the spread of cancer to the other parts of the body.
  1. Biotechnology, cell-biology and genetics has made home-medicines a way of life.

Lakshya ahead – (Way Forward)

  1. We need to maintain the balance between Staying at the cutting edge of the clinical protocols, technology, innovation and continuous deliver of the world class health care at an affordable cost.
  1. Sustainability of the efforts to improve the healthcare sector of country is crucial where in addition to this, it is to be inclusive.
  1. Private hospitals, talented professionals, far-reaching technology and well-built infrastructure should be the four pillars of our vision to make the aim of AB-NHPS/PMJAY successful.

Q. Ayushyaman Bharat Scheme is an unprecedented initiative taken by the government for healthy India. Discuss the features of the scheme and the challenges for the realisation of the targets of the same. (250 Words)

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