AYUSHMAN BHARAT

IMPORTANCE AND RELEVANCE OF SCHEME:

The Ayushman Bharat Yojana - National Health Protection Scheme, which has now been renamed as
Pradhan Mantri Jan Arogya Yojana, plans to make secondary and tertiary healthcare to poor
completely cashless. The PM Jan Arogya Yojana beneficiaries get an e-card that can be used to avail
services at an empanelled hospital, public or private, anywhere in the country. With it, you can walk
into a hospital and obtain cashless treatment.

The coverage includes 3 days of pre-hospitalisation and 15 days of post-hospitalisation expenses.

Moreover, around 1,400 procedures with all related costs like OT expenses are taken care of. All in
all, PMJAY and the e-card provide a coverage of Rs. 5 lakh per family, per year, thus helping the
economically disadvantaged poor obtain easy access to healthcare services.

The PMJAY scheme aims to provide healthcare to 10 crore families, who are mostly poor and have
lower middle income, through a health insurance scheme providing a cover of Rs. 5 lakh per family.
The 10 crore families comprise 8 crore families in rural areas and 2.33 crore families in urban areas.
Broken into smaller units, this means the scheme will aim to cater to 50 crore individual
beneficiaries.However, the scheme has certain pre-conditions by which it picks who can avail of the
health cover benefit. While in the rural areas the list is mostly categorized on lack of housing,
meagre income and other deprivations, the urban list of PMJAY beneficiaries is drawn up on the
basis of occupation.

PMJAY Rural:

The 71st round of the National Sample Survey Organisation reveals that a staggering 85.9% of rural
households do not have access to any healthcare insurance or assurance. Additionally, 24% of rural
families access healthcare facilities by borrowing money. PMJAY’s aim is to help this sector avoid
debt traps and avail services by providing yearly assistance of up to Rs. 5 lakh per family. The scheme
will come to the aid of economically disadvantaged families as per data in the Socio-Economic Caste
Census 2011. Here too, households enrolled under the Rashtriya Swasthya Bima Yojana (RSBY) will
come under the ambit of the PM Jan Arogya Yojana.

In the rural areas, the PMJAY health cover is available to:

 Those living in scheduled caste and scheduled tribe household.

 Families with no male member aged 16 to 59 year
 Beggars and those surviving on alms
 Families with no individuals aged between 16 and 59 years
 Families having at least one physically challenged member and no able-bodied adult
member
 Landless households who make a living by working as casual manual labourers7) Primitive
tribal communities
 Legally released bonded labourers
  Families living in one-room makeshift houses with no proper walls or roof
 Manual scavenger families

PMJAY Urban:

According to the National Sample Survey Organisation (71st round), 82% of urban households do not
have access to healthcare insurance or assurance. Further, 18% of Indians in urban areas have
addressed healthcare expenses by borrowing money in one form or the other. Pradhan Mantri Jan
Arogya Yojana helps these households avail healthcare services by providing funding of up to Rs. 5
lakh per family, per year. PMJAY will benefit urban workers’ families in the occupational category
present as per the Socio-Economic Caste Census 2011. Further, any family enrolled under the
Rashtriya Swasthaya Bima Yojana will benefit from the PM Jan Arogya Yojana as well.

In the urban areas, those who can avail of the government-sponsored scheme consist mainly of:

 Washerman / chowkidars
 Rag pickers
 Mechanics, electricians, repair workers
 Domestic help
 Sanitation workers, gardeners, sweepers
 Home-based artisans or handicraft workers, tailors
 Cobblers, hawkers and others providing services by working on streets or pavements
 Plumbers, masons, construction workers, porters, welders, painters and security guards
 Transport workers like drivers, conductors, helpers, cart or rickshaw pullers
 Assistants, peons in small establishments, delivery boys, shopkeepers and waiters

People not entitled for the Health Cover under Pradhan Mantri Jan Arogya Yojana:

 Those who own a two, three or four-wheeler or a motorised fishing boat

 Those who own mechanised farming equipment
 Those who have Kisan cards with a credit limit of Rs.50000
 Those employed by the government
 Those who work in government-managed non-agricultural enterprises
 Those earning a monthly income above Rs.10000
 Those owning refrigerators and landlines
 Those with decent, solidly built houses
 Those owning 5 acres or more of agricultural land

EFFECTIVENESS OF SCHEME:
The Rs. 5 lakh insurance cover provided by the Pradhan Mantri Jan Arogya scheme can be utilized
not just by individuals in particular, but also by families in general. This lumpsum is enough to cover
both the medical and surgical treatments in 25 specialities among which are cardiology,
neurosurgery, oncology, paediatrics, orthopaedics, etc. However, medical and surgical expenses
cannot be reimbursed simultaneously.
If multiple surgeries are necessary, the highest package cost is paid for in the first instance followed
by a 50% waiver for the second and a 25% discount for the third. Unlike other health insurance
schemes, there is no waiting period for pre-existing diseases under PMJAY scheme, which comes
under the larger umbrella scheme of Ayushman Bharat Yojana. Should any beneficiary or anyone in
their family require hospitalization, they need not pay anything, provided they are admitted in any
empanelled government or private hospital.

The cashless treatment and hospitalization is made possible due to a 60:40 cost sharing agreement
between the Centre and states. Once identified as a genuine beneficiary, you or your family member
will be issued a health card by specially trained Ayushman Mitras, who man kiosks in hospitals for
those unaware of the PMJAY scheme. With these details in hand, you can benefit from the features
of the Pradhan Mantri Jan Awas Yojana or help someone else get the healthcare cover benefit.

 IMPACT/EFFECTS OF SCHEME

1.. All families listed in SECC database to be covered:

Beneficiaries for the scheme are picked up from the Socio Economic Caste Census of 2011. These 10
crore beneficiary families comprise of 8 crore families from the rural areas and 2 crore families
residing in urban India.

2. Priority to girl child, women and senior citizens:There is no cap on the family size and age as this
health cover is meant to be inclusive for all. Moreover, the scheme holds women, children,
especially the girl child, and those over 60 in special regard.

3. It includes secondary and tertiary care:The scheme provides those in need to get secondary
healthcare benefits provided by specialists like cardiologists and urologists. Moreover, advanced
medical treatment like that for cancer, cardiac surgery and other is also covered.

4. All pre-existing diseases covered:Unlike most other insurance covers, the PMJAY secures those
who have pre-existing illnesses, and makes treatment in all public hospitals mandatory. This means
that those who require medical care cannot be turned away.

5. Cashless and paperless registration and administration:Removing the burden of out-of-pocket

expenses, PMJAY aims to make the entire process of paying for healthcare cashless. Additionally,
PMJAY beneficiaries can avail treatment throughout India.

6. Substantial reduction of out-of-pocket expenditure:All public hospitals and empaneled private

hospitals have been directed to not charge any extra payment for medical care from all PMJAY
beneficiaries to reduce any corruption or delay in services.

7. Private sector participation to help in achievement of public health goals:Since the scheme covers
such a large population, it will be purchasing services from private healthcare providers. This scheme
is also expected to encourage the production of more affordable healthcare equipment and drugs.

8. Improvement of quality of life of the population:This scheme is sure to improve the quality of life
of the weaker sections of society who are held back drastically due to health issues that can easily be
tackled with timely care and finances.
9. Broadening the health insurance network:PMJAY will not only lead to better infrastructure
development in rural and under-served areas across the country, but also lead to more and more
Indians having access to healthcare. As of now the government has created 1350 medical packages
that cover day care treatment, surgery, hospitalization, cost of diagnosis and medicines with the
PMJAY health cover.

COVERAGE TILL TODAY:

Ayushman Bharat Yojana, also known as the Pradhan Mantri Jan Arogya Yojana (PMJAY), is a scheme
that aims to help economically vulnerable poor Indians who are in need of healthcare facilities
.Prime Minister Narendra Modi rolled out this health insurance scheme on 23 September 2018 to
cover about 50 crore citizens in india and already has several success stories to its credit. As of
September 2019, it was reported that 18,059 hospitals have been empanelled, over 4,406,461 lakh
beneficiaries have been admitted and over 10 crore e-cards have been issued. As on July 23, a total
of 16,039 hospitals (8,059 private hospitals and 7,980 public hospitals) have been empanelled under
the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana .

SUSTAINABILITY OF SCHEME:

In last one year, around 46.4 lakh hospital treatments worth ₹7,500 crore have been carried out, and
60% of the amount spent was on tertiary care. As on date, the scheme has been implemented in 32
states and union territories. Various states are using different models for implementing their own
health insurance/assurance schemes. Given that states are at different levels of preparedness and
have varying capacity to manage such schemes, PM-JAY provides them with the flexibility of
choosing their implementation model. Seventeen states/UTs have implemented the scheme via the
Trust Mode, nine states/UTs via insurance mode and six states/UTs have used the mixed mode,
which is a combination of trust and insurance mode.

Public health experts have said that along with delivery and quality, the government will need to
adopt innovative funding models for long-term sustainability. While government spending on
healthcare in India is one of the lowest in the world at around 1.2% of GDP, the country’s health
system is crippled with shortage of workforce, poor infrastructure, compromised quality and
unavailability of services. For higher public spending in the government budget, India needs to
attract strategic funding through various other internal and external sources to sustain Ayushman
Bharat. With adequate financing and funding to the sector, rural-urban gaps in quality and delivery
systems can also be bridged.

RESTRUCTURING REQUIRED OR NOT??

Fraud was detected at 341 hospitals in 16 Indian states during the first year of the Ayushman Bharat
scheme’s implementation, the Union government said. An amount of Rs 230 lakh has been
recovered by the government from these hospitals.Action against as many as 55 hospitals was taken
in Gujarat for frauds under the scheme and Rs 12.63 lakh recovered from them.

The maximum recovery was in Uttarkahand — Rs 1.05 crore from 18 hospitals against which fraud
had been detected. Sixty-three hospitals in Maharashtra had been under the scanner and Rs 53 lakh
was recovered from there. Tamil Nadu, Chhattisgarh and Uttar Pradesh also figured in this infamous
list, with action being taken against 51, 76 and 30 hospitals respectively in these states.

Hence redesigning of scheme is required such that the names of these hospitals had been put on the
website of National Health Authority (NHA) under the ‘name and shame’ policy and artificial
intelligence would be used to detect frauds.

According to the annual report, 46.5 lakh hospital treatments were given under the scheme. Out of
these, 24.7 lakh patients were treated by private hospitals in the last one year and the rest by public
ones. As many as 8,571 government hospitals and 9,665 private hospitals had been empanelled in
one year.

Key data missing:

However, there was no data available on the NHA website or in the public domain about which
surgeries had been performed the most.The non-availability of this set of data remains one of the
major criticisms of the scheme. There is a dashboard of the scheme but it has not been made
accessible to the public. Just not the surgeries but some of them which require implants, like hip
implant or a stent for the heart, are also part of the package under this scheme.Another document
released by the government on the occasion, Lessons learnt in one year of implementation of PM-
JAY (Pradhan Mantri Jan Arogya Yojana) stated that as the scheme matured, it was observed that
with the imposition of implants, the potential for arbitrary variation in quality arose. Huge rate
differences of the same procedures in different states could also lead to irregularities in the scheme,
the document stated hence redesigning is necessary to deal with critical issues.