India took a giant leap toward ensuring access to quality healthcare services agnostic of economic status by launching the flagship health protection scheme, Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) in September 2018. The scheme has taken the country closer to Sustainable Development Goal 3.8, which envisions universal health coverage.
The scheme provides a health cover of Rs 5 lakh per family per year for secondary and tertiary care hospitalisation to more than 12 crore families (bottom 40 per cent of the population), making it the world’s largest health assurance scheme. The scheme’s success nudged the states/UTs (who are accountable for ensuring effective public health as it is a state subject) to extend it to more beneficiaries. About 15.5 crore families are covered under AB-PMJAY and states’ schemes are being implemented in convergence with it. This amounts to potential coverage for half of India’s population. Eleven states/UTs have pushed for 100 per cent coverage of their respective population.
As AB-PMJAY completes its fifth year, it is time to reflect on its strengths and achievements including its reducing out-of-pocket expenditure (OOPE), and efficient utilisation of the government budget.
The scheme has tried to bridge the shortfall between healthcare providers and service-takers. The commercialisation of healthcare hurt common people. The Ayushman Card is like a pre-paid card worth Rs 5 lakh, which can be used to avail free treatment at more than 27,000 empanelled hospitals. So far, more than 24 crore Ayushman Cards have been created. However, in order to realise the scheme’s full potential, the National Health Authority (NHA) along with its counterparts in the states should aim to provide every possible beneficiary with an Ayushman Card. It should be noted that a person on the beneficiary list is not denied service if she does not have a card.
The scheme has catered to more than 5.39 crore admission events worth Rs 66,284 crore in the last five years. If the beneficiaries had availed the same care outside AB-PMJAY’s ambit, the total cost of treatment would have been nearly two times higher. This has resulted in savings of more than Rs 1 lakh crore. Currently, daily, nearly 45,000 hospital admissions are authorised under the scheme — in other words, roughly 31 treatments per minute. It is heartening that 48 per cent of treatments under the scheme have been availed by women.
The success of the scheme can also be attributed to different stakeholders, especially service providers. To elicit the participation of private service providers, health benefit packages (HBPs) — covering all in-patient treatment — have been revised five times in the last five years. The latest national HBP master 2022 has 1,949 packages (365 more than the previous edition). This also includes cancer treatment. Further, the rates of 843 packages have been revised upward. Private sector hospitals which have avoided joining the scheme have no justifiable reason to stay out now. Efforts are being made to settle the claims within a defined standard of 15 days. A few states like Uttarakhand have brought down the claims settlement time to less than seven days. Efforts are being made to reward hospitals with a trustworthy record with an upfront payment of 50 per cent of the claim amount immediately after submission of claims, without adjudication.
The scheme caters to the poor and underprivileged sections of society. Its design ensures that the difficulties of people from this section in accessing healthcare services should be mitigated. Every hospital is mandated to have dedicated Pradhan Mantri Arogya Mitras (PMAMs) who guide the beneficiaries.
An important feature of AB-PMJAY is interstate portability. This means a patient registered in one state is entitled to receive care in any other state that has an AB-PMJAY programme. This has proved helpful to migrants, especially in emergencies.
Service delivery is end-to-end digitised, obviating systemic bias. Apart from an internal monitoring system, NHA has deployed a public dashboard where the scheme’s implementation, on a day-to-day basis, can be tracked. Details of people who have availed treatment under the scheme are also published without compromising their privacy. The claim processing is completely faceless.
The implementation of a scheme of this size requires real-time monitoring and constant efforts to plug all loopholes. The National Anti-Fraud Unit (NAFU) designs, implements and oversees anti-fraud initiatives. There are Anti-Fraud Units at the state level as well. As a first step towards checking abuse, Aadhaar-based authentication for card creation and registration for treatment has been mandated. The NHA has been using Artificial Intelligence (AI) and Machine Learning (ML) technologies to detect suspicious transactions/potential frauds. Further, desk and field audits (including surprise ones) are frequently conducted. More than 210 hospitals have been de-empanelled. The NHA’s call centre makes calls to every beneficiary who has availed treatment within 48 hrs of discharge to verify the quantity and quality of the treatment. Another call is made after 15 days to know about the
prognosis.
Staying true to its promise of inclusivity, the AB-PMJAY scheme added people from the transgender community to its list of beneficiaries. Around 50 packages were designed specifically for the community, including packages on Sex Reassignment Surgery (SRS).
AB-PMJAY guarantees cashless secondary and tertiary inpatient care for almost all health conditions to its beneficiaries. This ambitious scheme has extraordinary potential to protect people from serious health hazards and safeguard families against financial shocks due to healthcare expenditure.
The writer is Member (Health), NITI Aayog. Views are personal
