AB-PMJAY: A game changer in healthcare

With more than 18 crore golden cards issued, Ayushman Bharat-PMJAY scheme has considerably improved accessibility, availability, and affordability of healthcare in India
AB-PMJAY: A game changer in healthcare
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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)

Disclaimer: The views and opinions expressed in this article are the personal opinions of the author.

The facts, analysis, assumptions and perspective appearing in the article do not reflect the views of GK.

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