The National Health Policy 2017 advised the commencement of Ayushman Bharat, the government of India's flagship programme, to realize the goal of Universal Health Coverage (UHC). Rashtriya Swasthya Bima Yojana (RSBY) and the Senior Citizen Health Insurance Scheme(SCHIS), which are now centrally supported programmes, will be absorbed into Ayushman Bharat - National Health Protection Mission .
Ayushman Bharat represents an effort to transition from a sectoral and fragmented approach to the delivery of health services to a comprehensive need-based strategy. This programme intends to implement ground-breaking initiatives to comprehensively address the healthcare system at the primary, secondary, and tertiary levels (encompassing prevention, promotion, and ambulatory care).
Ayushman Bharat(HWCs and PM-JAY) | UPSC IAS IPS IFS
This programme was created to fulfil the Sustainable Development Goals (SDGs), whose overarching aim is to "leave no one behind." Health and Wellness Centers (HWCs) and Pradhan Mantri Ja Arogya Yojana (PM-JAY) are two interconnected components of the continuum of care strategy used by Ayushman Bharat.
The transformation of the current Sub Centers and Primary Health Centers would result in the development of 1,50,000 Health and Wellness Centers (HWCs), according to a February 2018 announcement by the Indian government. By bringing healthcare closer to people's homes, these facilities will provide Comprehensive Primary Health Care (CPHC). They provide care for non-communicable illnesses, including free critical medications and diagnostic services, as well as maternity and child health services.
The Pradhan Mantri Jan Arogya Yojana, more often known as PM-JAY, is the second element of Ayushman Bharat. Before being renamed, PM-JAY was once known as the National Health Protection System (NHPS). The largest health assurance programme in the world, Ayushman Bharat PM-JAY, aims to provide a health cover of Rs. 5 lakhs per family per year for secondary and tertiary care hospitalization to over 10.74 crores poor and vulnerable families (roughly 50 crore beneficiaries), who make up the bottom 40% of the Indian population. According to the socioeconomic caste census 2011 (SECC 2011) occupational and deprivation criteria for rural and urban regions, respectively, the families included are based on these factors.
Salient features of the scheme are:-
- The defined benefit coverage for Ayushman Bharat, the National Health Protection Program, would be worth Rs. 5 lacks per family per year.
- The plan's benefits are transferable across the nation, and beneficiaries who are covered by it are eligible to receive benefits from any public or private hospital that has been granted an empanelled status.
- The National Health Protection Mission (Ayushman Bharat) will be an entitlement-based programme, with eligibility determined by deprivation criteria in the SECC database.
- The beneficiaries may use both accredited private facilities and public ones to get benefits.
- To keep expenses in check, payments for treatment will be made on a package rate basis (to be determined in advance by the Government).
- Cooperative federalism and flexibility for the states are two fundamental tenets of Ayushman Bharat, the National Health Protection Plan.
- It is suggested to establish the Ayushman Bharat National Health Protection Mission Council (AB-NHPMC) at the highest level, under the leadership of the Union Minister for Health and Family Welfare, to provide policy guidance and promote cooperation between the Center and States.
- To put the plan into effect, each state would establish a State Health Agency (SHA).
- The transfer of monies from the Central Government through the Ayushman Bharat - National Health Protection Program to State Health Agencies may be done through an escrow account directly to ensure that the funds reach SHA on time.
- A strong, modular, scalable, and interoperable IT platform that would support a paperless, cashless transaction will be made operational in collaboration with NITI Aayog.
An Ayushman Bharat National Health Protection Mission Agency (AB-NHPMA) would be established at the federal level to govern. State Health Agency, a dedicated organisation, would advise States and UTs on how to administer the programme (SHA). To carry out the plan, they can either create a new entity or use an existing Trust, Society, Not for Profit Business, or State Nodal Agency (SNA). States and UTs have the option of putting the programme into effect either directly through the Trust or Society, through an insurance business, or by using an integrated approach.
The cover under the scheme includes all expenses incurred on the following components of the treatment.
- Medical examination, treatment and consultation
- Medicine and medical consumables
- Non-intensive and intensive care services
- Diagnostic and laboratory investigations
- Medical implantation services (where necessary)
- Accommodation benefits
- Food services
- Complications arising during treatment
- Post-hospitalization follow-up care up to 15 days
The Rs. 5,00,000 financial benefits are available on a family floater basis, allowing them to be utilised by any number of family members. A five-person family limit is applied to the RSBY. However, PM-JAY has been created in such a way that there is no restriction on family size or member age based on the lessons learned from earlier programmes. Pre-existing conditions are also covered starting on the first day. This implies that any qualified person who had a medical condition before PM-JAY coverage will now be able to receive treatment for all of those ailments under this programme starting the day they enroll.
The Central and State Governments divide the cost of implementation of PM-JAY, which is entirely funded by the Government. The cost of premium payment will be divided between the federal and state governments according to a specified ratio. The funding for the programme will be distributed as follows: 60% for all states and UTs that have their legislatures, 90% for the Northeastern states and the three Himalayan states of Jammu & Kashmir, Himachal Pradesh, and Uttarakhand, and 100% for UTs without a legislature. Moreover, states are permitted to continue their healthcare initiatives.
- It includes the treatment cost, room costs, doctor's fees, operating room, intensive care unit, diagnostic services, surgeon charges, etc. for about 1,393 operations.
- Hospitalization for secondary and tertiary care is covered.
- It covers pre-existing conditions from day one;
- Pre-hospitalization coverage is for 3 days; post-hospitalization coverage is for 15 days, including medications and diagnostics.
- Only nine critical illnesses are covered, excluding lung cancer, stroke, paralysis etc.
- OPD is not covered.
- There is a shortage of healthcare experts and employees required to operate such a big programme.
- There is also a problem with infrastructure since many primary healthcare facilities lack even the most basic amenities, such as regular access to power and water.
Benefits coverage under different publicly financed health insurance programmes in India has always been set at an upper maximum level, ranging from an annual cover of INR30,000 to INR3,00,000 per family across several States, which has led to a fragmented system. For the mentioned secondary and tertiary care problems, PM-JAY offers each qualified family a cashless cover of up to INR 5,00,000 annually. The National Rural Health Mission (NRHM) money has increased by barely 2%, even though the PM-JAY financial allocation has grown enormously. Hence, the plan has reduced the money available for NRHM.
Every year, PM-JAY needs adjustments to keep the programme current, much like every other public programme. To include major hospitals in the scheme, the Indian government must modify the procedure fees. At the local level, address the infrastructure problems. Make sure there is constant communication in places like Kashmir and the North East. To stop fraud, enhance surveillance at every level. Use cutting-edge technology to detect fraudulent beneficiaries and transactions, and enforce stringent legal penalties on offenders.