Policy Analysis: Ayushman Bharat

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According to “The Hindu”, to ensure continued critical care in serious diseases such as cancer and heart disease, the National Health Authority has launched its express efforts to put several private hospitals under Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB PM-JAY).

The Hospital Empanelment Module (HEM) Lite will allow patients with serious diseases including cancer, heart problems, and diabetes, whoever needs continued care, to receive stay in the hospital without fear of the infection. “The mechanism is also going to help empanel specialized hospitals COVID-19,” said a statement. As part of our effort to enhance our capacity to serve AB-PMJAY beneficiaries, we have temporarily planned and launched express empaneling of private hospitals to improve the provision of treatment under the scheme, “Dr. Indu Bhushan, CEO, Ayushman Bharat PMJAY, and National Health Authority quoted the release as saying.

The scheme covers more than 1,500 health insurance packages with secondary and tertiary care services, and hospitals are reimbursed at prefixed rates. The AB-PMJAY, a flagship healthcare scheme, provides around 50 crore poor and vulnerable people with coverage of Rs 5 lakh per family annually.

PMJAY provides the beneficiary with cashless and paperless access to facilities at the point of care at any (public and private) empanelled hospital in India. In other words, a patient from one state will benefit from anywhere in the country from an empanelled hospital.

Significance of this development:-

The move was in line with Covid-19’s current outbreak situation when a number of medical colleges, civic hospitals and district hospitals, which otherwise handled the bulk of patients with AB-PMJAY, were converted as devoted to Covid-19 facilities in States.

With the introduction of the Hospital Empanelment Module (HEM) Lite, patients suffering from serious illnesses such as cancer, heart issues and diabetes requiring continuous care will be able to continue to seek inpatient services without fear of infection.

The mechanism will also help to empanel dedicated COVID-19 hospitals as well, the National Health Authority (NHA) — the health insurance nodal implementing agency said. Hospitals can use a simple, user-friendly online system available on the scheme’s website www.pmjay.gov.in to empanel themselves for a temporary period of 3 months, it said.

The State Health Agency (SHA), which is the state government’s apex body responsible for enforcing AB PM-JAY in the state, can only sign a MoU for three months with a specifically empanelled hospital. At that time, the empanelment between the hospital and SHA will continue, but only after the thorough empaneling process, i.e. the whole form is completed and the District Implementation Unit ((DIU) and the SHA have checked the details of this process.

According to “The Hindu business line”; As of now, more than 8804 private hospitals are stacked in AB PM-JAY in the country, accounting for 51% (96 lakh hospitalizations) and 64% (Rs.13,000 crore) of hospital enrollment. The claim money is transferred to the hospital within 15 days of receipt and a comprehensive remedial program is available.

While the testing and treatment of Covid-19 are already free in public facilities, the Center aimed to make such services accessible for private players through private laboratories and private hospitals. This is critical as private hospitals in many states could be best prepared to deal with Covid-19 cases – with the requisite isolation beds, ICU equipment, ventilators, or respirator facilities.

According to the National Health Mission, the Gujarat government, 127 private hospitals treat Covid-19 patients in Gujarat, while 1,004 private hospitals are being empanelled under the authority of Ayushman.

There are about 2,269 empanelled hospitals in Tamil Nadu under Ayushman, of which 1,170 are public and 1,099 private hospitals. In early April, 110 private hospitals and about 21 government hospitals were approved to treat Covid-19 patients across the state, according to a release released by the Department of Health & Family Welfare, Government of Tamil Nadu. Yet the number of hospitals in Covid-19 has since scaled up. According to TS Selvavinayagam, additional director of Public Health and Preventive Medicine, 169 private hospitals in Tamil Nadu are currently approved to treat Covid-19 patients.

According to “The Hindu Businessline”; Treatment costs, both before and post-hospitalization costs, are covered in the empaneled hospitals on the basis of the defined rate packages. The Center has built and finalized a list of around 1,391 packages. Yet states are given a certain amount of freedom to tinker with package prices. In fact, states that already have their own health insurance/insurance systems in place have been permitted to proceed with their current plan rates. Aside from the cost of treating COVID-19-related symptoms, the package would also include extra ICU bed costs, personal protective equipment (PPE), ventilators, and other expenses.

Salient features of the scheme:-

Ayushman Bharat is a step towards encouraging, preventive, curative, palliative and rehabilitative aspects of Universal Healthcare through access to primary level health and wellness centers (HWCs) and providing financial support for secondary and tertiary access to curative treatment through interaction with both the public and private sectors. It adopts a continuum approach to healthcare, consisting of two linked elements: the creation of 1, 50,000 health and wellness centers, which bring healthcare to people’s homes. These centers will provide Comprehensive Primary Health Care (CPHC), covering both maternal and child health services and non-communicable diseases, including free essential drugs and diagnostic services.

Key features:-

  • Ayushman Bharat- Pradhan Mantri Jan Arogya Yojana (PMJAY) will pay for hospitalization for secondary and tertiary treatment up to 5 lakhs per family per year.   
  • PMJAY is an entitlement based scheme. This scheme covers poor and vulnerable families based on deprivation and occupational criteria as per SECC (Socio-economic caste census) data.
  • The eligibility for such benefits will extend to over 10.74 crore needy families (approximately 50 crore beneficiaries).
  • In any (public as well as private) empanelled Hospitals across India, PMJAY offers cashless and paperless access to beneficiary services at the point of service. All RSBY and SCHIS beneficiary families have the right to PMJAY benefits.
  • The PMJAY will contribute to reducing catastrophic hospital spending which impoverishes people and mitigates the financial risk resulting from disastrous episodes of health.
  • The States are free to choose the methods of implementation under PMAJY. They can enforce the scheme by insurance or by the trust or company or by a mixed model
  • There is no restriction on family size, which ensures that all members of designated families especially girls and elderly people are covered.
  • Hospitals cannot deny care for all pre-existing diseases covered.
  • Families will be able to use the quality health services they need without facing financial hardships.

Legal basis:-

Every citizen in India has the right to receive healthcare that is safe and of high quality. Under the Sustainable Development Goal, the achievement of universal health coverage is a priority. All UN member states, including India, have committed to trying to provide all their people with universal health coverage by the year 2030.

The central government has, however, launched Ayushman Bharat, which offers coverage of up to Rs 5 lakh per family per year for those enrolled under the scheme and those who are unable to afford secondary and/or tertiary health care without family size restriction.

In a series of cases, the Supreme Court held that the right to health and medical care was a fundamental right under Article 21, read with Articles 39(e), 41, and 43 of the Indian Constitution. Article 21 of the Constitution provides: “No person shall be deprived of his life or personal liberty except according to the procedure established by law.” Article 47 is one of the principles of the Directive and directs the State ‘to increase the level of nutrition and the standard of living and to improve public health, as one of its primary duties.’ It is, therefore, the duty of the State to take care of public health.

Objectives and purposes:-

The Ayushman Bharat objective is a highly ambitious, unparalleled and transformational initiative in India’s history. In the Indian healthcare industry, in particular the public sector, there are many crises that trigger a lot of pressure.

The ever-increasing cost of treatment is forcing a large number of people to either skip the treatment or sell their assets for treatment. A lot of vulnerable people have to deal with lifestyle as well as infectious or contagious diseases during this process of health transition and many secondary and tertiary care systems do not have the requisite resources and services to provide quality medical care. The vulnerable are deprived of innovative treatments and the resultant worsening of their life quality faces significant health problems. The Ayushman Bharat Scheme represents a significant phase in addressing the problems facing Indian public health.

This initiative is a government-focused effort to resolve the current challenges in primary, secondary and tertiary health care systems. The key aim is to improve primary health care by addressing the challenging problems and to make innovative services available through the implementation of highly affordable insurance schemes. Proper implementation of this project is the main thing, as its aims are quite positive in nature and innovative.

Different research reports suggest, as a result of the increasingly growing cost of treatment, that around 60 million people are poor. This is an extremely disturbing statistic and the Ayushman project answers the underlying problem of disadvantaged people not being affordable for advanced treatments. That is the 500 million families in India protected by the Government’s Health Programme. About 38% of the population would benefit immensely from the flagship plan.

Criticism:-

As with any other policy, the Ayushman Bharat scheme is not averse to commentaries on its shortcomings. The scheme has been the recipient of several allegations hinting towards its failure such as:

  • It has been pointed out that the financial backing for the scheme has been draining the National Health Mission of its resources which in turn has been reducing its aid towards other schemes such as the National Rural Health Mission.
  • Another shortcoming of the scheme relates to the shortage of personnel in healthcare which is a determining factor in the proper implementation of the scheme. The community health centers have witnessed shortfalls in surgeons, physicians and vital staff over the past year.
  • Awareness regarding the benefits offered under the scheme and the means to avail it is poorly communicated as there is not sufficient realization of the same, especially amongst the underprivileged and illiterate people.
  • Finally, the scheme does not account for those who depend on the unorganized sector with absolutely no access to healthcare or insurance.

Probable way forward:-

Since health seems to have earned priority in India, the opportunity should be used as a catalyst for the transformation and strengthening of the decisive and wider health system. Like every other government program, every year PM-JAY requires updates to ensure the system does not fall behind. To this impact, the Government of India needs to review the processing levels for including large hospitals in the system.

Fix infrastructural defects at the grassroots level. Ensure smooth connectivity in such areas as Kashmir and North-East, boost surveillance at all rates to avoid fraud. Ayushman Bharat has been established as a strong initiative to strengthen and meet the healthcare needs of the Indian community, but a long way to go. The need for India to achieve its sustainable development goals and to be a pioneer is an inter-sectoral collaboration and a political commitment to improve the entire health care system.

Conclusion:-

The AB-PMJAY is the unique opportunity to improve health and eradicate a significant cause of poverty for hundreds of millions of Indians. There are however major challenges that must be addressed to allow Indians to realize these benefits and make a sustainable contribution to India’s development towards the UHC (Universal Health Coverage). The success of the UHC is assessed by the community-wide provision of health care, the quality of services offered and the financial security given to the public.

While the implementation of AB-PMJAY has significant resource constraints, the performance of the scheme – or otherwise – in making progress on these three measures would also rely on overcoming other current and relevant systemic deficiencies in the Indian system such as public and private sector governance, governance, quality control, and the organization of the health system.

Author: Md Atif from Faculty of law, AMU.

Editor: Rashmi Senthilkumar from Sastra University, Thanjavur.

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