New health paradigm

Pradhan Mantri Jan Arogya Yojana will ease burden on poor, be a catalyst for more changes in health sector.

Written by Vinod Paul , Preeti Sudan | Updated: September 22, 2018 6:52:54 am

Unlike private insurance schemes, PMJAY does not exclude a person on account of pre-existing illnesses. The size of the family is no bar.

Ayushman Bharat is a far-reaching initiative aimed at ensuring holistic healthcare services. Its first component of expansion of services with elements of promotive and preventive healthcare under comprehensive primary health through health and wellness centres was launched on April 14 from Chhattisgarh’s Bijapur district. Since then, 2,287 health and wellness centres have come up around the country.

Its second component, the health assurance mission addressing concerns of catastrophic expenditure by vulnerable families for secondary and tertiary care, the Pradhan Mantri Jan Arogya Yojana (PMJAY), will be unveiled on September 23.

It will provide a cover of Rs 5 lakh per family per year for inpatient care to 10.74 crore families at the bottom of the pyramid. This translates into more than 50 crore people, around 40 per cent of India’s population. The health conditions and surgical procedures, covered free, are encompassed in over 1,350 packages that include practically all secondary and tertiary conditions requiring hospitalisation, barring a few such as organ transplantation. The services will be provided by empanelled public and private hospitals.

Unlike private insurance schemes, PMJAY does not exclude a person on account of pre-existing illnesses. The size of the family is no bar. There is also no need for formal enrolment; families that are listed with defined deprivation criteria on the Socio Economic and Caste Census database are automatically enrolled. All that is required is a proof of identity, which could be Aadhaar or any other government-issued identity card.

All but a few states have agreed to be a part of the PMJAY. Most have chosen to run the scheme in the trust mode, which means that the state health agencies will directly implement the mission. A strong fraud control mechanism has been conceived. An audit system has been put in place. Thousands of Ayushman Mitras are being trained. At each facility, one of them will receive the beneficiary, check her eligibility and facilitate in-patient care. A system for patient feedback and grievance redressal is also in place. The system will be cashless and largely paperless.

The Yojana will be implemented in concord with state-level schemes, if they exist. An autonomous and empowered National Health Agency (NHA) has been established with corresponding state level health agencies (SHAs). A plethora of guidelines on every aspect of the scheme has been developed and pre-tested. A robust IT system has been put in place. An efficient claims management system is functional with payments to be made within two weeks.

One unique feature of the PMJAY is its national portability once fully operational. If a beneficiary from Jharkhand falls sick in Uttar Pradesh (UP), she is entitled to receive treatment in any of the empanelled hospitals in UP. Her home state will make the requisite payment for the services availed.

The service package rates are based on an extensive exercise to determine market-discovered estimates. The rates of all state schemes as well as the CGHS system were carefully studied. The cost of packages is modelled on quality care in a general ward. On the base rates, states can add upto 10 per cent as required. The base rates can further be augmented by 10 to 15 per cent each if the hospital is accredited, if it is located in one of the 115 aspirational districts or is running a specialty education course. If a state’s existing scheme has a higher rate for a specific package compared to the PMJAY, the former will apply.

PMJAY will herald a new era in healthcare for four reasons. First, it will dramatically improve provision of healthcare for the poor. It is now possible for a construction worker with an injured knee to have an implant for free, a rickshaw-puller with a heart attack to undergo a stent procedure and a farmer’s wife to receive full treatment for breast cancer.

Second, the PMAJAY will be a catalyst for transformation. It will be an enabler of quality, affordability and accountability in the health system. The empanelled hospitals have been tasked to follow the treatment guidelines. Patient outcomes will be monitored. Another impact of the PMJAY will be rationalisation of the cost of care in the private sector. With an increase in demand created, it is expected that private sector will move from a low volume-high return paradigm to a high volume-fair return (and higher net profit) model.

The earnings of public hospitals under PMJAY will be available for their upgradation and also for incentivising the provider teams as these funds will be deposited with the Rogi Kalyan Samitis. Up to 30 per cent of the overall public spending on the scheme may return to public sector institutions.

Third, the PMJAY is a poverty-reducing measure. Each year, six to seven crore people, above the poverty line, fall below it because of health-related expenses. PMJAY would reduce this number significantly. More than a third of the out-of-pocket expenditure (around Rs 5,000 per household) is due to inpatient hospitalisations. One out of eight families have to incur health expenditure of more than 25 per cent of the usual household expenditure each year. PMJAY will ease this burden on the poor.

Fourth, the scheme will create lakhs of jobs for professionals and non-professionals — especially women. It will give a boost to the health technology industry.

The implementation of a mission of this size, ambition and complexity is hugely challenging. High uptake, quality care, beneficiary satisfaction, efficient operations and fraud-controlled systems are the key metrices of its success. With highly competent and dedicated teams at the NHA and SHAs, backed by the highest political will and the goodwill of the people, the PMJAY is poised to deliver on its promise. There is also willingness to learn, improve and reform.

Paul is member, NITI Aayog, Sudan is Secretary Health and Family Welfare, Government of India. Views expressed are personal