The disease strikes poor the hardest! These underprivileged sections of the society cannot afford to get ill, cannot afford to lose their daily wages, and cannot bear the ever-rising healthcare costs. Catastrophic out-of-pocket expenditure on health arising mostly from secondary and tertiary hospitalisations actually pushes people below the poverty line. So, by exclusively targeting the economically weaker sections of the society, Pradhan Mantri Jan Arogya Yojana (PMJAY) has begun filling a glaring gap between the need and accessibility of quality healthcare services in India.
When 32-year-old Indu Devi from Vaishali, Patna gets free treatment for a rare Spleen cancer which affects 1-2 persons per 10 lakh population (with about 1.5 kg tumour removed from the abdomen), with a surgery costing around a whopping Rs 1.5 lakh. Or when a 51-year-old man recovers from fracture of the femur, the strongest bone in the body through a complicated procedure known as Hip Bipolar Hemiarthroplasty at AIIMS Patna – we get know that the PMJAY has started spreading its wings to cover the poor, neglected and vulnerable sections of the society.
As per the current status, PMJAY reached a landmark 2 lakh patients availing benefits in less than 2 months as shown in the below tweet:
#AyushmanBharat #PMJAY reaches another landmark: 2 lakh patients have availed benefits in less than 2 months! The first 1 lakh beneficiaries reached in 4 weeks and second 1 lakh in 3 weeks despite Diwali festivities. #PMJAYrevolution @narendramodi @PMOIndia @JPNadda @amitabhk87
— Dr. Indu Bhushan (@ibhushan) November 12, 2018
Let us look at 5 pillars of the scheme that makes it different from the previous healthcare schemes of India which attempted to improve the healthcare scenario in our country.
1. Federal Structure
PMJAY is being run in alliance and full cooperation with the States. The development of the scheme’s architecture, formulation and methodology have truly undergone a federal process, following the distinctive principle of Cooperative Federalism by Prime Minister Narendra Modi. The Scheme is purely principle-based rather than rule-based.
- Inputs from all the important stakeholders from all the States and Union Territories were collated, through the organization of national conclaves, sectoral working groups, intensive field exercises and piloting of key modules.
- States have been allowed enough flexibility in terms of packages, procedures, scheme design, entitlements as well as other guidelines. However, at the same time ensuring that the key benefits of portability and fraud detection are ensured to the common man.
- Moreover, the State Health Agencies are free to choose the modalities for implementation of PMJAY, as they have been given a choice to implement the Scheme through an insurance company or directly through a Trust or Society (existing or new) or an Implementation Support Agency or through a mixed approach.
- Out of 33 states and union territories, 17 have adopted a trust-model, 8 states have opted for an insurance model and the remaining seven have adopted a mixed model. With Kerala signing a MoU with the National Health Agency (NHA) on November 1, 2018, yet to decide its PMJAY implementation model.
- All the claims are being disbursed from a corpus created from the central and state government contribution.
2. Infallible Efforts to Promote the Scheme among the Beneficiaries
PMJAY aims to reach 50 crore beneficiaries across the country. So, reaching out to these people was one of the big challenges in rolling out the scheme across the country. To tackle this issue, a massive awareness drive has been initiated, with the help of community health workers such as Aarogya Mitras, ASHAs and ANMs.
- These community health workers are going to each family to explain their entitlement, benefits of the scheme, other details such as a list of empanelled hospitals and how to approach the hospitals for seeking benefits etc.
- There is no registration required for the scheme, on the contrary, personalized letters with a unique family code are being sent to all the identified families. This is being done to drive awareness among the beneficiaries, promote transparency, and further ease their identification, i.e., when they visit points of care or Common Services Centres (CSC) centres.
Figure 1: PMJAY beneficiary identification letters being unloaded for delivery in East Champaran, West Champaran and Katihar in Bihar
- Another novel characteristic of PMJAY is the creation of a cadre of certified frontline health service professionals, called as ‘Aarogya Mitras’. The government has set an ambitious target to have 100,000 Arogya Mitras by the end of 2018.
- Once they reach the hospital, there will be an Aarogya Mitra to help them. They will be the primary point of facilitation for the beneficiaries to avail treatment at various healthcare centres. They will act as a support system to streamline health service delivery to all the beneficiaries.
- The Arogya Mitras will be the backbone of the scheme as they are comprehensively trained in software use, patient registration and interaction.
3. Involvement of the Private Hospitals
PMJAY engages the private sector through the purchase of designated services at a rational cost. The private sector is now accessible to the poor but on rational terms, as settled by the Government.
- Till September 2018, around 14,000 hospitals have been empanelled, with the rest in the process of review.
- Just after a month after the launch, more than 100,000 beneficiaries across regions, states and territories have been treated in with more than ₹150 crore released to the hospitals against the claims.
- The applied package rates reflect the fair pricing without any scope of profiteering.
- The government has been conducting comprehensive training for state-level officials on the IT systems.
- Aarogya Mitras training is being conducted in collaboration with National Skill Development Corporation (NSDC) and Ministry of Skill Development & Entrepreneurship (MSDE), to strengthen implementation and operational preparedness.
- Training has been conducted for around 4000 personnel, at State, District and Aarogya Mitras in 27 states, as of September 2018.
Figure 3: District level implementers participated in the CSC e-gov training workshop on Ayushman Bharat Beneficiary Identification System (BIS) in Budgam district, Jammu & Kashmir
5. Backed by Solid IT systems
Unique Beneficiary Identification System (BIS) and Transaction Management System (TMS) have been developed to deliver this cashless and paperless scheme. TMS is exclusively for the empanelled hospitals to facilitate various transactions, such as filing pre-authorization requests and claims submission.
Ayushman Bharat has been developed with a clear intent and a vision of ‘Healthier India’. It has effectively helped a number of scattered National and State Healthcare Schemes to converge into a larger and more comprehensive health care system for India. It looks at the broader vision of capitalizing on the bigger number of people covered, to ensure the health and consequently enhanced productivity, overall well-being and freedom from avert wage loss and impoverishment in a longer run. With around 40% of our country’s population now getting free treatment at any public or empanelled private hospital, it is surely a visionary step towards advancing the agenda of Universal Health Coverage.