Decoding Ayushman Bharat: A Beacon of Health & Hope | Current Affairs & Hindu Analysis: Daily, Weekly & Monthly - UPSC PDF Download

Decoding Ayushman Bharat: A Beacon of Health & Hope

Why in News?

• The Union Cabinet has expanded health coverage under the Ayushman Bharat- Pradhan Mantri Jan Arogya Yojana (PM-JAY) to include all senior citizens aged 70 and above.
• This decision is expected to benefit over 6 crore elderly individuals across India, providing them with free hospital treatment.
• Along with health coverage, senior citizens will also receive the Ayushman Vaya Vandana Card.

AB-PMJAY Scheme for Senior Citizens

Eligibility:

• Age: All senior citizens aged 70 or above are eligible, regardless of their economic status.
• Aadhaar Requirement: Aadhaar-based e-KYC is mandatory for enrolment.

Benefits:

• Health Coverage: Free medical treatment up to Rs 5 lakh per family annually (over and above Rs 5 lakh coverage of PM-JAY).
• No Income Restrictions: Senior citizens are eligible irrespective of their income.
• Immediate Access: Coverage starts immediately upon enrolment, with no waiting period.
• Dual Coverage: Senior citizens can receive PM-JAY benefits even if they have private health insurance.
• Exclusive Choice: Government retirees must choose between their existing scheme (e.g., CGHS) and PM-JAY, as dual benefits are not allowed.

What is the PM-JAY Scheme?

About Ayushman Bharat

• Launched in September 2018, Ayushman Bharat is India’s flagship health initiative aimed at achieving Universal Health Coverage (UHC).
• It focuses on providing financial protection for healthcare services to vulnerable populations.

Components of Ayushman Bharat

Health and Wellness Centres (HWCs):

• HWCs aim to provide Comprehensive Primary Health Care (CPHC) services to communities.
• Ayushman Arogya Mandirs (AAMs), formerly Ayushman Bharat Health and Wellness Centres (AB-HWCs), aim to provide comprehensive healthcare, including preventive, promotive, curative, rehabilitative, and palliative care.
• 1,50,000 AAMs will offer universal, free primary healthcare.
• These centers are designed to address preventive, promotive, and curative care needs by offering free consultations, medicines, and diagnostic services for maternal and child health, non-communicable diseases (NCDs), and other health concerns.
• The initiative focuses on bringing healthcare closer to the people, ensuring equity and accessibility for all.

Pradhan Mantri Jan Arogya Yojana (PM-JAY):

• PM-JAY provides Rs. 5 lakh per family per year for secondary and tertiary care hospitalization.
• It is targeted at 12 crore vulnerable families (approximately 55 crore beneficiaries), covering the poorest 40% of the population.
• The scheme aims to address catastrophic health expenditure and prevent families from falling into poverty due to high medical costs.
• PM-JAY is fully government-funded, with costs shared between the Central and State Governments.
• It allows beneficiaries to access care at both public and private empanelled hospitals across India.

What Benefits does PM-JAY Provide to Individuals and Families?

Reducing Financial Vulnerability: PM-JAY has benefited approximately 7.8 crore individuals over the past six years, preventing many from falling into poverty due to overwhelming health expenses. With a coverage of Rs 5 lakh, the scheme addresses the annual hospitalization needs of most families, ensuring access to essential care without the burden of debt. The proportion of Out-of-Pocket Expenditure (OOPE) in overall health expenditure decreased from 62.6% to 47.1% in 2019-20, reflecting progress toward financial protection and Universal Health Coverage for citizens.

Empowering the Elderly:

• A significant expansion of PM-JAY in 2024 broadened coverage to all citizens aged 70 and above, catering to the specific healthcare requirements of the elderly, who often deal with chronic illnesses and disabilities.
• Unlike private insurance companies, PM-JAY does not enforce waiting periods or exclusions for pre-existing conditions.

Increasing Access to Quality Healthcare:

• PM-JAY links over 29,000 empanelled hospitals (including 13,000 private facilities) across Tier 2 and Tier 3 cities, guaranteeing that even individuals in remote locations can access quality healthcare.
• More than 57% of hospital admissions occur in private hospitals, highlighting the significant contribution of the private sector to the scheme.

Gender Equity:

• The scheme has positively influenced gender equity, with 49% of Ayushman cards issued to women and over 3.61 crore hospital admissions utilized by women. This ensures equal access for women to life-saving healthcare services.

Strengthening Healthcare Delivery:

• The Health Benefit Package (HBP) has been expanded and rationalized, increasing from 1,393 procedures in 2018 to 1,949 procedures in 2022.
• Differential pricing enables states to adjust for regional variations in healthcare costs.

Scientific Studies Supporting PM-JAY's Impact:

• A study utilizing data from the Household Consumption Expenditure Survey 2022-23 indicates that PM-JAY has significantly mitigated financial shocks related to medical expenses for the bottom 50% of India’s population, enhancing economic resilience.

PM Ayushman Bharat Health Infrastructure Mission (PM-ABHIM)

The Prime Minister Atmanirbhar Swasth Bharat Yojana, now known as the PM Ayushman Bharat Health Infrastructure Mission (PM-ABHIM), was introduced in the FY 21-22 Budget with an allocation of Rs. 64,180 Crore for a duration of six years (up to FY 25-26).

The Cabinet approved the scheme in 2021, and it is designed to complement the National Health Mission.

• The primary goal of the mission is to strengthen health systems at primary, secondary, and tertiary levels.
• It emphasizes the development of an IT-enabled disease surveillance system, with laboratories established at various levels to enhance disease monitoring and response.
• The mission is focused on pandemic preparedness and ensuring an effective response to public health emergencies.
• Additionally, it includes a commitment to increase research on infectious diseases and promotes the One Health Approach, which addresses outbreaks in both humans and animals.

What are the Major Challenges of PM-JAY?

Fraudulent Claims and Data Management Issues:

• In 2023, the Comptroller and Auditor General (CAG) reported serious irregularities in the PM-JAY scheme, including instances where patients were reported to have received treatment after being declared dead.
• There were cases of multiple beneficiaries being linked to a single mobile number, such as 7.5 lakh beneficiaries connected to the same phone number 9999999999, and issues with Aadhaar duplication.
• The CAG also highlighted that Rs 12.32 crore in penalties from 100 hospitals across nine states are still pending.
• In six states and union territories, ineligible households were registered as PM-JAY beneficiaries, with costs ranging from Rs 12,000 in Chandigarh to Rs 22.44 crore in Tamil Nadu.
• Moreover, in nine states and UTs, there were delays in processing rejection cases, varying from 1 to 404 days, indicating significant lapses in the system regarding fraud and misuse in the PM-JAY.

Healthcare Infrastructure Shortfalls:

• Many public hospitals, especially in rural areas, lack the necessary infrastructure, equipment, and trained personnel required for effective healthcare delivery under the PM-JAY scheme.
• In several states, empanelled hospitals have reported issues like non-functional medical equipment and a shortage of qualified medical professionals, which compromises the quality of healthcare services provided to beneficiaries.

State Non-Participation and Regional Disparities:

• Significant states such as West Bengal, Odisha, and Delhi have chosen to opt out of the Ayushman Bharat scheme, preferring to implement their own health insurance programs.
• This non-participation creates regional disparities, where citizens in these states do not have access to the benefits of the Ayushman Bharat scheme, thus limiting its nationwide impact and effectiveness.

Unaddressed Indirect Costs for the Poor:

• The Ayushman Bharat scheme primarily focuses on covering direct healthcare costs, but it overlooks indirect costs that are significant for poor beneficiaries.
• Indirect costs such as transportation expenses, loss of income during hospitalization, and post-hospitalization expenses are not covered by the scheme, leaving vulnerable populations financially exposed and at risk.

Inadequate Primary Healthcare Support:

• The emphasis of the Ayushman Bharat scheme is more on secondary and tertiary healthcare services, while primary healthcare remains inadequately developed and supported.
• Health and Wellness Centres (HWCs), which are supposed to play a crucial role in providing primary care, are often under-resourced and lack the necessary funding and infrastructure.
• There is a pressing need for increased investment to strengthen preventive and basic healthcare services at the primary level to ensure a more balanced and effective healthcare system.

Limited Outreach and Awareness:

• A significant number of eligible beneficiaries are not adequately informed about the Ayushman Bharat scheme or face challenges during the enrollment process due to limited administrative capacity and infrastructure.
• This lack of outreach and awareness results in millions of deserving citizens being excluded from the benefits of the scheme, particularly in remote and underserved areas where information dissemination is crucial.

Weak Monitoring and Control Mechanisms:

• There is a noticeable deficiency in the monitoring of private hospitals participating in the Ayushman Bharat scheme, with some hospitals demanding upfront payments from patients.
• This practice undermines the cashless nature of the scheme and poses a barrier to beneficiaries who rely on this feature.
• Additionally, issues such as overprescription of drugs and fraudulent claims highlight the need for improved surveillance and control measures to prevent misuse and ensure the integrity of the scheme.

Way Forward

Strengthening IT Systems and Fraud Prevention:

• Implement advanced data validation tools to detect anomalies like duplicate Aadhaar entries and invalid mobile numbers.
• Enforce penalties for fraudulent claims and enhance multi-factor authentication (e.g., Aadhaar, biometrics) for beneficiary verification.
• Establish a fraud detection unit within the National Health Authority (NHA) to monitor irregularities and ensure swift corrective actions.

Ayushman Bharat Digital Mission:

• The Ayushman Bharat Digital Mission aims to provide digital health IDs, enabling seamless access to health records for hospitals and insurance firms.
• This initiative can enhance the benefits of the PM-JAY scheme by streamlining healthcare delivery and claims processing.

Enhancing Healthcare Infrastructure and Capacity:

• Prioritize upgrades to rural healthcare infrastructure, including equipment, services, and the recruitment of skilled professionals.
• Promote public-private partnerships (PPPs) to address gaps in healthcare access while ensuring accountability.

Bridging State Non-Participation and Regional Disparities:

• Engage non-participating states, such as West Bengal and Odisha, through dialogue and offer incentives to integrate their health programs with PM-JAY.
• Adjust policies to meet state-specific needs, making the scheme more flexible and appealing.

Addressing Indirect Costs for the Poor:

• Introduce provisions to cover indirect costs like transportation, income loss, and post-hospitalization expenses.
• Create community health funds or micro-insurance schemes to assist poor beneficiaries in managing these costs.

Strengthening National Health Claims Exchange (NHCX):

• Strengthen the NHCX to improve fraud detection and streamline claims settlements.

Strengthening Primary Healthcare Support:

• Boost funding for Health and Wellness Centres (HWCs) to improve infrastructure, supply essential medicines, and strengthen preventive care and early diagnosis services.

Expanding Outreach and Awareness:

• Launch awareness campaigns in underserved areas using technology, mobile apps, and door-to-door outreach to inform eligible beneficiaries.
• Simplify enrollment processes and enhance administrative capacity for better scheme access.

Improving Monitoring and Control Mechanisms:

• Conduct regular audits of empanelled hospitals to prevent fraud and ensure compliance with the scheme's guidelines.
• Strengthen real-time fraud detection systems and improve grievance redressal to address beneficiaries' issues efficiently.