AYUSHMAN BHARAT PROGRAM
DR KARTHIKA P JR1
HEALTH CARE ACROSS THE WORLD
The Out-of-Pocket Model:
• Most nations on planet too poor and too disorganized to provide Mass Medical Care
• Most of the healthcare expenditure is Out-of-Pocket
• Only rich get medical care and poor suffer or die
• Followers- African nations, South American countries, Rural
regions of Indian subcontinent and SouthEastAsia
SCENARIO
• 71st Round of National Sample Survey Organization (NSSO) has found 85.9% of rural households and 82% of urban households have no access to healthcare insurance/assurance.
• More than 17% of Indian population spend at least 10% of household budgets for health services.
• Catastrophic healthcare related expenditure pushes families into debt, with more than 24% households in rural India and 18% population in urban area have met their healthcare expenses through some sort of borrowings.
• Healthcare in India is largely underpenetrated, with government expenditure at around 1.25% of the GDP(Gross Domestic Product) and an underperforming public healthcare ecosystem.
• https://pmjay.gov.in/about/pmjay
EVOLUTION OF HEALTH INSURANCE IN INDIA
• 1948- Employees’ State Insurance Scheme
• 1954- Central Government Health Scheme
• 2003- Ex-Servicemen Contributory Health Scheme
• 2007- Aarogyasri Health Scheme
• 2008- Rashtriya Swasthya Bima Yojana
• 2015- Bhamashah Health Insurance Scheme
• 2016- Senior Citizen Health Insurance Scheme
• 2017- Mahatama Jyotiba Phule Jan Aarogya Yojana
• 2018- Biju Swasthya Kalyana Yojana
• 2018- AB-NHPM/NHPS/PM-RSSM
• AYUSHMAN BHARAT PROGRAMME(ABP) [2018-22] was launched at union
budget 2018
Ayushman Bharat, a flagship scheme of Government of India, was launched as recommended by the National Health Policy 2017, to achieve the vision of Universal Health Coverage (UHC).
This initiative has been designed to meet Sustainable Development Goals (SDGs) and its underlining commitment, which is to "leave no one behind.“
OBJECTIVES OF AYUSHMAN BHARAT PROGRAMME
2018-22
• focus on wellness of poor families.
• providing medical benefit to poor families.
• Establishing health and wellness centers at nearer distances so that patient will not have to travel a long distance
• To reduce out of pocket expenditure
TWO MAJOR INITIATIVES UNDER THIS PROGRAM
• Health and wellness centres
• Ayushman bharat scheme-National Health Protection Scheme-Pradhan Mantri Jan Arogya Yojana(PMJAY)
Health and Wellness Centres
• The National Health policy has envisioned Health and Wellness Centres as the foundation of INDIA’S health system.
• In February 2018, the Government of India announced the creation of 1,50,000 Health and Wellness Centers (HWCs) by transforming the
existing Sub Centers and Primary Health Centers.
• These centers are to deliver Comprehensive Primary Health Care (CPHC) bringing healthcare closer to the homes of people.
• They cover both, maternal and child health services and non-
communicable diseases, including free essential drugs and diagnostic services.
List of Services to be provided at Health & Wellness Centre
• Pregnancy care and maternal health services
• Neonatal and infant health services
• Child health
• Chronic communicable diseases
• Non-communicable diseases
• Management of mental illness
• Dental care
• Eye care
• Geriatric care Emergency medicine
PMJAY OVERVIEW
• launched on 23rd September, 2018 in Ranchi by PM.
• Ayushman Bharat PM-JAY is the largest health assurance scheme in the world which aims at providing a health cover of Rs. 5 lakhs per family per year for secondary and tertiary care hospitalization
• 10.74 crores poor and vulnerable families (approximately 50 crore beneficiaries)
• The households included are based on the deprivation and occupational criteria of Socio-Economic Caste Census 2011 (SECC 2011) for rural and urban areas
• PM-JAY was earlier known as the National Health Protection Scheme NHPS which subsumed the then existing RSBY.
• PM-JAY is fully funded by the Government and cost of implementation is shared between the Central and State Governments.
Key Features of PM-JAY
• PM-JAY is the world’s largest health insurance/ assurance scheme fully financed by the government.
• It provides a cover of Rs. 5 lakhs per family per year for secondary and tertiary care hospitalization through a network of Empaneled Health Care
Providers(EHCP).
• Over 10.74 crore poor and vulnerable entitled families (approximately 50 crore beneficiaries) are eligible for these benefits.
• PM-JAY provides cashless access to health care services for the beneficiary at the point of service, that is, the hospital.
• PMJAY will help reduce out of pocket hospitalization expenses, fulfill unmet
needs and improve access of identified families to quality inpatient care and day care surgeries.
• It covers up to 3 days of pre-hospitalization and 15 days post-hospitalization expenses such as diagnostics and medicines.
• There is no cap on family size and age as well as restriction on previous conditions
• Benefits of the scheme are portable across the country i.e. a
beneficiary can visit any empaneled public or private hospital in India to avail cashless treatment.
• Services include approximately 1,350 procedures covering all the costs related to treatment, including but not limited to drugs,
supplies, diagnostic services, physician's fees, room charges, surgeon charges, OT and ICU charges etc.
• Public hospitals are reimbursed for the healthcare services at par with the private hospitals.
Benefit Cover Under PM-JAY
• Medical examination, treatment and consultation
• Pre-hospitalization
• 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
CRITERIA
• The scheme is entitlement based.
• The inclusion of households is based on the deprivation and
occupational criteria of the Socio-Economic Caste Census 2011 (SECC 2011) for rural and urban areas, respectively.
• also includes families that were covered in the RSBY.
RURAL BENEFICIAIRES
• One out of the seven deprivation criteria
• D1- Only one room with kucha walls and kucha roof
• D2- No adult member between ages 16 to 59
• D3- Households with no adult male member between ages 16 to 59
• D4- Disabled member and no able-bodied adult member
• D5- SC/ST households
• D7- Landless households deriving a major part of their income from manual casual labour
• AUTOMATICALLY INCULUDED
• destitute/ living on alms,
• manual scavenger households
• primitive tribal group
• legally released bonded labour
• Household without shelter
Urban Beneficiaries
• 11 occupational categories of workers
• Ragpicker
• Beggar
• Domestic worker
• Street vendor/ Cobbler/hawker / other service provider working on streets
• Construction worker/ Plumber/ Mason/ Labour/ Painter/ Welder/ Security guard/ Coolie and other head-load worker
• Sweeper/ Sanitation worker/ Mali
• Home-based worker/ Artisan/ Handicrafts worker/ Tailor
• Transport worker/ Driver/ Conductor/ Helper to drivers and conductors/ Cart puller/
Rickshaw puller
• Shop worker/ Assistant/ Peon in small establishment/ Helper/Delivery assistant / Attendant/ Waiter
• Electrician/ Mechanic/ Assembler/ Repair worker
• Washer-man/ Chowkidar
17
HEALTH LEVELS OF AYUSHMAN BHARAT
NHA
Trusts, insurance companies
District Health Agency
State Health
Agency
Implementation Model
• Assurance Model/Trust Model
• most common implementation model adopted by most of the States
• scheme is directly implemented by the SHA without the intermediation of the insurance company.
• The financial risk of implementing the scheme is borne by the Government.
SHA essentially reimburses health care providers directly.
• SHA employ the services of an Implementation Support Agency (ISA) for claim management and related activities.
• SHA also has to carry out specialised tasks such as hospital empanelment, beneficiary identification, claims management and audits and other related tasks
Insurance Model
• SHA selects an insurance company through a tendering process
• SHA pays premium to the insurance company per eligible family for the policy period and insurance company, in turn, does the claims settlement and payments to the service provider.
• The financial risk for implementing the scheme is also borne by the insurance company in this model.
• insurance companies can only get a limited percentage of the premium for their profit and administrative costs.
Mixed Model
• SHA engages both the assurance/ trust and insurance model.
• This model is usually employed by brownfield States which had existing schemes covering a larger group of beneficiaries.
Category A States/ UTs
Arunachal Pradesh, Goa, Himachal Pradesh, Jammu and Kashmir, Manipur, Meghalaya, Mizoram, Nagaland, NCT Delhi, Sikkim, Tripura, Uttarakhand and 6 Union Territories (Andaman and Nicobar Islands, Chandigarh,
Dadra and Nagar Haveli, Daman and Diu, Lakshadweep and Puducherry) Category B
States
Andhra Pradesh, Assam, Bihar, Chhattisgarh, Gujarat, Haryana, Jharkhand, Karnataka, Kerala, Madhya Pradesh, Maharashtra, Odisha, Punjab, Rajasthan, Tamil Nadu, Telangana, Uttar Pradesh and West Bengal
Financing of The Scheme
• PM-JAY is completely funded by the Government and costs are shared between Central and State Governments
• The existing sharing pattern is in the ratio of 60:40
• For North-Eastern States and three Himalayan States (viz. Jammu and Kashmir, Himachal Pradesh and Uttarakhand), the ratio is 90:10.
• For Union Territories without legislatures, the Central Government may provide up to 100% on a case-to-case basis.
Hospital Empanelment
• At the State level, a State Empanelment Committee (SEC) has been set up under SHA and at the district level, a District Empanelment Committee (DEC).
• Each empaneled hospital needs to set up a dedicated help desk for the beneficiaries, which is manned by a dedicated staff appointed by the Empaneled Health Care Provider (EHCP).
• These help desk staff are called Pradhan Mantri Arogya Mitras (PMAMs)
• Every empaneled hospital receives a unique ID
PACKAGES AND RATES
• To ensure that the hospitals do not overcharge and rates do not vary across hospitals, empaneled health care providers (EHCP) are paid based on
specified package rates.
• A package consists of all the costs associated with the treatment, including pre and post hospitalization expenses
• The specified surgical packages are paid as bundled care (explained below) where a single all-inclusive payment is payable to the EHCP by insurer/SHA.
• The medical packages, however, are payable to the EHCP on a per day rate depending upon the admission unit
• Day-care packages are payable just like surgical packages
• The package rate (in case of surgical or defined day-care benefits) includes:
• Registration charges
• Bed charges (General Ward)
• Nursing and Boarding charges
• Surgeons, Anaesthetists, Medical Practitioner, Consultants’ fees, etc.
• Anaesthesia, Blood Transfusion, Oxygen, O.T. Charges, Cost of Surgical Appliances, etc.
• Medicines and Drugs
• Cost of Prosthetic Devices, implants (unless payable separately)
• Pathology and radiology tests: radiology to include but not be limited to X-ray, MRI, CT Scan, etc. (as applicable)
• Food to patient
• Pre and Post Hospitalisation expenses: Expenses incurred for consultation,
diagnostic tests and medicines before the admission of the patient in the same hospital, and up to 15 days of the discharge from the hospital for the same
ailment/ surgery
• Any other expenses related to the treatment of the patient in the EHCP
SWOT ANALYSIS ABP
STRENGTH
• world’s largest state-sponsored health assurance scheme
• Apparent shift from ‘disease specific’ and ‘Reproductive and child health’
• From ‘poor only’ to expanded approach of vulnerable and deprived population
• Seemingly high level of political commitment
• Acknowledgement of linkage between better health and economic growth of India
• Well-functioning primary healthcare system - potential to cater 80- 90% of health needs
• Cover over 10 crore poor and vulnerable families.
• Coverage up to 5 lakh rupees per family per year
• Reduction of out of pocket expenditure.
• Can avail services anywhere in India
• Unified different insurance schemes
WEAKNESS
• Policy shift towards a privatized insurance-led healthcare system
• Out-patient department visits: not part of PM-JAY
• Implants and Transplants not covered
• Health Benefit Packages not tailored according to patient needs.
• Limited attention and focus on reform of broader health system
• Over-treatment or unnecessary admission or surgeries
• HWCs: only part of primary healthcare system
• Existence of many state schemes
• Resistance from many states
• Impersonation
• reliance on private hospitals makes accessing healthcare for those from deprived classes and castes very challenging
OPPORTUNITIES
• Alignment with NHP 2017 and NITI Aayog’s three year Action Agenda 2017- 20.
• Media attention - can bring desired public accountability to expedite implementation
• Progressive universalization: UHC is about everyone, everywhere!
• Global and national level focus on universal health coverage (UHC)
• Potential - innovative models and strategies for strengthening entire healthcare system
• Implementation experience from RSBY could be utilized for rapid scale up
• More employment opportunities as Pradhan Mantri Arogya Mitras.
THREATS
• Change in the political leadership or the priorities of the elected governments
• Limited buy-in and interest by the Indian states: state’s own schemes
• Challenge in availability of mid-level care providers.
• Focus on these components only and the other broader health systems are ignored
• Disproportionate focus on one of two initiatives in ABP
• Impending economic crisis
• Hospitals under assurance model can collect money based on fraudulent claims
• Insurance model, companies have an incentive to reject legitimate claims.
The concise information about this program is available under the given url.
Kindly go through :
• https://pmjay.gov.in/about/pmjay
SWOT ANALYSIS ABP SWOT ANALYSIS ABP
