UPSC Editorial Analysis: Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PMJAY)
Kartavya Desk Staff
Source: IE
*General Studies-2; Topic: Welfare schemes for vulnerable sections of the population by the Centre and States and the performance of these schemes; mechanisms, laws, institutions and Bodies constituted for the protection and betterment of these vulnerable sections.*
Introduction
• Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PMJAY) is a flagship health insurance scheme launched by the Government of India in 2018.
• Its primary objective is to reduce the financial burden of healthcare and promote universal health coverage, ensuring accessible and affordable healthcare for all.
Case Study Overview:
• Raju, a young 18-year-old, faced a severe heart condition and struggled to get treatment due to financial constraints.
• His family, pushed into debt exceeding ₹5 lakh, sold livestock and land, unaware of their eligibility for PMJAY.
• After the family was informed about the scheme in 2022, Raju underwent a life-saving surgery costing ₹1.83 lakh, fully covered by the scheme.
• This case illustrates the life-changing impact of PMJAY on underprivileged families in India.
PMJAY’s Scope and Impact:
• Hospital Admissions: The scheme has facilitated over 7.8 crore hospital admissions in the past six years.
• Universal Health Coverage (UHC): It forms the cornerstone of India’s push towards UHC, with free healthcare up to ₹5 lakh per family for secondary and tertiary treatments.
• Reduction in Poverty: The scheme has prevented millions of families from falling into poverty due to healthcare costs.
• Widespread Reach: Beneficiaries come from both government and private hospitals, with a network of over 29,000 empanelled hospitals.
Healthcare Coverage and Benefits:
• Extent of Coverage: PMJAY covers ₹5 lakh for inpatient care annually for secondary and tertiary care, which, for most families, meets their annual healthcare needs.
• Limitations: The scheme does not cover outpatient services, which are being addressed separately through Ayushman Arogya Mandirs (AAMs).
• AAMs and Primary Healthcare: Over 1,75,000 AAMs provide free consultations, medicines, and diagnostics, complementing PMJAY’s focus on inpatient care.
Technological Advancements in PMJAY:
• Technology-Driven System: PMJAY is cashless, paperless, and technology-driven, ensuring seamless healthcare delivery.
• Claim Settlement: While most claim settlements are prompt, the government is making efforts to improve the system further, particularly in collaboration with state governments.
Health Benefit Package (HBP) Revision:
• Expansion of HBPs: The number of HBPs has increased from 1,393 in 2018 to 1,949 in 2022, making a broader range of treatments accessible.
• Customisation and Regional Flexibility: States and Union Territories can adapt HBP rates to local contexts, ensuring that healthcare costs align with regional variations.
Public-Private Partnership:
• Private Sector Participation: About 57% of PMJAY admissions occur in private hospitals, indicating the substantial role of the private healthcare sector.
• Growth in Tier-2 and Tier-3 Cities: PMJAY is driving the growth of healthcare infrastructure in smaller cities, addressing previously unmet demand for medical services.
Special Initiatives and Inclusivity:
• Inclusion of ASHA and Anganwadi Workers: Approximately 37 lakh families of ASHA and Anganwadi workers have been brought under PMJAY in 2023.
• Elderly Population: The scheme now covers all citizens aged 70 and above, benefiting around 6 crore elderly individuals, regardless of pre-existing conditions.
• Inclusivity for Women and the Vulnerable: With 58% of the elderly being women and 54% being widows, the scheme addresses the critical needs of vulnerable sections of society.
Positive Socioeconomic Impact:
• Reduction in Medical Vulnerability: A study based on the Household Consumption Expenditure Survey 2022-23 highlights that the bottom 50% of India’s population is now less vulnerable to healthcare-related financial shocks, attributed largely to PMJAY.
• Public Sector Strengthening: Public hospitals have used reimbursements to enhance infrastructure and services, showing that the scheme has bolstered the healthcare system across states.
Concerns / Challenges
• Improvement Needed: Despite the progress, there is scope for further efficiency in claim settlement, enhancing the system’s reach and impact.
• Despite the success of PMJAY, many eligible families are still unaware of their entitlement.
• There are significant variations in the availability of healthcare infrastructure across regions. Many rural and remote areas lack empanelled hospitals under the scheme, forcing beneficiaries to travel long distances for care.
• There have been reports of variable quality of care in hospitals empanelled under PMJAY, particularly in public sector hospitals.
• The scheme predominantly focuses on curative services, especially hospital-based care, rather than emphasizing preventive and primary healthcare.
• The involvement of private healthcare providers, raises concerns about the over-commercialization of healthcare.
• India faces a significant shortage of healthcare professionals, including doctors, nurses, and technicians. This shortage is particularly severe in rural and underserved areas.
Way Forward
• Enhancing existing Ayushman Arogya Mandirs to include comprehensive OPD coverage would provide more holistic health protection and prevent families from incurring out-of-pocket costs for minor illnesses and follow-up care.
• Increase outreach efforts through community-based programs, leveraging ASHA and Anganwadi workers to identify and inform eligible beneficiaries.
• Regional disparities in healthcare access, particularly in rural and remote areas, must be addressed.
• To ensure transparency, efficiency, and reduced fraud, the government can enhance artificial intelligence (AI) and machine learning (ML) technologies to monitor claim settlements and detect fraudulent activities.
• Establish specialized geriatric wards in hospitals and home-based care models for elderly patients who cannot frequently visit healthcare facilities.
• To ensure the scheme’s continued success, there must be a robust system for monitoring and evaluating its impact.
Conclusion:
• PMJAY exemplifies India’s commitment to inclusive healthcare. Through a blend of public and private sector participation, technological advancements, and tailored health benefit packages, the scheme is not only saving lives but also reducing the financial burden of healthcare on millions of families.
• As Mahatma Gandhi once said, “It is health that is real wealth and not pieces of gold and silver.” The scheme is poised to be a key driver of a Viksit Bharat (developed India), ensuring that health becomes the foundation of a prosperous and equitable society.
Practice Question:
Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PMJAY) is considered one of the world’s largest health insurance schemes. Discuss the scope and impact of PMJAY in providing Universal Health Coverage (UHC) in India, especially for vulnerable sections of society. (250 words)