Ayushman Bharat- Efforts and challenges to tackle with. - Seeker's Thoughts

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Wednesday, 13 March 2019

Ayushman Bharat- Efforts and challenges to tackle with.

Indian healthcare and Ayushman Bharat 

Good health is part of ‘social contract’ between the Government and the people and essential for sustaining economic growth of the country. There have been programmes earlier yet that was not enough. The population is on the rise, so is the problems related to health. 

So, Modicare, or Ayushman Bharat Scheme was launched by the government to ensure the healthcare services for people who live in remote areas and to make secondary and tertiary care available which included even travelling expenses.

The first component of expansion of services with elements to promote the  preventive healthcare under comprehensive primary health through health. Not only that but the wellness centres were launched. 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.

So the scheme which is also known as the Pradhan Mantri Jan Arogya Yojana (PMJAY) is unveiled recently.

Pradhan mantri Jan Aarogya Yojana

The plan is to integrate and merge already existing PMJAY with existing schemes such as Rashtriya Swasthya Bima Yojana (RSBY) and state-level health insurance schemes.

There is a heavy focus on rural areas with 8.3 crore families participating, and remaining 2.33 crore families are urban. Some states that were providing insurance through RSBY or own schemes had wider coverage than provisioned in PMJAY. Combining these with PMJAY could widen the total insurance coverage to reach around 60-65% of the population.

RSBY and other state insurance schemes are all enrolment-based schemes, whereas PMJAY is an entitlement scheme. Hence, if you fall under the beneficiary list, then you are automatically covered under PMJAY.

The PMJAY implementation strategy proposes two models: trust model and insurance-based model. Currently, majority of states have opted for the trust model for a variety of reasons, like package rates, existing contracts, etc.

Officials from various authorities will jointly form the Ayushman Bharat-National Health Protection Mission Governing Board (AB-NHPMGB), which will be responsible for governance.

The National Health Agency (NHA) has been formed to provide vision and stewardship for design, roll-out, implementation and management.

The scheme aims to provide annual health insurance cover of Rs 5 lakh to 10.74 crore beneficiary families i.e. over 50 crore beneficiaries across India. It is touted as world’s largest healthcare scheme.


This mission enables increased access to in-patient health care for the poor and lower middle class. The access to health care is cashless and nationally portable.

It spurs increased investment in health and generate lakhs of jobs, especially for women, and will be a driver of development and growth. It is a turning point for the health sector.

It will bring healthcare system closer to the homes of people.

The new program would be a vast expansion of health coverage, allowing people to visit the country’s many private hospitals for needs as varied as cancer treatment and knee replacements. 

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.

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. If a state’s existing scheme has a higher rate for a specific package compared to the PMJAY, the former will apply.

It will dramatically improve provision of healthcare for the poor. 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 PMJAY is a poverty-reducing measure. 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.

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

With more private and NABH-accredited hospitals getting empanelled, the quality of care provided to the beneficiaries will improve going forward, paving the way for standardisation of care across the country

The following problems with Indian healthcare system need to be resolved to make Ayushmann Bharat a success:-

Massive shortages in the supply of services(human resources, hospitals and diagnostic centres in the private/public sector) which are made worse by grossly inequitable availability between and within States.

For example, even a well-placed State such as Tamil Nadu has an over 30% shortage of medical and non-medical professionals in government facilities.

Health budget is the need 

  The health budget has neither increased nor is there any policy to strengthen the public/private sector in deficit areas.

  While the NHPS provides portability, one must not forget that it will take time for hospitals to be established in deficit areas. This in turn could cause patients to gravitate toward the southern States that have a comparatively better health infrastructure than the rest of India.

Infrastructure constraints have to be adressed

There are doubts on the capacity of this infrastructure to take on the additional load of such insured patients from other States, growing medical tourism (foreign tourists/patients) as a policy being promoted by the government, and also domestic patients, both insured and uninsured.

Absence of primary care has to be taken care of

 In the northern States there are hardly any sub-centres and primary health centres are practically non-existent.

The wellness clinic component is a step towards bridging that lacuna but funding constraints are here too.

High Expenditure

 Even the poor are forced to opt for private healthcare,  and, hence, pay from their own pockets. Resultantly, an estimated 63 million people fall into poverty due to health expenditure, annually. 

Inequalities in Healthcare

Inequities in the health sector existdue to many factors like geography,  socio-economic status and income groups among others. Compared with countries like Sri Lanka, Thailand and China, which started at almost similar levels, India lags behind peers on healthcare outcomes.

The Government has launched many policies and health programmes but success has been partial at best.

Way forward

There is a need for multi-sectoral planning and ‘health in all policies’ approach, where initiative of different departments and Ministries is developed and planned coordination, accountability  assigned and progress monitored jointly. It has to be coordinated at the level of Prime Minister or the Chief Minister’s office, as the case may be.

PPP in India needs a nuanced approach and systematic mechanisms, includinglegislation and regulatory aspects. The process requires wider stakeholder engagement and deliberations and oversight from top leadership.

There is a need to reform and re-design institutions to broader health system goals to contribute achieve sustainable development goals.

Policy proposals, such as setting up of Indian Medical Service, establishing public health cadre as well as mid-level healthcare providers and exploring lateral entry of technical experts in academic and health policy institutions, including in the health Ministry (up to the levels Joint Secretary and Additional Secretary levels) should be deliberated and given due priority.

 A competitive price must be charged for services provided at public facilities as well. The government should invest in public facilities only in hard to reach regions where private providers may not emerge.

The government must introduce up to one-year long training courses for practitioners engaged in treating routine illnesses. This would be in line with the National Health Policy 2002, which envisages a role for paramedics along the lines of nurse practitioners in the United States.

There is urgent need for accelerating the growth of MBBS graduates to replace unqualified “doctors” who operate in both urban and rural areas. 

The government needs to provide adequate funding to improve the quality of services as well.

In a federal polity with multiple political parties sharing governance, an all-India alignment around the NHPS requires a high level of cooperative federalism, both to make the scheme viable and to ensure portability of coverage as people cross State borders.

State governments, which will administer it through their own agency, will have to purchase care from a variety of players, including in the private sector, at predetermined rates. Reaching a consensus on treatment costs through a transparent consultative process is vital for a smooth and steady rollout.

A large-scale Information Technology network for cashless treatment should be set up and validated. State governments need to  upgrade the health administrative systems. The NHPM has a problem with the distribution of hospitals, the capacity of human resources, and the finances available for cost-sharing.