7 PM | In one year, PM-JAY has created a framework for comprehensive universal healthcare | 23rd September, 2019

Context: Insights on Ayushman Bharat Scheme.

More in news: A year ago, on September 23, the prime minister launched the ‘(Pradhan Mantri Jan Arogya Yojana PM-JAY)’ in Ranchi, Jharkhand.

Ayushman Bharat:

  • Ayushman Bharat, a flagship scheme of Goverment 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 on the lines as to meet SDG and its underlining commitment, which is “leave no one behind”.
  • Ayushman Bharat is an attempt to move from sectoral and segmented approach of health service delivery to a comprehensive need-based health care service.
  • Aim of Ayushman Bharat: The aim is to undertake path breaking interventions to holistically address health (covering prevention, promotion and ambulatory care), at primary, secondary and tertiary level.
  • The scheme adopts a continuum of care approach, comprising of two inter-related components:
    • Health and Wellness Centres (HWCs)
    • Pradhan Mantri Jan Arogya Yojana (PM-JAY)

Health and Wellness Centres (HWCs):

  • The Government of India in 2018 announced the creation of 1,50,000 Health and Wellness Centres (HWCs) by transforming existing Sub Centres and Primary Health Centres. 
  • Functions:
  • These centres would deliver Comprehensive Primary Health Care (CPHC) bringing healthcare closer to the homes of people covering both maternal and child health services and non-communicable diseases, including free essential drugs and diagnostic services.
  • Health and Wellness Centers, are envisaged to deliver an expanded range of services to address the primary health care needs of the entire population in their area, expanding access, universality and equity close to the community.
  • The emphasis of health promotion and prevention is designed to bring focus on keeping people healthy by engaging and empowering individuals and communities to choose healthy behaviours and make changes that reduce the risk of developing chronic diseases and morbidities.

Pradhan Mantri Jan Arogya Yojana (PM-JAY):

  • The second component under Ayushman Bharat is PM-JAY, which aims at providing health insurance cover of Rs. 5 lakhs per family per year for secondary and tertiary care hospitalization to over 10.74 crores poor and vulnerable families (approximately 50 crore beneficiaries).
  • There is no cap on the family size under the scheme.
  • This scheme was earlier known as National Health Protection Scheme (NHPS) before it was rechristened to PM-JAY.
  • PM-JAY has been rolled out for the bottom 40% of poor and vulnerable population.
  • The households included are based on the deprivation and occupational criteria of Socio-Economic Caste Census 2011 (SECC 2011) for rural and urban areas respectively.
  • The scheme subsumed then existing Rashtriya Swasthya Bima Yojana (RSBY), launched in 2008.
  • PM-JAY is completely funded by the Government, and cost of implementation is shared between Central and State Governments.

Role of Private Hospitals:

  • More than half of the empaneled hospitals are private.
  • Over 62 per cent of the treatments have been done by private hospitals.
  • PM-JAY has created a massive demand for private (and public) sector services by making hospital facilities accessible to 55 crore people.
  • In tier II and tier III cities, private sector hospitals are already witnessing an almost 20 per cent increase in footfall.

Pradhan Mantri Arogya Mitras:

  • The Pradhan Mantri Arogya Mitra is the primary contact for the beneficiaries at every empanelled hospital care provider.
  • Pradhan Mantri Arogya Mitra plays three main roles under AB PM-JAY.
  • As a Trusted Partner of Beneficiaries
  • As a Representative of Authorities
  • As a System Operator.
  • The Pradhan Mantri Arogya Mitra shall be responsible for the following broad areas:
  • Guiding the Beneficiary about the overall benefits under AB PM-JAY and providing information about receiving prompt treatment at Empanelled Health Care Provider.
  • Operating the Beneficiary Identification System to identify and verify the beneficiaries entitled under AB PM-JAY
  • Operating the Transaction Management System such as submitting requests for PreAuthorization, Updating Surgery/Treatment Details and Filing for Claims
  • Ensure the privacy and confidentiality of personal and sensitive beneficiary information is maintained while operating IT systems under AB PM-JAY.

Use of ICT:

  • It is supported by a strong IT backbone that facilitates the identification of beneficiaries, records treatments, processes claims, receives feedback, and addresses grievances.
  • A live dashboard helps in monitoring and improving performance, based on real-time data and regular analysis. This platform also helps states to compare their performance.
  • Strong and sophisticated fraud prevention, detection and control system at the national and state level has proved to be critical for PM-JAY to ensure that frauds are largely prevented.

Opportunities ahead:

  • Exploiting the potential of collective bargaining and leveraging economies of scale. This could deliver more affordable and quality healthcare by negotiating better prices for various devices, implants and supplies, and also leveraging other policies such as Make in India.
  • Ensuring quality treatment of patients by prescribing and ensuring adherence to standard treatment protocols is another opportunity waiting to be fully harnessed.
  • Further strengthening the linkage between HWCs and PMJAY will improve the backward and forward referrals and enhance overall healthcare services, especially to the poor.
  • “Green field” states with no past experience of implementing healthcare schemes have to work harder to scale up their progress. All states will need to make sincere efforts towards providing seamless health services to the last mile.

Source: https://indianexpress.com/article/opinion/columns/pmjay-scheme-india-health-sector-ayushman-bharat-modi-govt-6018952/

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