• Sakonsa Organisation

Achieving Universal Health Coverage via “Ayushman Bharat Yojana”



One of the biggest healthcare schemes in the world, Ayushman Bharat Yojana also known as Pradhan Mantri Jan Arogya Yojana(PM-JAY) aims to cover more than 50 crores, Indian citizens, out of which 10 crore families comprise 8 crore family in a rural area & 2.23 crore in urban area have availed this opportunity. The program was introduced with the intent to reduce the financial burden on poor and vulnerable groups who have to pay out - of pocket for hospitalization & to provide good quality healthcare service to these sectors This initiative has been designed to meet Sustainable Development Goals (SDGs) and Universal Health Care (UHC) its underlying commitment, which is to "leave no one behind."

Ayushman Bharat is an attempt to move from a segmented health service delivery to a comprehensive need-based health care service. This scheme aims to undertake path-breaking interventions to holistically address the healthcare system (covering prevention, promotion, and ambulatory care) at the primary, secondary and tertiary levels. Ayushman Bharat adopts a continuum of care approach, comprising of two interrelated components, which are -

· Health and Wellness Centres (HWCs)

· Pradhan Mantri Jan Arogya Yojana (PM-JAY)


1. Health and Wellness Centers (HWCs)


The Government of India announced the creation of 1,50,000 Health and Wellness Centres (HWCs) by transforming the existing sub-centers and Primary Health Centres. 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 with empowering individuals and communities to choose healthy behaviors and make changes that reduce the risk of developing chronic diseases and morbidities.



2. Pradhan Mantri Jan Arogya Yojana (PM-JAY)


PM-JAY is the world’s largest health insurance/ assurance scheme fully financed by the government. Beneficiaries of the scheme can avail of hospitalization for necessary treatment by showing their PM-JAY e-card. It provides a cover of Rs. 5 lakhs per family per year for secondary and tertiary care hospitalization across public and private empaneled hospitals in India. Even COVID-19 treatment is available under this scheme.


Features:-

  • Cashless hospitalization.

  • Covers up to 3 days of pre-hospitalization expenses such as medicines and diagnostics.

  • Covers up to 15 days of post-hospitalization expenses which include medicines and diagnostics.

  • No restriction on the family size, gender, or age.

  • Can avail services across the country at any of the impaneled public and private hospitals.

  • All pre-existing conditions covered from day one.

  • The scheme includes 1,393 medical procedures.

  • Includes costs for diagnostic services, drugs, room charges, physician’s fees, surgeon charges, supplies, ICU, and OT charges.

  • Public hospitals are reimbursed at par with private hospitals.



Problems

1. Huge demand for health care service -India with a 1.3 billion population is the second populated country in the world. The share of the population above 60+ is 19 percent. Thus demand is comparative high


2. Catastrophic health out-of-pocket expenditure -17.3per cent of people spend more than 10 percent of their behavior household’s total expenditure in healthcare and the poor come under the BPL line.


3. Changing disease profile Almost 23 percent of the population is at risk of premature death due to non-communicable disease.Till date Coronavirus Cases: 18,762,976 Deaths: 208,330 Recovered:15,384,418 in India Communicable disease.


4. Health Indices –India’s infant mortality rate has fallen from 42 percent in 2012 to 33 percent in 2015. The life expectancy rate of India for five years has gone up by 62.3percent 63.9 percent 2011-2015 & 2021 average lifespan of India is 69 years & 4 months to which the world's average lifespan is 72 years.


5. Health care infrastructure & workforce – India has 1 hospital bed per 1000 population lowest among developing nations. India has 0.7 physicians per 10,000 population.


6. The disparity of health status in India – Kerala championed the largest state with74.01 while Uttar Pradesh was the least performing state with a score of 28.61. Among the smaller state scores varied 38.51 in Nagaland & 74.97 in Mizoram Among the UT scores varied 41.66 in Daman and Diu & 63.62 in Chandigarh.

The other challenges include: Reducing the cost of diagnosis and diagnostics. A technological solution to measure and track the quality of healthcare, maximizing beneficiary awareness, reducing infection rates at hospitals, developing robust and real-time fraud detection systems.



Recommendation


1. The PM-JAY Anti-Fraud framework as laid out in Anti-fraud Guidelines 2018, aims to detect, prevent and deter fraudulent and abusive malpractices under the scheme. There are 6% of global health care fraud each year.


2. IT infrastructure can create a large amount of data and with that, we can study and understand different disease patterns, help improve and implement policies and support the health sector & joint working groups on hospital management.



3. Make in India Manufacturers of healthcare commodities, private providers, and private insurers can access an Ayushman Bharat guaranteed market and in return for volumes and revenue, they can offer better prices, comply with better regulation, and share their performance data to allow benchmarking and encourage healthy competition. thus no import of healthcare equipment.


4. The government should invite start-ups & companies to provide innovative ideas as to how to expand coverage & improve the quality, reduce the cost of healthcare.





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