The government rolled out Pradhan Mantri Jan Arogya Abhiyan recently.
What is the scheme all about?
The programme is being touted as the world’s largest health protection scheme.
The scheme has two pillars under it –
Ayushman Bharat (AB) - 5 lakhs health sub-centres will be converted into health and wellness centres.
National Health Protection Mission (NHPM) - Provides health cover of Rs. 5 lakhs per family, per annum, reaching out to 50 crore beneficiaries.
The benefits of the scheme are portable across the country for secondary and tertiary care hospitalisation.
Also, a beneficiary covered under the scheme will be allowed to take cashless benefits from any public/private empanelled hospitals across the country.
Coverage - The scheme will aim to target over 10 crore families based on SECC (Socio-Economic Caste Census) database.
It will target poor, deprived rural families and identified occupational category of urban workers’ families.
It will cover 1,300 illnesses, including serious ones such as cancer and heart diseases.
Private hospitals would also be part of the scheme.
To ensure that nobody from the vulnerable group is left out of the benefit cover, there will be no cap on family size and age in the scheme.
The insurance scheme will cover pre and post-hospitalisation expenses, including pre-existing illnesses.
Funding - The expenditure incurred in premium payment will be shared between central and state governments in a specified ratio –
60:40 for all states and UTs with their own legislature.
90:10 in Northeast states and the three Himalayan states of Jammu and Kashmir, Himachal and Uttarakhand.
100 per cent central funding for UTs without legislature.
The states are also free to continue with their own health programmes.
Mode of funding - In a trust model, bills are reimbursed directly by the government.
Andhra Pradesh, Telangana, Madhya Pradesh, Assam, Sikkim and Chandigarh are the states that will use a trust model for the mission.
In an insurance model, the government pays a fixed premium to an insurance company, which pays the hospitals.
Gujarat and Tamil Nadu have opted for mixed mode implementation.
What more does it need?
Primary care - The NHPM is pushing for hospitalisation at secondary and tertiary-level private hospitals, while disregarding the need for accessing primary care.
Hence, households should be made to register at the 1.5 lakh ‘health and wellness clinics’.
It should provide them access to district-specific, evidence-based, integrated packages of preventive health care.
It will also result in early detection of cancers, diabetes and chronic conditions, mostly needing long-term treatment and home care.
This will further minimise the demand for hospitalisation.
Investment in primary care would thus reduce the overall cost of health care for the state and the consumer.
Private sector - The National Health Policy 2017 proposed “strategic purchasing” of services from secondary and tertiary hospitals for a fee.
Competent health-care providers from private sectors can be roped in and standard treatment protocols and guidelines notified by the government.
This will rule out potential for any unnecessary treatment, since the fees are getting fixed per episode, and not per visit.
Competition - Health-care providers should be accredited without any upper limit on the number of service providers in a given district.
The annual premium for each beneficiary would be paid to those service providers, for up to a renewable one year, as selected by beneficiaries.
This will enhance competition and service quality while keep costs in check.
Also, District hospitals be upgraded to government medical colleges and teaching hospitals, so that capacities at the district levels be increased.
Sectoral co-ordination - Clean drinking water, sanitation, garbage disposal, waste management, food security, nutrition and vector control under various ministries be brought together to link health with development.
Swachh Bharat programme could be incorporated in the PMJAY, so that the overall co-operation of all these sectors will reduce the disease burden.
Technology - AI-powered mobile applications will soon provide high-quality, low-cost, patient-centric, smart wellness solutions.
The scaleable and inter-operable IT platform being readied for the Ayushman Bharat is encouraging.
Thus, with the integration of prevention, detection and treatment of ill-health, PMJAY would become a well-governed ‘Health for All’ scheme.
