India takes a giant leap towards providing accessible and affordable healthcare to the common man with the launch of Ayushman Bharat – Pradhan Mantri Jan AarogyaYojana (AB-PMJAY) by the Prime Minister, Shri Narendra Modi on 23rd September, 2018 at Ranchi, Jharkhand. Under the vision of Ayushman Bharat, Pradhan Mantri Jan AarogyaYojana (AB-PMJAY) shall be implemented so that each and every citizen receives his due share of health care. With Ayushman Bharat – Pradhan Mantri Jan AarogyaYojana, the government is taking healthcare protection to a new aspirational level. This is the “world’s largest government funded healthcare program” targeting more than 50 crore beneficiaries.
BENEFITS UNDER THE SCHEME:
- Ayushman Bharat- Pradhan Mantri Jan ArogyaYojana (PMJAY) will provide a cover of up to Rs. 5 lakhs per family per year, for secondary and tertiary care hospitalization.
- Over 10.74 crore vulnerable entitled families (approximately 50 crore beneficiaries) will be eligible for these benefits.
- PMJAY will provide cashless and paperless access to services for the beneficiary at the point of service.
- PMJAY will help reduce catastrophic expenditure for hospitalizations, which impoverishes people and will help mitigate the financial risk arising out of catastrophic health episodes.
- Entitled families will be able to use the quality health services they need without facing financial hardships.
- When fully implemented, PMJAY will become the world’s largest fully government-financed health protection scheme. It is a visionary step towards advancing the agenda of Universal Health Coverage (UHC).
FEATURES OF THE SCHEME
Ayushman Bharat is a progression towards promotive, preventive, curative, palliative and rehabilitative aspects of Universal Healthcare through access of Health and Wellness Centers (HWCs) at the primary level and provision of financial protection for accessing curative care at the secondary and tertiary levels through engagement with both public and private sector.
It adopts a continuum of care approach, comprising of two inter-related components: Creation of 1,50,000 Health and Wellness Centres which will bring health care closer to the homes of the people.
These centres will provide Comprehensive Primary Health Care (CPHC), covering both maternal and child health services and non-communicable diseases, including free essential drugs and diagnostic services. The first Health and Wellness Centre was launched by the Prime Minister at Jangla, Bijapur, Chhatisgarh on 14th April 2018.
The second component is the Pradhan Mantri Jan ArogyaYojana (PMJAY) which provides health protection cover to poor and vulnerable families for secondary and tertiary care.
The Health and Wellness Centres will play a critical role in creating awareness about PMJAY, screening for non-communicable diseases, follow-up of hospitalization cases among others. The features of the scheme are as follows.
Pradhan Mantri Jan ArogyaYojana: Financial protection from catastrophic expenditure:
- 71st Round of National Sample Survey Organization (NSSO) has found 85.9% of rural households and 82% of urban households have no access to healthcare insurance/assurance. More than 17% of Indian population spend at least 10% of household budgets for health services. Catastrophic healthcare related expenditure pushes families into debt, with more than 24% households in rural India and 18% population in urban area have met their healthcare expenses through some sort of borrowings.
- PMJAY primarily targets the poor, deprived rural families and identified occupational category of urban workers’ families as per the latest Socio-Economic Caste Census (SECC) data for both rural and urban areas as well as the active families under the RashtriyaSwasthyaBimaYojana (RSBY).
- Approximately 10.74 crore identified families (approximately 50 crore beneficiaries) will be entitled to get the benefits. There is no cap on family size and age as well as restriction on pre-existing conditions.
Pradhan Mantri Jan ArogyaYojana: Hospitalization cover from inpatient care to post hospitalisation care:
- The objectives of the Yojana are to reduce out of pocket hospitalisation expenses, fulfil unmet needs and improve access of identified families to quality inpatient care and day care surgeries.
- The Yojana will provide a coverage up to Rs. 5,00,000 per family per year, for secondary and tertiary care hospitalization through a network of Empanelled Health Care Providers (EHCP).
- The EHCP network will provide cashless and paperless access to services for the beneficiaries at the both public and private hospitals.
- The services will include 1350 procedures covering pre and post hospitalization, diagnostics, medicines etc.
- The Yojana beneficiaries will be able to move across borders and access services across the country through the provider network seamlessly.
Pradhan Mantri Jan ArogyaYojana in alliance with the States:
- The scheme architecture and formulation has undergone a truly federal process, with stakeholder inputs taken from all States and UTs through the national conclaves, sectoral working groups, intensive field exercises and piloting of key modules.
- The Scheme is principle based rather than rule based, allowing States enough flexibility in terms of packages, procedures, scheme design, entitlements as well as other guidelines while ensuring that key benefits of portability and fraud detection are ensured at a national level.
- States have the option to use an existing Trust/Society or set up a new Trust/Society to implement the Scheme as State Health Agency and will be free to choose the modalities for implementation.
- States can implement the Scheme through an insurance company or directly through the Trust/Society/Implementation Support Agency or a mixed approach.
PROGRESS OF THE SCHEME:
MOUs with the states: 30 states and UTs have signed the MoU and have started working on implementation of the mission. Maharashtra has joined on 14th August 2018. MoU has been signed with Tamil Nadu on 11th September 2018.
Pilot launch of PMJAY:
Pilot launch of the scheme has started. The focus of the pilot launch of the mission is to test and enhance the developed IT systems and streamline the state preparedness for a comprehensive launch.
The pilot been done in around 22 States / UTs (Arunachal Pradesh, Chandigarh, Chhattisgarh, Dadar Nagar & Haveli, Daman & Diu, Haryana, Himachal Pradesh, Madhya Pradesh, Manipur, Meghalaya, Mizoram, Nagaland, Uttarakhand, West Bengal, Uttar Pradesh, Jammu & Kashmir, Goa, Maharashtra among others).
The pilot launch is taking place in specific hospitals to test the Beneficiary Identification System (BIS) and Transaction Management System (TMS) systems. The pilot launch involves over 1280 hospitals.
Pradhan MantriAarogyaMitra (PMAM):
- The scheme is creating a cadre of certified frontline health service professionals called Pradhan MantriAarogyaMitras (PMAMs) who will be primary point of facilitation for the beneficiaries to avail treatment at the hospital and thus, act as a support system to streamline health service delivery.
- MoU was signed between National Health Agency and Ministry of Skills Development & Entrepreneurship (MSDE) on 27th August 2018 in New Delhi.
- AarogyaMitras training is being conducted in collaboration with National Skill Development Corporation (NSDC) and Ministry of Skill Development to strengthen implementation and operational preparedness.
- Training has already been conducted in across 20 states and around 3519 AarogyaMitras have been trained so far. Training programs for State, District and PMAMs have been conducted in 27 states.
- A total of around 3936 personnel have been trained at state, district and PMAM levels.
Hospital Empanelment:
So far 15,686 applications for hospital empanelment have been received.
Fraud detection and Data privacy:
- Detailed guidelines have been prepared to address the issues around potential fraudulent activities that could be committed by any individual or organization.
- Anti-fraud cells will be established at the national and state level, and strong IT tools will be deployed to prevent and detect fraud.
- NHA Information Security Policy & Data Privacy Policy are being institutionalized to provide adequate guidance and set of controls on the secure handling of Beneficiaries Personal Data & Sensitive Personal Data in compliance with all laws and regulations applicable. International standards/regulation, like ISO 27001, National Institute of Standards & Technology (NIST), Health Insurance Portability and Accountability Act (HIPAA), General Data Protection Regulation (GDPR); and Indian regulations such as Aadhaar Act 2016, Indian IT Act 2000, IT (amendment) Act, 2008 and Personal Data Protection Bill by former judge BN Sri Krishnan (Yet to be enacted) are referenced while drafting these policies.
IT systems update:
- Beneficiary Identification System (BIS) has been developed to identify and verify the beneficiaries at CSCs and point of care.
- NHA has tested the software in 80 districts across 10 states and further enhanced the system based on feedback.
- Hospital empanelment module has been active from 4th July and has already received empanelment requests from over 7,857 hospitals across 354 districts in 22 States / UTs. A comprehensive
- Transaction Management System (TMS) has been developed to facilitate transactions from hospitals (such as filing pre-authorization requests and claims submission).
- There have been trainings across the state concerning the operability of IT systems to enhance the state preparedness and receive feedback on the IT systems.
- Focused workshops have been organized to train the state level officials in operating the developed IT systems.
- Robust measures are being put in place in the IT platform to ensure privacy and security of the data.
Beneficiary related:
- MoU has been signed with Common Service Centre (CSC) for Beneficiary Identification and will utilize the over 3 lakh village level entrepreneurs for identifying beneficiaries.
- Personalized Letters with unique family code are in the process of being sent to the identified families in the Additional Data Collection Data (ADCD) drive. This will drive awareness among the beneficiaries and further ease the identification process when they visit points of care or CSC centres.
Ayushman Bharat – Pradhan Mantri Jan AarogyaYojana (AB-PMJAY) is a paradigm shift from sectorial, segmented and fragmented approach of service delivery through various national and State schemes to a bigger, more comprehensive and better converged and need based service delivery of secondary and tertiary care.
