Health is a resource for the physical, social and mental well being for living a life full of prosperity. Ensuring healthy lives and promoting well being for all at all ages is important for building prosperous societies. Healthy people are the foundation for healthy economies as healthy populations live longer, are more productive and save more. So, a nation needs to ensure healthy lives. Ensuring healthy lives for all requires a strong commitment by the nation states. The benefits of strong health initiatives outweighs the cost.
Indian Constitution under Article 47 directs the state to raise the level of nutrition and standard of living of its people and mentions the improvement of public health among its primary duties. On the health parameters, India has made a great improvement over the past decades. The life expectancy has crossed 69 years, infant mortality rate, under five mortality rate and the rate of disease incidence are declining. Many diseases such as polio, guinea worm diseases, yawns and tetanus have been eradicated.
Yet the poor, marginalised and the vulnerable people are not able to avail healthcare and are deprived of good quality health services. It is in this context that the government launched the Ayushman Bharat health initiative so that the marginalised and the downtrodden are able to get healthcare benefits and medical treatment free of cost in any government or private empanelled hospital all over the country. The family will be eligible for secondary and tertiary healthcare facilities.
The State of Healthcare in India
With the raging coronavirus outbreak in the world that adversly affected India, healthcare for all is considerably difficult in a country where only 20% of the population has health insurance coverage. There is a large group that is missing out. India has a vast healthcare system, but there remains many differences in quality between rural and urban areas as well as public and private health care. Indian healthcare system is run by both public and private healthcare providers but they have their own limitations. Public sector hospitals in India are overburdened; under staffed and also faces shortages of drugs and equipments.
The private healthcare system is responsible for providing majority of healthcare in India but it is very expensive. According to data published by National Sample Survey Office, 55 million Indians are pushed into poverty in a single year because of having to fund their own healthcare. Out of this, 38 million fall below the poverty line due to spending on medicines alone.
Role of Government
To overcome inefficiencies and achieve a healthy nation with high standard of living and improved quality of life, Indian government is continuously working to formulate health promoting laws. The National Health Policy launched in 2018 which mandated a comprehensive healthcare scheme to achieve the vision of Universal Health Coverage (UHC) is an example of such an effort. The policy has been put in place with launch of the initiative known as Ayushman Bharat in 2018 This initiative has been designed to provide comprehensive healthcare coverage to the citizens and meet the Sustainable Development Goals (SDGs) and its underlining commitment, which is ‘leave no one behind!
Ayushman Bharat also known as Pradhan Mantri Jan Arogya Yojana is a health insurance scheme to cater to the poor, lower section of society and the vulnerable population. It is a dedicated attempt to move from segmented approach of healthcare service delivery to a comprehensive need-based healthcare service. It aims to undertake path breaking interventions to address healthcare issues covering prevention, promotion and ambulatory care, at primary, secondary and tertiary levels.
Components of Ayushman Bharat
The scheme has two interrelated components known as Health and Wellness Centres (HWCs) and Pradhan Mantri Jan Arogya Yojana (PM-JAY). Over 1.5 lakh Health and Wellness Centres (HWCs) will be setup by transforming existing Sub Centres and Primary Health Centres. These centres would deliver Comprehensive Primary Health Care (CPHC) that will bring healthcare closer to the homes of people. It will be covering both maternal and child health services and non-communicable diseases. The main aim is disease prevention and health promotion to curb the increasing epidemic of non-communicable diseases. There will be free essential drugs and diagnostic services. It will emphasise on keeping people healthy by choosing healthy behaviours and make changes in their lives that reduce the risk of developing chronic diseases.
The second component under Ayushman Bharat is PM-JAY (Pradhan Mantri Jan Arogya Yojana), which aims at providing health insurance cover of 3 5 lakhs per family per year for secondary and tertiary care hospitalisation. It aims to cover over 10.74 crores poor and vulnerable families (approximately 50 crore beneficiaries), which makes it the largest health cover initiative in the world. There is no gap on family size and age. It will create a system of demand-led healthcare reforms that meet the immediate hospitalisation needs of the eligible beneficiary family in a cashless manner, thus, ating the family from catastrophic financial shock. It will help the poor families by providing financial protection for selected secondary and tertiary healthcare hospitalisations. This will reduce catastrophic out of pocket health expenditure, improve access to quality health care and meet the unmet need of the population for hospitalisation care,
PM-JAY will cover 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 for rural and urban areas respectively. PM JAY will secure those who have pre-existing illness and makes treatment in all public hospitals mandatory. This means that those who require medical treatment can not be turned away.
Funding and Implementation
The scheme is completely funded by the Government, and cost of implementation is shared between Central and State Governments. At the implementation level, the States are given the flexibility to use their own database if they were already implementing a health insurance/assurance scheme and were covering more families than those eligible as per the Socio Economic Caste Census, 2011 database.
As the new initiative is comprehensive, it will provide cashless cover of upto 5 lakh per family under the following components-medical examination, treatment and consultation, pre-hospitalisation, medicines, non-intensive and intensive care services, diagnostic and laboratory investigations, medical implant services (where necessary), accommodation benefits, food services, complications arising during treatment and post-hospitalisation follow-up care upto 15 days.
Awareness Generation Under Ayushman Bharat
Since, it is an entitlement-based scheme where there is no advance enrolment process, making beneficiaries aware of the scheme is the most critical aspect. Information, education and communication activities are also carried out to educate beneficiaries about the scheme. Various modes of communication such as leaflets, booklets, hoardings, TV, radio spots etc are being used for creating a comprehensive communication strategy for spreading the desired messages across the target audience. A detailed communication strategy has been developed by NHA (National Health Authority) which is to be implemented at both National and State levels. NHA is also working on the overall cooperation and capacity-building with the states for implementation and development of communication strategy required for increasing awareness at the state level.
The scheme is being implemented under two models : Assurance model and Insurance model. Under the assurance model, the scheme is directly implemented by the State Health Agency without the intermediation of the insurance company. The financial risk of implementing the scheme is borne by the Government in this model. Under the Insurance Model, the State Health Agency competitively selects an insurance company through a tendering process to manage PM-JAY in the State. Based on market determined premium, it pays premium to the insurance company per eligible family for the policy period and insurance company, in turn does the claims settlement and payments to the service provider.
The financial risk for implementing the scheme is also borne by the insurance company in this model. National portability is one of the key positive under Ayushman Bharat. It is a positive step towards achieving the goals of universal healthcare. By this, the beneficiaries can move throughout the country for their treatment. There is a provision for Pradhan Mantri Arogya Mitra (PMAM). Its main function is to guide, identify and assist the beneficiaries in availing the treatment.
Benefits of Ayushman Bharat
When implemented fully, this huge initiative will help India progressively achieve Universal Health Coverage (UHC) and Sustainable Development Goals (SDG). It will also ensure improved access and affordability of quality secondary and tertiar care services through a combination of public hospitals and private healthcare providers. This will significantly reduce out of pocket expenditure for hospitalisation and reduce the financial risk arising out of catastrophic health related illness and impoverishment for poor and vulnerable families.
Limitations of Ayushman Bharat
Though Ayushman Bharat is a welcome step taken by the government for universal health coverage but it has certain limitations. Funding is the main concern to run this scheme smoothly. Shortages of Doctors and Specialists are also one of the major concern, most of the hospitals across India have this problem. This scheme is confined only to weaker sections of society identified a per the Socio-Economic Caste Census, 2011. Hence, it will not be called as universal coverage in true sense. Many states lack internal capacities and sophisticated procedures for implementing national portability which is a key feature of PM-JAY.
Another limitation is that it requires the states to contribute 40% of the expenditure but most states are under a poor fiscal situation. The infrastructure is already severely stressed in the Tier II and Tier III cities. There is also an urgent need to strengthen the healthcare professionals, skilling & reskilling programs.
Ayushman Bharat is not only a positive step towards universal health coverage, it will also help in poverty reduction and employment generation. By providing health coverage to all, it keeps the disease out of door. Thus, the initiatives like Ayushman Bharat are boon to society which helps to achieve good health to harness the potential of demographic dividend.
Referring to the Ayushman Bharat scheme, World Health Organisation (WHO) Chief Tedros Adhanom Ghebreyesus has stated that, “COVID-19 pandemic, which has presented challenges for several nations could be an opportunity for India to speed up the health insurance scheme such as Ayushman Bharat.”
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