Raju (name changed), aged 18 years, felt breathless and tired, even while normally walking around. In 2017, chest pain led to the diagnosis of a serious heart condition. His father sold the family livestock and land, plunging into a debt of over five lakhs to fund an endless search for treatment. In 2019, they received a letter from Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB PMJAY)but overlooked its import. In 2022, Raju’s condition worsened, requiring urgent surgery. Desperate and out of options, a hospital staff member asked the family to check about PMJAY and confirmed his eligibility, and Raju underwent life-saving surgery there costing around Rs. 1.83 lakhs. After 67 days in the hospital, he was finally discharged to live a new life.
This story of hope, health and happiness is one among countless others, woven around the lives of beneficiaries of AB PMJAY.
With approximately 7.8 crore hospital admissions authorized under the scheme over the last six years, PM-JAY has improved and saved millions of lives and, at the same time, prevented respective families from plunging into impoverishment and suffering due to hospital costs. The scheme stands as a testament to India’s commitment to Universal Health Coverage (UHC) envisioned by Hon’ble Prime Minister.
PMJAY has touched the very base of healthcare delivery across government and private hospitals by providing free healthcare of upto Rs 5 lakhs for secondary and tertiary treatment per beneficiary family. This amount may appear small compared to the whopping numbers promoted by private health insurers, but the impact of this amount for millions of families is life-changing and life-saving given the design and scale of the scheme. Analyses show that, in general, almost all the annual inpatient care requirements of a family are met by this coverage.
By design, PMJAY is for inpatient secondary and tertiary care and outpatient services are not a part of the scheme. The latter component of Universal Health Coverage (UHC) is being addressed through the equally ambitious comprehensive primary health care mission under which over 1, 75,000 Ayushman Arogya Mandirs (AAMs), earlier called Health and Wellness Centres, have been established where free consultations, and many medicines (upto 172) and diagnostics (upto 63) are being provided free. Stronger two-way convergence and continuity of care across the two systems is currently the focus of government effort. Bharat’s UHC model is based on publicly-funded comprehensive primary healthcare. Health policy and services need to be seen in totality and not in isolation.
Over the course of scheme implementation, the procedures and prices under Health Benefit Package (HBP) have been revised and rationalised. From 1393 HBPs in 2018, the number now stands at 1949 since 2022. A concept of differential pricing has been introduced, to account for regional variation in the costs of healthcare services. Concurrently, States and UTs have been given additional flexibility to further customize the HBP rates to local context.
To ensure seamless delivery of services and mitigate scope of abuse in the system, PMJAY is inherently technology-driven, and paperless as well as cashless. There is no provision of reimbursement or co-payment. Though most claim settlements are timely, intense efforts are being made for further improvements in partnership with the states.
The scheme’s success and the government’s commitment to public welfare have led to two major initiatives this year to expand its coverage. In the interim budget, the government extended the scheme to approximately 37 lakh families of ASHA and Anganwadi workers and helpers.
Second, in the wake of India’s rising life expectancy, another major development is the government’s decision to extend PMJAY coverage to all citizens aged 70 and above, regardless of the socio-economic status. This would benefit 4.5 crore families with 6 crore such senior citizens. The National Sample Survey (NSS) 75th round report on Health in India shows that the hospitalization rate for this age group exceeds a high 11%. The Longitudinal Ageing Study of India (LASI) 2021 report reveals that 75% of the elderly have one or more chronic diseases, 40% have some form of disability, and 1 in 4 suffers from multi-morbidity. Notably, 58% of the elderly population are women, with 54% being widows. Unlike many private insurance products for senior citizens, PMJAY does not exclude anyone because of a pre-existing illness; nor does it impose any waiting period of year(s) before the benefits are allowed. By addressing the healthcare needs of senior citizens, the scheme empowers them to lead healthy and dignified lives.
PMJAY connects the public and private health sectors into one-nation, one- system. As on date, PMJAY has a pan India network of more than 29,000 empanelled hospitals including about 13,000 private ones. Further, around 25,000 hospitals of these are situated in tier-2 and tier-3 cities. The proportion of hospital admissions authorized in private sector by count and amount are 57% and 67%, respectively, indicating significant participation of this sector. Beneficiary has the choice to pick the empanelled hospitals, public or private, as per the state guidelines.
The scheme has also significantly impacted service delivery in public sector hospitals across many states. These hospitals have utilized funds reimbursed under the scheme to enhance their amenities and infrastructure. With increasing pace of coverage and reach, PMJAY has the potential to spur growth of private hospitals in tier 2 and 3 cities by creating a market where there was previously unmet demand due to lack of paying capacity.
A recent study by an eminent economist (based on unit-level data from Household Consumption Expenditure Survey 2022-23) concluded that the bottom 50 per cent of our population has become significantly less vulnerable to medical expenditure-related shocks in the past 10 years; and this trend is closely associated with PMJAY. Many more people are accessing healthcare services today and, at the same time, preserving their assets and savings.
Ayushman Bharat PMJAY is poised to play a pivotal role in building a Viksit Bharat. Good health, after all, is the very foundation of wellbeing, national productivity and prosperity.
(The Author is Member (Health) NITI Aayog. Views are personal. Courtesy: PIB)
