Ayushman Bharat- PMJAY has led to an increase in the insurance coverage, finds NFHS survey.(GS Paper-II, Polity, Constitution and Governance) Source:  Hindustan Times

Why in news?

  • 5th edition of National Family Health survey showed 12.3% increase in the health insurance over the last edition which indicates the impact of Ayushman Bharat Pradhan Mantri Jan Arogya Yojana(PMJAY)

  • The survey found out that its coverage in urban areas is 38.1 % and in rural sector is 42.4 %.

Key features:

  • PMJAY was launched in 2018 and is the world’s largest Health Insurance which is fully financed by the government.

  • The aim of the scheme is to help economically vulnerable sections of the society who are in the need of Healthcare facilities.

  • The objective of the scheme is to cover 10 crore families or 50 crore beneficiaries who mostly belong to poor or lower middle income groups, through a Health Insurance Scheme covering ₹5 lakh per family.

  • PMJAY is a step to ensure cashless and paperless access of the service to beneficiaries at the secondary and tertiary Health Care Centre.

  • The nodal agency for its implementation is National Health Authority.

Provisions:

  • It does not include any restriction on family size, gender or age.

  • It covers the expenses of up to 3 days of pre hospitalization and 15 days post hospitalization plus the transportation cost.

  • The  reimbursement  given to the public Hospital is on par with the private hospital.

  • Its funding is provided by the centre and the state in the 60:40 ratio for all states and UT with their own Legislative Assembly. 90:10 for the North East states, Jammu and Kashmir Himachal Pradesh and Uttarakhand. It is 100% centrally sponsored for union territory with no legislative assembly.

  • The beneficiaries are identified by the latest Socio-Economic Caste Census data.

Significance of PMJAY:

  • It helps poor families by providing them with better Healthcare facilities without falling into the Trap of debt.

  • The robust mechanism with the large coverage of the scheme lays the foundation for the wide reforms in India Healthcare system.

  • It’s packages include provisions like pre-hospitalization and post hospitalization cost including transportation cost, helping the out of pocket people.

  • As per the latest economic survey PMJAY has contributed to the improvement of the health outcomes on many parameters in the state implementing it.

  • States implementing the scheme have had greater success in expanding the coverage of Health Insurance .This resulted in the reduction of infant and child mortality rate, improved the family planning and greater awareness about HIV.

  • The scheme is backed by the robust IT mechanism which stores the data about the beneficiaries and related treatment which can be used for the grievance redressal if need arises.

Issues:

  • Inadequate health capacities of the public sector cause for the collaboration with the private sector Hospital.

  • The scheme was criticized on the grounds that the private sector has been given a very important role to play  but their regulation is very marginal.

  • Many private hospitals which are generally established for profit, see the government offer as unviable.

  • There is a chance of fraud and addition of potential  unnecessary treatment by the private hospitals to increase their reimbursement.

  • The centre and the state both are key in providing the funds to the scheme. It becomes necessary to streamline the existing State Health Insurance Scheme to PMJAY.

Way forward:

  • The recent success story of PMJAY provides opportunities for the Indian Healthcare system to pursue a systematic Reform to meet its Universal health coverage aim.

  • In order to ensure universal coverage , more resources need to be infused into the health infrastructure which certainly need to be accompanied with effective governance to ensure the sustainability and effectiveness of the scheme.