INDEX
REFERENCE WITH UPSC-CSE SYLLABUS
- WHY IN NEWS
- BACKGROUND
- AIM
- TWO INTER-RELATED COMPONENTS
- HEALTH AND WELLNESS CENTRES (HWCs)
- PRADHAN MANTRI JAN AROGYA YOJANA (PM-JAY)
- KEY POINTS OF PRADHAN MANTRI JAN AROGYA YOJANA (PM-JAY)
- BENEFIT COVER UNDER PM-JAY
- WHAT PM-JAY COVER
- FLOATER BASIS BENEFIT
- CRITICISM OF PM-JAY
- CASE STUDY
- CONCLUSION
- EXPECTED PRELIMS QUESTIONS
EXPECTED MAINS QUESTIONS
REFERENCE WITH UPSC-CSE SYLLABUS
- General Studies-II
- Government Policies and Interventions for Development in various sectors and Issues arising out of their Design and Implementation.
- Issues Relating to Development and Management of Social Sector/Services relating to Health, Education, Human Resources.
WHY IN NEWS
- The Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) Social Endeavour for Health and Telemedicine (SEHAT) scheme via video-conferencing to extend health insurance coverage to all residents of Jammu and Kashmir (J&K) was recently launched by the Prime Minister.
- Ayushman Bharat Health Scheme for CAPF was launched by government.
BACKGROUND
- As recommended by the National Health Policy 2017, to achieve the vision of Universal Health Coverage (UHC) Ayushman Bharat, a flagship scheme of Government of India, was launched.
- Its underlining commitment, which is to leave no one behind.
- To meet Sustainable Development Goals (SDGs) this initiative has been designed.
- From sectoral and segmented approach of health service delivery to a comprehensive need-based health care service, it is an attempt to move on.
AIM
- To improve healthcare system (covering prevention, promotion and ambulatory care) at the primary, secondary and tertiary level.
TWO INTER-RELATED COMPONENTS
- Ayushman Bharat including of two inter-linked components, which are:
- Health and Wellness Centres (HWCs)
- Pradhan Mantri Jan Arogya Yojana (PM-JAY).
HEALTH AND WELLNESS CENTRES (HWCs)
- Creation of 1,50,000 Health and Wellness Centres Government has announced for transforming the existing Sub Centres and Primary Health Centres in February 2018.
- Bringing healthcare closer to the homes of people these centers will deliver comprehensive Primary Health Care.
- It cover non-communicable diseases, free essential drugs and diagnostic services and maternal and child health services.
- Health and Wellness Centers are envisaged so that it can address the primary health care needs of the entire population in their area, expanding access, universality and equity close to the community.
- To bring focus on keeping people healthy by engaging and empowering individuals and communities to choose healthy behaviors.
- Behaviour changes that reduce the risk of developing chronic diseases and morbidities, so the emphasis of health promotion and prevention is designed in such a way.
PRADHAN MANTRI JAN AROGYA YOJANA (PM-JAY)
- The Pradhan Mantri Jan Arogya Yojana or PM-JAY as it is popularly known is the second component under Ayushman Bharat.
- In Ranchi, Jharkhand On 23rd September, 2018 Prime Minister of India, Shri Narendra Modi launched it.
- Largest health assurance scheme in the world
- A health cover of Rs. 5 lakhs per family per year for vulnerable families (approximately 50 crore beneficiaries) that form the bottom 40% of the Indian population and for secondary and tertiary care hospitalization to over 10.74 crores poor.
- The households included are based on occupational and the deprivation criteria of Socio-Economic Caste Census 2011 (SECC 2011) for rural and urban areas respectively.
- Before being rechristened, earlier PM-JAY was known as the National Health Protection Scheme (NHPS).
- Rashtriya Swasthya Bima Yojana (RSBY) which had been launched in 2008 it subsumed.
- Families that were covered in RSBY but are not present in the SECC 2011 database, it also includes them.
- Cost of implementation is shared between the Central and State Governments and it is fully funded by the Government.
KEY POINTS OF PRADHAN MANTRI JAN AROGYA YOJANA (PM-JAY)
- World’s largest health insurance scheme fully financed by government.
- Across public and private empaneled hospitals in India, it provides a cover of Rs. 5 lakhs per family per year for secondary and tertiary care hospitalization.
- Eligibles for these benefits are over 10.74 crore poor and vulnerable entitled families (approximately 50 crore beneficiaries)
- Cashless access to health care services for the beneficiary at the point of service, that is, the hospital, PM-JAY provides.
- To help mitigate catastrophic expenditure on medical treatment which pushes nearly 6 crore Indians into poverty each year, PM-JAY envisions.
- 3 days of pre-hospitalization and 15 days post-hospitalization expenses such as diagnostics and medicines, it covers.
- On the family size, age or gender, no restriction.
- From day one all pre–existing conditions are covered.
- Scheme benefits are transferrable across the country i.e. a beneficiary can visit any empaneled public or private hospital in India to avail cashless treatment.
- All the costs related to treatment, including 1,393 procedures, supplies, diagnostic services, physician's fees, room charges, surgeon charges, OT and ICU charges etc.
- Public hospitals are refunded for the healthcare services at par with the private hospitals.
- Cap of five members in a family
- No cap on family size or age of members.
- From day one Pre-existing diseases are covered.
- From the day they are enrolled, any eligible person suffering from any medical condition before being covered by PM-JAY will now be able to get treatment for all those medical conditions as well under this scheme.
data from pmjay.gov.in
BENEFIT COVER UNDER PM-JAY
- Benefit cover under various Government-funded health insurance schemes in India have always been structured on an upper ceiling limit ranging from an annual cover of INR30,000 to INR3,00,000 per family across various States which created a fragmented system.
- To each eligible family per annum for listed secondary and tertiary care conditions, cashless cover of up to INR5,00,000.
WHAT PM-JAY COVER
It includes all expenses incurred on the following components of the treatment:
- Medical examination, treatment and consultation
- Pre-hospitalization
- Medicine and medical consumables
- Non-intensive and intensive care services
- Diagnostic and laboratory investigations
- Medical implantation services (where necessary)
- Accommodation benefits
- Food services
- Complications arising during treatment
- Post-hospitalization follow-up care up to 15 days
FLOATER BASIS BENEFIT
- The benefits of INR 5,00,000 are on a family floater basis which means that it can be used by one or all members of the family.
CRITICISM OF PM-JAY
- Providing primary health care to the people, the private sector has been given a large role.
- There is a shortage of healthcare professionals and personnel needed to implement the scheme.
- Basic facilities such as electricity, regular water supply, is a problem in some health care centers.
CASE STUDY
- For example, one beneficiary had undergone a septoplasty , and so his treating physician obtained approval for a septoplasty.
- However, the hospital charged the beneficiary Rs 13,000 while AB-PMJAY approved only Rs 5,000.
- Without any other options the patient paid the remaining Rs 8,000 out of his pocket – but not before he got into a fight with the doctors, administration and billing staff.
- As he recalled, he kept arguing that he was a beneficiary of AB-PMJAY and was entitled to free treatment.
- Members of the hospital staff spent a considerable amount of time with this beneficiary explaining the package system under PFHI schemes.
- He recalled their words: “For your specified surgery, the government has fixed only 5,000 rupees.
- The extra charges that you are asked to pay are because of your extended stay in the hospital and additional services due to your comorbidities.
- The package amount – amount payable to the hospital by the government – is fixed based on predetermined criteria that don’t factor in your comorbidities.”
- Are these additional charges legal? And who is to blame for such situations – the hospital, the government or the patient?
Data from thewire.in
CONCLUSION
- Supply side financing (by creation of health and wellness centers) for primary care and promoting demand-side financing for tertiary care this model (ESPECIALY IN HEALTH CARE SECTOR) has been questioned by various economist.
- On public healthcare, India’s lower per-capita spending and relying on private hospitals for tertiary and secondary care sometimes seems justified.
- But lack of user choice, inability to target the poor, absence of linkages between provider payments and performance are some criticism of supply side financing of healthcare.
- Specialist’s shortage in public healthcare forces poor people to go in private-sector hospitals and they end up paying huge amount of money.
- Some patients are caught in a poverty trap from which they rarely escape.
- Implementation at the grassroots level is the key for any policy to be successful.
EXPECTED PRELIMS QUESTIONS
Q1. Consider the following statement regarding Pradhan Mantri Jan Arogya Yojana (PM-JAY)
(a) The Pradhan Mantri Jan Arogya Yojana or PM-JAY as it is popularly known is the second component under Ayushman Bharat.
(b) It is the largest health assurance scheme in the world
Which of the following statement is correct?
(1) a only
(2) b only
(3) Both a and b
(4) Neither a nor b
SOLUTION
STATEMENT A is correct because the Pradhan Mantri Jan Arogya Yojana or PM-JAY as it is popularly known is the second component under Ayushman Bharat.
STATEMENT B is correct because it is the largest health assurance scheme in the world.
Q2. Consider the following statement regarding Pradhan Mantri Jan Arogya Yojana (PM-JAY)
(a) It provides a cover of Rs. 10 lakhs per family per year for secondary and tertiary care hospitalization across public and private empaneled hospitals in India.
(b) Pre-existing diseases are covered from the very first day.
Which of the following statement is correct?
(1) a only
(2) b only
(3) Both a and b
(4) Neither a nor b
SOLUTION
STATEMENT A is incorrect because it provides a cover of Rs. 5 lakhs per family per year for secondary and tertiary care hospitalization across public and private empaneled hospitals in India.
STATEMENT B is correct because pre-existing diseases are covered from the very first day.
Q3. Consider the following statement regarding Pradhan Mantri Jan Arogya Yojana (PM-JAY)
(a) It is fully funded by the Government and cost of implementation is shared between the Central and State Governments.
(b) It covers up to 5 days of pre-hospitalization and 10 days post-hospitalization expenses such as diagnostics and medicines.
Which of the following statement is correct?
(1) a only
(2) b only
(3) Both a and b
(4) Neither a nor b
SOLUTION
STATEMENT A is correct because it is fully funded by the Government and cost of implementation is shared between the Central and State Governments.
STATEMENT B is incorrect because it covers up to 3 days of pre-hospitalization and 15 days post-hospitalization expenses such as diagnostics and medicines.
EXPECTED MAINS QUESTIONS
Q1.Critically analyses Ayushman Bharat scheme in addressing the healthcare sector in our country.
Sources used:
The Hindu,The Indian Express, British Broadcasting Corporation News, Press Trust of India, Business Standard, The Economic Times