PM Jan Arogya Yojana

Published on 13 Feb 2025

Ayushman Bharat - Pradhan Mantri Jan Arogya Yojana is the world’s largest health assurance scheme, which was launched in 2018 as recommended by the National Health Policy, 2017. The scheme envisions Universal Health Coverage through preventive, curative, palliative and rehabilitative care.

Features

✔     Health cover: To provide 5 lakh per family per year, taking care of secondary and tertiary care requirements. This covers both pre and post-hospitalization expenses.

✔     No cap on family size: To ensure no person is left behind, there is no cap on family size and age.

✔     Health and wellness centres: To cover primary care hospitalization by providing comprehensive health care

✔     Portability: The scheme has all-India portability, which means that a beneficiary registered in one state can avail services in any other state.

✔     Hospitals: The beneficiary can avail the benefits in all public hospitals and empanelled private hospitals. Moreover, PPP models like trust based models or insurance based models of hospitals are also promoted.

✔     Funding: The scheme is centrally sponsored, with a funding ratio of 60:40 for most states, 90:10 for northeast and Himalayan states and 100:0 for Union territories.

✔     Arogya Mitras: A dedicated workforce who guide the beneficiary for verification, registration, pre-authorization, claim submission etc.

✔     Use of technology: Robust IT platform to ensure seamless delivery of services. Faceless claim processing and National Anti-Fraud Unit to ensure transparency and prevent fraud.

Significance of PM JAY

✔     Access to healthcare: The scheme has ensured better access to quality health care for a comprehensive list of 1949 packages including cancer care, cardiac care, neurosurgery etc.

●      Example: Over five years, around 15.5 crore families have been covered under the programme, thus increasing the access to tertiary care by 65%.

✔     Affordability to poor: Assured health cover has aided the poor in reducing the extra spending incurred on health by the poor.

●      Example: The out of pocket expenditure of the beneficiaries was reduced by 60%, which amounts to savings of around 1 lakh crore.

✔     Improved quality of service at hospitals: The introduction of standard treatment protocol, quality certification and performance based incentives have benefitted the hospitals.

●      Example: Uttar Pradesh received two awards for excellent work in PM- JAY and on the Ayushman Bharat Digital Mission from the centre.

✔     Inclusivity: Provisions like adding people from the transgenders to the list of beneficiaries underscores the inclusivity aspect of the programme.

●      Example: Around 50 packages, including one on Sex Reassignment Surgery, have been designed for the transgender community.   

✔     Responsive healthcare: Provisions like settling the claims within 15 days and feedback mechanism within 48 hours have made the programme more responsive and citizen-centric.

●      Example: States like Uttarakhand have reduced the claim settlement time to less than 7 days.

Challenges in the implementation of PM JAY

✔     Registration of beneficiaries: The beneficiaries were identified based on SECC, which is outdated. Also, the arbitrary manner of selection has led to inclusion and exclusion error.

●      Example: CAG has highlighted the presence of invalid names, unrealistic date of birth and duplicated health IDs while reviewing the performance of CAG.

✔     Improper empanelling of hospitals: Certain hospitals have failed to provide the specified services to the beneficiaries. Moreover, some of the empanelled hospitals have remained missing.

●      Example: Out of the 27000 hospitals empanelled for Ayushman Bharat, only 18783 remain active.

✔     Resource shortage: The lack of availability of adequate infrastructure and personnel has affected delivery of services in many hospitals.

✔     Fraud practices: The anti-fraud mechanisms have failed to prevent events of fraud, which were done to exploit the scheme for personal gain.

●      Example: The CAG has revealed that nearly 7.5 lakh beneficiaries were linked to a single cell phone number.

✔     Reimbursement issue: There have been instances like delayed payment, low package rate, high denial rate etc., which have reduced the efficacy of the scheme.

●      Example: Private hospitals in Punjab decided to stop new PMJAY admissions due to delay in bill payment.

Way forward

✔     Targeted beneficiary identification: The beneficiary list needs to be updated through standardized procedures to eliminate errors.

✔     Revamp empanelled hospitals: The hospitals need to be monitored to ensure the listed hospitals have the infrastructure to offer the services mentioned in the package.

✔     Anti-fraud measures: Use of Artificial Intelligence for identifying cases of fraud and dis empanel those hospitals involved in fraud.

Thus, Ayushman Bharat PM -JAY has played a pivotal role in ensuring affordable health access to the poor. The government has also acknowledged the relevance of the scheme and the recent event of Arogya Manthan to celebrate 5 years of the scheme indicates its relevance.

Tags:
Social Justice

Keywords:
PMJAY Health assurance Arogya Mitras PPP model NHP 2017

Syllabus:
General Studies Paper 2

Topics:
Social Justice