Background

Ayushman Bharat is an attempt to achieve the vision of universal health coverage by shifting from sectoral and segmented approach to a comprehensive need-based healthcare service provision. It was rolled out on September 23, 2018 by the Prime Minister of India Shri Narendra Modi, with an assurance that it would transform the healthcare system and ensure access to quality healthcare to the poor and vulnerable.

According to the current estimates, the Ayushman Bharat Scheme has provided 6.2 crore free hospital admissions, thereby, saving 1.25 lakh crore poor and vulnerable people from out-of-pocket expenses. (As from PIB  News article published on 14-01-2024). (1)

This flagship programme by National health Authority currently has four pillars through which it ensures universal health coverage. (2)

The four pillars of Ayushmann Bharat Scheme are:

1. Health and Wellness Centres:  Ayushman Bharat Health and Wellness Centres (AB-HWCs) also known as Ayushman Arogya Mandir - Sub centres, PHC and UPHCs are upgraded to AB-HWCs to provide comprehensive primary health care through 12 package of services and around 14 diagnostic tests.

2. Pradhan Mantri Jan Arogya Yojana (PM-JAY): World’s largest Health Insurance scheme which caters to 12 crore vulnerable families covering more than 55 crore people which accounts to about 40% of India’s population.

3. Ayushman Bharat Digital Health Mission: Launched in 2021 to provide an integrated digital health care system and bridge the gap among different stakeholders and beneficiaries. Under this initiative, the citizen was enabled to link their personal health record digitally through the unique ID, i.e., ABHA number and ABHA card.

4. Pradhan Mantri Ayushman Bharat Health Infrastructure Mission (PM-ABHIM): Launched in 25th October 2021 with an aim to strengthen infrastructure of healthcare institutions across all level and hence provide continuum of care.

AYUSHMAN AROGYA MANDIR:

The primary level health care centres have now been upgraded to Health and Wellness Centre (Now known as Ayushman Arogya Mandir) with the objective of providing comprehensive primary health care services to the beneficiaries. As of 31st March 2024, there are a total of 1,72,151 functional Ayushman Arogya Mandir across the country. (3)

Table 1 : Distribution of functional Ayushman Arogya Mandir

Key components or services provided at AB-HWCs:

• Maternal Health

• Immunization

• Tele Consultation

• Yoga

• Health awareness

• Drug distribution

Figure 2: Schematic diagram of Comprehensive Primary Health Care Delivery Through Health and Wellness Centres.

The Out-of-Pocket Expenditure (OOPE) crisis:

The World Bank defines OOPE as any direct cost bore by households, including gratuities or payment in any form to health practitioners, pharmaceuticals, therapeutic appliances, and other goods and services with the aim of restoring and enhancing the health status of an individual or group of individuals. (4) It can be assumed to be type of private health expenditure. When these spending exceeds the households’ capacity to pay for healthcare including food, housing, and utilities by 40% then it is said to be catastrophic health expenditure. (5) In India where majority of the poor and vulnerable sections are not covered under any health insurance, PMJAY has acted as a boon for many of these households, preventing Out-of-pocket and catastrophic health expenditure.

Figure 3: Government Health Expenditure and Out-of-pocket expenditure as % of Total Health Expenditure (%) (6)

*OOPE- Out of Pocket Expenditure

GHE- Government Health Expenditure

THE- Total Health Expenditure

Till the initial decade of the 21st century, nearly 2/3rd of the health care needs of the country were contributed from the catastrophic Out-of-Pocket Expenditure and only 1/3rd was from the Government revenue. This led to may Indian being forced to enter and re-enter the state of poverty. (7)

 According to the National Sample Survey Office (NSSO) report, released in 2016, 80% of Indians were not covered under any health insurance plan. Among those who were covered, 14% were from rural while only 18% were from urban areas. Also, majority were unaware of any health insurance scheme. (7)

Evolution of AB-PMJAY: (8)

 Rashtriya Swasthya Bima Yojana (RSBY) was launched by Ministry of Labour & Employment, Government of India to provide health insurance coverage for Below Poverty Line (BPL) families with the coverage of Rs.30,000 per annum on a family floater basis.

RSBY was integrated into health system and it was transferred to Ministry of Health and Family Welfare (MoHFW).

Ayushman Bharat-National Health Protection Scheme (AB-NHPS), an amalgamation of RSBY and Senior Citizen Health Insurance Scheme (SCHIS) was an upgradation, with a vision to reduce the Out-of-Pocket Expenditure (OOPE) of the Below Poverty Line families.

Table 2: Insurance coverage eligibility of various schemes after launch of PM-JAY (7)

Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY): (9)

This second component of Ayushman Bharat was launched by the Prime Minister of India in September,2018.

Households were added based on the deprivation and Occupational criteria of Socio-Economic Caste Census 2011(SECC2011).

The eligible households were ranked based on their status of seven deprivation criteria (rural households) and occupational categories (Urban households).

What prevents the OOPE -PMJAY(Financing):

• PM JAY is funded fully by government (shared by Central and state government)

• The ratio for sharing pattern (Central Government: State Government)

• 90:10- North Eastern states & three Himalayan states (Jammu and Kashmir, Himachal Pradesh, Uttarakhand)

• 60: 40-states other than and union territories with legislature.

What makes PM-JAY unique?

• 12 crore poor and vulnerable families are entitled for benefits including cashless access to health services.

• 1929 procedures covered including costs of all services viz, medical examination, treatment, drugs, investigations, intensive and non-intensive services, accommodation, and food services from 3 days pre-hospitalization to post hospitalization follow-up care till 15 days.

• Unlike other insurance schemes, all pre-existing conditions are covered and no restriction in terms of age/gender or size of family is observed and the beneficiary can avail treatment from day one.

Which hospitals are empaneled under PM-JAY?

• All National Institutes run by MoHFW

• Institutes of national importance

• ESIC (Based on bed occupancy ratio)

• All public hospitals (community health center and above)

• Private hospitals - empaneled by State Health Agencies (SHA)

How does it reach the pockets?

The schemes are implemented through one of the three models depending upon the state’s preference

1.    Trust or assurance Model:

• SHA employs an Implementation Support Agency (ISA) and directly reimburses the Health Care Providers.

• Majority of states follow this model.

2.    Insurance model:

• SHA competitively selects an insurance company to manage PM-JAY in the state by paying premium to the insurance per family eligible for the policy period.

• The insurance company henceforth takes the financial risk of implementing the scheme and settling the claims and payments to the service provider.

• The profit made by the insurance company is kept at check through a mechanism such that the insurance company can get only a limited percentage of the premium for its profit.

3.    Mixed model:

• SHA engages both the models discussed above.

• In this way, the money needed for the health care needs is taken care of and is directly paid instead of reaching the beneficiary’s pocket hence his/her pocket remains undisturbed.

Benefit of AB PM-JAY and ESIC convergence:

• Any beneficiary enrolled under either of the two schemes viz, ESIC or AB-PM JAY is entitled to access free treatment and avail services under both schemes.

Figure 4: Total umber of special procedures carried out and conditions treated under PMJAY within 5 years of launch. (10)

Figure 5: Trend of Hospital Admissions in the past 5 years. (10)

Table 3: Achievement of Ayushman Bharat in last 5 years (based on indicators) (3,10)

Sustainability and way forward:

1.    Technology in Healthcare: (6,11)

• Ayushman Bharat Digital Mission (Previously known as National Digital health Mission was launched in 2021 to fulfill the vision of providing accessible healthcare through technology.

• As of now, 40 digital health service applications have been integrated with ABDM.

• It was created with a vision of creating a National digital health ecosystem to support Universal Health Coverage to enforce adoption of open standards at national level.

• It is an integrated system of personal health records with easy accessibility.

• Mobile based Ayushman App enables beneficiaries create Ayushman Cards on their own.

• ABDM uses user application, unified health interface ,health building blocks etc.,

 The ABDM infrastructure includes :

• ABHA number as a Unique ID

• ABHA mobile app

• Healthcare Professional Registry(HPR)

• Health Facility Registry(HFR)

 2.    Monitoring : Zero tolerance to fraudulence is and corruption is practiced and routine scrutiny is conducted to maintain integrity: (12)

 NAME AND SHAME: Empaneled hospitals when found ineligible or to have involved in corruption were de-empaneled and displayed on the NHA website.

 NAME AND FAME: Hospitals with exemplary work will be rewarded with their name being displayed on the NHA website.

 3.    Anti-Fraud measures:

• Guidelines for prevention of fraudulent activities.

• Steps to prevent misuse: Realtime dashboard entries and enrollment to National Anti Fraud Unit and State Anti Fraud Unit.

 4.    Auxiliary programs:

 School  health and wellness programme : (13)

• Implemented in government and government aided schools.

• Two teachers designated as Health and wellness ambassadors (1 male and 1 female) will carry out activities planned weekly, monthly, quarterly and biannually and also facilitate linkage with other ongoing school based programmes like WIFS, NDD, MHS, RBSK, Fit India Movement ,Eat Right Campaign, POSHAN abhiyaan.

• Digitalized student health cards for each student with screening and services access.

Conclusion:

The Ayushman Bharat Scheme is currently the largest umbrella scheme following National Health Mission, with various parallel schemes and initiatives continuing to benefit all sectors of the community. The remarkable progress in the last 5 years continue to grow in strides with digitalization and innovation. With the introduction of novel schemes focusing on digital health , health infrastructure and health insurance, Ayushman Bharat continues to pave its path towards in fulfilling the vision of “Health For All” .

References:

1. Press Information Bureau (2024). 30 crore Ayushman Cards created under Ayushman Bharat Pradhan Mantri Jan Arogya Yojana. [online] Available at: https://pib.gov.in/PressReleseDetail.aspx?PRID=1996010  [Accessed 28 March 2024]

2. Press Information Bureau (2022) Ayushman Bharat holistic healthcare for India. Available at: https://static.pib.gov.in/WriteReadData/specificdocs/documents/2022/apr/doc202243051901.pdf [Accessed: 28 March 2024].

3. MOHFW (2024) Ayushman Arogya Mandir. Available at: https://www.ab-hwc.mohfw.gov.in/ [Accessed: 28 March 2024].

4. World Bank. Out-of-pocket health expenditure (% of total expenditure on health). Available at: https://databank.worldbank.org/metadataglossary/africa-development-indicators/series/SH.XPD.OOPC.TO.ZS#:~:text=Out%20of%20pocket%20expenditure%20is,of%20the%20health%20status%20of [ Accessed: 28 March 2024]

5. WHO. Households with out-of-pocket payments greater than 40% of capacity to pay for health care (food, housing and utilities approach - developed by WHO/Europe). Available at: https://www.who.int/data/gho/indicator-metadata-registry/imr-details/4989#:~:text=Catastrophic%20health%20spending%20occurs%20when,to%20pay%20for%20health%20care. [Accessed: 28 March 2024]

6. Press Information Bureau (2018). Cabinet approves Ayushman Bharat – National Health Protection Mission. Available at: https://pib.gov.in/PressReleasePage.aspx?PRID=1525683 [Accessed: 28 March 2024]

7. Niti Ayog (2021). Health Insurance for India’s Missing Middle. Available at:  https://www.niti.gov.in/sites/default/files/2023-02/Health-Insurance-for-India%E2%80%99s-Missing-Middle_08-12-2021.pdf [Accessed: 28 March 2024]

8. Press Information Bureau (2023). National Health estimates 2019-20 report launch. Available at: https://pib.gov.in/PressReleaseIframePage.aspx?PRID=1919582#:~:text=The%20share%20of%20Out%2Dof,Universal%20Health%20Coverage%20for%20citizens. [Accessed: 28 March 2024]

9. Press Information Bureau (2018). Ayushman Bharat –Pradhan Mantri Jan AarogyaYojana (AB-PMJAY) to be launched by Prime Minister Shri Narendra Modi in Ranchi, Jharkahnd on September 23, 2018. [online] Available at: https://pib.gov.in/PressReleseDetail.aspx?PRID=1546948 [Accessed: 28 March 2024].

10. National Health Authority (2019). National Health Authority | GOI. [online] nha.gov.in. Available at: https://nha.gov.in/PM-JAY. [Accessed : 28 March 2024]

11. Press Information Bureau. 40 digital health service applications successfully integrated with Ayushman Bharat Digital Mission (ABDM). [online] Available at: https://pib.gov.in/PressReleseDetail.aspx?PRID=1824411 [Accessed 28 March 2024].

12. Press Information Bureau (2019). Available at: https://pib.gov.in/PressReleasePage.aspx?PRID=1586707 [Accessed : 28 march 2024]

13. NHM. (2018). Operational Guideline on School Health Programme under Ayushman Bharat. Available at: https://nhm.gov.in/index1.php?lang=1&level=4&sublinkid=1385&lid=747. [Accessed: 28 March 2024]