Date : 31/07/2023

Relevance – GS2 – Health, Government Policies & Interventions, Issues Arising out of their Design & Implementation

Keywords – PHCs, PMJAY, SECC 2011

Context –

A newly published confidential document alleges "Circumventing Ayushman Bharat and misleading underprivileged patients at Safdarjung Hospital in Delhi."

India’s Healthcare Sector

Healthcare has emerged as one of the largest sectors in India, contributing significantly to both revenue generation and employment opportunities. The country's healthcare sector is experiencing rapid growth, driven by improved coverage, expanded services, and increased investments from both public and private entities.

India's healthcare delivery system can be broadly classified into two major components: the public and private sectors. The public healthcare system primarily consists of limited secondary and tertiary care institutions located in key urban centers, and its primary focus is on providing basic healthcare facilities through primary healthcare centers (PHCs) in rural areas. On the other hand, the private sector plays a dominant role in providing secondary, tertiary, and quaternary care services, with a strong presence in metropolitan areas and tier-I and tier-II cities.

What Report Says –

Key Findings of the PMJAY Scheme: The Significance of Treating Doctors and Claims Settlement Time

The report brings to light two important revelations regarding the Pradhan Mantri Jan Aarogya Yojana (PMJAY) scheme. Firstly, it underscores the crucial role of treating doctors in determining the appropriate medical package for patients and whether they will be registered under the PMJAY scheme at all. Additionally, the report exposes instances where patients might be misled by doctors, falsely claiming that "Ayushman Bharat Clearance" could take several months.

Contrary to common beliefs, the report debunks the notion that the time taken to settle claims in public healthcare facilities is unreasonably long. Among the claims registered across all facilities, 54 percent were successfully settled, with an average settlement time of approximately 21 days.

However, the report also reveals signs of a lack of active interest in the PMJAY scheme among the medical teams working in public facilities. These findings prompt a closer examination of the scheme's implementation and effectiveness, calling for measures to improve medical team engagement and overall transparency in the process.

Pradhan Mantri Jan Aarogya Yojana (PMJAY): Bringing Universal Health Coverage to India

About:

Launched in September 2018 as per the National Health Policy 2017, PMJAY aims to achieve Universal Health Coverage (UHC) in India. It is a Centrally Sponsored Scheme under Ayushman Bharat Mission, focusing on early prevention, detection, and management through enhanced health system preparedness and infrastructure development, including specialized pediatric care.

Key Features:

• World's largest fully government-funded health insurance/assurance scheme.
• Central and State Governments share the cost of implementation.
• Provides a cover of Rs. 5 lakhs per family per year for secondary and tertiary care hospitalization in public and private empanelled hospitals.
• Covers pre-hospitalization (up to 3 days) and post-hospitalization (up to 15 days) expenses, including diagnostics and medicines.
• No restrictions on family size, age, or gender.
• Covers all pre-existing conditions from day one.

Eligibility:

• Identification of households based on deprivation and occupational criteria from the Socio-Economic Caste Census 2011 (SECC 2011) for rural and urban areas.
• Includes families previously covered under RSBY but not present in the SECC 2011 database.

Benefits:

• Provides cashless access to healthcare services at hospitals.
• Aims to prevent catastrophic expenditure on medical treatment that pushes around 6 crore Indians into poverty annually.

PMJAY represents a significant step towards achieving UHC in India, ensuring financial protection and improved healthcare access for millions of households across the country.

Challenges

The medical team's lack of active engagement in the Pradhan Mantri Jan Aarogya Yojana (PMJAY) scheme within public facilities can be attributed to various factors:

• Inadequate Incentives for Doctors: The guidelines of the National Health Authority (NHA) require a percentage of claim revenues transferred to public facilities to be distributed as staff incentives. While treating doctors receive a financial incentive, it may not be sufficient to motivate them to register patients under the scheme.
• Inadequate Incentives for Arogyamitra: Public facilities often face resource constraints, leaving the medical team stretched with clinical activities. The Arogyamitra, responsible for registering patients under suitable packages, receives remuneration based on the number of successfully registered cases (pre-authorizations) but not on claims settlement. This lack of incentive discourages proactive follow-up and efficient claim settlement.
• Vested Interests: Information asymmetry between doctors and patients, particularly the less informed poor, can lead to the denial of benefits to eligible individuals, serving vested interests. District-level data indicates that the proportion of settled claims in public facilities is considerably lower compared to private facilities.

Addressing these challenges is crucial to enhancing the medical team's participation and ensuring the successful implementation of the PMJAY scheme in public facilities, ultimately benefiting the vulnerable sections of society.

Suggestions

To fully realize the impact of the Pradhan Mantri Jan Aarogya Yojana (PMJAY) in public facilities, a strategic focus on improving the incentive structure and operational dynamics is imperative. By fostering active interest within these facilities, a significant increase in revenues can be achieved, enabling the allocation of funds for infrastructure development and improved amenities, creating a virtuous cycle of growth.

Key Steps for Success:

• Enhanced Incentive Structure: Revamping the incentive system for medical personnel can bolster their engagement with the PMJAY scheme. Providing adequate financial incentives to doctors and Arogyamitras for patient registrations and successful claims settlement can drive their proactive participation.
• Infrastructure Development: Investing in improved infrastructure will enable public facilities to cater to a broader range of medical packages, ultimately expanding healthcare coverage for the underprivileged. Additionally, addressing database errors in eligibility will ensure that no deserving individual is excluded from benefiting.
• Complementary Role of State Governments:State governments must play an active role in supporting the PMJAY scheme by providing sufficient manpower and enforcing accountability in public facilities. This collaboration will lead to a higher volume of services, ensuring effective implementation.
• Incorporating these strategic measures will encourage the medical team's active engagement and unlock the scheme's potential in public facilities, positively impacting the lives of millions of vulnerable individuals across the nation.

Conclusion –

The well-being of the Indian population, encompassing health and education, holds paramount significance in shaping the country's achievements during the next 25 years of Amrit Kaal. Finding avenues to increase funding for healthcare and optimizing resource utilization are crucial to unlocking the true potential of every Indian and ensuring a prosperous future for the nation.

Source – Indian Express