Ayushman Bharat Yojana

In 2017 an Indian version of the Global Burden of Disease Study reported major diseases and risk factors from 1990 to 2016 for every state in India.[5] This study brought a lot of interest in government health policy because it identified major health challenges which the government could address.[6] A large percentage of the population is left underserved by the Indian health system, which relies on out-of-pocket payments from patients to fund care.[7] These payments hinder a lot of patients from being able to receive healthcare services. In 2018 the Indian government described that every year, more than six crores Indians were pushed into poverty because of out of pocket medical expenses.[8] Despite various available regional and national programs for healthcare in India, there was much more to be done. The Indian government first announced the Ayushman Bharat Yojana as a universal health care plan in February 2018 in the 2018 Union budget of India. The Union Council of Ministers approved it in March. In his 2018 Independence Day speech Prime Minister Narendra Modi announced that India would have a major national health program later that year on 25 September, also commemorating the birthday of Pandit Deendayal Upadhyaya.[9]

PM-JAY stamp

In June 2018 the applications opened for hospitals through an "empanelment process". In July 2018, the Ayushman Bharat Yojana recommended that people access benefits through Aadhaar, but also said that there was a process for people to access without that identity card. AB PM-JAY was first launched on 23 September 2018 at Ranchi, Jharkhand.[10] By 26 December 2020 the scheme was extended to the Union Territories of Jammu Kashmir and Ladakh.[11] The program has been called "ambitious".[12][13]

A health and wellness centre established as a part of Ayushman Bharat Yojna at Mahua community development bloc, Bihar.

Features of PM-JAY include the following— providing health coverage for 10 crores households or 50 crores Indians;[14] providing a cover of ₹5 lakh (equivalent to ₹5.6 lakh or US$7,000 in 2023) per family per year for medical treatment in empaneled hospitals, both public and private; offering cashless payment and paperless recordkeeping through the hospital or doctor's office;[15] using criteria from the Socio Economic and Caste Census 2011 to determine eligibility for benefits;[16][17] no restriction on family size, age or gender; all previous medical conditions are covered under the scheme; it covers 3 days of pre-hospitalisation and 15 days of post-hospitalisation, including diagnostic care and expenses on medicines; the scheme is portable and a beneficiary can avail medical treatment at any PM-JAY empanelled hospital outside their state and anywhere in the country;[18] providing access to free COVID-19 testing.[19][20]

In India, rather than focusing on strengthening essential primary, secondary, and tertiary healthcare in the public system, a shift toward an insurance-based system has been promoted.[21] Chronic underfunding of India’s public health sector compared to private sector, and the liberalization of the market for private health insurance by the Indian government in the late 1990s resulted in increased health disparities, as private health insurance is only affordable for higher class, richer communities.[22] In the mid 2000s, government-funded health insurance emerged as a new type of healthcare financing, helping individuals prevent catastrophic out-of-pocket health expenditures.[22] Through this model, the state would pay premiums to private insurers that would allow eligible individuals to receive free treatment at any public or private institution that has joined the PMJAY scheme. The Indian government recognized that individual out-of-pocket expenditures were pushing people into poverty and treatment in government hospitals could not protect people against catastrophic health expenditures.[22] The alternative of government-funded health insurance allows poorer individuals to still be able to access private health care without the extra expenses.[22]

When Ayushman Bharat Yojana began there were questions of how to reconcile its plans with other existing health development recommendations, such as from NITI Aayog.[37] A major challenge of implementing a national health care scheme would be starting with infrastructure in need of development to be part of a modern national system.[37] While Ayushman Bharat Yojana seeks to provide excellent healthcare, India still has some basic healthcare challenges including relatively few doctors, more cases of infectious disease, and a national budget with a comparatively low central government investment in health care. Some of the problems lay outside the Health Ministry such as urban development or transport.[38] While many government hospitals have joined the program, many private corporate hospitals have not. The private hospitals report that they would be unable to offer their special services at the government low price, even with a government subsidy.[25]

There has been misuse of the Ayushman Bharat scheme by private hospitals through submission of fake medical bills. Under the Scheme, surgeries have been claimed to be performed on persons who had been discharged long ago and dialysis has been shown as performed at hospitals not having kidney transplant facility.[39] There are at least 697 fake cases in Uttarakhand State alone, where fine of ₹1 crore (equivalent to ₹1.1 crore or US$140,000 in 2023) has been imposed on hospitals for frauds under the Scheme.[40] Initial analysis of high-value claims under PMJAY has revealed that a relatively small number of districts and hospitals account for a high number of these, and some hint of an anti-women bias, with male patients getting more coverage. Despite all efforts to curb foul-play, the risk of unscrupulous private entities profiteering from gaming the system is clearly present in AB-PMJAY.[41]

• Official website