(GIST OF YOJANA) Moving Towards Better, Equitable and Affordable Health Services [AUGUST-2019]
(GIST OF YOJANA) Moving Towards Better,
Equitable and Affordable Health Services
Moving Towards Better, Equitable
and Affordable Health Services
Ayushman Bharat PMJAY:
A Bold New Approach to Healthcare Delivery in the Subcontinent To
address these gaps, last year Government of India launched Ayushman Bharat
which is a two pronged approach towards universal health care.
The first is Health and Wellness Centres (HWCs) which will provide
Comprehensive Primary Health Care, covering maternal and child health
services, screening for noncommunicable diseases, free essential drugs and
follow-up of hospitalisation cases. 150.000 HWCs will be set up by 2022 and
will be able to handle more than 70 per cent of all outpatient care
including non-communicable diseases and mental illnesses. The centre will
also conduct yoga sessions to promote wellness and have a much wider
range of free drugs and diagnostics, including many that need to be
prescribed but can be made available locally by the health workers.
The second is Pradhan Mantri Jan Arogva Yojana (PMJAY). the
world’s largest fully government funded health insurance scheme, which
provides a health protection cover of Rs. 5 lakh per family per year to
10.74 crore poor and vulnerable families (or 50 crore people) for
hospitalisation expenses towards the treatment of serious illnesses.
Through PMJAY. Government of India aims to offer financial risk
protection to the beneficiary families through a system of demand-led
healthcare initiative that meets their immediate hospitalization needs in a
cashless manner. The objectives of PMJAY are to reduce catastrophic
out-of-pocket health expenditure, improve access to quality healthcare and
meet the unmet needs of the population for hospitalization care. The scheme
was launched on 23rd September last year by the Prime Minister in Ranchi,
Thus, Ayushman Bharat represents a significant transition from a
sectoral, segmented approach to comprehensive, holistic approach bringing
together preventive, promotive, curative,
rehabilitative aspects of care along a continuum of care. Ayushman Bharat
marks a paradigm shift in how health is looked at in India. It is the advent
of new thinking about health where health is no longer looked at as a
challenge to be solved through a silo-approach but a reality to be reckoned
with and approached through a continuum of care offering an entire gamut of
healthcare services from primary to secondary to tertiary and followup care.
Who is Covered Under PMJAY PMJAY has been rolled out for the
bottom 40 percent of poor and vulnerable population. In absolute numbers,
this is close to 10.74 crore (100.74 million) households. The inclusion of
households is based on the deprivation and occupational criteria of the
Socio-Economic Caste Census 2011 (SECC) for rural and urban areas,
respectively. This number also includes families that were covered in the
RSBY but were not present in the SECC database. The SECC involves ranking of
households based on their socio economic status. It uses exclusion and
inclusion criteria and accordingly decides on the automatically included and
automatically excluded households.
Rural households which are included (not excluded) are then ranked
based on their status of seven deprivation criteria (D1 to D7). Urban
households are categorised based on occupation categories. In line with the
approach of the Government to use the SECC database for social welfare
schemes. PMJAY also identifies targeted beneficiary families through this
Out of the total seven deprivation criteria for rural areas. PMJAY
covered all such families who fall into at least one of the following six
deprivation criteria (D1 to D5 and D7) and automatic inclusion 6 criteria:
D1-Only one room with kuchu walls and kucha roof
D2- No adult member between ages 16 to 59
D3-Households with no adult male member between ages 16 to 59
D4-Disabled member and no able bodied adult member
D5- SC/ST households
D7- Landless households deriving a major part of their income from
manual casual labour
Urban Beneficiaries- For urban areas, the following 11
occupational categories of workers are eligible for the scheme:
Street vendor/ Cobbler/hawker other service provider working on
Construction worker/ Plumber/Mason/ Labour/ Painter/
Welder/Security guard/ Coolie and other head-load worker.
Even though PMJAY uses the SECC as the basis of eligibility of
households, many States are already implementing their own health insurance
schemes with a set of beneficiaries already identified.
Thus, States have been provided the flexibility to use their own
database for PMJAY. However, they will need to ensure that all the families
eligible based on the SECC database are also covered.
Key Features of PMJAY
PMJAY provides cashless cover of up to FNR 5,00.000 to each
eligible family per annum for listed secondary and tertiary care conditions.
The cover under the scheme includes all the expenses incurred from
diagnostic and laboratory investigations, full treatment, non-intensive and
intensive care services, medicine and medical consumables and
posthospitalization follow up care up to 15 days.
There is no cap on family size and age of members. 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.
All pre-existing diseases are covered from the very first day.
This means that any eligible person suffering from any medical condition
before being covered by PMJAY will now be able to get treatment for those
medical conditions under the scheme. This is a major advantage over regular
private insurance schemes that often do not cover illnesses being suffered
by the policyholder.
Benefits covered under PMJAY are portable across the country and
any eligible beneficiary can visit any empanelled hospital across the
country and receive cashless treatment.
1393 secondary and tertiary treatment packages covering 23
specialties are offered. PMJAY has also made provision for unspecified
surgical package to cover treatment for ailments that are not in the list of
surgical packages. However, mandatory pre-authorisation approval is required
to book a patient under this package.
Implementation Model: A Bulwark of Cooperative e Federalism
Insurance Mode-The State Government appoints an insurer at a
defined premium rate for taking over the financial risk of the
beneficiaries. Nine States have chosen the Insurance
Trust Mode- The State Government creates an agency (State Health
Agency) which will pay the claims of the hospitals as per actual utilisation.
The risk of health protection lies with
the State. 17 States are implementing the scheme in the trust
Mixed Mode - The State uses a combination of Insurance and Trust
modes generally where low' cost common procedures (secondary care) is
managed by the insurer and high cost
specialised procedures managed by the State trust. Six States have
chosen the Mixed mode.
Financing of the Scheme
PMJAY. being a centrally sponsored scheme is fully funded from the
Consolidated Fund of India and the budget allocated is received from
Government of India as recurring grant-in aid. Under the Union Budget the
allocation for PMJAY for 2019-20 is Rs. 6400 crore.
The expenditure under PMJAY is shared between Central Government
and State Governments/Union Territories as per the sharing instructions
issued by the Ministry of Finance in vogue.
The existing sharing ratio is as under;
For North Eastern and 3 Himalayan States: 90 (Centre): 10
For Union Territories with Legislation and Other States: 60
(Centre): 40 (States).
For Union Territories without Legislation: 100 (Centre).
Payment of Central Share
Insurance model- A flat premium per family, irrespective of the
number of members under PMJAY in that family, is paid to the State
Government which in turn pays this to the insurer based on the number of
Assurance model -Central share of the contribution is paid based
on the actual cost of claims or the ceiling whichever is lower. If the State
is using an Implementation Support Agency, then cost of ISA, determined
through tender, is also shared between Centre and State.
Reflections on the 2019-20 Budget
Ayushman Bharat represents the priority accorded to health by the
Government of India flowing from the highest level and the will to
mainstream health of the citizens and link it to their economic growth and
development of the country'.
This is reflected in the 2019-20 budget with a Rs. 6,400 crore
allocation for PMJAY, up from Rs. 2,400 crore in 2018-2019, the year of its
The outlay for overall health sector at Rs. 62.659 crore, the
highest in the last two financial years, marked an increase of around 19 per
cent over the 2018-19 fiscal when the health allocation was Rs. 52.800 crore.