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(GIST OF YOJANA) Moving Towards Better, Equitable and Affordable Health Services [AUGUST-2019]

(GIST OF YOJANA) Moving Towards Better, Equitable and Affordable Health Services
[AUGUST-2019]

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, Jharkhand.
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 data.

Rural Beneficiaries

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:
Ragpicker
Beggar
Domestic worker
Street vendor/ Cobbler/hawker other service provider working on streets
Construction worker/ Plumber/Mason/ Labour/ Painter/ Welder/Security guard/ Coolie and other head-load worker.
Sweeper/ Sanitation worker/Mali
Home-based worker/Artisan/Handicrafts worker/ Tailor
Transport worker/ Driver/Conductor/ Helper to drivers and conductors/ Cart puller/ Rickshaw puller
Shop worker/Assistant Peon in small establishment/Helper/Delivery assistant/Attendant/ Waiter.
Electrician/ Mechanic/Assembler Repair worker/Washerman/Chowkidar.
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.

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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
mode.
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 mode.
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 (States).
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 eligible families.
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 launch.
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.