Pradhan Mantri Jan Arogya Yojana (PMJAY): A Step Towards Universal Health Coverage in India

Introduction:

The Ayushman Bharat or Pradhan Mantri Jan Arogya Yojana (PMJAY) is a flagship health insurance scheme launched by the Government of India in September 2018. The scheme aims to provide financial protection to vulnerable families from the burden of high medical expenses and improve access to quality healthcare services in the country. The PMJAY is a major initiative in the direction of achieving universal health coverage in India, and it is the world’s largest government-funded healthcare scheme.

Overview of the PMJAY:

The PMJAY aims to provide health insurance coverage to around 10 crore families, which translates to approximately 50 crore beneficiaries. The scheme provides coverage of up to Rs. 5 lakh per family per year for secondary and tertiary care hospitalization. The benefits under the scheme are portable across the country, which means that beneficiaries can avail of the scheme benefits in any part of the country where empanelled hospitals are available.

The PMJAY is targeted at families identified as deprived and vulnerable based on the Socio-Economic Caste Census (SECC) 2011 data. The scheme covers individuals and families falling under the defined deprivation criteria in both rural and urban areas. The scheme has a robust fraud detection mechanism and other checks and balances to ensure that only the intended beneficiaries receive the scheme benefits.

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Implementation of the PMJAY:

The implementation of the PMJAY is a joint effort of the Central and State Governments. The Central Government is responsible for setting the norms and standards for implementation, providing financial assistance to the States, and monitoring and evaluation of the scheme. The State Governments are responsible for the implementation of the scheme at the state and district levels, including the identification and validation of the beneficiaries, empanelling the hospitals, and providing the necessary infrastructure for the scheme’s implementation.

The PMJAY is implemented through an online IT platform called the National Health Authority (NHA), which acts as the nodal agency for the scheme. The NHA is responsible for the registration and validation of the beneficiaries, issuance of e-cards, and empanelling hospitals for the scheme’s implementation. The NHA also provides the necessary support to the States for the effective implementation of the scheme.

Benefits of the PMJAY:

The PMJAY has several benefits for the beneficiaries, healthcare providers, and the overall healthcare system in the country. Some of the key benefits of the PMJAY are:

1. Financial protection: The PMJAY provides financial protection to vulnerable families from the burden of high medical expenses. The scheme provides coverage of up to Rs. 5 lakh per family per year for secondary and tertiary care hospitalization, which can significantly reduce the out-of-pocket expenses for the beneficiaries.
2. Improved access to quality healthcare: The PMJAY aims to improve access to quality healthcare services in the country, especially for vulnerable families. The scheme has empanelled several private and public hospitals across the country, which provides beneficiaries with a wide range of healthcare services.
3. Reduction in health inequalities: The PMJAY is targeted at families identified as deprived and vulnerable based on the SECC 2011 data. The scheme aims to reduce health inequalities by providing health insurance coverage to those who cannot afford it.
4. Job creation: The PMJAY has the potential to create several job opportunities in the healthcare sector, especially in the areas of healthcare services, insurance, and administration. The scheme’s implementation requires a large workforce, which can generate employment opportunities in the country.

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Challenges in the implementation of the PMJAY:

The implementation of the PMJAY has faced several challenges since its launch in September 2018. Some of the key challenges in the implementation of the PMJAY are:

1. Identification of beneficiaries: The identification and validation of beneficiaries is a crucial step in the implementation of the PMJAY. The scheme relies on the SECC 2011 data for identifying the beneficiaries, which has several limitations. The data is outdated, and several eligible families may have been left out of the list. The implementation of the scheme also requires accurate identification and validation of beneficiaries, which can be a challenging task.
2. Empanelling hospitals: The PMJAY requires a vast network of hospitals to provide quality healthcare services to the beneficiaries. The empanelling of hospitals is a complex process that requires several checks and balances to ensure that only the eligible hospitals are empanelled. The process of empanelling hospitals can be time-consuming and may delay the implementation of the scheme.
3. Infrastructure and manpower: The effective implementation of the PMJAY requires adequate infrastructure and manpower at the state and district levels. The implementation of the scheme requires several administrative and technical staff, which can be a challenge for the States. The lack of adequate infrastructure and manpower can delay the implementation of the scheme and affect its effectiveness.
4. Awareness and outreach: The success of the PMJAY depends on the awareness and outreach efforts to reach out to the beneficiaries. The lack of awareness and outreach efforts can limit the scheme’s reach and effectiveness. The awareness and outreach efforts require significant resources, which can be a challenge for the States.

Let’s Check Shortly 

-> Launched Sep 2018

-> Designed to provide financial assistance to low-income families for health care

-> Each family under the scheme can claim up to Rs 5 lakh in a year.

-> These initiatives will cover around 50 crore beneficiaries.

-> Health and Wellness Centers (HWC) and Pradhan Mantri Jan Arogya Yojana are two aspects of Ayushman Bharat (PM-JAY).

-> The scheme takes care of accommodation and food in case of hospitalization.

-> Post hospitalization expenses up to 15 days

-> The policy also covers the cost of pre-hospitalization expenses (3 days).

-> PMJAY offers around 1,350 medical packages across any private network hospitals and all public hospitals.

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-> Covered : 

• Anterior spine fixation
• Carotid angioplasty with stent
• Coronary artery bypass grafting
• Double valve replacement surgery
• Prostate cancer
• Pulmonary valve surgery
• Skull base surgery
• Tissue expander for disfigurement following burns

-> Eligibility Criteria: 

• Households with no members aged between 16-59 years
• Families without healthy adults
• Families with one or more disabled members
• Families with members working as scavengers
• Households with no male members between the ages of 16-59
• Families living in one-room or mud-walled and thatched houses
• Families who do not own land and earn income through manual labor.

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