Analysis Of PM Jan Arogya Yojna, 2018

Policy Update
Mohd Asif

Background

Ayushman Bharat is a key initiative of the Government of India, introduced based on recommendations from the National Health Policy of 2017, with the aim of achieving Universal Health Coverage (UHC). This program is designed to fulfill the objectives of the Sustainable Development Goals (SDGs), particularly its core principle, “leaving no one behind.”

Ayushman Bharat seeks to shift from a fragmented, sector-specific approach to healthcare delivery towards a more comprehensive and need-based healthcare system. The plan aims to introduce significant reforms in the healthcare system, addressing prevention, promotion, and outpatient care at primary, secondary, and tertiary levels. Adopting a continuum of care, Ayushman Bharat consists of two interconnected components:

Health and Wellness Centres (HWCs)
Pradhan Mantri Jan Arogya Yojana (PM-JAY)

1. Health and Wellness Centres (HWCs):

In February 2018, the Government of India announced the establishment of 1,50,000 Health and Wellness Centres (HWCs). These centres will replace existing sub-centres and primary health centres, aiming to provide essential healthcare services closer to people’s homes. The centres will offer care for mothers and children, as well as treat non-communicable diseases. In addition, they will provide free essential medicines and diagnostic services.

The goal of the Health and Wellness Centres is to ensure that everyone in their region has access to necessary health services, promoting equity in healthcare. The centres will focus on keeping people healthy by encouraging preventive measures and good habits to avoid illness. The aim is to educate people on adopting a lifestyle that helps prevent chronic diseases and other long-term health issues.

2. Pradhan Mantri Jan Arogya Yojana (PM-JAY)

The second part of Ayushman Bharat is the Pradhan Mantri Jan Arogya Yojana (PM-JAY), launched by Prime Minister Narendra Modi in Ranchi, Jharkhand on 23rd September 2018. The scheme benefits over 12 crore poor and vulnerable families, covering approximately 40% of India’s population (around 55 crore people).

Under this scheme, families are selected based on the 2011 Socio-Economic Caste Census (SECC 2011) for both rural and urban areas, focusing on the deprived and specific occupational groups. Originally known as the National Health Protection Scheme (NHPS), PM-JAY also absorbed the Rashtriya Swasthya Bima Yojana (RSBY) launched in 2008, extending coverage to RSBY families not listed in the SECC 2011. The scheme is fully funded by the government, with costs shared between the central and state governments.

Features of PM JAY

PM-JAY is the world’s largest government-funded health insurance scheme, offering Rs. 5 lakh coverage per family annually for secondary and tertiary care at both public and private hospitals across India. It benefits over 12 crore poor and vulnerable families (approximately 55 crore people), providing cashless healthcare at the hospital.

The scheme aims to reduce the financial burden of medical expenses, which forces nearly 6 crore Indians into poverty each year. It covers pre-hospitalization expenses for up to 3 days and post-hospitalization costs for 15 days, including diagnostics and medicines. There are no restrictions on family size, age, or gender, and all pre-existing conditions are included from day one. PM-JAY benefits are portable across the country, allowing beneficiaries to seek cashless treatment at any empanelled hospital. The scheme covers around 1,929 procedures, accounting for costs such as drugs, diagnostics, doctor’s fees, room charges, and surgical expenses. Public hospitals are reimbursed at rates comparable to private hospitals.

Benefits of PM-JAY

Government-funded health insurance schemes like CGHS (Central Government Health Scheme) and ESIS (Employees’ State Insurance Scheme) are more focused on specific population segments, offering distinct advantages like OPD care and a comprehensive range of services for their respective target groups, In India typically offered benefit which covers annual limits ranging from INR 30,000 to INR 3,00,000 per family, leading to a fragmented healthcare system. In contrast, PM-JAY provides a cashless cover of up to INR 5,00,000 annually for each eligible family for specified secondary and tertiary care conditions. The scheme encompasses all costs associated with the following treatment components:

Medical examinations, treatments, and consultations
Pre-hospitalization expenses
Medicines and medical supplies
Both non-intensive and intensive care services
Diagnostic tests and laboratory investigations
Medical implantation services, if required
Accommodation costs
Food services
Complications arising during treatment
Post-hospitalization follow-up care for up to 15 days

Allowing any eligible family member to access the coverage without a cap on family size or age. Unlike the RSBY, CGHS, ESIS which limited coverage to five family members, PM-JAY addresses this limitation. Additionally, it covers pre-existing conditions from day one, ensuring that individuals with existing medical issues can receive treatment immediately upon enrollment.

Achievements of Scheme

As of September 9, 2024, the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB PM-JAY) has significantly enhanced access to healthcare services across the country. A total of 35.4 crore Ayushman cards have been issued, granting health insurance benefits to millions of families. The scheme is now operational in 33 states and union territories, though it has yet to be implemented in Delhi (NCT), West Bengal, and Odisha.

One major achievement is that over 7.79 crore hospital admissions have been approved, with a total expenditure of ₹1,07,125 crores. In terms of gender distribution, 49% of the Ayushman cards have been issued to women, and 3.61 crore women have benefited from hospital admissions, underscoring the scheme’s contribution to promoting gender equity in healthcare.

The scheme’s portability feature allows beneficiaries to receive treatment at any empanelled hospital nationwide, regardless of their home state. This feature has enabled 11.9 lakh hospitalizations, amounting to ₹3,100 crores in costs, making healthcare services more accessible across the country.17,063 public hospitals and 13,466 private hospitals, giving beneficiaries a wide range of options for treatment. By September 1, 2024, a significant number of hospital admissions have been authorized across various medical procedures.

Conclusion

Pradhan Mantri Jan Arogya Yojana (PM-JAY), part of the Ayushman Bharat initiative, is a significant step toward achieving universal health coverage in India. It aims to reduce out-of-pocket healthcare expenses for vulnerable populations.

A recent expansion under the AB PM-JAY scheme specifically benefits senior citizens aged 70 and above. Eligible senior citizens from families already enrolled in AB PM-JAY will receive an additional, exclusive top-up of INR 5 lakh annually. For seniors not covered under existing family plans, coverage will be extended up to INR 5 lakh on a family basis.

Additionally, senior citizens currently covered under other government health schemes, such as the Central Government Health Scheme (CGHS) or the Ex-Servicemen Contributory Health Scheme (ECHS), have the option to continue with their existing coverage or switch to AB PM-JAY. Seniors holding private health insurance or those under the Employees’ State Insurance Scheme (ESIS) are also eligible to access AB PM-JAY benefits, thereby broadening their healthcare options and reducing financial constraints. PM-JAY is structured to build a resilient healthcare system, offering flexibility and extended coverage options for senior citizens while striving toward universal healthcare accessibility across the country.

Way Forward

To address the irregularities in PMJAY, it is crucial to implement corrective actions such as stricter beneficiary verification, enhanced oversight of hospitals, and the establishment of a strong grievance redressal system. These measures are necessary to uphold the scheme’s intended goals and ensure its effectiveness.

On September 11, 2024, the Union Cabinet approved a significant expansion of the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB PM-JAY). This initiative will provide health coverage to all senior citizens aged 70 and above, regardless of income, benefiting approximately 4.5 crore families and 6 crore senior citizens with free health insurance coverage of up to Rs 5 lakh per family.