Ayushman Bharat, a flagship initiative of the Government of India, is a transformative program designed to achieve Universal Health Coverage (UHC). Launched as recommended by the National Health Policy 2017, Ayushman Bharat aims to address healthcare holistically, moving from a fragmented approach to a comprehensive, need-based system. This scheme is structured around two interconnected components: Health and Wellness Centres (HWCs) and Pradhan Mantri Jan Arogya Yojana (PM-JAY).
Ayushman Bharat: A Two-Pronged Approach
Ayushman Bharat adopts a continuum of care approach, focusing on both preventive and curative healthcare. It is comprised of two inter-related components:
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Health and Wellness Centres (HWCs):
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Transformation of Existing Centers: The government aims to create 150,000 HWCs by transforming existing Sub Centres and Primary Health Centres.
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Comprehensive Primary Health Care (CPHC): These centers deliver CPHC, bringing healthcare closer to people’s homes.
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Expanded Services: HWCs offer a wide range of services, including maternal and child health services, non-communicable disease care, free essential drugs, and diagnostic services.
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Health Promotion and Prevention: They emphasize health promotion and prevention, empowering individuals and communities to choose healthy behaviors and reduce the risk of chronic diseases.
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Pradhan Mantri Jan Arogya Yojana (PM-JAY):
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World’s Largest Health Assurance Scheme: Launched on September 23, 2018, PM-JAY is the world’s largest health assurance scheme, providing a health cover of ₹5 lakh per family per year for secondary and tertiary care hospitalization.
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Targeted Beneficiaries: The scheme covers over 12 crore poor and vulnerable families (approximately 55 crore beneficiaries), representing the bottom 40% of the Indian population.
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Socio-Economic Caste Census (SECC) 2011: Beneficiaries are identified based on the deprivation and occupational criteria of the SECC 2011.
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Inclusion of RSBY Families: PM-JAY also covers families previously covered under the Rashtriya Swasthya Bima Yojana (RSBY).
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Government Funded: PM-JAY is fully funded by the government, with implementation costs shared between the Central and State Governments.
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Key Features of PM-JAY:
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Cashless Access: Provides cashless access to healthcare services at empanelled hospitals.
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Financial Protection: Aims to mitigate catastrophic expenditure on medical treatment, which pushes nearly 6 crore Indians into poverty each year.
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Pre and Post-Hospitalization Coverage: Covers up to 3 days of pre-hospitalization and 15 days of post-hospitalization expenses.
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No Restrictions: No restrictions on family size, age, or gender.
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Pre-Existing Conditions Covered: All pre-existing conditions are covered from day one.
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Portability: Benefits are portable across the country, allowing beneficiaries to avail treatment at any empanelled hospital in India.
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Comprehensive Coverage: Includes approximately 1,929 procedures covering all costs related to treatment.
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Equitable Reimbursement: Public hospitals are reimbursed at par with private hospitals.
Benefit Cover Under PM-JAY:
PM-JAY provides a cashless cover of up to ₹5 lakh per eligible family per year for listed secondary and tertiary care conditions. The cover includes:
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Medical examination, treatment, and consultation.
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Pre-hospitalization expenses.
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Medicines and medical consumables.
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Non-intensive and intensive care services.
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Diagnostic and laboratory investigations.
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Medical implantation services.
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Accommodation benefits.
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Food services.
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Treatment of complications.
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Post-hospitalization follow-up care up to 15 days.
The ₹5 lakh cover is on a family floater basis, meaning it can be used by one or all family members. There is no cap on family size or age of members, and pre-existing diseases are covered from day one.
Why PM-JAY: A Background
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Socio-Economic Disparities: Despite economic growth, a significant portion of India’s population lives in poverty, with limited access to affordable healthcare.
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Triple Burden of Disease: India faces a “triple burden of disease,” with ongoing communicable diseases, a rising prevalence of non-communicable diseases (NCDs), and injuries.
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Healthcare Supply Gap: The public healthcare system is overburdened, while the private sector is largely unregulated and concentrated in urban areas.
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Underfunding of Public Health: Government expenditure on health has remained stagnant, leading to high out-of-pocket expenses.
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Poverty: High out-of-pocket health expenditure is a leading cause of poverty in India, pushing millions into poverty each year.
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Fragmented Health Insurance: Previous government-funded health insurance schemes were fragmented and lacked a link with primary healthcare.
Addressing Challenges Through Ayushman Bharat:
To address these challenges, the government adopted a two-pronged approach:
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Health and Wellness Centres (HWCs): To focus on disease prevention and health promotion by upgrading existing primary healthcare infrastructure.
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Pradhan Mantri Jan Arogya Yojana (PM-JAY): To provide financial protection for hospitalization needs and improve access to quality healthcare.
Coverage under PM-JAY:
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Target Population: PM-JAY targets the bottom 40% of the population, based on the SECC 2011 data.
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Rural Beneficiaries: Rural households are included based on seven deprivation criteria (D1 to D7) and automatic inclusion criteria.
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Urban Beneficiaries: Urban households are categorized based on 11 occupational categories of workers.
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State Flexibility: States can use their own databases for PM-JAY, ensuring all families eligible under SECC are covered.
Implementation Models:
States have the flexibility to choose their implementation model:
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Assurance/Trust Model: The State Health Agency (SHA) directly implements the scheme, reimbursing healthcare providers, with the financial risk borne by the government.
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Insurance Model: The SHA selects an insurance company to manage PM-JAY in the state, with the insurance company bearing the financial risk.
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Mixed Model: States combine both assurance/trust and insurance models to suit their specific needs.
Financing of the Scheme:
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PM-JAY is fully funded by the government, with costs shared between the Central and State Governments.
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The Central Government determines a national ceiling amount per family.
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The actual premium or ceiling amount is shared between the Central Government and States/UTs as per the extant directives.
Hospital Empanelment:
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Hospitals are empanelled through a transparent online process.
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A State Empanelment Committee (SEC) and a District Empanelment Committee (DEC) are set up for scrutiny and verification.
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Empanelled hospitals must have a dedicated help desk manned by Pradhan Mantri Arogya Mitras (PMAMs).
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Hospitals are incentivized to achieve higher quality standards through higher package rates for NABH accreditation and teaching institutions.
National Health Care Providers (NHCP):
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Eminent tertiary and specialized care hospitals operating under the Ministry of Health and Family Welfare (MoHFW) are directly empanelled by the National Health Authority (NHA).
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All NABH-accredited private hospitals in the National Capital Region (NCR) are also directly empanelled by NHA.
Expansion of Coverage and Convergence:
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PM-JAY aims to converge various state-level health insurance schemes and provide national portability of care.
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States have the flexibility to use their own databases, expand coverage, and revise package prices.
Ayushman Bharat, with its two components of HWCs and PM-JAY, represents a significant step towards achieving Universal Health Coverage in India. By focusing on both preventive and curative care, and by providing financial protection to vulnerable populations, the scheme aims to create a healthier and more equitable society.