Ayushman Bharat: A Giant Step Towards A Healthier India

Ayushman Bharat National Health Protection Mission (AB-NHPM), one of the largest government funded healthcare schemes in the world, was formally commissioned on 25 September 2018, from Jharkhand.

The scheme targets 10.74 crore poor, vulnerable, rural and urban families on the basis of the deprivation criteria of the latest socio-economic caste census (SECC) data, of which 8.03 crore are rural and the rest, urban families.

The scheme is being implemented through a network of empanelled health care providers (EHCPs) and will subsume the existing Rashtriya Swasthya Bima Yojana (RSBY) launched in 2008 by the United Progressive Alliance government - one that largely remained a non-starter due to lack of political will.

The fact that RSBY launched by the Congress-led coalition was simply a paper tiger can be gauged by the fact that currently, there are 1.35 million hospital beds for around 180 million people covered under the scheme, according to a recent report by PwC-Confederation of Indian Industry (CII).

The Narendra Modi government's big challenge has, therefore, been putting in place the right infrastructure to meet the burgeoning bed capacity demand. At least 33 per cent of the people covered by the AB-NHPM scheme will have no previous health insurance coverage and would have a hospital admission incidence rate of 6 per cent with an average three-day stay. With these numbers in mind, the Centre has ensured that systemic glitches are duly resolved to ensure that AB-NHPM succeeds, where RSBY failed.

Indeed, within barely two months of launch, the response to AB-NHPM has been hugely encouraging, with 66 per cent of the total beneficiaries having availed themselves of treatment in private hospitals under the Ayushman Bharat scheme. Dinesh Arora, deputy chief executive of the National Health Agency (NHA), the apex body implementing the scheme, said till 26 November 2018, of the total 365,394 beneficiaries who were admitted to hospitals for various surgeries and procedures, 204,000 were treated in private hospitals and the remaining 34 per cent made use of treatment under the scheme at public hospitals, with the NHA having already paid to hospitals concerned an amount of Rs 312 crore towards claims.

AB-NHPM is in more ways than one, a universal healthcare scheme that seeks to cover over 38 per cent of the population, via secondary and tertiary hospitalisations, with a coverage of 5 lakh for each family, has no restrictions on family size or age of the beneficiary, to ensure no financially vulnerable person is left out.

The scheme will lead to increased access to quality health and medication, timely treatments, improvements in health outcomes, patient satisfaction, improvement in productivity, efficiency and job creation, thus leading to improvement in quality of life.

Benefits of the scheme are portable across the country and a beneficiary covered under the scheme will be allowed to take cashless benefits from any public/private empanelled hospitals across the country. The beneficiaries can avail benefits in both public and empanelled private facilities. To control costs, the payments for treatment will be done on package rate (to be defined by the government in advance) basis.

AB-NHPM will have a major impact on the reduction of out of pocket (OOP) expenditure on the ground. In addition, the unmet needs of the population which remained hidden due to lack of financial resources for decades will be catered to. The beneficiaries will not be required to pay any charges and premium for the hospitalisation expenses. The benefits also include pre- and post-hospitalisation expenses. Also, all the beneficiaries will be provided with letters having QR codes which are scanned and a demographic authentication is conducted for identification and to verify his or her eligibility to avail the benefits of the scheme.

AB-NHPM is delivering comprehensive primary healthcare including universal screening for non-communicable diseases such as diabetes, hypertension and common cancers as well as tuberculosis and leprosy, via a two-pronged approach.

On the one hand, wellness centres will offer medical assistance to the poor people for free, including diagnostic services and medications, all individuals who are registered under the programme will be able to seek medical assistance from any top-rated private or government hospitals and health care centres without facing the inconvenience of making advanced payments. The cost for facilities will be borne by the state government (40 per cent) and the central government (60 per cent).

On the other hand, on a larger scale, the Ayushman Bharat programme also focusses on offering health protection, medical benefits and insurance coverage scheme for over 10 crore economically poor families nationwide, expected to benefit more than 50 crore beneficiaries, making this the world’s largest healthcare programme.

RSBY launched by Congress was far smaller in size where the annual benefit available was limited to just a paltry Rs 30,000 per family on payment of insurance premium of Rs 300-400 per year, in contrast to the generous Rs 5 lakh per family for virtually free, under AB-NHPM. Also, scope of ailments covered under RSBY was very limited in nature whereas Ayushman Bharat covers just about everything - from knee cap replacements to open heart surgeries and more!

Each empanelled hospital under AB-BHPM has an 'Ayushman Mitra' to assist patients and will coordinate with beneficiaries and the hospital. They will run a help desk, check documents to verify the eligibility, and enrolment to the scheme. All pre-existing conditions will be covered from day one of the policy’s implementation. The beneficiaries can avail benefits in both public and empanelled private facilities. All public hospitals in the states implementing AB-NHPM will be deemed empanelled for the scheme. Hospitals belonging to ESIC may also be empanelled based on the bed occupancy ratio parameter. As for private hospitals, they will be empanelled online based on a defined criteria.

Around 25,000 health and wellness centres have been approved thus far, of which, 5,000 are operational. The idea is to either set up or convert existing sub centres and have 150,000 wellness centres by 2022, in what will give a huge impetus to AB-NHPM. As for hospitals, while over 32,814 requests had been received by October 2018, over 13,865 hospitals had been empanelled and that number has only grown.

The sheer scale and speed of this outstanding scheme is evident from the fact that within barely 10 days of its launch, 23,299 claims were received, of which 23,287 were settled at a cost of Rs 38 crore. Overall, AB-NHPM will cost the government not more than Rs 12,000 crore annually.

One of the core principles of Ayushman Bharat is co-operative federalism and greater flexibility to states. For giving policy directions and fostering coordination between Centre and states, the Ayushman Bharat National Health Protection Mission Council (AB-NHPMC) at apex level, chaired by Union Health and Family Welfare Minister, will do what is needed.

States will need the assistance of a dedicated entity called State Health Agency (SHA) to implement the scheme. To ensure that the funds reach SHA on time, the transfer of funds from the central government, through AB-NHPM, to State Health Agencies are done through an escrow account directly. In partnership with NITI Aayog, a robust, modular, scalable and interoperable IT platform is being made operational which will entail paperless, cashless transactions for beneficiaries.

Ayushman Bharat National Health Protection Mission Agency (AB-NHPMA) would help in the implementation of the programme. States/ Union Territories (UTs) would be advised to implement the scheme with the help of a dedicated entity called State Health Agency (SHA). They can either use an existing trust/ society/not for profit company/state nodal agency (SNA) or set up a new entity to implement the scheme. States/ UTs can decide to implement the scheme through an insurance company or directly through the trust/society or use an integrated model.

The expenditure incurred in premium payment will be shared between central and state governments in specified ratio as per Ministry of Finance guidelines in vogue. The total expenditure will depend on actual market determined premium paid in states/ UTs where Ayushman Bharat - National Health Protection Mission is being implemented through insurance companies. In states/ UTs where the scheme is being implemented in trust/ society mode, the central share of funds will be provided based on actual expenditure or premium ceiling whichever is lower in the pre-determined ratio.

AB-NHPM is an entitlement based scheme where beneficiaries are identified based on the deprivation categories (D1, D2, D3, D4, D5, and D7) identified under the SECC database for rural areas based on 2011 census. The different categories in rural areas include families having only one room with kuchcha walls and roofs; families having no adult member between the ages of 16 years and 59 years; female-led households with no adult male member between the ages of 16 years and 59 years; disabled members and no able-bodied adult member in the family; Scheduled Caste/Scheduled Tribe households and primitive tribal groups; destitute and landless households deriving major part of their income from manual casual labour, manual scavenging or living on alms.

For urban areas, 11 defined occupational categories are entitled under the scheme. Beggars, ragpickers, domestic workers, street vendors, cobblers, hawkers, construction workers, plumbers, masons, painters, welders, security guards, coolies, head-load workers, sweepers, sanitation workers, gardners, artisans, handicraft workers, tailors, drivers conductors, helpers to drivers, cart pullers, rickshaw pullers, shop workers, assistants, peons in small establishments, delivery assistants, attendants, waiters, electricians, mechanics, assemblers, repair workers, washer-men, chowkidars would fit into one of these 11 categories.

A list of eligible families has been shared with the respective state governments as well as state level departments like the ANMs, BMO, and BDOs of relevant areas. A dedicated AB-NHPM family identification number is allotted to eligible families. Only families whose name is on the list are entitled for the benefits of AB-NHPM. Additionally, families with an active RSBY cards as of 28 February 2018 are covered. No additional new families can be added under AB-NHPM. However, names of additional family members can be added for those families whose names are already on the SECC list.

Services under the scheme can be utilised at all public hospitals and empanelled private hospitals. The basic empanelment criteria allows empanelment of a hospital with a minimum of 10 beds, with the flexibility provided to states to further relax this if required. Empanelment of hospitals under AB-NHPM is conducted through an online portal by the state government. Information about empaneled hospitals is made available through different means such as government websites and mobile apps.

To control costs, the payments for treatment are done on a package rate (to be defined by the government in advance) basis. However, hospitals with NABH/NQAS accreditation can be incentivised for higher package rates subject to procedure and costing guidelines.

Standardised guidelines for treatment include improved consistency of care, curbing the tendency to overcharge patients, increase in evidence-based treatment, and uniform billing across centres.

About 1,350 treatments and surgical procedures have been identified for which package rates are fixed. AB-NHPM aims to generate repositories on hospitals, providers and other human resource and the insurance sector will be assisted with the management of claim costs in case of fraudulent claims.

The data generated during the implementation of the scheme is helping in designing better and targeted health programmes for the future. The scheme also aims to better the Registry of Hospitals in Network of Insurance (ROHINI) system through relevant measures.

Ayushman Bharat that is also called Pradhan Mantri Jan Arogya Yojana (PMJAY) is a scheme that is very much the need of the hour especially in the Indian context where the quantum of public expenditure on health was consistently low at barely 1.15-1.25 per cent of GDP, under decades of erstwhile Congress dispensations. In the USA, public spend on healthcare is over 18 per cent of the GDP. As a consequence, India’s out-of-pocket expenditure has been as high as 62 per cent with catastrophic health expenditures contributing to an increase in poverty levels in rural and urban areas by 3.6 per cent and 2.9 per cent respectively, on an average, for the last many decades under successive insensitive Congress regimes.

PMJAY is superior to its closest replica in Indonesia, the Indonesian healthcare scheme previously known as Askeskin, now Jamkesmas, that has been gradually expanded to cover more than 30 per cent of the population and is projected to cover the entire population. PMJAY is built on four pillars: community empowerment; health financing; access to health services; effective surveillance, which will be translated into concrete programmes to achieve the Modi government's ambitious goals.

A huge amount of preparatory work was undertaken prior to the launch and rollout of the Pradhan Mantri Jan Arogya Yojana. The National Health Agency was established, which in coordination with its counterpart at the state and union territory level, performs several key functions such as setting standards, determining the process for empanelling hospitals, monitoring the quality of services and minimising unnecessary hospitalisation, among others. Further, pre-authorisation has been made mandatory for nearly half of the 1,350 treatment packages covered under the programme to ensure that people who are insured do not go through additional healthcare interventions regardless of their needs. Additionally, a robust IT backbone has been tested prior to the rollout of the scheme across the country. The technology platform will serve as a key enabler for ensuring that the scheme is implemented in a transparent and data-driven manner.

The PMJAY scheme not only provides an unprecedented opportunity to address the health needs of 50 crore citizens in a comprehensive manner but also to define the priorities for the health system as well as shape future policies by drawing insights from the large data sets that will be generated. This information can pave the way for the advancement of personalised medicine in the country as well as improve the governance of health facilities by providing crucial data on the quality of care offered.

S Jayaprakash, a leading health insurance expert says, PMJAY would require a list of specialists like actuaries, claim processing specialists, fraud analysts, fraud investigators etc, to extend its reach. Ayushman Bharat would have to incentivise hospitals to get NABH (National Accreditation Board for Hospitals & Healthcare Providers) or Joint Commission International (JCI) accreditation for quality processes. Currently, India has only 538 NABH and 34 JCI hospitals.

Again, profitability in health insurance depends upon various factors like mortality, morbidity, expenses and the ability to manage operations with efficient processes within the boundaries of the premium income received. There is no one-size-fits-all operational model when it comes to the successful implementation of a scheme.

However, what most people have completely missed is the fact that where Ayushman Bharat stands out is the fact that it combines the best of three; people, processes and technology and more importantly, it not only relies on the law of large volumes but essentially focusses on decentralisation, whereby states will have ample freedom in implementing the scheme.

Also, many states are executing the scheme more as a "Trust Model" rather than as a pure "Insurance Model", without deviating from the core ethos of the scheme. Jharkhand, in less than three months of the launch of Ayushman Bharat, has already brought 57 lakh people or roughly 84 per cent of its population under AB-NHPM.

The rapid strides by the Modi dispensation in the field of healthcare is best amplified by the latest report by global consulting firm, Milliman, which in its latest report says that from a high of 76 per cent of the population that never had any significant form of health cover under a criminally negligent Congress dispensation in 2013 - that number today is down to 56 per cent. In effect, in the last four years, a solid 20 per cent of the population has been brought under health cover by the Modi government.

Also, government financing of healthcare and health insurance schemes which was abysmal for the last many decades, has improved dramatically under the Modi rule, to about 30 per cent and counting. That being the case, PMJAY has the potential to not only improve the medical infrastructure, but also continue pushing health insurers to increase penetration and come out with innovative products that can fill any gaps and reduce out-of-pocket expenses further, via effective clinical audits, claims management, hospital scrutiny, strict control processes using claim analytics, de-duplication of customers to control leakages and frauds.

Also, according to the Naukri Job Speak Index for November 2018, the Indian healthcare industry registered a remarkable year-on-year increase of 34 per cent during the month in terms of jobs created, as compared with the same period last year, putting to rest unwanted speculation on this count.

The speed with which PMJAY is transforming lives in its march towards a healthier India is best summed up by Indu Bhushan, the CEO of Ayushman Bharat, who tweeted about how by 7 December 2018, over 17.24 lakh e-cards had been generated, more than a million calls had been received on the helpline number and over 3 million hits had been received on the mera.pmjay.gov.in website. Most importantly, well over 5 lakh people had received treatment and all this, within less than three months of the scheme being launched.

With time, the number of people receiving treatment will only grow manifold, in what is truly not just one of the biggest government funded healthcare programmes in the world for the marginalised and the deprived, but unarguably, a giant step towards a fitter and healthier India.