PRADHAN MANTRI JAN AROGYA YOJNA

News: Recently, CAG has presented a report on performance of PM Jan Arogya Yojna.

Objectives:

• • To achieve the vision of Universal Health Coverage (UHC).
  • To reduce out of pocket expenditures for poor and vulnerable sections.
  • Ensure availability, accessibility and affordability.

Features:

• • It is a centrally sponsored scheme.
  • It is the world’s largest health assurance scheme fully financed by the government.
  • It is one of the components of Ayushman Bharat. Other being Creation of Health and Wellness Centres (HWCs).
  • It provides health cover of Rs 5 lakhs per family per year for secondary and tertiary care hospitalization across public and private empaneled hospitals across India.
  • It provides cashless access to healthcare services for beneficiaries at the point of service.
  • There is no cap on family size.
  • It covers upto 3 days of pre-hospitalization and 15 days of post-hospitalization expenses.
  • The identification of beneficiaries is done through deprivation and occupational criteria of the Socio-Economic Caste Census (SECC) for both rural and urban areas.
  • Three modes of implementation:
    • Assurance/Trust model: State Health Authority directly reimburses the health care providers eliminating the intermediary role of insurance companies.
    • Insurance model: SHA pays premium to insurance company, selected through tendering process.
    • Mixed model: it is the mix of above two.
  • The scheme is completely funded by the government and the cost is equally shared between centre and states as:
    • 90:10 – for northeast and three Himalayan states (Jammu & Kashmir, Himachal Pradesh and Uttarakhand)
    • 60:40 – for other states and UTs with legislature.
  • The scheme promotes transparency and accountability as-
    • 4 modes verification of beneficiaries via Aadhaar based e-KYC, fingerprint, iris scan and face authentication.
    • Anti-fraud units are envisaged to counter fraudulent transactions and entities by carrying out surprise inspections, imposing penalties etc.
    • Provision of whistleblower policy to ensure the anonymity of griever.

Achievements:

• • 33 states and UTs are participating in the implementation of scheme.
  • 58 crore Ayushman cards issued.
  • 27353 hospitals are empanelled.
  • 82% of Ayushman cards are issued in rural areas. (Rural Empowerment)
  • 48% female hospital admissions. (women Empowerment)

Issues highlighted by CAG report:

• • Inadequate beneficiary registration: Only 73% (7.87 crore) of the total targeted households of 10.74 crore were registered.
  • Around Rs 6.97 crore was allotted to the treatment of patients already declared dead previously in the database.
  • Almost 7.5 lakh beneficiaries were linked to single mobile number.
  • Irregularities in identification as only 2.08 crore households were identified from SECC-2011 database.
  • Hospital empanelment and management issues:
    • Shortage of infrastructure, doctors, equipments.
    • Some Empanelled Health Care Providers (EHCPs) neither fulfilled minimum criteria of support system and infrastructure nor conformed to the quality standards.
    • Many beneficiaries were even charged for the treatment.
  • Poor claims management:
    • 57 lakh claims took more than the specified time of 12 hours in approval of pre-authorisation.
    • There is delay in submission of claims by hospitals.
  • Financial Mismanagement:
    • Many states did not maintain separate escrow account for PMJAY.
    • National Health Authority (NHA) and State Health Authority (SHA) fail to comply with the instructions of government of India to track the expenditure flow through PFMS.
  • Monitoring and Grievance Redressal:
    • Many states did not adopt the whistleblower policy.
    • State grievance redressal committees are either not constituted or meetings not held.
    • Lack of infrastructure and staff.
    • Delay in grievance redressal as less than 10% of grievances were redressed within a turnaround time of 15 days.

Recommendations:

• • Beneficiary identification and registration:
    • Strengthen the mechanism to avoid delay and weed out ineligible beneficiaries in a time-bound manner.
    • Validation checks to increase accuracy and reliability of data.
    • Setting up of designated IEC cells to increase awareness about the scheme.
  • Hospital empanelment and management
    • Upgrade the quality of healthcare sector by increasing public expenditure.
    • Encourage private hospitals to join the scheme.
    • Monitoring mechanisms to curb out for pocket expenditure.
  • Claims management:
    • Time bound scrutiny and payment of claims.
    • Ensuring that claim amount us utilised for infrastructure development.
  • Financial management
    • Every SHA to have designated escrow account to deposit their upfront share in time bound manner.
    • Proper mechanism to map and identify the PMJAY beneficiaries to avoid overlap with other state specific schemes.
    • Utilize PFMS to track the flow of expenditure.
  • Monitoring and grievance redressal
    • District Implementing Units to be formed with adequate manpower and infrastructure ensuring smooth functioning of Scheme.
    • Initiate anti-fraud activities on urgent basis and penalize defaulters in timely manner.
    • Ensure effective grievance redressal.