Eighteen-year-old Raju (name changed) felt breathless and tired, even while performing usual tasks. He was diagnosed with a serious heart condition after an episode of chest pain. An endless search for treatment pushed the family into a debt of over Rs 5 lakh. Raju’s father had to sell the family’s livestock and land. In 2019, they received a letter from the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) but overlooked it. In 2022, Raju’s condition worsened and he required urgent surgery. The family was desperate and out of options. Then, a hospital staff asked them to check about PMJAY. His eligibility for the scheme was confirmed and Raju underwent life-saving surgery, costing around Rs. 1.83 lakh. After 67 days in a hospital, he was discharged to live a new life.
This story of hope, health and happiness is one among countless others, centred on AB-PMJAY beneficiaries.
With approximately 7.8 crore hospital admissions authorised under the scheme over the last six years, PMJAY has saved millions of lives and prevented the impoverishment of their families due to hospital costs. The scheme is a testament to India’s commitment to Universal Health Coverage (UHC) envisioned by Prime Minister Narendra Modi.
PMJAY forms the foundation of healthcare delivery across government and private hospitals by providing free healthcare of up to Rs 5 lakh for secondary and tertiary treatment per beneficiary family. This amount may appear small compared to the numbers flaunted by private health insurers, but it is life-changing and life-saving for millions of families. Analyses show that, in general, almost all the annual inpatient care requirements of a family are met by this coverage.
By design, PMJAY is for inpatient secondary and tertiary care. Outpatient services are not a part of the scheme. The latter component of Universal Health Coverage (UHC) is being addressed through the equally ambitious comprehensive primary health care mission under which over 1,75,000 Ayushman Arogya Mandirs (AAMs), earlier called Health and Wellness Centres, have been established where free consultations and many medicines (up to 172) and diagnostics (up to 63) are being provided free. The government has begun focusing on a stronger two-way convergence and continuity of care across the two systems. Bharat’s UHC model is based on a public-funded comprehensive primary healthcare. Health policy and services need to be seen in totality and not in isolation.
During the scheme’s implementation, the procedures and prices under the Health Benefit Package (HBP) have been revised and rationalised. From 1,393 HBPs in 2018, the number now stands at 1,949 since 2022. A concept of differential pricing has been introduced to account for regional variation in the costs of healthcare services. Concurrently, states and Union Territories have been given additional flexibility to customise the HBP rates to local contexts.
To ensure seamless delivery of services and mitigate the scope of abuse in the system, PMJAY is technology-driven, paperless and cashless. There is no provision for reimbursement or co-payment. Though most claim settlements are timely, intense efforts are being made for further improvements in partnership with the states.
The scheme’s success and the government’s commitment to public welfare have led to two major initiatives this year. In the interim budget, the government extended the scheme to approximately 37 lakh families of ASHA and Anganwadi workers and helpers. Second, taking account of India’s rising life expectancy, another major development is the government’s decision to extend PMJAY’s coverage to all citizens aged 70 and above, regardless of their socioeconomic status. This will benefit 4.5 crore families and about 6 crore such senior citizens. The National Sample Survey’s (NSS) 75th round report on Health in India shows that the hospitalisation rate for this age group exceeds 11 per cent. The Longitudinal Ageing Study of India (LASI) 2021 report reveals that 75 per cent of the elderly have one or more chronic diseases, 40 per cent have some form of disability, and one in four suffers from multi-morbidity. Notably, 58 per cent of the elderly population are women, with 54 per cent being widows. Unlike many private insurance products for senior citizens, PMJAY does not exclude anyone because of a pre-existing illness, nor does it impose a year-long waiting period before the benefits are allowed. The scheme empowers the elderly to lead healthy and dignified lives.
PMJAY connects the public and private health sectors into a one-nation, one-system. It has a pan India network of more than 29,000 empanelled hospitals of which 13,000 are in the private sector. Close to 25,000 of these hospitals are in Tier-2 and Tier-3 cities. About 57 per cent of hospital admissions are in the private sector, indicating the significant participation of this sector.
The scheme has also significantly impacted service delivery in public sector hospitals across many states. These hospitals have utilised funds reimbursed under the scheme to enhance their amenities and infrastructure. With an increasing pace of coverage and reach, PMJAY has the potential to spur the growth of private hospitals in Tier 2 and 3 cities by creating a market where there was previously unmet demand due to a lack of paying capacity.
A recent study by an eminent economist (based on unit-level data from Household Consumption Expenditure Survey 2022-23) concluded that the bottom 50 per cent of our population has become significantly less vulnerable to medical expenditure-related shocks in the past 10 years and that this trend is closely associated with PMJAY.
PMJAY is poised to play a pivotal role in building a Viksit Bharat. Health, after all, is the very foundation of well-being, national productivity and prosperity.
The writer is a Member (Health) NITI Aayog. Views are personal
