By Amitabh Kant & Dr. Indu Bhushan
The sight of a family teetering on the brink of hope and despondency, surviving and falling into economic ruin on account of ill health is distressingly common. GoI’s health expenditure at 1.13% of its GDP is the lowest among the emerging developing countries. China’s expenditure is 2.45%, and Thailand’s 2.90% of its GDP.
Out-of-pocket expenses push nearly 66 lakh Indian households into poverty every year. About 24.9% of households in rural areas and 18.2% in urban areas meet medical expenditures through borrowings, and 17.3% of India’s population spend more than 10% of their household budget for accessing health services. The poorest of the poor are the worst impacted.
Ayushman Bharat demonstrates GoI’s strong resolve to address this issue by ensuring primary healthcare through the establishment of 1,50,000 health and wellness centres, the first of which was launched in Bijapur, Chhattisgarh, in May. Digitally linked to district hospitals, these will provide comprehensive healthcare and will be responsible for providing essential drugs and diagnostic services. They will also have convergence with yoga and Ayurveda.
The second key component of Ayushman Bharat is the Pradhan Mantri Jan Arogya Yojana (PMJAY) that will provide. Rs 5 lakh cover to around 50 crore economically weaker citizens and will be launched on September 25. This will be the world’s largest government-sponsored healthcare scheme covering a populationthe size of the US, Canada and Mexico.
The mission will provide inpatient care in an empanelled network of healthcare providers (secondary and tertiary care) for more than 1,300 packages in specialties, ranging from general medical and surgical procedures to cardiovascular and oncological ones. The benefits shall be available to all those entitled and be cashless, paperless, portable, and backed by an IT infrastructure that will provide seamless service delivery at all points of care.
PMJAY will leverage capacities available in both public and private sector hospitals, while providing standardised high-quality care, with strong fraud protection mechanisms and an efficient, service-driven architecture that will transform India’s healthcare systems in the years to come.
The National Health Agency (NHA) and the State Health Agencies (SHAs) are the keystone for the strategic purchasing of medical services at such a massive scale. NHA will be the instrumentality to expand coverage, benefits and financial protection.
As a substantive purchaser implementing PMJAY, NHA and SHAs will use the tools of pricing and incentives to drive down costs of services in the healthcare sector. The rates that have been fixed for the procedures have undergone a rigorous vetting mechanism in more than 50 cities in the country.
PMJAY will rely heavily on fraud detection and monitoring and building complex, intelligent systems that trigger and raise red flags on suspicious transactions, built upon extensive diagnostic guidelines and self-learning pattern-recognition algorithms.
The aim is to build a world-class intelligent system for fraud mitigation, grievance redressal, monitoring and evaluation, and research that allows the programme to scientifically evolve. Pre-authorisation protocols have been defined for 621fraud-prone and high-cost procedures for ensuring discipline in the provider network.
The states are the key partners in this alliance. The scheme architecture allows the states freedom for innovations and context-specific customisations. Till date, 29 of the 36 states and Union territories are on board. The states have been given flexibility to push for providing greater inpatient department (IPD) care through public institutions, as well as a framework for upgrading their infrastructure. The portability of services across a pan-India network provides beneficiaries in the migrant community to access services without hindrances.
PMJAY will be a truly disruptive influence over India’s healthcare system. It presents India an opportunity to move towards a mature, data-driven, intelligent and predictive health systems built on top of individualised, secure and access-controlled health records, a verified provider registry and tech-enabled drugs and diagnostics supply chains.
India, through health and wellness centres, is finally shifting the focus of healthcare provision towards providing primary healthcare to its citizens. The care on prevention and early management of healthcare will reduce the need for complicated specialist care and outof-pocket expenses.
While catering to 50 crore beneficiaries, PMJAY will leverage facilities in both private and public hospitals. This comprehensive healthcare system linking primary, secondary and tertiary care has the potential to transform the health delivery system in India.
Union Minister J P Nadda launches the official logo of Pradhan Mantri Jan Arogya Yojana, in New Delhi on August 27, 2018.
*Amitabh Kant is CEO, NITI Aayog, and Dr. Indu Bhushan is CEO, Ayushman Bharat-National Health Protection Mission (AB-NHPM) and the National Health Agency (NHA).