Ayushman Bharat Pradhan Mantri Jan Arogya Yojana: Evolution and journey so far

INTRODUCTION Indian healthcare has seen a revolution in the field of secondary and tertiary care for the impoverished and susceptible population in recent years through the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY), a flagship health assurance scheme of the Government of India.[1] The objective of AB-PMJAY is to alleviate the economic strain on this impoverished and susceptible population and to avoid catastrophic expenditure from hospitalisations,[2] by providing cashless and quality healthcare services to them through a nationwide network of public and private sector healthcare providers.[3] EVOLUTION OF AYUSHMAN BHARAT PRADHAN MANTRI JAN AROGYA YOJANA Rashtriya Swasthya Bima Yojana (RSBY) was a health insurance scheme launched by the Government of India in 2008 under the Ministry of Labour and Employment to provide cashless healthcare facilities to families living below the poverty line.[4] It was transferred to the Ministry of Health and Family Welfare in April 2015, citing several deficiencies in the execution of RSBY. The increase in out-of-pocket health expenses for beneficiaries was one of them.[4] It was replaced by AB-PMJAY, a more comprehensive and ambitious healthcare scheme,[4] launched by the Honourable Prime Minister of India, Shri Narendra Modi in September 2018. It gives coverage to over 100 million Indian families with Rs. 5 lacs annually for advanced medical treatment. An organisation called the National Health Authority (NHA) was constituted to act as the central organisation responsible for the development of policies and execution of AB-PMJAY.[1,2,5] ADMINISTRATIVE STRUCTURE AND FUNDING AB-PMJAY utilises a three-tiered structure to ensure effective implementation nationwide. At the national level, the NHA is the apex body overseeing its implementation within the states. It is headed by a Chief Executive Officer (CEO) and organised into various vertices for streamlined operations. The governing board provides the NHA with strategic directions and policy guidance.[6] At the state level, the State Health Agency (SHA) is the nodal agency executing AB-PMJAY. Each SHA is headed by a CEO and is equipped with a dedicated team of experts. Every SHA has a governing council that provides oversight and guidance to the SHA, ensuring the scheme is aligned with its objectives.[6] The District Implementation Unit (DIU) is created at the district level to manage day-to-day AB-PMJAY activities. The DIU coordinates with all the stakeholders and submits regular implementation reports.[6] AB-PMJAY employs a shared funding model between the central and state governments. For most states, the central government contributes 60% of the funding, while the state contributes 40%. However, to support development in northeastern states, Himachal Pradesh, Uttarakhand and the Union Territory of Jammu and Kashmir, a funding ratio of 90:10 (central:state) is applied. In Union Territories lacking legislatures, the Central Government funds up to 100% of AB-PMJAY costs on a case-by-case basis.[6] FUNCTION AND FOCUS The AB-PMJAY scheme prioritises the most deprived and vulnerable population, comprising the bottom 40% of the population (a whopping 500 million plus). Eligibility for participation is determined by factors such as deprivation and occupational characteristics specified in the Socio-Economic Caste Census 2011.[3] To bolster the beneficiary base, in 2022, the NHA initiated the integration of various welfare schemes' databases to boost AB-PMJAY coverage.[7] The primary functions of AB-PMJAY are to provide cashless access to quality healthcare services and to cover expenses related to hospitalisation, including pre- and post-hospitalisation expenditures too, across a wide range of public and private hospitals around the country.[3] There are no limitations on the number of family members, their age or gender. In addition, the coverage includes all pre-existing medical conditions from the outset. AB-PMJAY provides mobility advantages across India and encompasses almost 1949 secondary and tertiary care procedures in its recent health benefits packages, including diagnostics, medications, supplies and all expenses associated with treatment.[3] The benefit of 5 lacs is given on a family floater basis, which is different from the former RSBY plan, which had a limit of five members per family and INR 30,000. Its design has been impacted by lessons learnt from previous schemes, resulting in removing restrictions on family size.[3] The scheme's characteristics have successfully shielded millions of people from financially devastating medical expenses that annually drive numerous families into poverty.[3] MODELS OF IMPLEMENTATION Various models are utilised to successfully implement the AB-PMJAY, like using the services of insurance companies, while another model, known as the Assurance or Trust Model, involves directly implementing the programme without the involvement of an insurance firm. The government bears the financial risk in this model as the State Health Authority directly reimburses the healthcare providers. Under the Trust Model, the government can utilise an implementation support agency to handle claim administration and other associated services. Another prominent approach is the mixed model, in which the government involves insurance and trust entities in different capacities. The purpose is to achieve greater economic efficiency and flexibility.[3] LEVERAGING TECHNOLOGY PMJAY is a paperless and technology-driven scheme that operates through a robust IT system that ensures end-to-end information security and privacy of beneficiaries' data, enabling grievance management and anti-fraud measures. There are several critical components of the PMJAY IT system. The Beneficiary Identification System helps verify beneficiaries from the database and create beneficiary registries.[8] The Transaction Management System allows capturing inpatient data on admission, treatment and discharge and facilitates hospital claims and financial settlements. It consists of two sub-modules: pre-authorisation and claims processing.[8] A Hospital Empanelment Module (HEM) is responsible for empanelling hospitals under the scheme.[8] The scheme has also implemented two key systems: Risk Assessment Detection and Analytical Reporting (RADAR) and Fraud Analytics Control Tracking System (FACTS), which will reinforce its zero-tolerance stance towards fraud and cultivate an anti-fraud culture across all aspects of its governance. Establishing the National Anti-Fraud Unit was crucial in implementing the Anti-Fraud and Abuse Control Framework. The RADAR dashboard was developed to monitor the scheme for irregular variable trends, while the FACTS portal serves as a platform for reporting fraudulent entities.[8] The Central Grievance Redressal Management System handles the registration, processing, management, monitoring and resolution of all complaints from stakeholders involved in the PMJAY programme.[9] An Insights Portal and Impact Portal provide a real-time comprehensive view of scheme performance through interactive dashboards, analytics and visualisations, enabling data-driven decision-making and monitoring.[10] Furthermore, the NHA has created Health Benefit Packages (HBPs) and Standard Treatment Guidelines (STGs) to streamline the processes. HBPs are revised at regular intervals. Its initial version was launched in 2018 with the scheme and had 1393 packages.[8] In 2019, HBP 2.0 brought multiple new concepts to the package design, such as cross-speciality procedures, add-on procedures, stand-alone procedures, follow-up procedures, stratifications and special conditions.[9] In 2020, a minor update on rate adjustments for specific procedures was made (HBP 2.1). In November 2021, a significant change was made with approximately 400 procedures having a price revision (HBP 2.2), and a package for black fungus was also added in this version.[11] In April 2022, the HBP packages underwent revision, increasing the number of procedures to 1949 across 27 specialities, with rate revisions too.[6] The STGs aim to ensure consistent, quality care across hospitals, streamline processes such as pre-authorisation and claims and prevent fraud. They include sections on package details, clinician guidelines, processing team instructions and transaction management system guidelines, serving as a vital tool for standardised, efficient healthcare delivery within PM-JAY. The growth of AB-PMJAY over the past 5 years has been steady, with cards issued increasing from 103 million on completion of the 1st year of scheme implementation to 334 million in March 2024 [Figure1].[6,8-12]Figure 1: Ayushman Bharat Pradhan Mantri Jan Arogya Yojana – e-Cards Issued (in million)When comparing the statistics of beneficiaries who have taken the treatment under AB-PMJAY scheme, we observe an upward trend both in the number of hospitalisation and value of treatments over the years [Figure 2].[6,8-12]Figure 2: Ayushman Bharat Pradhan Mantri Jan Arogya Yojana hospital treatmentThe hospital empanellment has increased from 18,236 hospitals in 2018 to 29,972 hospitals as of March 2024 [Figure 3],[6,8-12] with a good mix of the public and private sectors providing the services. States carried out de-empanelment activities at hospitals that were inactive, leading to a decline of 3.38% in 2023.[6,13] As of March 18, 2024, out of the 29,972 empanelled hospitals that cater to the patients of AB-PMJAY, 57.6% (17,267) are public hospitals and 42.4% (12,705) are private hospitals [Figure 3].[12]Figure 3: Hospitals empanelled under the Ayushman Bharat Pradhan Mantri Jan Arogya YojanaAB-PMJAY has made a significant transition in the healthcare sector by providing healthcare to the marginalised and nudging states to do more for their citizens. In Assam, the integration of AB-PMJAY and the Ayushman Asom Mukhyamantri Jan Arogya Yojana ensures that all families registered in the National Food Security Act (NFSA) database receive Ayushman Bharat cards.[14] Similarly, the State of Jammu and Kashmir adopted the NFSA database,[15] in 2022, and then moved to cover all.[6] Meghalaya[16] has demonstrated a proactive commitment to achieving Universal Health Coverage within the state, complementing the efforts of the AB-PMJAY initiative. In conclusion, the AB-PMJAY is a cornerstone in India's healthcare landscape, ushering in a transformative era of accessible and affordable healthcare for millions. The multifold consumption can see the importance of these schemes for the vulnerable population in terms of claims count and amount. The poor and vulnerable have shown confidence and come forward to utilise these benefits, emphasising the significance of AB-PMJAY in addressing the healthcare needs of the most marginalised segments of society. In essence, the journey of AB-PMJAY signifies a monumental stride towards a healthier and more equitable India, where healthcare is not just a privilege but a fundamental right accessible to all. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.