Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PMJAY)
What is it?
- Launched in 2018 to provide health insurance coverage to the economically weaker sections of India.
- The scheme aims to offer financial protection to around 100 million families (500 million beneficiaries) by covering treatment costs of up to ₹5 lakh per family per year for secondary and tertiary care.
Success
- Healthcare Access Expansion: Provides health insurance coverage of ₹5 lakh per family per year for secondary and tertiary care to around 500 million beneficiaries from economically weaker sections.
- Wide Network of Hospitals: Empanelment of 25,000+ hospitals (both public and private), ensuring healthcare access across urban and rural areas.
- Financial Protection: Reduces out-of-pocket expenses for low-income families, protecting them from catastrophic health expenditures.
- Focus on Specialised Treatments: Covers high-cost treatments like cardiac surgeries, cancer therapies, and dialysis, focusing on secondary and tertiary care.
Challenges
- Insufficient Awareness and Utilisation: Many eligible families are unaware of the scheme or do not fully understand how to access the benefits, leading to underutilization in certain regions.
- Limited Coverage of Outpatient Care: The scheme primarily covers inpatient care, with inadequate coverage for outpatient consultations, diagnostics, and medications.
- Challenges in Implementation Across States: Uneven implementation across states due to infrastructure limitations and political will. Delayed payments and low reimbursement rates deter some private hospitals from joining the scheme.
- Quality of Healthcare: There have been concerns over the quality of care provided under the scheme, especially in empanelled private hospitals. Some hospitals have been accused of performing unnecessary surgeries or providing substandard services to maximise profits.
- Delayed Payments and Low Reimbursement Rates: Delayed payments to hospitals by insurance companies and low reimbursement rates for certain procedures have discouraged some private hospitals from fully participating in the scheme.
- Overburdened Public Healthcare System: The scheme has increased the workload on government hospitals, many of which were already under strain due to inadequate staff and infrastructure.
- Exclusion of Mental Health Services: Mental health services are largely excluded from the scheme, despite a growing recognition of the importance of mental health in overall well-being.
- Fraud and Misuse: Instances of fraud have been reported, where hospitals or individuals misuse the system by submitting false claims.