Ayushman Bhava!

For Bhavishye, a resident of Rohtak in Haryana, Ayushman Bharat scheme proved to be life-saving. The 42-year-old suffered a heart attack in October 2018 after which he was rushed to the Ram Manohar Lohia Hospital in Delhi. On arrival, it was found out that one of his arteries was 99 per cent blocked and the other was 80 per cent blocked. Doctors at the hospital conducted a procedure on him.

"There was no other option but to perform an Angioplasty and put stents to clear the blockage. We performed this the same day he arrived and the patient was discharged three days later, without any hassle," said Dr Tarun Kumar, Associate Professor, Cardiology, Ram Manohar Lohia Hospital.

Bhavishye's procedure became the first Angioplasty under the Ayushman Bharat scheme, just one month after the scheme (also called Pradhan Mantri Jan Arogya Yojana) was launched in September 2018, in a bid to provide comprehensive health care to the vulnerable groups. In the one year since its announcement, the scheme has become one of the most successful health schemes of all times, with over one million beneficiaries and over ten million (one crore) e-cards generated already.

Announced on February 1, 2018, and launched seven months later, Ayushman Bharat is the world's largest healthcare scheme, which will reduce the financial burden of millions of families suffering from illnesses. It has been paying up to Rs 5 lakh in hospitalisation costs to poor and vulnerable families, which also cover drugs and diagnostic expenses. As per the scheme guidelines released on August 31, 2018, approximately 10.74 crore identified families (approximately 50 crore beneficiaries) will be entitled to get the benefits.

Ayushman Bharat

Ayushman Bharat Yojana or the Pradhan Mantri Jan Arogya Yojana (PM-JAY) was launched in 2018 with an aim to help the poorest 40 per cent of the population to afford quality secondary and tertiary care. In one year of its announcement and under 150 days of inception, the scheme has managed to cross ten lakh (one million) hospital admissions by January 31, 2019.

Under, what was called an ambitious scheme, an annual health cover of Rs 5 lakh, a straight increase from the earlier Rs 30,000, to a vulnerable family for secondary and tertiary care, hospitalisation is being provided along with cashless access to services at the point of service. Every year, 6 crore people are pushed below the poverty line due to catastrophic expenditure for hospitalisations. The scheme intends to help mitigate the financial risk arising out of catastrophic health episodes.

The scheme has, till now, provided treatment worth Rs 1,338.5 crore to more than 9.93 lakh beneficiaries across the country, reveals official data. Claims worth Rs 984.2 crore have been submitted till January 31 and of these, Rs 768.8 crore has been approved. Another Rs 1,379.4 crores has been authorised for hospital admissions.

"We have already registered 12 lakh beneficiaries under the scheme. Jammu and Kahsmir became the second fastest issuer of Ayushman Bharat Gold Cards in the country. Our performance in the overall health indicators is also being constantly recognised at the national level. We are committed to sustaining and building on the achievements registered so far," said Satya Pal Malik, Governor, Jammu & Kashmir.

More than 6 lakh families with 30 lakh individuals in Jammu and Kashmir are being covered under the scheme.

Similarly in Tamil Nadu, after merging its Chief Minister's Comprehensive Health Insurance Scheme (CMCHIS) with the Centre's flagship Ayushman scheme, the state has become one of the top states in terms of the claims with about 89,000 beneficiaries claiming over Rs 200 crore.

The state covers about 1.58 crore families, which is double the number targeted by the flagship insurance scheme that offers cover to deprived rural families and identified occupational categories of urban workers' families as per the latest Socio-Economic Caste Census data.

However, in states like Bihar, which never had a state scheme, there are many areas that need to be looked at for the scheme to reach maximum people.

The family of Sharda Devi, a resident of Patna, who makes her living by working as a domestic help, is among the beneficiaries of the yojana. In December, her daughter-in-law underwent a cesarean delivery following some complications.

"We were very worried when the doctor said there was some complication. My son, who works as a daily wage labourer, got to know about this insurance scheme and my daughter-in-law's cesarean delivery was done without any expense. Otherwise, the operation at any private hospital might have led to expenses that my family wouldn't have been able to afford and we would have borrowed the money," said Devi.

Yojana's challenges

While Devi's family benefited through the scheme, the doctors say that there is no better infrastructure other than providing safe deliveries at many facilities.

Bihar Swasthya Suraksha Samiti has been constituted for the scheme and contractual recruitment of required personnel will be done for its smooth implementation.

But doctors of Patna Medical College and Hospital, the largest state-run hospital in Bihar, which is also empanelled under the scheme, say Bihar needs to cover a lot of ground in healthcare infrastructure for the scheme to be a success in the state. "Most of the cases which are presently coming under PM-JAY pertain to delivery and that is because the public hospitals empanelled in the districts hardly have any infrastructure for advanced services," said a senior doctor.

However, most of the doctors agreed that there was an increased awareness regarding the scheme among the section of the people it is meant for. For the states which already had a state scheme, the burden of the enhanced cover for a larger number of beneficiaries will fall under the state.

For Tamil Nadu, a senior official of the Directorate of Public Health and Preventive Medicine said that for a beneficiary nothing much changes as he has to produce the CMCHIS card to claim benefits. United India Insurance, which is the state's insurance partner for the earlier CMCHIS, will cover only specified procedures up to to the sum insured of Rs 1 lakh or 2 lakh.?

The official added that for uncovered procedures beyond the sum insured, reimbursement will be done by the state. "The state has retained its package rates under the earlier CMCHIS rather than going with those under the new scheme, which has led to seamless empanelments of hospitals for Ayushman," the official said.?

The health insurance scheme has been implemented in the state since July 2009. Former chief minister M Karunanidhi launched Chief Minister Kalaignar Insurance Scheme for Life Saving Treatments for the poorest of the poor and unorganised workers. After the AIADMK came to power in 2011, the then chief minister J Jayalalithaa dropped the name of her arch-rival from the scheme and renamed it as CMCHIS aimed at benefiting 1.34 crore families. While the Karunanidhi regime introduced the scheme in the tie-up with a private insurance scheme, Jayalalithaa reserved it for a nationalised insurance company.

Other than the infrastructure and premium issues, the scheme also is suffering from a budget cut this time. In a recent update, the scheme will not be allocated the demanded Rs 7,400-crore budget as it is cutting into the budgets of other state and Union schemes. The Ministry of Health and Family Welfare has recently written to the Ministry of Finance to cut down budgets as other schemes were getting affected. The budget may see a cut down of at least Rs 800 crore. It may be revised to Rs 6,400 crore.

Another major challenge faced by PM-JAY is the reluctance of private hospitals to join the scheme. This is because most of the corporate hospitals pay huge sums of money in salaries and spend even more in infrastructure and thus coming on board on the same rates as advised by the scheme makes them reluctant to join. The rates of the scheme are even lower than the CGHS rates.

Grievances & frauds

The National Health Agency receive regular complaints from patients who are either denied cashless treatment at hospitals or are charged a fee. In all such cases, the NHA is known to take strong actions and get in touch with the concerned state. 194 such grievances have been registered till January 31, 2019.

On January 30, 2019, the agency's team, which looks at fraud websites selling scheme registrations to people took down 17 mobile applications.

Over 88 such fraud mobile applications have been tracked and taken down along with 78 fake websites. While 48 of these websites have been removed, another 30 are registered outside India and the team is looking at removing them. It has also filed FIRs.