The Pradhan Mantri Jan Arogya Yojana (PMJAY), also known as Ayushman Bharat, is one of India's largest healthcare schemes aimed at providing health insurance to the economically vulnerable populations. Launched on September 23, 2018, the scheme offers a sum insured of ₹5 lakh per family for both secondary and tertiary care. Secondary care includes treatments that do not require a specialist, while tertiary care involves treatment by super-specialists. PMJAY ensures that cashless and paperless healthcare services are available at empanelled hospitals, making access to healthcare more convenient for beneficiaries.
Under the scheme, health benefit packages cover a variety of services, including:
- Surgery
- Medical and day care treatments
- Cost of medicines
- Diagnostics
These services are provided at
packaged rates, which means a fixed, all-inclusive price that covers the entire treatment, ensuring transparency. Once a rate is set, hospitals cannot charge additional fees. The scheme also has a
daily limit for medical management, ensuring cost control.
Beneficiaries of PMJAY:
PMJAY is an
entitlement-based scheme, targeting those who are identified through the latest
Socio-Economic Caste Census (SECC) data. This database helps determine eligibility and once identified, families are considered insured under the scheme. Beneficiaries can avail of healthcare services in any
empanelled hospital across India. The inclusion of both
rural and urban populations ensures wide coverage of vulnerable groups, including farmers, landless laborers, and those living below the poverty line.
Funding and Implementation:
PMJAY operates with a
shared funding model:
- 60:40 ratio for all states and UTs with their own legislature (the Centre contributes 60% and states 40%).
- 90:10 for Northeast states, Jammu and Kashmir, Himachal Pradesh, and Uttarakhand (Centre provides 90%, states contribute 10%).
- 100% funding for UTs without legislature, where the entire cost is borne by the Central Government.
The scheme is implemented by the
National Health Authority (NHA), an autonomous body formed under the
Society Registration Act, which works in close collaboration with state governments. The
State Health Agency (SHA), in each state, is responsible for the implementation of the scheme within that state.
Challenges in the Implementation of PMJAY:- Cooperation of States: Since health is a State subject, the cooperation of state governments is crucial for the successful implementation of PMJAY. Some states, like West Bengal, Telangana, Odisha, and Delhi, have not yet implemented PMJAY, which affects its universal reach. States are expected to contribute 40% of the funding, which can be a barrier in harmonizing state-level health schemes with PMJAY.
- Burden of Costs: There is a challenge regarding the cost burden shared by the government and healthcare providers. Many private, for-profit hospitals believe the rates set by the government under PMJAY are unviable, potentially leading to resistance in offering services under the scheme.
- Inadequate Health Capacities: Public sector healthcare infrastructure is often ill-equipped to meet the demand of PMJAY services. This necessitates partnerships with private healthcare providers to ensure service delivery. Without stringent accountability and quality control, the implementation of the scheme could be compromised.
- Unnecessary Treatment: The issue of unnecessary treatments has been flagged by the National Health Policy 2017, which recommends strategic purchasing of services. Contracts with healthcare providers must clearly define and adhere to standard treatment protocols to prevent fraud and unnecessary medical interventions.
Achievements of PMJAY:- Beneficial for the Poor: PMJAY has had a significant impact on the vulnerable population. Within the first 200 days of implementation, more than 20.8 lakh people received free treatments worth over ₹5,000 crore. This includes both secondary and tertiary care treatments, which are often financially out of reach for economically disadvantaged families.
- During COVID-19: PMJAY's portability feature allowed migrant workers and other displaced populations to continue accessing healthcare services at any empaneled hospital across the country, regardless of their state of residence. This was particularly beneficial during the COVID-19 pandemic, when large numbers of workers were moving across states.
Related Scheme:
India Covid-19 Emergency Response & Health System Preparedness Package – Phase-II (ECRP-II): This scheme, launched by the government, is designed to support the
health system’s preparedness for COVID-19, with a focus on strengthening
paediatric care and other health infrastructure. It has been crucial in addressing the immediate response needs, as well as long-term improvements in the healthcare sector.
Way Forward:
The
Ayushman Bharat PMJAY program has the potential to become a transformative force for the healthcare system in India. To achieve
Universal Health Coverage (UHC), it requires a multifaceted approach:
- Resource Injection: India’s healthcare system is underfunded, and PMJAY will need continued financial support to ensure equitable access to healthcare services.
- Governance and Quality Control: PMJAY’s success will depend on efficient governance, ensuring that standards are adhered to by healthcare providers and that resources are allocated efficiently.
- Innovation and Technology: Leveraging technology and innovation, such as AI-powered mobile applications, can reduce the overall costs of healthcare and increase efficiency. The use of an interoperable IT platform within PMJAY is a step toward improving service delivery, reducing paperwork, and enhancing transparency.
- Sustainability and Accountability: To make PMJAY sustainable in the long term, there must be a focus on creating a robust system of accountability, ensuring that healthcare providers deliver quality services and adhere to treatment protocols.
By addressing these challenges and optimizing the system, PMJAY has the potential to transform India’s healthcare landscape and achieve the ambitious goal of
Universal Health Coverage for all.
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