New Delhi: The ambitious Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (PMJAY) completes a year on Monday, with impressive numbers to show but it still faces challenges of sustainability, synchronization and financial fulfilment.

Other factors pushing the programme to its limits include increasing population, disease burden, concentration of health services in urban areas, and lack of awareness of the scheme among a major chunk of entitled beneficiaries.

Prime Minister Narendra Modi launched the scheme on 23 September 2018 from Ranchi.

According to the ministry of health and family welfare, in the last one year, around 46.4 lakh hospital treatments worth 7,500 crore have been carried out, and 60% of the amount spent was on tertiary care. As on date, the scheme has been implemented in 32 states and union territories. Various states are using different models for implementing their own health insurance/assurance schemes.

Given that states are at different levels of preparedness and have varying capacity to manage such schemes, PM-JAY provides them with the flexibility of choosing their implementation model. Seventeen states/UTs have implemented the scheme via the Trust Mode, nine states/UTs via insurance mode and six states/UTs have used the mixed mode, which is a combination of trust and insurance mode.

Billed as the world’s largest health assurance scheme, AB-PMJAY aims to provide free health insurance of 5 lakh per family to nearly 40% of the population—more than 100 million poor and vulnerable families. But by the government’s own admission, the uneven geographic distribution of poor families makes it difficult to find out the real targeted beneficiaries given the uneven geographic distribution of poor families. Inspite of many people having been treated under the scheme, many remain unaware of the programme.

“Our focus is to ensure that more and more vulnerable Indians are being made aware of their entitlements, so that they can avail of the hospitalization benefits during their illness," said Indu Bhushan, CEO, National Health Authority (NHA), implementing authority of the scheme.

“Focused efforts are being made to ensure that the poor and vulnerable are made aware of their entitlements, and e-cards are issued to these beneficiaries. In one year, 10.3 crore e-cards have been issued to entitled beneficiaries under PM-JAY. The distribution of e-cards is continuing to take place at a very fast pace. 3 e-cards are being distributed every second across the length and breadth of India, and 91% e-cards linked with Aadhaar, which aids verification of the entitled beneficiaries," said Bhushan.

Under the scheme, more than 18,236 hospitals have been empanelled across India. Of the hospitals empanelled, 53% are private, especially multi-specialty. Implemented under the public private partnership (PPP) model, one of the most promoted government schemes, AB-PMJAY, is yet to loop in top corporate hospitals. In India there is a very low penetration of health insurance and high out-of-pocket spending for healthcare services.

Public health experts say that Ayushman Bharat lacks in rational pricing and health insurance for all as it covers only a section of the population.

“There is a need to scale up this programme with quality and sustainability for all stakeholders. We need to strengthen delivery mechanism which includes expansion of private providers’ network, shift towards organized care delivery, innovations, speciality, low cost, and value-based care," said Dr. H. Sudarshan Ballal, president, NATHEALTH, an healthcare industry body.

“The package rates for private providers remained an unsettled issue in the past year. The focus needs to be on coverage of those who are outside the ambit of healthcare. Expansion of coverage to include the lower-middle and middle class needs to be a priority, going forward," he said.

Public health experts have said that along with delivery and quality, the government will need to adopt innovative funding models for long-term sustainability. While government spending on healthcare in India is one of the lowest in the world at around 1.2% of GDP, the country’s health system is crippled with shortage of workforce, poor infrastructure, compromised quality and unavailability of services.

“For higher public spending in the government budget, India needs to attract strategic funding through various other internal and external sources to sustain Ayushman Bharat. With adequate financing and funding to the sector, rural-urban gaps in quality and delivery systems can also be bridged," said Siddhartha Bhattacharya, secretary-general, NATHEALTH.

A study published in the PLOS Medicine journal in March stated that there is a need for wide reforms across public and private providers of care if India is to meet its stated aims of providing universal health coverage for its population.

The success of the programme will rely on a reformed and adequately resourced public sector to lead implementation, delivery, and monitoring of the scheme, the study said.

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