Context: Two research institutes, Public Health Foundation of India and Duke Global Health Institute, United States have revealed that India’s flagship health insurance scheme, dubbed the world’s largest fully government-subsidised scheme, has  failed to deliver when it was needed the most.

Key Issues

• Pradhan Mantri Jan Arogya Yojana (PM-JAY) provided a cushion to only 14.25 per cent of people hospitalized for the COVID-19, between April 2020 and June 2021. 
• Union Minister for Health and Family Welfare Mansukh Mandaviya in a reply to the Lok Sabha also acknowledged that PM-JAY paid for only 0.52 million COVID-19 hospitalisations across the country.
• Though no official data is available on total COVID-19 hospitalisations in the country, the share is negligible keeping in mind that the scheme claims to cover 165 million beneficiaries across the country.

Observations that support the report

• When DTE team visited nine states where hospitalisation rates were high during the pandemic, they found that while the government insurance schemes did not cover all the target groups and eligible individuals, even those enrolled under insurance schemes were forced to fight the pandemic on their own and cough up large amounts of money to avail treatment.

Hospitals demand cash during admission

• Hospitals insist on a signed declaration that PM-JAY would not be used for ICU
• Private hospital says PM-JAY covers surgeries, not hospitalisation; expenses never get reimbursed. Officials have even rejected some applications without giving them a clear reason
• Finding an empanelled hospital is a futile exercise in areas where hospitals are few and far between. This has remained a major problem, particularly in smaller towns and villages, where hospitals are few and far between.
• Many have been left out of the insurance scheme’s ambit despite being eligible.

PM-JAY, which aims to provide insurance coverage to the poorest 40 per cent of the population, has not only left out individuals, but also certain communities.

• Thousands of sex workers in Pune’s Budhwar Peth zone, for example, fought a solitary battle against the pandemic.
• Several ragpickers interacted with in Pune’s Shivajinagar area also said they were not enrolled under the scheme. This is despite the PM-JAY manual stating that ragpickers are covered under the scheme, along with people who survive on alms and other similar categories.
• The cost of ICU hospitalisation of a COVID-19 patient on an average is equivalent to what a casual worker (someone who is employed from time to time according to exigencies of work) earns in almost 1.5 years.

Road Ahead

• Raise the percentage of GDP allocated to health
• Government hospitals need infrastructure and machinery up-gradation, which can be done by the earnings of public hospitals under PMJAY.
• A larger share of India’s public health expenditure to be allocated to preventive care.
• The prime objective of PM-JAY is to reduce catastrophic out-of-pocket health expenditure by improving access to quality health care for its underprivileged population. More work needs to be put to deal with this.
• The scheme directs that complaints of denial of treatment by an empanelled hospital need to be resolved within six hours. This will also require major intervention.
• Ensuring adaptive price setting, third-party monitoring, strict regulation, and quality improvements in public sector hospitals.
• PMJAY will need a gamut of skilled manpower as facilitators and administrative staffs at various levels.

About Pradhan Mantri Jan Arogya Yojna (PM-JAY)

• The scheme was launched in September 2018 and recommended by the National Health Policy 2017, to achieve the vision of Universal Health Coverage (UHC).
• It is a Centrally Sponsored Scheme having a central sector component under Ayushman Bharat Mission
• PM-JAY was earlier known as the National Health Protection Scheme (NHPS) before being rechristened. 
• It subsumed the then-existing Rashtriya Swasthya Bima Yojana (RSBY) which had been launched in 2008.