Policy Update
Lakshita Singh
Introduction
On September 11, 2024, the Union Cabinet approved a significant expansion of the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB PM-JAY). This extension ensures that all senior citizens aged 70 and above, irrespective of their income levels, will now be eligible for health coverage. Approximately 4.5 crore families, including 6 crore senior citizens, will benefit from this move, which provides free health insurance coverage of up to Rs 5 lakh per family. With this decision, every senior citizen in this age group will have access to the scheme’s benefits, regardless of their socio-economic background.
Key features
- New Distinct Card: Senior citizens aged 70 and above who qualify for the AB PM-JAY scheme will receive a unique card tailored specifically for their use.
- Top-Up Coverage: Senior citizens already under AB PM-JAY coverage will be given an additional top-up insurance of up to Rs 5 lakh annually. This top-up will be solely for their use and will not need to be shared with family members below the age of 70.
- Family Coverage: Senior citizens not currently included in an AB PM-JAY family plan will be provided with an annual family health insurance coverage of up to Rs 5 lakh.
- Choice of Schemes: Those senior citizens already benefiting from other public health insurance schemes, such as the Central Government Health Scheme (CGHS), Ex-Servicemen Contributory Health Scheme (ECHS), or Ayushman Central Armed Police Force (CAPF), can choose to either continue with their existing plan or switch to AB PM-JAY.
- Eligibility with Private Insurance: Senior citizens with private health insurance policies or enrolled in the Employees’ State Insurance scheme are also eligible for benefits under AB PM-JAY.
About Ayushman Bharat
Ayushman Bharat, a flagship initiative of the Government of India, was launched in line with the recommendations of the National Health Policy 2017 to realize the goal of Universal Health Coverage (UHC). This program is aligned with the Sustainable Development Goals (SDGs) and reflects a core commitment to “leave no one behind.”
Ayushman Bharat marks a shift from a sectoral, fragmented approach to health service delivery toward a comprehensive, need-based healthcare system. The scheme aims to introduce transformative interventions to address the healthcare sector holistically, covering prevention, promotion, and treatment across primary, secondary, and tertiary care levels. It follows a continuum of care model, comprising two interconnected components:
- Health and Wellness Centres (HWCs)
- Pradhan Mantri Jan Arogya Yojana (PM-JAY)
1. Health and Wellness Centres (HWCs)
In February 2018, the Government of India announced the establishment of 1,50,000 Health and Wellness Centres (HWCs) by upgrading existing Sub-Centres and Primary Health Centres. These centers aim to provide Comprehensive Primary Health Care (CPHC) by bringing essential healthcare services closer to people’s homes. They offer both maternal and child health services, along with care for non-communicable diseases, and include free essential medicines and diagnostic services.
Health and Wellness Centres are designed to deliver a wider range of services to meet the primary healthcare needs of the population in their respective areas. The focus is on increasing accessibility, equity, and universality of healthcare services at the community level. By emphasizing health promotion and disease prevention, these centers seek to empower individuals and communities to adopt healthy lifestyles and make choices that lower the risk of chronic diseases and other health issues.
The second key component of Ayushman Bharat is the Pradhan Mantri Jan Arogya Yojana (PM-JAY), which was officially launched on September 23, 2018, in Ranchi, Jharkhand, by the Prime Minister of India, Shri Narendra Modi.
Ayushman Bharat PM-JAY is the world’s largest health assurance scheme, offering health coverage of Rs. 5 lakh per family annually for secondary and tertiary care hospitalization to over 12 crore poor and vulnerable families, which is about 55 crore beneficiaries from the bottom 40% of India’s population. The inclusion of households is determined by the deprivation and occupational criteria from the Socio-Economic Caste Census 2011 (SECC 2011) for both rural and urban areas.
Initially referred to as the National Health Protection Scheme (NHPS), it was renamed PM-JAY and absorbed the existing Rashtriya Swasthya Bima Yojana (RSBY), which had been launched in 2008. Thus, families covered under RSBY, but not listed in the SECC 2011 data, are also included in PM-JAY. The scheme is entirely government-funded, with the cost shared between the Central and State Governments.
As of September 9, 2024, more than 35.4 crore Ayushman cards have been issued across India under the AB-PMJAY. The scheme is active in 33 States and Union Territories, excluding the National Capital Territory of Delhi, West Bengal, and Odisha. To date, the healthcare scheme has authorized 7.79 crore hospital admissions, totaling Rs. 1,07,125 crore in financial coverage as of September 9. The beneficiary base of AB PM-JAY has seen significant growth. Initially covering 10.74 crore poor and vulnerable families, the Government expanded the coverage in January 2022 to 12 crore families, reflecting an 11.7% increase in India’s population since 2011.
Additionally, the scheme has been extended to provide healthcare benefits to 37 lakh Accredited Social Health Activists (ASHAs), Anganwadi Workers (AWWs), and Anganwadi Helpers (AWHs) and their families. Following the recent cabinet decision, the AB PM-JAY will now also offer free health coverage of Rs 5 lakh to all citizens aged 70 and above nationwide.
The Ayushman Bharat Health Accounts (ABHA), a crucial element of the Ayushman Bharat Digital Mission (ABDM), is designed to enhance India’s digital health infrastructure. It offers a 14-digit unique number that simplifies the digital access and sharing of medical records. This system streamlines interactions with verified healthcare providers, making it easier to access lab reports, prescriptions, and other health information. As of September 12, 2024, a total of 66.70 crore Ayushman Bharat Health Accounts have been created, with 42.01 crore health records linked to these accounts.
The “Ayushman Bhav” initiative aims to provide comprehensive healthcare coverage in every village and town, embodying Prime Minister Narendra Modi’s commitment to ensuring healthcare access for all, including the most remote areas.
As of July 2024, the campaign has reached several significant milestones:
- Wellness, Yoga, and Meditation: 16.96 lakh sessions have been conducted.
- Teleconsultations: 1.89 crore sessions have been held.
- Free Drugs and Diagnostics: 11.64 crore individuals received free medications, and 9.28 crore people benefited from free diagnostic services.
- Ante-Natal Check-Ups (ANC) and Immunization: 82.10 lakh mothers and 90.15 lakh children received these services.
- Screening Services: 34.39 crore people were screened for TB, Hypertension, Diabetes, Oral Cancer, Breast Cancer, Cervical Cancer, and Cataracts.
- Consultations and Surgeries: 2.0 crore patients received general outpatient consultations, 90.69 lakh sought specialist consultations, while 65,094 major surgeries and 1,96,156 minor surgeries were performed.
- ABHA and Ayushman Cards: 13.48 crore ABHA accounts have been created, and 9.50 crore Ayushman cards generated.
- Ayushman Sabhas: 1.20 lakh Sabhas have been organized.
- Health Melas: 20.66 crore people attended 25.25 lakh health melas as of March 31, 2024.
2. Pradhan Mantri Aarogya Mitra (PMAM):
The scheme is developing a cadre of certified frontline health service professionals known as Pradhan Mantri Aarogya Mitras (PMAMs), who serve as the primary facilitators for beneficiaries to access hospital treatment, thereby supporting the smooth delivery of health services. A Memorandum of Understanding (MoU) was signed between the National Health Agency and the Ministry of Skills Development & Entrepreneurship (MSDE) on August 27, 2018, in New Delhi.
The Aarogya Mitras training is conducted in partnership with the National Skill Development Corporation (NSDC) and the Ministry of Skill Development to enhance implementation and operational readiness.Training has already been provided across 20 states, with approximately 3,519 Aarogya Mitras trained so far. Additionally, training programs for state, district, and PMAM personnel have been conducted in 27 states.
Significance
Historically, government-funded health insurance schemes in India have operated with varying annual coverage limits, ranging from INR 30,000 to INR 3,00,000 per family, creating a fragmented healthcare system across different states. In contrast, the Pradhan Mantri Jan Arogya Yojana (PM-JAY) offers cashless coverage of up to INR 5,00,000 per family annually for specified secondary and tertiary care treatments. This comprehensive coverage includes all expenses related to medical examinations, consultations, pre-hospitalization, medicines, intensive and non-intensive care services, diagnostic tests, medical implants, accommodation, food services, treatment complications, and post-hospitalization follow-up care for up to 15 days.
The scheme’s INR 5,00,000 coverage is provided on a family floater basis, meaning that the entire amount can be utilized by one or multiple family members. Unlike the Rashtriya Swasthya Bima Yojana (RSBY), which capped coverage at five family members, PM-JAY has no restrictions on family size or the age of family members. Moreover, the scheme covers pre-existing conditions from day one, ensuring that anyone enrolled can receive treatment for conditions they had prior to coverage.
The significance of PM-JAY lies in its ability to provide a unified and extensive healthcare safety net for India’s poorest populations. As one of the largest health assurance schemes globally, it simplifies healthcare access by offering wide-ranging services without the financial burden typically associated with serious medical treatments. With no caps on family size and immediate coverage of pre-existing conditions, the scheme ensures equitable healthcare for millions of vulnerable citizens. Its implementation has also fostered significant growth, with over 35 crore Ayushman cards issued and millions of hospital admissions covered as of 2024, further demonstrating its transformative impact on India’s healthcare landscape.
Emerging Issues
While the decision to offer free health coverage up to ₹0.5 million annually for a section of the population is commendable, it falls short of addressing critical public health needs. PM-JAY’s focus on secondary and tertiary care hospitalization excludes essential outpatient services, diagnostics, and medicines, which are crucial given India’s rising burden of chronic diseases. Elderly individuals, especially those over 70, often face multiple chronic conditions, and a significant portion of their healthcare costs (40%-80%) stems from outpatient care, which is not covered by the scheme. Additionally, the scheme’s reach in smaller towns and cities has been limited, and public sector primary and secondary healthcare remains underdeveloped in many regions, particularly outside southern states.
A strong primary and secondary healthcare system could reduce the pressure on tertiary care and improve the success of PM-JAY. Thailand’s approach, which strengthened its primary care and redirected funds from urban hospitals to rural health centers, successfully achieved universal health coverage. In contrast, India’s reliance on insurance-based models, similar to the U.S., has led to higher healthcare costs. Media reports indicate that two-thirds of PM-JAY funds go to private hospitals, with 53% in southern states. Over-reliance on private hospitals risks diminishing the government’s commitment to public healthcare, making PM-JAY a necessary but incomplete solution.
Way forward
The Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PM-JAY) represents a transformative step in India’s healthcare landscape, offering substantial cashless coverage of up to INR 5,00,000 per family per annum for secondary and tertiary care to over 12 crore vulnerable families. To ensure its success, it is essential to enhance awareness through community engagement and digital platforms, simplify the enrollment process, strengthen healthcare infrastructure, and integrate the scheme with other health initiatives.
Monitoring and evaluation mechanisms should be established to ensure effective service delivery, while preventive care programs must be promoted to reduce the healthcare burden. Expanding coverage to include more vulnerable groups and ensuring financial sustainability through innovative funding models will further enhance the scheme’s impact. The significance of PM-JAY lies in its ability to provide equitable access to healthcare, particularly for marginalized populations, thus contributing to improved health outcomes and reduced poverty. In the long run, this initiative has the potential to foster a healthier society, improve productivity, and drive economic growth, ultimately moving India closer to achieving Universal Health Coverage (UHC) and fulfilling the Sustainable Development Goals (SDGs).
References
About the Contributor- Lakshita singh is a research intern at IMPRI, currently pursuing her graduation in BA Hons History from Delhi University.
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