When India rolled out the Pradhan Mantri Jan Arogya Yojana (PM-JAY) in September 2018 to provide cashless annual hospitalisation cover of up to ₹5 lakh to at least 107.4 million families, it was building on the experience of the country’s first nationwide social health insurance scheme, the Rashtriya Swasthya Bima Yojana (RSBY), which used public-private partnerships (PPP) to fill the gaps in public health delivery and increase access.

While much larger in scale, PM-JAY expanded on several aspects of RSBY’s PPP model, such as scheme design, involvement of the private sector, use of contracts, incentives given and overall administrative structure to offer provider plurality without having to pay money upfront.

The PMJAY design indicates that the strengths and weaknesses of RSBY were kept in mind during its development, but gaps remain, points out Sonalini Khetrapal in her insightful new book, Healthcare for India’s Poor: The Health Insurance Way (Academic Foundation; ₹1,195).

There is considerable scale up under PM-JAY, with beneficiaries increasing from 150 million to 107.4 million families (around 500 million individuals), hospitalisation cover rising from ₹30,000 to ₹5 lakh per family per year, removal of the cap on family from five per family under RSBY, expansion of treatment packages from 1,090 to 1,345, with no restriction on pre-existing conditions.

Greater transparency can be ensured by engagement with the community through elected village and local body representatives, NGOs, and rogi kalyan samitis (patient welfare boards) to prevent “cream skimming”, where private sector chooses to treat only selected profitable packages, and ensure continuity of all services, writes Khetrapal, who is a wildlife photography enthusiast who has won several international awards, including the Sony World Photography and Siena International Photo awards.

The need for a health protection scheme like PM-Jay cannot be overstated. Around 85.9% of rural households and 82% of urban households in India had no access to healthcare insurance/assurance in 2015, according to 17th National Sample Survey Organization 2015, with more than 17% of population spending at least 10% of household budgets for health services.

India’s new health vision also provides free out-patient services and over-the-counter medicines to everyone for ailments like fevers that don’t need hospitalisation at the newly set-up Health and Wellness Centres staffed by community health officers (CMOs). The CMOs are trained to do simple diagnostics tests like malaria tests, and measure blood pressure and blood glucose to refer cases that need clinical review to hospitals.


Leave comment

Your email address will not be published. Required fields are marked with *.