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PMJAY (Features (Targets poor, deprived rural families and identified…
PMJAY
Features
Targets poor, deprived rural families and identified occupational category of urban workers’ families as per SECC data as well as active families under the Rashtriya Swasthya Bima Yojana (RSBY). No cap on family size and age.
From inpatient care to post hospitalization care: Through a network of Empanelled Health Care Providers (EHCP).
Beneficiaries will be able to move across borders and access services across the country through the provider network seamlessly. No card needed, Aadhaar numbers will suffice.
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Principle based rather than rule based - flexibility to states in terms of packages, procedures, scheme design, entitlements, guidelines ensuring key benefits of portability and fraud detection at a national level.
States have option of implementing it through a Trust model or Insurance Company based model, though the Trust model will be preferred.Share: 60:40
Ayushman Bharat National Health Protection Mission Council (AB-NHPMC) Chaired by MoHFW => Giving policy directions and fostering coordination between Centre and States
Partnership with NITI Aayog => IT platform => paperless, cashless transaction.
NHA Information Security Policy & Data Privacy Policy => secure handling of Beneficiaries Personal Data & Sensitive Personal Data in compliance with all laws and regulations applicable.
PM Aarogya Mitra (PMAM): cadre of certified frontline health service professionals => primary point of facilitation for the beneficiaries to avail treatment at the hospital and thus, act as a support system to streamline health service delivery.
Significance
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Rationalisation of the cost of care in the private sector. increase in demand => a high volume-fair return model.
Earnings of public hospitals => deposited with the Rogi Kalyan Samitis. 30% of the overall public spending on the scheme may return to public sector institutions.
Each year, 6-7 crore people fall below poverty line because of health-related expenses. 1/3rd out-of-pocket expenditure is due to inpatient hospitalisations. 1/8th families have to incur health expenditure of 25% of household expenditure.
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Concerns ahead
NITI Ayog: Rs 12,000 crore required. Allocation of just ₹2,050 crore during the current year. Not all States and UTs are in a position to raise their own share, some haven't joined the scheme.
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Covers only the deprived => many schemes of states have a wider range of beneficiaries e.g. Karnataka’s health insurance scheme covers all the residents of the state.
Sustainability of insurance companies has to be ensured. IRDAI: incurred claims ratio for government-sponsored health schemes went up to 87% in 2012-13 to 122% in 2016-17.
People spend much more on illnesses that don’t need hospitalisation and are not covered under insurance. NSSO 2014: no relief from increasing health expenditure w.r.t 2004.
Along with Insurance model focus must be on strengthening health infra. Successful in implementing health insurance schemes. e.g. Thailand, extensively focused on strengthening the public health infrastructure before rolling out its Universal Coverage Scheme in 2001.