The AB PM-JAY scheme saw a 51 percent dip in the average weekly claims during the lockdown.
Lucknow: It was a bright November afternoon in Lucknow when Zulekha, a mother of two had gone into labour. With already a lot of health complications, she was rushed to the hospital for the delivery of her third child.
This time was unusual for her and her family, as they could not go to a government hospital for the delivery. All the government hospitals turned into Covid-19 centers, so the family had to rush to a private hospital. Yet, their socio-economic background was not allowing them to do so. Finally, her husband was informed that they could also go to a private hospital, as there are some Ayushman Bharat empanelled hospitals in the city.
The family looked out for the nearest hospital and rushed Zulekha to it. She gave birth to a boy in the hospital, but soon after her delivery, the family was hit by misfortune. The baby was born with severe health complications and died the same day despite the doctors making efforts to save him.
On the next day of the delivery, Zulekha was discharged with a fat bill amounting to Rs. 25,000. With a monthly income of roughly Rs. 10,000, the family was forced to borrow money from the relatives after the hospital refused to cover them under the Ayushman Bharat– Pradhan Mantri Jan Arogya Yojna (AB PM-JAY).
The Ayushman Bharat scheme is a government flagship program launched by the government of India as recommended by the National Health Policy, 2017. The scheme was launched to achieve the vision of Universal Health Coverage (UHC) and to meet Sustainable Development Goals (SDGs) that commit to “leave no one behind”.
The scheme aims to cover card-bearing patients at primary, secondary, and tertiary levels of healthcare. It together caps two interrelated components, which include Health and Wellness Centers (HWCs) and Pradhan Mantri Jan Arogya Yojna (PM-JAY).
In 2018, the Indian government announced plans to create 1,50,000 HWCs by transforming already existing Sub-Centers and Primary Health Centers. These centers were set up to provide Comprehensive Primary Health Care (CPHC) to bring healthcare closer to the people. They cover maternal and child health services and non-communicable diseases, including free essential drugs and diagnostic services. The HWCs aimed to deliver a range of services that came under the primary health care needs of the entire population of a certain area.
The PM-JAY scheme was introduced later in 2018 in Ranchi, Jharkhand by the Prime Minister, Narendra Modi. The PM-JAY is the largest health insurance scheme in the world as it aims to provide a health cover of Rs. 5 lakhs per family per year for secondary and tertiary care hospitalization to about 11 crore poor and vulnerable families which counts nearly 50 crore beneficiaries. This number amounts to about 40 percent of the Indian population. The included households are based on the deprivation and occupational criteria of the Socio-Economic Caste Census 2011 (SECC) for both rural and urban people.
It has been more than a year since the pandemic broke out and the nation was locked inside for months. During this period hospitals were functional, but they diverted their focus towards the Covid-19 patients. This diversion in the hospitals left other patients with varied diseases and emergencies to suffer physically and financially. A lot of families near the poverty line suffered due to this. The hospitals stopped providing basic healthcare services to the economically weaker section of the society that was covered under the PM-JAY scheme.
The women who were expecting a child suffered financial losses because of this. As per the Janani Suraksha Yojana report, they and their families had to make an out-of-pocket expense of about Rs. 5,000. This expense has pulled many families down to poverty and even below it.
Dr. Devika, a General Duty Medical Officer in N.R. Colony Maternity Home, Bengaluru said, “The Ayushman Bharat scheme was held by another doctor before the pandemic, but I have no idea what is happening with it now, as we have not been following it lately.”
The scheme covers three days of pre-hospitalization and 15 days of post-hospitalization expenses, which includes diagnostics, medicines, etc. Despite all these facilities being provided on paper, Zulekha could not get any coverage for just her 30 plus hours of hospitalization. Salma, who is the sister of Zulekha, also delivered a child in January this year. However, she gave birth to her daughter at home, as she did not possess an Ayushman Bharat card and nor did she have enough money to visit a hospital.
The mother of one said that she and her husband tried very hard to get the card made so that they can go through all the medical process that is required, yet they could not find a solution. Every time they tried to contact a concerned authority, they would be sent further to meet another authority. The cycle continued till the family finally decided to give up on their plans to get the card made. They still sometimes seek help from the authorities, but always end up being helpless.
The PM-JAY scheme head of Rajarajeshwari Medical College and Hospital, Bengaluru said that the situation currently is very adverse with the rapidly rising covid cases. “We currently have only one patient in the hospital who is being treated for Chronic Kidney Disease under the Ayushman Bharat Yojana. We are running out of beds and facilities and therefore we are not taking any admissions under the scheme,” he added.
The health insurance schemes in India under the previous governments like Rashtriya Swasthya Bima Yojana (RSBY) have always been structured on an upper ceiling limit ranging from an annual cover of Rs. 30,000 to Rs. 3,00,000 per family across various states. But, PM-JAY promised to provide cashless cover of up to Rs. 5,00,000 to all the eligible families every year for the listed secondary and tertiary treatment.
The scheme promises to include Medical examination, treatment, consultation, pre-hospitalization, medicine, medical consumables, non-intensive and intensive care services, diagnostic and laboratory investigations, medical implantation services, accommodation benefits, food services, complications arising during treatment, and post-hospitalization follow-up care up to 15 days.
Like Zulekha, many others who bore the card were left with thick bills in their hands which they were bound to pay to the hospital by any means.
“According to the SECC database, nearly 12 crore families and 60 crore beneficiaries stand eligible for the Ayushman Bharat registration. Yet, only 14 crore people have been registered so far in our system as beneficiary onboarding remains a major issue. The second problem occurs when the beneficiaries don’t avail of the scheme. Out of the 14 crore beneficiaries, two crores have already been treated under the scheme,” said Abhishek Kumar, Director of National Health Authority, New Delhi.
“In the last 4 to 5 months some major work has been done towards the onboarding of beneficiaries and a special scheme called ‘Ayushman Bharat Apke Dwaar’ was launched to facilitate them. Things are moving in the right direction as of now. After the special scheme around two crore people got registered in a very short period of time,” he added.
In the last year, the healthcare system has faced major challenges, most of them pulling the entire system down. During this period the Ayushman Bharat Scheme also failed to cover the needy. The National Health Authority, which is the apex body responsible for the implementation of the AB PM-JAY scheme released data earlier this year. The data indicated a 51 percent dip in the average weekly claims under the scheme during the lockdown period. Whereas, claims for cancer care and child deliveries fell by 64 percent and 26 percent respectively.
The central government during the migrant workers crisis announced that the AB PM-JAY scheme will be made available to the returnees. But, to date, only 300-odd Covid-19 treatments have fallen under the scheme.
“Ayushman Bharat scheme is not a telecommunication scheme and to avail it people need to go to the hospital. After the pandemic, people are afraid to visit hospitals, hence the dip in claims,” added Abhishek.
A Block Progress Community Manager (BPCM) of a government hospital from Lucknow who manages the scheme on ground levels said that most of the people who face issues in getting the card made are because sometimes either the Aadhar Card number of the beneficiary is absent from the machine records or the name of the beneficiary on the Aadhar Card is spelled wrong.
“The people who are hired to visit the villages and help the beneficiaries with the process, charge Rs. 30 per card, which also becomes a hurdle for the hospitals. Some beneficiaries do not show interest in getting the card made, even if we launch awareness programs and send Accredited Social Health Activists (ASHA) workers to promote the scheme. In some cases, the name of the beneficiary is missing from the registration list that is provided to us by the government. This also stops us from providing help to the said person,” she added.
“The dip in claims comes back to the awareness among people. The scheme was designed for the economically challenged class of the society, hence the beneficiaries most of the time do not know what steps they should take to avail the benefits of the scheme. This unawareness caused the dip in the claims of the scheme,” she said.
A summed-up reality
Dr. Aqsa Haq (name changed), a gynecologist in a government hospital in Lucknow said, “The scheme is majorly held on managerial levels. The involvement of doctors in the scheme is the least. During these times of crisis, all the hospitals have shut down their Out-patient Department (OPD) considering the fatal situation all around. Even the patients only prefer visiting the hospital under dire situations like delivery. Anything else that has the possibility of being delayed is being preferred to be delayed by the patient itself.”
“Government or private doctors barely know about the scheme, as they treat the patient, get their fees or salary from the hospital and leave. All the other work is left for the management staff. The staff after the treatment of the patient looks at the bill and then further adds it on the portal for claims from the government,” she added.
Dr. Anjani Singh Sisodia, who is a homeopathic doctor and a public health expert from Lucknow said, “The monitoring of the scheme is very necessary in such crucial times. Some beneficiaries actually need help but cannot get it, and then other beneficiaries fraud the scheme. In these times when the needy can only turn towards private hospitals, as the government ones have turned into covid centers, many private hospitals make fat bills to extract money from the government.”
“There have been instances when these private hospitals register a disease way bigger than it actually is. They print expensive bills in the name of the treatment of the patients, which is way more than the actual cost of the treatment, and extract money from the government under those bills. These steps need to be monitored closely by the government. Only close monitoring can help the scheme grow and reach every person who needs it,” he added.
Dr. Aadil Ahmad (name changed), who is a private general surgeon and performs surgery in various hospitals around Lucknow said, “The scheme is providing extremely cheap treatment to the beneficiaries. The prices are so low that the private hospitals are very hesitant to admit the patients covered under the scheme.”
“The hospitals are assumed to cover all the extra cost that is spent on the patient apart from the money allocated to the hospital for a certain treatment. During the pandemic era, the hospitals have become even more hesitant in admitting the beneficiaries as the costs will rush up if the patient tests positive for the virus. The already tight private hospitals are avoiding such admissions,” he added.
The ground reality of the scheme is such that both parties eventually suffer. Zulekha, who is still indebted, has no way to escape this reality. On the other hand, the private hospitals suffer losses with the patients who hold the ‘golden card’. Altogether, the scheme seems to be failing in times of crisis, as it leaves both parties helpless.