There is no doubt that the Prime Minister Jan Arogya Yojana (PMJAY) is the biggest effort ever by any government anywhere in the world to provide health cover. To begin with, the scheme provides assurance up to Rs 500,000 to more than 500 million beneficiaries in the country. There is no limitation of family size. This goes well beyond the cover of Rs 30,000 and family size limited to five under the Rashtriya Swasthya Bima Yojana (RSBY) launched in 2007.
The government has also put in place an extremely competent team to implement the scheme that has the potential of transforming health care in the country. The traditionalists who have lived with and promoted unadulterated supply-side management of health care would question this approach, but we know what this obsession with supply-side management has done to health care in India. Hence, there is a need to put the money (read entitlement) in the hands of the consumer and allow him to choose between public and private players providing health care. The benefits are portable and the beneficiary can avail of them from any empanelled hospital anywhere in the country. The scheme has started with a bang, with beneficiary numbers rising to 7,000 in a day — quite remarkable indeed!
The scheme will, however, face the real test now as the demands on the health infrastructure as well as the software backbone (borrowed from Andhra’s Arogyashree) will increase. True success will be determined by the ability of the scheme to bring down out-of-pocket expenditure. Let us look at some of the challenges that the scheme is likely to face.
The first and the foremost challenge would be in the form of communicating the benefits of the scheme to the beneficiaries. How do you even “inform” the beneficiary that he is covered? An insurance scheme launched in a state during the early years of this millennium ended up benefitting only the insurance company. The scheme was announced with a lot of fanfare at the state capital but the beneficiaries, most of whom were in far-flung areas and illiterate, never got to know about the scheme, which was abandoned after a year. Effective communication strategy would be critical for the scheme. This strategy will have to go beyond pure “publicity” to keep select audience happy.
Latest Socio Economic Caste Census (SECC) data are being used to determine the list of beneficiaries. We are all aware that there are huge infirmities in these data. These infirmities will creep into the scheme as well. Thus, some “real” beneficiaries could be deprived of the benefits and the “ineligible” ones that have somehow smuggled into the list will get the benefit.
Identification of beneficiaries will be a huge challenge. The hospital will have to access two data sets, one related to Aadhaar and the other related to eligibility. These data sets sit elsewhere. Hence, access and connectivity will pose a challenge for hospitals in remote area. A few cases of delays and mishaps as a consequence of these could bring a bad name to the scheme. There could have easily been an off-line management, but the structuring of the scheme is such that the data sets will have to be accessed even from remote locations.
Remote areas do not have private hospitals. Even the public health infrastructure is not up to the mark. The success of the scheme will be determined by the additional value that the scheme brings to the beneficiary. The beneficiary already has free access to public healthcare, irrespective of PMJAY. The value to him will come either by improved facilities in government hospitals or through an additional option of healthcare that he can avail of in private hospitals. In a number of districts in the country there aren’t very many hospitals that qualify to be empanelled. Thus, the beneficiary will have to seek services only from government hospitals. It is, however, expected that private healthcare facilities will come up as a consequence of the “demand” created under PMJAY. This will have to be pro-actively facilitated and incentivised. If this doesn’t happen the true benefits of the scheme will not accrue to the target group.
Prompt settlement of claims raised by hospitals is critical to the success of the scheme. It is essential to keep hospitals interested. Only time will tell how this would be done. There is a mechanism prescribed in the guidelines for settlement of claims, but to make them effectively operational will require enormous amount of effort and capacity building.
Most of the states have opted for “Trust” model and not the “insurance” model. Barring a few, other states are setting up government-run institutions to settle the claims of the hospitals. This is extremely tricky and the states do not have the capacity to handle this complex operation. In Andhra Pradesh, from where this model has been picked up, it evolved over a period of time. Insurance model enables a “business” check on the hospitals as the liability of the government is limited to the premium paid and it is in the business interest of the insurance company to keep a check on the hospitals. The government-run “trust” will neither have the capacity nor a business interest to curb these. It would be difficult for these trusts to check frauds. This could emerge as one of the biggest threats to the scheme.
The scheme holds a lot of promise and has begun well. It has a committed and competent set of officers to run it. However, this team will have to take into account the challenges mentioned above to make the scheme a success.
The author retired as secretary in the Union Ministry of Human Resource Development on June 30, 2018 .
Disclaimer: Views expressed are personal. They do not reflect the view/s of Business Standard.