AYUSHMAN

BHARAT
 Contents
• Introduction & Background
• Objectives
• Salient features
• Implementation Strategy
• Expenditure involved
• Number of beneficiaries
• States /Districts covered
• Major Impact
 Background

Based on Universal
Health Coverage
• Government-sponsored insurance schemes are
critical for UHC

• While multiple government-sponsored insurance

schemes exist in India…. the overall penetration is still
relatively low
 Introduction
Ayushman Bharat Yojana or Ayushman Bharat – Pradhan Mantri
Jan Aarogya Yojana (AB-PMJAY)
• Ayushman Bharat is a fundamental restructuring of the manner in
which beneficiaries access healthcare services at the primary,
secondary and tertiary care levels
• It represents a transition from segmented, sectoral and
fragmented program implementation models towards a
comprehensive, holistic, need-based healthcare system
• It encapsulates a progression towards promotive, preventive,
curative, palliative and rehabilitative aspects through access of
Health and Wellness Centers (HWCs) at the primary level

• It provides provision of financial protection for access of curative

care at the secondary and tertiary levels through engagement with
both public and private sector
 Why there was need for Ayushman Bharat?

• Existing schemes were unable to decrease out of pocket expenditure

• To address the catastrophic health problems
• Insufficient coverage by the previous schemes
• To achieve universal health coverage

This scheme subsumes Rashtriya Swathya Bima Yojana (RSBY) as well

as many other state-government funded health insurance programmes
7
More than two-thirds of healthcare spend
is out-of-pocket expenditure
 Universal health coverage
UHC is defined as “ensuring that all people have access to
needed promotive, preventive, curative and rehabilitative health
services, of sufficient quality to be effective, while also ensuring
that people do not suffer financial hardship when paying for
these services” (WHO, 2012)

•Goal: to ensure that all people obtain the health services they
need without suffering financial hardship when paying for them
 RSBY
Overview of RSBY:
• Launched by Ministry of Labour and Employment,
Government of India on 1st April 2008
Benefit • Rs 30000/- per family per annum
• Secondary and tertiary care
• All pre-existing diseases covered
• Transportation costs (covered upto a maximum of Rs.
1,000/- with Rs. 100/- per visit)

Registration fees Rs 30 per per family at the time of enrollment

Implementation Public or private insurance company finalized by
State government 1
0
• Ayushman Bharat, a flagship scheme of Goverment of
India was launched as recommended by the National
Health Policy 2017, to achieve the vision of Universal
Health Coverage (UHC)
• This initiative has been designed on the lines as to meet
SDG and its underlining commitment, which is "leave
no one behind"
 Rationale
• Healthcare in India is largely underpenetrated with government
expenditure at around 1.25 % of the GDP (Gross Domestic Product)

• Nearly 55-60 million Indians are pushed into poverty every year to
meet medical needs

• The hospitalisation expenses for critical ailments had shot up by

300 percent over a decade

• An estimated 6 million families sink into poverty each year

due to hospitalization
 Aim

• Ayushman Bharat aims to undertake path breaking interventions to

holistically address health (covering prevention, promotion and

ambulatory care), at primary, secondary and tertiary level

 Background
• RSBY was launched in the year 2008 by the Ministry of Labour and
Employment and provides cashless health insurance scheme with benefit
coverage of Rs. 30,000/- per annum on a family floater basis [for 5
members], for Below Poverty Line (BPL) families, and 11 other defined
categories of unorganised workers

• To integrate RSBY into the health system and make it a part of the
comprehensive health care vision of Government of India, RSBY was
transferred to the Ministry of Health and Family Welfare (MoHFW) w.e.f
01.04.2015
• During 2016-2017, 3.63 crore families were covered under RSBY
in 278 districts of the country and they could avail medical
treatment across the network of 8,697 empanelled hospitals

• The NHPS comes in the backdrop of the fact that various Central
Ministries and State/UT Governments have launched health
insurance/ protection schemes for their own defined set of
beneficiaries

• There is a critical need to converge these schemes, so as to

achieve improved efficiency, reach and coverage
 Background
• The Union Minister for Finance and Corporate Affairs, Shri Arun Jaitely
while presenting the General Budget 2018-19 in Parliament on 1st February,
2018 announced Ayushman Bharat Yojana for a new India -2022
• Prime Minister Shri Narendra Modi, in his Independence Day speech of
2018, announced the launch of the Ayushman Bharat-National Health
Protection Scheme (AB-NHPS)
• On September 23, 2018, the Prime Minister Narendra Modi launched
Ayushman Bharat, world's largest government-funded healthcare scheme
in Jharkhand's capital Ranchi
• Became operational from September 25 on the birth anniversary of Pandit
Deendayal Upadhyay
 The Initiatives

• Health and Wellness Centre

• National Health Protection Scheme

 Health and wellness centres
The National Health policy has envisioned Health and Wellness
Centres as the foundation of INDIA’S health system
 1.5 lakh centres to be established
 Providing comprehensive health care, including NCD’S & Maternal
and child services, Chronic communicable diseases, Management of
Mental illness, Dental care & Geriatric care
 Provision of free essential drugs and diagnostic services
 Allotment of Rs. 1200 crore for this flagship programme
 Contribution of private sector in adopting these centres, through
philanthropic institutions
 Health and Wellness Center (HWC) 7

 The sub-centers (SC) are converted as health and wellness center

 1st HWC- Jangla, Bijapur, Chhattisgarh on 14th April 2018
Proposed infrastructure Staff pattern
• Branding/ color coding of all SCs will be • Mid-Level Health Provider
done and Citizen charter will be (MLHP)
displayed at each SC • MPW female- 2
• Space for examination room with • MPW male- 1
adequate privacy • 5 ASHAs as outreach team per
• Diagnostics & medicine dispensing HWCs
room
• Wellness room and waiting area
• Labor room at delivery points
 Continuum of
Care –
Telehealth
Partnership Expanded
for /Referral
Service
Knowledge & Delivery
Implementati
on
Expanding
HR - MLHP &
Robust IT
CPHC Multiskilling
System through
HWC
Medicines &
Expanding
Financing/ Diagnostics -
point of
Provider
care & new
technologies
Paymen
Community
t
Mobilisation
Reforms
Infrastructure and Health
Promotion
 CPHC - Essential package of services
1. Care in Pregnancy and Child-birth
2. Neonatal and Infant Health Care Services
3. Childhood and Adolescent Health Care Services
4. Family Planning, Contraceptive Services and other Reproductive Health
Care Services
5. Management of Communicable Diseases: National Health Programmes
6. General Out-patient Care for Acute Simple Illnesses and Minor Ailments
7. Screening, Prevention, Control and Management of Non-communicable
Diseases
8. Care for Common Ophthalmic and ENT Problems
9. Basic Oral Health Care
10. Elderly and Palliative Health Care Services
11. Emergency Medical Services including Burns and Trauma
12. Screening and Basic Management of Mental Health Ailments
 HWCs in Urban Areas
• One UPHC for every 50,000-60,000
• All existing Urban Primary Health Centers (roughly 4000) to
be strengthened as HWCs by March 2020
• Where dispensaries exist, they could be upgraded to serve as
H&WC, based on the HR available and geographical context
• Frontline workers- 4-5 ASHAs and 1 MPW(F) for 10,000
population - trained to deliver preventive and promotive services
through outreach, including monitoring drug compliance for
chronic diseases.
• MLHP would not be required, as MO MBBS is already approved
for UPHCs
 National Health protection scheme
• The second flagship of programme under Ayushman Bharat is
National Health Protection Scheme, which will cover over 10 crore
poor and vulnerable families (approximately 50 crore beneficiaries)
providing coverage upto 5 lakh rupees per family per year for
secondary and tertiary care hospitalization
• Aim is to create a system of demand-led health care reforms that
meet the immediate hospitalisation needs of the eligible beneficiary
family in a cashless manner thus insulating the family from
catastrophic financial shock
• This will be the world’s largest government funded health care
programme
• Adequate funds will be provided for smooth implementation of this
programme
 Objectives

• To reduce the Out of Pocket (OOP) expenditure

• To focus on wellness of poor families

• To provide the medical benefits to poor families

• To establish Health & wellness centres at the nearer

distance, so that patients will not have travel a long
distance
 Benefits covered under Ayushman

• The government health insurance scheme covers most of the medical

treatment costs, medicines, diagnostics and pre-hospitalization expenses.
Additionally, the scheme offers cashless hospitalization services through
the Ayushman Bharat Yojana/ PMJAY e-card

• With the intention to provide accessible healthcare to the poor and needy,
the Ayushman Bharat Yojana Scheme offers coverage of up to Rs.5 lakh
per family per year for secondary and tertiary hospitalization care
The health insurance under AB-PMJAY includes hospitalization costs of
beneficiaries and includes the below components:
• Medical examination, consultation and treatment
• Pre-hospitalization
• Non-intensive and intensive care services
• Medicine and medical consumables
• Diagnostic and laboratory services
• Accommodation
• Medical implant services, wherever possible
• Food services
• Complication arising during treatment
• Post-hospitalisation expenses for up to 15 days
• COVID-19 (Coronavirus) treatment
 Services not Covered Under
Ayushman Bharat Yojana Scheme

Similar to other types of health insurance policies, the Ayushman Bharat

Yojana Scheme has some exclusions.
Components not covered under the scheme are:
• Out-Patient Department (OPD) expenses
• Drug rehabilitation
• Cosmetic surgeries
• Fertility treatments
• Individual diagnostics
• Organ transplant
 Features of Ayushman Bharat
Yojana Scheme
• It is one of the world’s largest health insurance schemes financed by the GOI
• Coverage of Rs.5 lakh per family per annum for secondary and tertiary care
across public and private hospitals
• Approximately 50 crore beneficiaries (over 10 crore poor and vulnerable entitled
families) are eligible for the scheme
• Cashless hospitalisation
• Covers up to 3 days of pre-hospitalisation expenses such as medicines and
diagnostics
• Covers up to 15 days of post-hospitalisation expenses which include
medicines and diagnostics
• No restriction on the family size, gender or age
• Can avail services across the country at any of the empanelled
public and private hospitals
• All pre-existing conditions covered from day one
• The scheme includes 1,393 medical procedures
• Includes costs for diagnostic services, drugs, room charges,
physician’s fees, surgeon charges, supplies, ICU and OT charges
• Payment for treatment to be done on package rates basis defined
by Govt
• Co operative federalism and flexibility to States
• For fostering coordination between centre and states
• States to have State Health Agency (SHA) for implementation

• In partnership with NITI Aayog, a robust, modular & interoperable

IT platform is made operational that entails a paperless, cashless
transaction
• Comprehensive media and outreach strategy is developed to
ensure that the scheme reaches the intended beneficiaries
List of Critical Diseases or Illnesses Covered Under
Ayushman Bharat Yojana Scheme:
The medical care scheme extended coverage for more than 1300 medical packages
at empanelled public and private hospitals in the country
Some of the critical illnesses covered under the Ayushman Bharat Yojana are:

• Prostate cancer • Skull base surgery

• Anterior spine fixation
• Double valve replacement
• Laryngopharyngectomy with gastric
• Coronary artery bypass graft pull-up
• Tissue expander for disfigurement
• COVID-19
following burns
• Pulmonary valve replacement • Carotid angioplasty with stent
 Beneficiaries

• AB-NHPM will target about 10.74 crore poor, deprived rural families and
identified occupational category of urban workers' families as per the
latest Socio-Economic Caste Census (SECC) data covering both rural
and urban

• The scheme is designed to be dynamic and aspirational and it would take

into account any future changes in the exclusion/ inclusion/ deprivation/
occupational criteria in the SECC data
Ayushman Bharat Yojana Scheme Eligibility
Criteria For Rural & Urban Population
• The scheme has been launched to cover the bottom 40% of poor
and economically weaker sections of the country.
• This was based on the deprivation and occupational criteria of the
Socio- Economic Caste Census 2011 for rural and urban areas
• The Ayushman Bharat Yojana Eligibility is designed with pre-
conditions so that only the underprivileged people of the society
benefit from the initiative
 Rural area categories
• Total deprived Households targeted for PMRSSM who belong to one of the six
deprivation criteria:
D1: Only 1 room with kucha walls and kucha roof
D2: No adult member between age 16 to 59
D3: Female headed households with no adult male member between
age 16 to 59
D4: Disabled member and no able-bodied member
D5: SC/ST Households
D7: Landless households
 Rural area categories

Automatically included :
a) Households without shelter
b) Destitute/ living on alms
c) Manual
  scavenger families
d) Primitive tribal groups
e) Legally released bonded labour
 Urban area categories
• For urban areas, 11 defined occupational categories are entitled
under the scheme
1. Beggars
2. Rag-pickers
3. Domestic workers
4. Street vendors/cobblers/hawkers/other service providers working
on the streets
5. Construction workers/ plumbers/ masons/ labor/ painters/ welders/
security guards/coolies and other head-load workers
6. Sweepers/sanitation workers/malis
 Urban area categories
7. Home-based workers/ artisans/handicrafts workers/ tailors
8. Transport workers/ drivers/ conductors/helpers to drivers and
conductors/cart pullers/ rickshaw pullers
9. Shop workers/ assistants/ peons in small establishments/ helpers/
delivery assistants / attendants/ waiters; electricians/ mechanics/
assemblers/repair workers
10. Washer-men/ chowkidars; Other work/Non-work
11. Non-work (Pension/ Rent/ Interest etc.) 

In addition, Rashtriya Swasthya Bima Yojna (RSBY)

beneficiaries in states where it is active are also included
AYUSHMAN BHARAT PM-JAY SCHEME - HOW DOES IT WORK

Confirm person is an eligible

Hospital selects Discharge summary and post
beneficiary under PM-JAY
package, check treatment evidence
using software
balance submitted
Confirm identity through Submits supporting
individual and family ID evidence required for Electronic payments
proof treatment
Beneficiary feedback
 How will the
beneficiary
be identified at
the hospital?

Ayushman Mitra (AM) is

a certified frontline health
service professional who
shall be present at each of
the Empanelled Health
Care Provider (EHCP) and
shall serve as a first
contact point for
beneficiaries
Process Flow at Empanelled Hospital
 Implementation strategy

• At national level Ayushman Bharat National Health Protection

Mission Agency (AB-NHPMA) would be put in place
• States / UTs advised to implement the scheme by a dedicated
entity called State Health Agency
• States /UTs to implement the scheme through an insurance
company or directly through the trust /society or use an integrated
model
 Expenditure involved

• The expenditure will be shared between central and state

governments in specified ratio (60:40) as per ministry of finance
guidelines
• The total expenditure to depend on actual market determined
premium paid in States/Union territories where AB-NHPM will be
implemented through insurance companies
 States / Districts covered

AB-NHPM will be rolled out across all states / union

territories in all districts with an objective to cover all the

targeted beneficiaries
 States/ Districts covered

• Simultaneously launched in 445 districts

• 30 States and Union Territories have signed Memorandum of

Understanding with Centre

• No- Launch States:

Telangana, Odisha, Delhi, Kerala, Punjab
 States that have opted out of PM-JAY
States Existing scheme
West Bengal Swasthyasathi
Telangana Aarogyasri scheme
Kerala Comprehensive Health Insurance Agency of
Kerala (CHIAK)
Odisha Biju Swasthya Kalyan Yojna
Delhi Delhi model healthcare
 Major impact
AB- NHPM will have a major impact on OOP expenditure on ground of:-
• Increased benefit cover to nearly 40% of the population
(poorest & vulnerable)
• Covering almost all secondary and many tertiary hospitalisations
• Coverage of 5 lakh for each family
• This will lead to timely treatments, improvements in health outcomes,
patient satisfaction hence efficient access to health care and
medication
• This will lead to increased access to quality health and medication
• In addition, the unmet needs of the population which remained
hidden due to lack of financial resources will be catered
 Benefits of PMJAY
Health System –

• Help India progressively achieve Universal Health Coverage (UHC) and

Sustainable Development Goals (SDG)

• Ensure improved access and affordability, of quality secondary and tertiary

care services through a combination of public hospitals and well measured
strategic purchasing of services in health care deficit areas, from private
care providers, especially the not-for profit providers

• Significantly reduce out of pocket expenditure for hospitalization.

• Mitigate financial risk arising out of catastrophic health episodes and

consequent impoverishment for poor and vulnerable families
• Acting as a steward, align the growth of private sector with public health goals
• Enhanced use of evidence-based health care and cost control for improved
health outcomes
• Strengthen public health care systems through infusion of insurance revenues
• Enable creation of new health infrastructure in rural, remote and under-served
areas
• Increase health expenditure by Government as a percentage of GDP
• Enhanced patient satisfaction
• Improved health outcomes
• Improvement in population-level productivity and efficiency
• Improved quality of life for the population
A team of three dedicated PM-JAY app
professionals travelled over 45 Created by the National Health
days to various villages across Authority
India to collect these stories of (NHA), the app was launched on
hope, joy and triumph. Tuesday, February 6
SWOT Analysis
of
Ayushman
Bharat
 Strength
• Shift from ‘disease specific’ and ‘Reproductive and child health’ focus of
government initiatives to comprehensive Primary healthcare
• Expanded approach to include vulnerable and deprived population
along with poor. Exclusion criteria clearly mentioned
• High level of political commitment. Increase in budget for this scheme
in 2019 budget
• Covering almost all secondary and many tertiary hospitalization
(Empanelment)
• Coverage of 5 lakh for each family (no restriction of family size)
• Generating employment
 Weakness

• HWCs are only a part of primary healthcare system, requires

broader strengthening of entire health system

• Out-patient department visits, which constitute a large part of

out of pocket expenditure, not part of PM-JAY
 Opportunities

• Global and national level focus on universal health coverage

• Potential to develop innovative models and strategies for
strengthening entire healthcare system in India
 Threat
• Change in the scheme and its implementation if the government
changes
• All states not accepting the scheme. Difference in opinion of
Central and State government for implementation and funding of
the scheme
• Monitoring of the programme after implementation as the scheme
is applicable on vast mass of people
• Compliance on the part of empaneled hospitals. Many hospitals not
willing to get empaneled
 Assignment

1. Short note on Ayushman Bharat (5 marks)

2. Write in brief about Merits and Demerits of Ayushman
Bharat (5 points each)
3. Write 5 differences between RSBY and Ayushman
Bharat
THANKS