PM-JAY

The Rashtriya Swasthya Bima Yojana (RSBY) was hailed by the World Bank 'as a model of good design and implementation with important lessons for other programmes in India'. The International Labour Organisation (ILO) and the UNDP picked up the scheme for publication amongst the top few social security schemes in the world. The Wall Street Journal quoted one of the beneficiaries describing the scheme as "the best scheme in the country". Yet the scheme was dumped by a Group of Secretaries, none of whom had any clue about the nuances of health insurance. The scheme was starved of funds and languished till it was revived in a different form (as Prime Minister's Jan Arogya Yojana — PM-JAY) after three years of struggle to find a substitute.

Since its launch in 2018, PM-JAY has come a long way. PM-JAY, like its predecessor, is an entitlement based scheme. RSBY was an enrolment based scheme where a smart card was mandatorily issued in advance to each beneficiary family. This was also due to the fact that internet connectivity was not good in 2007 at the time of the launch of RSBY. However, when PM-JAY was designed and launched in 2018, the situation had completely changed and therefore it was not required to have a smart case card-based scheme. Consequently, a decision was taken to make PM-JAY an entitlement based scheme where making the card in advance was not required and any entitled beneficiary could go to an empanelled hospital and get treatment after verification. This also resulted in the saving of time and energy at the beginning of the scheme and the scheme could be scaled up fast.

One of the big learning from RSBY was the lack of a strong national institution to manage the scheme. Learning from this, the National Health Authority (NHA) was established right in the beginning so as to anchor the scheme nationally and guide the states. Headed by a Secretary, Government of India level officer as CEO with a large team, NHA has played an important role in the early success of the scheme.

One of the most crucial tasks in any national scheme is to engage constructively with the states. This becomes even more critical in the context of health as it is a state subject. Therefore, NHA has adopted a partnership approach in dealing with the states. In PM-JAY, state governments have been provided flexibility to use any of the 3 models out of the insurance model, trust model and mixed model to implement the scheme based on the ground realities of the state. States have also been provided flexibility to use their own IT system. In such a case, states provide data to NHA through API mechanisms. Clear co-branding guidelines were prepared which helped the states to converge their existing health insurance schemes with PM-JAY. All these steps resulted in quick adoption of the scheme by as many as 32 states/UTs. Other states are likely to follow soon.

More than 22,000 hospitals, including more than 10,000 in the private sector, have been empanelled under the scheme. These hospitals include large chains, medium-size hospitals and small nursing homes. One of the challenges the scheme is facing is insufficient participation by large multi-speciality hospitals. Efforts are being made to get them on board through intensive engagement.

Drawing lessons from the past, schemes like RSBY, PM-JAY designed more than 1,300 packages and their rates at the time of launch of the scheme. Most of the states adopted these rates. Based on the experience of the past one year, NHA has already launched health benefits package 2.0 wherein packages have been rationalised and also designed in such a manner that it makes much easier for hospitals to use them.

PM-JAY has taken a big step towards improving quality in the hospitals through its purchasing power. A grading system for hospitals has been introduced where hospitals are graded based on quality parameters and hospitals in higher grade get a higher rate for the same treatment. To encourage larger hospitals and hospitals in hard-to-reach areas, incentives to these hospitals are also provided. These incentives and grading systems will go a long way in improving the quality of healthcare services in both public and private hospitals.

One of the main challenges faced by health insurance schemes across the world is tackling fraud and abuse. The NHA has taken various proactive steps to prevent, detect and manage fraudulent activities. In fact, NHA has hired one of the top agencies in this field in the world for this purpose. Automatic triggers are generated and artificial intelligence and machine learning tools are being used to detect fraud and abuse.

NHA has partnered with National Skill Development Corporation (NSDC) for the training of hospital-based 'Arogya Mitras'. This has worked quite well. NHA has also developed a strong online learning management system which will be used now to train all the stakeholders through a mix of offline and online tools. This unique state-of-the-art system will play a pivotal role in building capacities at various levels.

Making people aware of the scheme is one of the main challenges in any entitlement based scheme. In this regard also NHA has hired one of the top firms of India. Field workers, like ASHA workers, have been used extensively in many states to reach out to the beneficiaries. The emphasis has been on using existing systems and mechanisms and building on them rather than creating new and parallel structures.

In around 20 months of the launch of the scheme, more than 1.2 crore persons have already been benefited under the scheme through cashless and free access to hospital care. These cases are worth more than Rs 14,800 crore. Since PM-JAY rates are almost 30-40 per cent lower than the market rate, it can safely be said that this has resulted in the saving of out-of-pocket expenditure worth more than Rs 20,000 crore for these poor and vulnerable families. Poor families now have access to very high-end tertiary care treatment through the scheme. Portability of benefits across the country is another major advantage of the scheme and in almost 150,000 cases, beneficiaries have taken treatment outside the state. This is a boon, especially for migrant workers. Earlier, poor families had to sell their assets or dip into savings or take debt to take care of their medical expenses but PM-JAY has provided them cashless treatment which has prevented lakhs of families from slipping below the poverty line.

A huge beginning has been made. However, there is a long way to go. There are still a few unresolved issues. But the beauty of the scheme is that each state is learning from other states and the scheme is scaling pretty fast. It presents a great example of a public-private partnership. The scheme epitomises the essence of the Nexus of Good.

Views expressed are personalThe Rashtriya Swasthya Bima Yojana (RSBY) was hailed by the World Bank 'as a model of good design and implementation with important lessons for other programmes in India'. The International Labour Organisation (ILO) and the UNDP picked up the scheme for publication amongst the top few social security schemes in the world. The Wall Street Journal quoted one of the beneficiaries describing the scheme as "the best scheme in the country". Yet the scheme was dumped by a Group of Secretaries, none of whom had any clue about the nuances of health insurance. The scheme was starved of funds and languished till it was revived in a different form (as Prime Minister's Jan Arogya Yojana — PM-JAY) after three years of struggle to find a substitute.

Since its launch in 2018, PM-JAY has come a long way. PM-JAY, like its predecessor, is an entitlement based scheme. RSBY was an enrolment based scheme where a smart card was mandatorily issued in advance to each beneficiary family. This was also due to the fact that internet connectivity was not good in 2007 at the time of the launch of RSBY. However, when PM-JAY was designed and launched in 2018, the situation had completely changed and therefore it was not required to have a smart case card-based scheme. Consequently, a decision was taken to make PM-JAY an entitlement based scheme where making the card in advance was not required and any entitled beneficiary could go to an empanelled hospital and get treatment after verification. This also resulted in the saving of time and energy at the beginning of the scheme and the scheme could be scaled up fast.

One of the big learning from RSBY was the lack of a strong national institution to manage the scheme. Learning from this, the National Health Authority (NHA) was established right in the beginning so as to anchor the scheme nationally and guide the states. Headed by a Secretary, Government of India level officer as CEO with a large team, NHA has played an important role in the early success of the scheme.

One of the most crucial tasks in any national scheme is to engage constructively with the states. This becomes even more critical in the context of health as it is a state subject. Therefore, NHA has adopted a partnership approach in dealing with the states. In PM-JAY, state governments have been provided flexibility to use any of the 3 models out of the insurance model, trust model and mixed model to implement the scheme based on the ground realities of the state. States have also been provided flexibility to use their own IT system. In such a case, states provide data to NHA through API mechanisms. Clear co-branding guidelines were prepared which helped the states to converge their existing health insurance schemes with PM-JAY. All these steps resulted in quick adoption of the scheme by as many as 32 states/UTs. Other states are likely to follow soon.

More than 22,000 hospitals, including more than 10,000 in the private sector, have been empanelled under the scheme. These hospitals include large chains, medium-size hospitals and small nursing homes. One of the challenges the scheme is facing is insufficient participation by large multi-speciality hospitals. Efforts are being made to get them on board through intensive engagement.

Drawing lessons from the past, schemes like RSBY, PM-JAY designed more than 1,300 packages and their rates at the time of launch of the scheme. Most of the states adopted these rates. Based on the experience of the past one year, NHA has already launched health benefits package 2.0 wherein packages have been rationalised and also designed in such a manner that it makes much easier for hospitals to use them.

PM-JAY has taken a big step towards improving quality in the hospitals through its purchasing power. A grading system for hospitals has been introduced where hospitals are graded based on quality parameters and hospitals in higher grade get a higher rate for the same treatment. To encourage larger hospitals and hospitals in hard-to-reach areas, incentives to these hospitals are also provided. These incentives and grading systems will go a long way in improving the quality of healthcare services in both public and private hospitals.

One of the main challenges faced by health insurance schemes across the world is tackling fraud and abuse. The NHA has taken various proactive steps to prevent, detect and manage fraudulent activities. In fact, NHA has hired one of the top agencies in this field in the world for this purpose. Automatic triggers are generated and artificial intelligence and machine learning tools are being used to detect fraud and abuse.

NHA has partnered with National Skill Development Corporation (NSDC) for the training of hospital-based 'Arogya Mitras'. This has worked quite well. NHA has also developed a strong online learning management system which will be used now to train all the stakeholders through a mix of offline and online tools. This unique state-of-the-art system will play a pivotal role in building capacities at various levels.

Making people aware of the scheme is one of the main challenges in any entitlement based scheme. In this regard also NHA has hired one of the top firms of India. Field workers, like ASHA workers, have been used extensively in many states to reach out to the beneficiaries. The emphasis has been on using existing systems and mechanisms and building on them rather than creating new and parallel structures.

In around 20 months of the launch of the scheme, more than 1.2 crore persons have already been benefited under the scheme through cashless and free access to hospital care. These cases are worth more than Rs 14,800 crore. Since PM-JAY rates are almost 30-40 per cent lower than the market rate, it can safely be said that this has resulted in the saving of out-of-pocket expenditure worth more than Rs 20,000 crore for these poor and vulnerable families. Poor families now have access to very high-end tertiary care treatment through the scheme. Portability of benefits across the country is another major advantage of the scheme and in almost 150,000 cases, beneficiaries have taken treatment outside the state. This is a boon, especially for migrant workers. Earlier, poor families had to sell their assets or dip into savings or take debt to take care of their medical expenses but PM-JAY has provided them cashless treatment which has prevented lakhs of families from slipping below the poverty line.

A huge beginning has been made. However, there is a long way to go. There are still a few unresolved issues. But the beauty of the scheme is that each state is learning from other states and the scheme is scaling pretty fast. It presents a great example of a public-private partnership. The scheme epitomises the essence of the Nexus of Good.

Views expressed are personal