This article has been written by Adarsh Vasudeva, pursuing the Certificate Course in Advanced Civil Litigation from LawSikho.

Introduction

Ayushman Bharat is a flagship scheme of the Indian government aimed at achieving the vision of Universal Health Coverage (UHC). The aim of this effort is to achieve the Sustainable Development Goals (SDGs) and the underpinning promise to “leave no one behind.” Ayushman Bharat is an effort to transition from a sectoral and segmented approach to a comprehensive, need-based health care system. This program seeks to implement ground-breaking approaches at the primary, secondary, and tertiary levels to approach the healthcare system holistically (including prevention, promotion, and ambulatory care). Ayushman Bharat being the largest health insurance scheme has a vital role to play during Covid-19 and therefore this article analyses the effectiveness of the Ayushman Bharat scheme pre and post Covid-19. This article also covers key features, budget and coverage of the Ayushman Bharat policy.

Policy key features

Ayushman Bharat was initiated with the aim of establishing 1,50,000 “health and wellness centres” in the country and providing health insurance coverage of INR 5 lakh to 10 crore families (50 crore people). This policy has two components:

1. Health and Wellness Centers will offer Comprehensive Primary Health Care (CPHC), which will provide free essential medications and diagnostic facilities for both mothers and children.
2. Pradhan Mantri Jan Arogya Yojana (PMJAY) – To deliver health protection of INR 500,000 per family per year (on a family floater basis) for secondary and tertiary care hospitalization through public and private empanelled hospitals in India, to poor and needy families against financial danger resulting from devastating health episodes.

• The aim for this part is to reach 10.74 crore poor and needy families (roughly 50 crore beneficiaries) who make up the bottom 40% of India’s population. The households included are dependent on the Socio-Economic Caste Census 2011 (SECC 2011) deprivation and occupational standards for rural and urban areas, respectively.
• It includes up to 3 days of pre-hospitalization and 15 days of post-hospitalization costs such as diagnostics and medications for the recipient at the point of operation, which is the hospital. There are no restrictions about the height, age, or gender of the household. The scheme’s benefits are portable around the world, meaning that a beneficiary can seek cashless care at any empanelled public or private hospital in India.  
• Benefits provide about 1,393 treatments to include all prescription expenses, including but not limited to medications, equipment, laboratory facilities, physician’s bills, room charges, surgeon charges, OT and ICU charges, and so on. Public hospitals are reimbursed at the same rate as commercial hospitals for healthcare services.

Roll out/ Implementation

The aim of Ayushman Bharat of covering PAN India is fragmented as the Ayushman Bharat – Pradhan Mantri Jan Arogya Yojana is not being enforced in the National Capital Territory (NCT) of Delhi, Odisha, Telangana, or the West Bengal States as of 10.03.2021. The Government of the National Capital Territory of Delhi declared during the 2020 budget session that AB-PMJAY will be introduced in the State, but no further action has been taken. The AB-PMJAY scheme was introduced in West Bengal from September 23, 2018, to January 10, 2019, with a central share of Rs. 31.28 crore released to cover scheme-related expenses. On the 10th of January 2019, however, the state government agreed to stop implementing the program. In the cases of Odisha and Telangana, ongoing consultations with the respective state governments are underway to persuade them to introduce the AB-PMJAY.  Rest all other states have implemented the aforesaid scheme. Irrespective of the fact that public health is a state responsibility and the State government in charge of implementing AB-PMJAY has the final say, the vision of this scheme is incomplete without implementing it in the national capital itself, including other major states.

Coverage

• As of 25.11.2019, 1,363.14 lakhs beneficiary families are covered under this scheme and 62,49,095 no of hospital admissions have taken place under the benefit of this scheme.
• Some important researchers have pointed out that the programme is off-track for the ones who need it the most. According to a report by the Federation of Indian Chambers of Commerce and Industry and EY, a comparison of the cost of select procedures and the reimbursement tariffs offered under Ayushman Bharat reveals that the tariff just covers 40-80% of the total cost, which is less than the variable cost (which includes cost of materials – drugs, consumables, implants, patient food, linen and clinician payout). 
• According to a study, while an additional 3.5 lakh beds would be needed to fulfil the demands of PM-JAY at a gross capital expenditure of Rs 1 lakh crore, existing hospital operators would not be able to raise bed allocation by more than 25% even after cost optimization.

Role and implementation of Ayushman Bharat amid Covid-19

• At the start of the coronavirus epidemic, the national government included treatment for Covid-19 under the ‘Ayushman Bharat Yojana.’ According to a March 2020 circular, Covid-19 therapy and testing will be provided free of charge in any of the private institutions that have been approved for the initiative.

However, in order to make use of the Ayushman Bharat scheme’s benefits, a person must be hospitalised in a hospital for at least one day. If you test positive for Covid-19, you can only use the programme until you are admitted to a hospital. With the condition of being eligible for Ayushman Bharat Yojana, a person can receive treatment for Covid-19 at private facilities affiliated with the scheme.

• The COVID19 epidemic and accompanying pan-India lockdown, which has been in effect since March 2020, has slowed AB PMJAY’s growth and uptake in several states. Different states, with varying levels of experience and infrastructure for plan implementation, reacted to the pandemic in different ways. Following the implementation of Covid-19, AB PM-JAY aided the healthcare ecosystem by ensuring that the beneficiary registration procedure remained active and that empanelled institutions continued to deliver services to scheme beneficiaries. However, issues such as constraints on movement, limits on elective operations, reluctance from scheme users to attend hospitals owing to fear of infection, and classification of public institutions as special Covid centres had a considerable influence on the plan’s effectiveness.
• Since its establishment, the Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (AB PMJAY) has authorised nearly 1.26 crore hospital admissions as of 21.09.2020. Out of which 5.13 lakh hospital admissions have been dedicated towards testing and treatment of COVID-19. (Ref: Lok Sabha unstarred question no. 2122 answered on 23rd September 2020). Under Ayushman Bharat, packages for ‘Testing for COVID-19’ and ‘Treatment of COVID-19’ have been notified for treatment of Covid patients in private hospitals.

Utilization of Ayushman Bharat scheme for Covid-19

• With a population of over 11 crore people, just 19 individuals in Bihar availed treatment for Covid-19 through the Ayushman Bharat Scheme. According to statistics supplied by the National Health Authority (NHA) of the government of India in response to an RTI request, 875 and 1,419 individuals in Uttar Pradesh and Jharkhand, availed treatment.
• Under the Ayushman Bharat initiative, three states — Andhra Pradesh, Karnataka, and Maharashtra — each treated over 1.5 lakh individuals. However, no patient is said to have taken advantage of the plan in Punjab, Gujarat, or Daman. Furthermore, under the programme, ten states reported zero testings.
• Up to the first week of June 2021, a total of 23.78 lakh (17.73 lakh testing and 6.05 lakh treatments) admissions have been allowed for free testing and treatment under the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PMJAY) which shows that The number of people who have been tested is about three times more than the number of people who have been treated through this system.
• Ahead of the announcement of the first nationwide lockdown on March 23, 2020, ABPMJAY saw a 50% reduction in use. From a daily average of 19,161 hospital admissions before the lockdown, the early lockdown period saw a decline to 7,432 admissions per day.
• Several external causes have led to the sharp decline in usage for the states indicated above. For example, due to increased strain on empanelled hospitals, states like Maharashtra and Karnataka have seen a decrease in case of bookings on the PMJAY IT system.

Hospitals

• Before the lockdown, 51% of the empanelled hospitals were operational. This percentage decreased to 25% during the late lockdown phase. The study reveals a downward trend in the number of active hospitals in both the public and private sectors, with the number of active hospitals falling by over 40% compared to active hospitals before the lockdown. In comparison to before the shutdown, 63 percent of hospitals were open during the late lockdown (59 percent for public and 66 percent for private active hospitals). Small and medium-sized hospitals with less than 100 beds were the most hit, with activity dropping at a faster rate than other empanelled institutions.
• Fear of getting COVID-19 infection among hospital owners and employees, or fear of being stigmatised and losing business if they treat COVID-19 patients, might explain the drop-in hospital activity in private hospitals. At the same time, the decrease at public hospitals might be attributed to a lack of staff and resources due to the fact that they are responsible for the bulk of COVID-19 treatments.

Budget of Ayushman Bharat Amid Covid-19

The Government of India’s health insurance allocations has improved substantially since the start of PMJAY. Allocations in the Revised Estimate (RE) were 2,400 crores when PMJAY was launched in FY 2018-19 and raised to 6,400 crores in FY 20 Budget Estimates (BEs), which were the same as Interim Budget allocations. However, there is no raise in funding for the central government’s flagship programme, Pradhan Mantri Jan Arogya Yojana— Ayushman Bharat (PMJAY-AB) for the fiscal year 2020-21. It was Rs 6,400 crore in 2019-20, and it will be the same in 2020-21. COVID-19 has impacted those who have the least access to health services, so the health scheme, which mostly focuses on underprivileged society, should have received more attention before allocating the budget. The INR 6400 crore budgeted for the scheme is insufficient to cover the target population. Even if the beneficiaries spend only 1% of their INR 5 lakh quota in a year, the annual spending will be about INR 50,000 Cr, which is much more than the government’s current estimate and allotment. 

Shortage of funds amid Covid-19

Funds Data of AB-PMJAY since the inception of the scheme as on 21.09.2020
Year	Budget Amount            (Amount in Crores)	Disbursed Amount          (Amount in Crores)	Percentage
2018-19	2,400	1,849.50	77.06%
2019-20	6,400	2,993	46.76%
2020-21	6,400	631	9.86%
Total	15,200	5,473	36.01%

Ref: Lok Sabha unstarred question no. 2122 answered on 23rd September 2020.

The above table compares the budgeted amount and disbursed amount for Ayushman Bharat -Pradhan Mantri Jan Arogya Yojana (AB PMJAY) and observes the following points:

• Since the inception of the scheme, only 36% of the budgeted amount has been released. 
• In 2019-20, less than 50% of funds were released for the scheme.
• In the year when the COVID-19 disaster struck and when the scheme was required the most, only 10% of the total funds allotted was released.

According to the aforementioned data, Ayushman Bharat, which was designed particularly for the poor, should have got 100% of the budget allotted. Health flagship programmes should be on their toes at a time when COVID is taking away millions of jobs and lives.  But we should also look at the other side of the coin which shows that following the announcement of the first nationwide lockdown on March 23, 2020, ABPMJAY saw a 50% decline in utilisation. 

Major State-wise fund allocation in the time of Covid-19

Major States\ Funds (Crores)	Allocation in 2018-19	Allocation in 2019-20	Allocation in 2020-21	% Change during Covid-19 (2019-2021)
Assam	68.67	97.6	89.69	-8.1
Bihar	88.5	88.78	119.22	34.3
Chhattisgarh	36.42	65.66	28.08	-57.2
Gujarat	44.64	49.98	69.75	39.6
Jharkhand	26.02	75.81	0	-100.0
Madhya Pradesh	87.74	87.82	140.35	59.8
Maharashtra	91.27	97.64	138.6	42.0
Uttar Pradesh	176.1	330.85	279.52	-15.5

The table shows an allocation of Ayushman Bharat funds to major states.

Observations

• Assam (-8.1%), Chhattisgarh (-57.2%) and Uttar Pradesh (-15.5%) have observed a decline in their fund allocation from 2019 to 2021. Whereas, no fund has been allocated to Jharkhand in the year 2020-21. 
• There has been a significant increase in fund allocation to the states of Maharashtra (42%), Madhya Pradesh (59.8%), Bihar (34.3%) and Gujarat (39.6%).
• While Covid-19 is at its peak in India, the allocation of funds has increased in most of the states whereas states like Uttar Pradesh which was severely affected by Covid-19 has witnessed a decrease in their fund allocation.

Conclusion

As every scheme has the scope of improvement, constant development even in this scheme will help it to achieve its objective. The scheme is somehow underfunded and is impossible to function with 100% compliance. A policy brief paper published by the National Health Authority (NHA), the apex body in charge of implementing Ayushman Bharat, exposes flaws in budget use, especially in poor states. To understand the demand and supply-side concerns that must be addressed, it will be necessary to perform deep dives at the state level through conversations and beneficiary and provider surveys. Based on state-specific studies, guidelines, and inputs, many state health authorities are beginning to perform deeper investigations to examine the feasibility and suitability of these changes for the local environment. In order to guarantee that poor and disadvantaged people have access to vital healthcare, it is critical to harness the ever-growing potential of the private healthcare sector, as well as dramatically improve the infrastructure and quality of care offered in public hospitals. Monitoring the quality and appropriateness of care, as well as having a clear set of standards for hospitals to make their employees and beneficiaries aware of the preventative measures and protect their safety during this epidemic, are also crucial.

During COVID19, AB PMJAY plays a key role in delivering healthcare to impoverished and vulnerable people. All efforts must be ramped up to guarantee that all essential and non-essential hospitalisation treatment is supplied through public and private empanelled hospitals under the AB PMJAY programme, in conjunction with primary care supplied through the public health infrastructure.

References

1. https://pmjay.gov.in/sites/default/files/2020-10/Assessing_Impact_of_COVID-19_on_PMJAY.pdf.
2. https://www.thehindu.com/news/national/coronavirus-can-private-hospitals-charge-covid-19-patients-at-ayushman-bharat-rate-asks-supreme-court/article31757698.ece.
3. https://qz.com/india/1865845/ayushman-bharat-has-a-role-to-play-in-indias-covid-19-response/.
4. https://krishijagran.com/news/covid-19-positive-heres-how-ayushman-bharat-yojana-will-help-you-get-free-treatment/.
5. https://www.livemint.com/news/india/covid-19-is-now-covered-under-ayushman-bharat-scheme-death-toll-86-so-far-11586001274077.html.

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