ABSTRACT
The chapter analyses the performance of the Pradhan Mantri Jan Arogya Yojana (PMJAY), along with state government-funded health insurance schemes (GFHISs) under implementation, and suggests policy changes in their operations to meet the goal of universal health coverage (UHC). PMJAY has emerged as a major health sector programme that aims to provide cashless access to healthcare services to 120 million poor and vulnerable families in both private and public health facilities. To assess the performance of GFHISs (including PMJAY) and identify key gaps, the chapter reviews secondary literature and data from various government sources, including the data available from the PMJAY dashboard and the recently published Comptroller and Auditor General of India (CAG) report. It builds on this literature and data, with findings from Karnataka and Maharashtra through field visits as key informant discussions/interviews with the stakeholders and participant observations.
The review throws up several systemic weaknesses and policy issues in GFHIS implementation. Firstly, beneficiaries’ access, coverage, and active participation have remained limited. Secondly, the empanelment of private hospitals has provided limited help in covering poorly served areas and states. Thirdly, good-quality private hospitals appear disinterested in empanelment and participating in the programme, and there is little oversight in the functioning of the participating hospitals. Fourthly, PMJAY and the state GFHISs may have had minimal impact on reducing out-of-pocket health expenditures of low-income households. Fifthly, there is a lack of focus on the participation of public hospitals and their access to PMJAY funds to strengthen public hospital infrastructure. Sixthly, in its current form, PMJAY and the GFHISs may distort health priorities and divert resources away from the public healthcare system. Finally, neither the trust nor the insurance models are efficacious, and the health insurance market needs to become competitive and efficient to enable the government to transfer risk to health insurance providers at optimum cost. The chapter concludes by stating that while GFHISs hold promise in the journey towards UHC, key policy changes and reforms are required. This would require changes in the operational structure of PMJAY and in the erstwhile state insurance schemes that it has subsumed, to provide primacy to public hospitals to make the scheme effective and fiscally sustainable. The chapter recommends enhancement in health budgets, priority to public hospitals, priority to vulnerable groups, focus on backward regions and on reduction in out-of-pocket expenditure on health, promotion of a competitive health insurance market, and measures such as reservation of treatments and ‘ringfencing’ to truly reflect the correct understanding of ‘strategic purchasing’ in health policy.
