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Healthcare in India is largely underpenetrated, with government expenditure at around 25% of the GDP and an underperforming public healthcare ecosystem.
Introduction
Out of pocket expenditure pushing people into poverty– It is extremely worrying that nearly 55–60 million Indians are pushed into poverty every year because they are unfortunately compelled to shell out half of their annual household expenditure to meet medical needs, specially for hospitalisation.
Shortages in government run insurance schemes- A majority of insured population is covered under Employees’ State Insurance Scheme or government sponsored schemes but these schemes have significant coverage limitations.
In order to address the shortages in healthcare system in India, one of the major policy initiatives of the government has been the announcement of the Ayushman Bharat – National Health Protection Mission (AB-NHPM) for the vulnerable section of the Indian population which, if implemented effectively, will help the nation move closer to the Sustainable Development Goal of ‘Universal Health Coverage’. It is expected that the scheme will have a far-reaching impact on the entire Indian healthcare and insurance landscape.
Features of Ayushman Bharat:
1. AB-NHPM will have a defined benefit cover of Rs. 5 lakh per family per year.
This cover will take care of almost all secondary care and most of tertiary care procedures. To ensure that nobody is left out (especially women, children and elderly) there will be no cap on family size and age in the scheme. The benefit cover will also include pre and post-hospitalisation expenses. All pre-existing conditions will be covered from day one of the policy. A defined transport allowance per hospitalization will also be paid to the beneficiary.
2. Benefits of the scheme are portable across the country and a beneficiary covered under the scheme will be allowed to take cashless benefits from any public/private empanelled hospitals across the country.
3. AB-NHPM will be an entitlement based scheme with entitlement decided on the basis of deprivation criteria in the SECC database, The different categories in rural area include families having only one room with kucha walls and kucharoof; families having no adult member between age 16 to 59; female headed households with no adult male member between age 16 to 59; disabled member and no able bodied adult member in the family; SC/ST households; and landless households deriving major part of their income from manual casual labour, Also, automatically included families in rural areas having any one of the following: households without shelter, destitute, living on alms, manual scavenger families, primitive tribal groups, legally released bonded labour. For urban areas, 11 defined occupational categories are entitled under the scheme. The beneficiaries can avail benefits in both public and empanelled private facilities. All public hospitals in the States implementing AB-NHPM, will be deemed empanelled for the Scheme. Hospitals belonging to Employee State Insurance Corporation (ESIC) may also be empanelled based on the bed occupancy ratio parameter. As for private hospitals, they will be empanelled online based on defined criteria.
4. To control costs, the payments for treatment will be done on package rate (to be defined by the Government in advance) basis. The package rates will include all the costs associated with treatment. For beneficiaries, it will be a cashless, paper less transaction. Keeping in view the State specific requirements, States/ UTs will have the flexibility to modify these rates within a limited bandwidth.
5. One of the core principles of AB-NHPM is to co-operative federalism and flexibility to states. There is provision to partner the States through co-alliance. This will ensure appropriate integration with the existing health insurance/ protection schemes of various Central Ministries/Departments and State Governments (at their own cost), State Governments will be allowed to expand AB-NHPM both horizontally and vertically. States will be free to choose the modalities for implementation. They can implement through insurance company or directly through Trust/ Society or a mixed model.
6. For giving policy directions and fostering coordination between Centre and States, it is proposed to set up Ayushman Bharat National Health Protection Mission Council (AB-NHPMC) at apex level Chaired by Union Health and Family Welfare Minister.
7. States would need to have State Health Agency (SHA) to implement the scheme States will have the option to use an existing Trust / Society / Not for Profit Company/ State Nodal Agency or set up a new Trust / Society / Not for Profit Company/ State Health Agency to implement the scheme and act as SHA. At the district level also, a structure for implementation of the scheme will need to be set up. 8. To ensure that the funds reach SHA on time, the transfer of funds from Central Government through AB-NHPMA to State Health Agencies may be done through an escrow account directly. The State has to contribute its matching share of grants within defined time frame.
9. In partnership with NITI Aayog, a robust, modular, scalable and interoperable IT platform will be made operational which will entail a paperless, cashless transaction. This will also help in prevention / detection of any potential misuse / fraud / abuse cases. This will be backed by a well-defined Grievance Redressal Mechanism. In addition, pre-Authorisation of treatments with moral hazards (Potential of misuse) will be made mandatory.
Policy shortcomings:-
Systemic challenges that needs to be addressed:-
Foreseeable fraud challenges in NHPS like
Way forward
By: Priyank Kishore ProfileResourcesReport error
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