Ayushman Bharat and Health Sector Reforms for UPSC

Ayushman Bharat: PM-JAY, Health and Wellness Centres, and the Digital Stack

Ayushman Bharat combines financial protection for hospital care (PM-JAY), strengthened primary care (Health and Wellness Centres), and a digital health backbone (ABDM). The goal is a continuum of care: prevention and early detection close to home, seamless referrals for hospital care, and interoperable health records that reduce out-of- pocket expenditure (OOPE) and improve quality.

PM-JAY: Hospitalisation Cover

• Coverage: Cashless cover up to ₹5 lakh per family per year for secondary/tertiary care; ~12 crore vulnerable families (SECC deprivation criteria plus state lists); portability across India.
• Network: Public and empanelled private hospitals; packages across specialties with pre-authorisation norms. Over 26,000 hospitals are empanelled nationwide.
• Utilisation and impact: Crores of authorised admissions to date; early evaluations show reduced OOPE for beneficiaries compared to non-beneficiaries.
• Challenges: Variable state uptake, claim delays in some regions, low package rates in select specialties, uneven private participation, and fraud risks (upcoding, phantom billing).
• Safeguards: IT-based claim audits, anti-fraud units, de-empanelment provisions, grievance redress, periodic package revision, and quality-linked incentives.

Health and Wellness Centres (HWCs)

• Scope: Upgrade sub-centres/PHCs to provide comprehensive primary care—NCD screening, maternal/child health, family planning, basic diagnostics, essential drugs, palliative/mental health services, and referrals.
• Progress: Large numbers of HWCs are operational toward the 1.5 lakh target, with teleconsultations via eSanjeevani expanding reach; community health officers anchor services.
• Importance: Strong primary care prevents catastrophic spending, detects NCDs early, and decongests hospitals; essential to complement insurance which focuses on hospitalisation.

Ayushman Bharat Digital Mission (ABDM)

• Core components: ABHA (unique health ID), health professional and facility registries, consent manager, and health information exchange APIs.
• Adoption: Hundreds of millions of ABHAs generated; growing number of facilities/providers onboarding; pilots integrating HMIS/LIS with ABDM for seamless record sharing.
• Privacy and consent: User-controlled sharing, tokenised IDs, encryption, and audit trails are critical; alignment with DPDP Act and sectoral rules is necessary to avoid data misuse or exclusion.

Financing and Financial Protection

• OOPE context: Out-of-pocket spending still accounts for a large share of health expenditure in India;\n PM-JAY aims to cut catastrophic hospital costs while HWCs and essential drugs reduce outpatient burdens.
• State convergence: Many states top up PM-JAY or run parallel schemes; aligning benefit packages and IT\n systems reduces duplication and confusion for beneficiaries.
• Monitoring: Regular audits of claims patterns, package pricing, and quality can keep costs predictable\n for governments while protecting patients.

Complementary Initiatives

• PM-ABHIM: Health infrastructure mission for public health labs, critical care blocks, and disease surveillance systems to strengthen preparedness.
• Human resources: Expanding medical/nursing seats, deploying mid-level health providers at HWCs, and upskilling paramedics for emergency and critical care.
• Quality: Linking PM-JAY empanelment with NQAS/NABH standards; nudging infection control and patient safety practices.

Outstanding Issues and Way Forward

• Package adequacy and provider mix: Periodic price revision and higher incentives in underserved areas to attract quality private providers while investing in public hospitals.
• OPD and diagnostics: PM-JAY covers hospitalisation; outpatient care and diagnostics must be anchored in HWCs/state schemes to prevent cost-shifting to patients.
• Awareness and inclusion: Enrolment drives, helplines, and hospital kiosks to help eligible families use entitlements; focus on migrants and remote areas.
• Fraud control: Use analytics, field audits, and pre-auth checks; strong penalties for phantom billing/ unnecessary procedures.
• Digital adoption with safeguards: Ensure ABHA is voluntary and consent-based; build capacity in smaller facilities to use ABDM tools without excluding low-digital-literacy patients.
• Data for governance: Use claims and HWC data to identify disease burden, tweak packages, and target health promotion efforts.

UPSC Pointers

• Three pillars: PM-JAY (₹5 lakh cover, portability), HWCs for primary care, ABDM for digital interoperability.
• Recall supportive missions: PM-ABHIM (infrastructure), eSanjeevani (teleconsultation).
• Challenges: package rates, private participation, fraud control, OPD gap, awareness, data privacy/consent.
• Way forward: strengthen primary care/diagnostics, fair pricing, robust audits, privacy-by-design in ABDM, and public investment in HR and infrastructure.

Bottom line: Ayushman Bharat is shifting India toward a continuum of care—from prevention at HWCs to cashless hospitalisation and interoperable records. Its success depends on strong primary systems, adequate provider networks, vigilant fraud control, and privacy-conscious digital rollout.