Most vulnerable availed fewer benefits of PMJAY | India News


A detailed analysis of the Pradhan Mantri Jan Arogya Yojana (PMJAY), the government’s flagship health insurance scheme, has shown that those most vulnerable — whether in terms of states, communities or gender — have not been able to use it as well as the relatively better off.
For instance, though Scheduled Castes (SCs) and Schedules Tribes (STs) constitute about 28% of the population, their share in private hospital admissions at the national level since the scheme’s inception was found to be just 5% and 2%, respectively. States with low poverty and disease burden, such as Kerala and Himachal Pradesh, were found to be using services under the scheme much more than poorer states with high needs, such as Bihar, Madhya Pradesh, Assam and Uttar Pradesh.
In terms of gender, though enrolment under the scheme is almost equal for men and women, the total number and value of claims were higher for males. And though private hospitals constituted 56% of empanelled hospitals, they accounted for 75% of the money spent on reimbursing claims under PMJAY.
The analysis was published in The Lancet Regional Health — Southeast Asia and done by researchers from Association for Socially Applicable Research (ASAR), Pune and Duke University School of Medicine in the US. The study looked at the 2018-2022 period.
Vulnerable population groups like SCs, Other Backward Classes, Muslims, and families with children and elderly have higher cases of catastrophic health expenditure (CHE) — a situation where health spending exceeds 10% of a household’s consumption expenditure — the paper noted. Also, impoverishment due to health expenditure is higher in rural areas and poorer states. PMJAY, launched in September 2018, was meant to protect the most vulnerable, about 50 crore belonging to the bottom 40% of the population, from financial hardships.
The study cited a 2021 national household survey that showed that awareness and enrolment levels were the lowest among households in the poorest 40% of the population. “Thus, overall, the scheme is failing to target the most vulnerable population,” it stated.
According to the authors, the discrepancy in utilisation between states was due to poor supply-side factors, including a low number of empanelled hospitals, an inefficient beneficiary identification system, and weak health governance in states with greater poverty and disease burdens.
“A similar pattern is seen at the district level, where socio-economically backward districts (also known as aspirational districts) have lower beneficiary identification rates, total number of claims and total claim amounts than non-aspirational districts. The majority of aspirational districts are located in Jharkhand, Orissa and Chhattisgarh,” noted the paper.
The analysis showed that more vulnerable groups accessed care through public hospitals. For instance, while more male claims were seen at private hospitals and for tertiary conditions, more female claims were seen at public hospitals and for secondary conditions. SC and ST populations also were more likely to use public hospitals.
On the portability of services under PMJAY, the study found that just 1.4% of beneficiaries had used portability, but the portability for very high-value claims was 5.4% and for high-value claims 2.4%. Beneficiaries in poorer districts used portability benefits less than those in better-off districts. Portability was being used mostly for tertiary health services, including cardiology, cardiovascular surgery and orthopaedics.


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