By Dr. Gyan Pathak
Prime Minister Narendra Modi slammed Delhi and West Bengal on October 29 for not joining Ayushman Bharat scheme, and expressed his concern that senior citizens in these two states would not be able to avail themselves of free treatment under the expanded scheme which he was launching. Only a day after AAP supremo Arvind Kejriwal hit back claiming that the programme was “a major scam” citing CAG’s 2023 report.
Politically speaking, Delhi is AAP’s fort and West Bengal is TMC’s, where PM Narendra Modi’s BJP’s has been unsuccessfully trying to make inroads for a decade. Healthcare has been a political issue in both the states, Arvind Kejriwal in Delhi, and Mamata Banerjee in West Bengal has been refusing to implement PM Narendra Modi’s Ayushman Bharat Scheme under Pradhan Mantri – Jan Arogya Yojana (PM-JAY) claiming that they have better healthcare schemes.
Since Delhi is going to have Vidhan Sabha election early next year, AAP Supremo Arvind Kejriwal had to hit back on PM Modi’s slamming on Delhi government for not implementing the Ayushman Bharat Scheme. He said on October 30 that there is no need to implement the Ayushman Bharat Scheme since AAP government provides free treatment of up to Rs 1 crore to all city residents. Additionally, Union government’s flagship health insurance is worth only Rs5 lakh, he said. “Every resident of Delhi, whether they have a simple cold or need hospitalisation, receives treatment, medication, and tests free of charge — no limits, no caps. In Delhi, whether it’s a five-rupee tablet or a treatment costing ₹1 crore, everything is provided free of charge.”
Kejriwal further said, “If medicines, tests, and treatment are all free in Delhi, then there is no need for the Ayushman Bharat scheme here. Modiji should study the Delhi healthcare scheme and implement it across the country.” However, more serious was his claim that Ayushman Bharat Scheme is riddled with scam referring to CAG’s 2023 report.
What exactly the CAG’s report has found? One must revisit the report on Ayushman Bharat – Pradhan Mantri Jan Arogya Yojna (AB-PMJAY), the central scheme . The Scheme aims to provide health cover of Rs5 lakh per family per year for secondary and tertiary care hospitalization to over 10.74 crore families from the poor and vulnerable section of the population, based on the deprivation and occupational criteria of the Socio-Economic Caste Census (SECC), 2011. The aim is to improve affordability, accessibility, and quality of care for the poor and vulnerable section of the population.
However, the audit noted numerous faults in its implementation. As per the National Health Authority (NHA) records only 7.87 crore beneficiary households were registered, constituting73 per cent of the targeted households of 10.74 crore (November 2022).Out of this, 2.08crore households had been identified from SECC-2011 database, as envisaged in the Scheme guidelines.
When pointed out this dismal record, the NHA had replied that Government of India has approved (January 2022) the expansion of the beneficiary base to cover 12 crore families based on National Food Security Act (NFSA) data.
CAG said in its report that the match confidence score, which the online system of beneficiary registration, generates based on matching the documents of a beneficiary with the SECC list of eligible beneficiaries, has been rendered ineffective as applications for registration were approved or rejected irrespective of the match confidence score. Data analysis revealed that match confidence score was not applied during the approval/rejection process of registration of a person.
In the absence of adequate validation controls, errors were noticed in beneficiary database i.e. invalid names, unrealistic date of birth, duplicate PMJAY IDs, unrealistic size of family members in a household etc. In 36 cases, two registrations were made against 18 Aadhaar numbers and in Tamil Nadu, 4761 registrations were made against seven Aadhaar numbers. Registration of multiple beneficiaries against same or invalid mobile number ranging from 11to 7,49,820 beneficiaries were noted in the Beneficiary Identification System (BIS). In Jammu& Kashmir and Ladakh, during the period 2018 to 2021, 16865 and 335 ineligible beneficiaries respectively were identified by the SHA after cleaning the SECC data.
In six States/UTs, ineligible households were found registered as PMJAY beneficiaries and had availed the benefits of the Scheme. The expenditure on these ineligible beneficiaries ranged from ₹0.12 lakh in Chandigarh, to ₹22.44 crore in Tamil Nadu. In nine States/UTs, there were delays in processing of rejection cases. The delay ranged from one to 404 days.
In seven States/UTs, Information, Education and Communication (IEC) cell was formed. In12 States/UTs, IEC Cell was not formed whereas no information was available in the remaining States. IEC plan was prepared only in four States, Chhattisgarh, Madhya Pradesh, Manipur and Rajasthan. In Maharashtra, although plan was prepared in2020-21, it was not implemented.
In 14 States/UTs, expenditure on IEC activities ranged from 0 to 20.24 per cent of the allotted budget against the prescribed benchmark of 25 per cent.
In several States/UTs, there was shortage of infrastructure, equipment, doctors, etc. The available equipment were found non-functional. Some of the Empanelled Health Care Providers (EHCPs) neither fulfilled minimum criteria of support system and infrastructure nor conformed to the quality standards and criteria prescribed under the Guidelines.
In several States/UTs, mandatory compliances criteria for empanelment of hospitals relating to infrastructure, fire safety measures, Bio-medical waste management, Pollution Control and Hospital registration certificate were not fully followed. In some EHCPs, fire safety certificates had expired before empanelment under PMJAY.
Some of the EHCPs did not conform to the prescribed quality standards and criteria, which were crucial to the safety and wellbeing of the beneficiaries in care and were mandatory minimum conditions for empanelment.
The availability of Empanelled Health Care Providers (EHCPs) per lakh beneficiaries is very low in the States/UTs, Assam (3.4), Dadra Nagar Haveli-Daman Diu (3.6), Maharashtra(3), Rajasthan (3.8) and Uttar Pradesh (5), etc. Further, availability of EHCPs per one lakh beneficiaries ranged from 1.8 EHCPs in Bihar to 26.6 EHCPs in Goa.
Physical verification was not conducted by District Empanelment Committee (DEC) before empanelment in 163 EHCPs in Manipur (17), Tripura (103) and Uttarakhand (43).
In Jharkhand, two private EHCPs were not providing three specialities under the PMJAY, which were otherwise available for the general public. In Assam, 13 EHCPs were providing4 to 80 per cent of available facilities to PMJAY beneficiaries. In four States/UTs, lack of Specialties were noted in EHCPs.
In five States, Assam (18), Chhattisgarh (65), Gujarat (20), Jharkhand (08) and Manipur(15), EHCPs treated beneficiaries for non-empanelled specialities.
In Andhra Pradesh (524 EHCPs), Jharkhand (59 EHCPs), Punjab (5 EHCPs), Tamil Nadu (19 EHCPs) and Uttar Pradesh (40 EHCPs), no treatment was provided by the EHCPs.
In 14 States/UTs, 2,733 hospitals were empanelled with delay ranging for period of more than one day to 44 months. Further, in six States, empanelment of 418 Hospitals was under process with delay ranging from two days to 29 months.
In Himachal Pradesh (50) Jammu and Kashmir, (459), Jharkhand (36) and Meghalaya(13,418) beneficiaries were charged for their treatment in empanelled EHCPs resulting in increase in out-of-pocket expenditure of beneficiaries.
In Bihar, empanelment of Ananya Memorial Hospital was suspended on 30 August 2019, but payment of 12 claims amounting to ₹67,900 was settled during 2018-20. SHA did not conduct necessary investigation of the claims paid to the hospital. In Jharkhand, five de-empanelled EHCPs treated 1,777 patients and got claim amount of ₹1.37 crore. In11 States, 241 hospitals were de-empanelled either voluntarily or due to low-performance and mal-practices noted in EHCPs.
In Jharkhand, eight EHCPs were empanelled twice by SHA with different identification, though locations of the EHCPs were the same. In Tamil Nadu, 57 empanelled Government/private EHCPs were allotted two or more unique ID.
These are only examples. CAG’s 2023 report has found many irregularities in claims management, financial management, and monitoring and grievance redressal. PM Modi on the other hand, has twitted, “Augmenting the healthcare infrastructure is our priority. Initiatives relating to the sector launched today will make top-quality and affordable facilities available to the citizens.” (IPA
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