CURRENT SCENARIO OF IMPLEMENTATION OF AYUSHMAN BHARAT

Out of 28 states and 8 Union territories in India, Delhi, Odisha, and West Bengal have not implemented the AB-PMJAY scheme, and Telangana joined the scheme in May 2021. As depicted in Table 1, Out of the 33 states and UTs, 23 have adopted the Trust model, 7 have adopted the Insurance model, and 3 have chosen the Hybrid model. As of May 2023, 15 states/UTs have covered more than 50% of eligible families under the AB-PMJAY scheme. Moreover, Arunachal Pradesh, Jharkhand, and Meghalaya have covered 100% of the eligible families under the scheme [5].

As of June 26, 2023, around 23 crore Ayushman cards have been created, and 5 crore hospital admissions have been made. Madhya Pradesh (359.35 lakhs), Uttar Pradesh (294.08 lakhs) and Chandigarh (193.44 lakhs) have issued the highest number of Ayushman cards, and Tamil Nadu (90.49 lakhs), Rajasthan (57.41 lakhs) and Karnataka (52.67 lakhs) have done maximum authorised hospital admissions. Overall, 28,877 hospitals empanelment’s have been done with 15,950 public and 12,927 private hospitals. Karnataka has the maximum number of empanelled hospitals (5,007), followed by Uttar Pradesh (3,411) and Gujarat (2,836) [6]. As illustrated in Figure 3, the maximum number of patients have taken consultation for General medicine (110.84 lakhs) followed by Infectious disease (43.17 lakhs) and General Surgery (30.74 lakhs), and top procedures constitute haemodialysis (64.05 lakhs) and screening for COVID-19 (40.76 lakhs) [6]. As depicted in Figure 1&2 , 43.42% of AB-PMJAY claims were approved after 30 days and 39.83% of claims were paid after 45 days [7].

AB-PMJAY has undergone significant updates in various aspects since its inception. However, there are still certain crucial areas where it falls short. These include ensuring equity in supply and utilization, targeting the most vulnerable population, and providing outpatient coverage [8]. A National Household Survey conducted in 2021 revealed that while over 70% of the states implementing PM-JAY were aware of the scheme, only 16% were enrolled. Moreover, awareness and enrolment were higher in urban areas than in rural regions [9]. Consequently, the system needs to effectively reach the most vulnerable individuals, leading to adequate utilization and supply of the scheme. Outpatient care costs, which constitute a significant portion of out-of-pocket expenses, are not covered by PM-JAY as it only includes secondary and tertiary hospitalization expenses [8]. The utilization of the allocated funds for the scheme could have been improved, as there was a decline from 83% in 2018-19 to 50% in 2019-20 and further decreasing to 42% in 2020-21. Research by the National Council of Applied Economic Research (NCAER) revealed that there is need for more awareness among beneficiaries regarding their entitled health benefits and access process. To achieve universal access to healthcare through health insurance schemes, it is essential to enhance beneficiaries’ knowledge about the scheme, their benefits and entitlements. Comprehensive health provision will be addressed with proper strategies to inform cardholders about where to seek healthcare and how to claim benefits. If this trend continues, future budgets may witness reduced allocations due to underutilization [10].

IMPORTANCE OF TECHNOLOGY FOR AYUSHMAN BHARAT

Today, technology is used globally in all sectors to provide various services to people. In response to the growing need for digitization in India’s healthcare sector, the government launched the Ayushman Bharat Digital Mission (ABDM) in September 2021. This mission creates and utilizes Digital Public Goods to enhance the availability, accessibility, affordability, and acceptability of healthcare through various building blocks. This mission aims to establish an integrated, effective, and inclusive national digital health ecosystem [11].

As of 25th June 2023, 40.8 crore Ayushman Bharat Health Accounts (ABHAs) have been created, 1.98 lakh healthcare professionals have been enrolled in the scheme, and 27.8 crore health records have been registered under ABDM. Andhra Pradesh has topped the list by creating 403.3 lakhs ABHA, followed by Madhya Pradesh (398.4 lakhs) and Uttar Pradesh (354.5 lakhs). Overall, 51.54% of males and 48.45% of females have ABHA. As depicted in Figure 4, Karnataka (36,140), Uttar Pradesh (33,694), and Bihar (27,819) have the maximum number of registered healthcare professionals. All India Institute of Medical Sciences (AIIMS), New Delhi, has topped the list by generating 74,526 ABHA via online scan and share module for registration of patients across the country in June, followed by Swaroop Rani Nehru Hospital, Prayagraj, Uttar Pradesh and Ganesh Shankar Vidyarthi Medical College, Kanpur, Uttar Pradesh with 36,073 and 34,763 ABHA’s respectively [12].

EFFECT OF DEMOGRAPHIC CHANGES AND EPIDEMIOLOGICAL TRANSITION ON AYUSHMAN BHARAT

Lower infant mortality, longer life expectancies, a growing population, government emphasis on disease eradication, increasing disposable income, and the ability to pay for private healthcare facilities, all of these have contributed to the $41 billion growth in India’s healthcare business.  India’s public health spending, which includes spending by the federal and state governments, was stable between 2008 and 2015 at about 1.3% of GDP and very marginally increased to 1.4% in 2016–17. The National Health Policy 2017 recommended a rise in this proportion to 2.5% by 2025. The total health expenditure is estimated to be 3.9% of GDP, including private sector spending [13].

With advancements in technology and medical means, healthcare conditions have undoubtedly improved. With the initiation of Ayushman Bharat, there has been considerable development in the country's health policy and programme implementation [14]. More than half (51%) of all claims arise from the age groups within 19 to 50. This can be attributed to the demographics of the nation, where this age group constitutes 47% of the entire population. Medical disciplines within PM-JAY also exhibit specific age-wise utilisation trends. Monitoring these utilisation trends is crucial in light of the nation’s changing demographics. India's elderly population will also increase during the next two to three decades [8].

The burden of healthcare will shift from Communicable diseases to Noncommunicable diseases (NCDs) and age-related problems due to improvements in managing infectious diseases and an ageing population. Therefore, to meet the public needs, it would be required to alter the health package composition of PM-JAY promptly. Investigating systematic skews in the supply and utilisation of PM-JAY across healthcare industry, genders, age groups, and social categories is essential.  Despite lower level of disease and poverty, Kerala and Himachal Pradesh use more services. Males are found to be more likely to seek care under PM-JAY as compared to females. People who belonged to Scheduled Castes and Scheduled Tribes rarely use services. Due to healthcare accessibility issues, such discrepancies may further push the most vulnerable communities into poverty [8].

UTILIZATION OF AYUSHMAN BHARAT DURING THE COVID-19 PANDEMIC

The global healthcare and administrative systems have been put to the test since the coronavirus pandemic (COVID-19) first emerged. India, which has the world’s second-largest population, is significantly disadvantaged [15]. The burden of disease has been observed to aggravate poverty and financial exclusion. According to the various statistical figures, it is seen that the burden of NCDs with communicable diseases has been a challenge in terms of management. The Ayushman Bharat scheme has shown promise as an effective tool in this scenario [14]. More than two crore individuals have received free treatment through Ayushman Bharat since its launch in 2018. Once the pandemic has stabilised, this programme is anticipated to offer around one crore treatments annually. People from all social classes and geographical areas of the country had access to appropriate healthcare facilities during these periods because AB-PMJAY covered the diagnosis and treatment of COVID-19, Black Fungus, etc. Ayushman Bharat has an excellent feature like call centres with a nationwide helpline number. They are designed to be scalable and ready to manage massive incoming traffic 24 hours daily [15].

A study was conducted in a tertiary care centre in Karnataka to understand the utilization of Ayushman Bharat among COVID-19 positive individuals. The pandemic worsened the situation of underprivileged people, and the loss of jobs and livelihoods added to the problem. The Ayushman Bharat Arogya Karnataka (ABArK) scheme helped the beneficiaries to cope with catastrophic out-of-pocket expenditures. A total of 1367 COVID-19 positive cases were included in this investigation. 93.92% of the patients were from Karnataka, the state with the highest percentage. 906 (66.27%) subjects qualified for ABArK, of which 714 (78.8%) had used the programme. Men accounted for 443 (62.04%),  while 271 (37.95%) women  utilised the ABArK scheme. The study elicits the importance of awareness and health literacy concerning the benefits of the scheme and health insurance programs. It also lessens the financial strain and accessibility issues of the medical treatment [16].

 AYUSHMAN BHARAT AND THE FUTURE OF HEALTH CARE DELIVERY SYSTEM

Ayushman Bharat pioneers a holistic approach to healthcare. By establishing access to HWCs at the primary level  and ensuring financial protection for accessing curative care at the secondary and tertiary levels, Ayushman Bharat encapsulates a progression towards promotive, preventive, palliative, and rehabilitative aspects of UHC. It has emerged as a fundamental global healthcare policy which aimed at improving the health of the world’s population and combating the scourge of medically related poverty. If finances are appropriately managed and the scheme's beneficiaries are given quality care, the Ayushman Bharat can succeed in future [17].

By cutting back on spending on medications and outpatient care, it could reduce Out-of-Pocket Expenditures on Healthcare (OOPHE) significantly. According to recent studies and estimations, HWCs might effectively cover outpatient care costs and prescription drug expenses. However, given the history of the public health care system’s growth in India, which has been marked by significant rural–urban variations, there may be considerable variations in the degree to which HWCs can reduce OOPHE on outpatient treatment and medications. Additionally, much outpatient care and medical spending occurs at the tertiary level. The scheme covers only up to 3 days pre-hospitalisation expenses  and 15 days post-hospitalisation expenses. Follow-up care is provided to those patients who does not require hospitalization. Additionally, the majority of HWCs are situated in rural areas, leaving 35% of the urban population without HWC access. The government should consider incorporating medicines and outpatient care at the tertiary level in the AB-PMJAY for future improvements [18].

The AB-PMJAY is a rare opportunity to enhance the health of Indians and eliminate a significant cause of the country’s poverty. However, significant obstacles must be removed for the Indian people to experience these benefits and for the programme to advance India's pursuit of UHC sustainably. Under the sustainable development goals (SDGs), UHC has emerged as a global benchmark for health systems to enhance population health and eradicate medical-related poverty. Despite the evidence, the people's ability to receive healthcare services, the services delivered, and the level of financial protection provided to the population are indicators of UHC's performance. Given the limited resources available for AB-PMJAY implementation, the scheme's ability to advance on these three metrics will also depend on its ability to address several persistent and interconnected structural flaws in the Indian system, including problems with public and private sector governance, stewardship, quality control, and health system organisation [19].

SWOT ANALYSIS 

As per the existing literature, the SWOT analysis of the Ayushman Bharat is prepared and presented in Figure 5. [17,20,21,22].

RECENT ADVANCES

As illustrated in Figure 6, the estimated budget for the AB-PMJAY for the fiscal year 2023-24 is 7,200 crores, which is 12% higher than the previous year's revised budget. Until the financial year 2021-22, the revised estimates for the scheme were usually half of the budget estimates. However, in the financial year 2022-23, the scheme's budget and revised estimates were the same at 6,412 crores. The state government have established HWCs in all those states where the AB-PMJAY scheme is not implemented, except for National Capital, Delhi, where HWCs are not operationalized [23].

As of March 2022, the Health Benefits Package (HBP) 2.0 has also been revised; the current version of HBP 2.0 includes HBP 2.1 and HBP 2.2, which consists of 871 packages and 1,578 procedures covering 94 specialities. All states and Union Territories have implemented HBP 2.0 except for Goa, Karnataka, Meghalaya, Tamil Nadu, and Maharashtra. For the financial year 2023-24, the Government of India has allocated 341 crores to ABDM, more than double the previous year's revised estimates of 140 crores [24]. To achieve the goal of AB-PMJAY and to increase its reach, the state health department of Uttar Pradesh has decided to intensify the incentive scheme. The field workers, including ASHA workers, ANMs and Anganwadi workers, are provided with an incentive of 5 rupees per person for facilitating the issuance of Ayushman Bharat card [25]. The state health authority of Madhya Pradesh has introduced a plan to issue a ranking of hospitals empanelled under the AB-PMJAY scheme. This ranking would help patients get information about hospitals offering the best services. This ranking would also penalise mistakes and incentives for providing better services, and the state would also cancel MoUs with hospitals and de-empanel them from the scheme if they are found frauds like charging out of pocket from patients [26].

 CONCLUSION

This review has evaluated the Ayushman Bharat scheme and assessed its progress since it started. It has discussed the scheme’s current state, technology use, and how demographic and epidemiological transition changes have affected it. It also examined how the scheme was utilized during the COVID-19 pandemic, identified specific gaps, and emphasized its importance in the future healthcare system.

A WAY FORWARD

An increase in the utilization of the Ayushman Bharat scheme can be accelerated by relaying the benefits at the grassroots level and ensuring optimal usage of the resources by continuous monitoring and evaluation of the program. The stakeholders must understand the scheme’s importance and make the other beneficiaries understand the profits of utilization. In addition to attaining the SDGs, there is a reduction in the economic burden on individuals and families due to increased accessibility to healthcare resources. Looking at the pandemic, most nations’ national economy has suffered, and India is no exception. This scheme’s success can help revive the economy and the healthcare infrastructure. An essential aspect of utilising the Ayushman Bharat scheme is awareness among the population. A gap exists between the beneficiaries being aware of the entitled healthcare services and the accessibility of the resources. Being a developing nation, an enormous portion of a household's income is spent on healthcare, especially OOPE. To reduce the economic burden, the Ayushman Bharat scheme can be utilized. Furthermore, the concept of UHC is heightened by the equitable distribution of resources and how India can achieve it. The Ayushman Bharat scheme has proved essential in achieving the potential and facilitating the transition towards UHC.

 DECLARATIONS

DISCLOSURE OF INTEREST: The authors reported there are no competing interests to declare. 

FUNDING: The authors reported there is no funding associated with the work featured in this article.

ETHICAL APPROVAL: There are no human participants in this article and informed consent is not applicable.