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ORIGINAL ARTICLE
Year : 2023 | Volume
: 14
| Issue : 1 | Page : 22-25
Assessing the coverage of the pradhan mantri jan arogya yojana scheme and out-of-pocket expenditure in Mysore Urban slum dwellers
Vijaylakshmi Rao Vadaga, Deepak Anil, Shabeena Akbar, M R Narayana Murthy, Sunil Kumar Doddaiah
Department of Community Medicine, JSS Medical College, JSS Academy of Higher Education and Research, Sri Shivarathreeshwara Nagara, Mysuru, Karnataka, India
Correspondence Address:
Dr. Vijaylakshmi Rao Vadaga
Department of Community Medicine, JSS Medical College, Shivarathreeshwara Nagara, Mysore - 570 015, Karnataka
India
Source of Support: None, Conflict of Interest: None
DOI: 10.4103/injms.injms_92_22
Introduction: In 2018, the Government of India launched the Pradhan Mantri Jan Arogya Yojana (PM-JAY), a part of the Ayushman Bharat scheme as a progressive step toward universal health coverage. The scheme was intended to provide health insurance for the socioeconomically deprived population. This study was undertaken to assess the coverage of the scheme and to assess the reduction in medical out-of-pocket expenditure (OOPE). Methods: This was a cross-sectional study conducted among the urban slum dwellers in Mysuru. A semi-structured questionnaire was used for the study. Oral consent was taken from the participants before administering the questionnaire. Data were collected by face-to-face interviews. Statistical tests such as percentages and mean were calculated using SPSS software (Version 26, Licensed by JSSAHER). Results: The study was conducted among 104 individuals, of which 73% were females. Only 38 (33%) of the participants had PM-JAY cards while 59 (56.73%) did not have any health insurance. Thirty percentage (78.95%) of the card holders had utilized the insurance in the past 1 year and incurred an OOPE of Rs. 25,873/-. For all the cardholders, this amount was spent from their savings. Conclusion: The coverage of the scheme and OOPE reduction toward health care is still lacking. Greater measures need to be taken by medical officers, medicosocial workers, and other field workers to identify eligible households and help them avail the benefits of this scheme.
Keywords: Ayushman Bharat scheme, health insurance, out-of-pocket expenditure, Pradhan Mantri Jan Arogya Yojana
Universal health coverage (UHC) as defined by World Health Organization is a means to enable all people and communities to use promotive, preventive, curative, rehabilitative, and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship. The Government of India launched the Ayushman Bharat health-care scheme on September 23rd, 2018, as a step toward its efforts toward UHC. This scheme has two components: Pradhan Mantri Jan Arogya Yojana (PM-JAY) and Health and Wellness Centers (HWCs).[1]
According to the 2014 health profile report by WHO, 3.2% of Indians fall below the poverty line due to high OOPE annually.[2] It is seen that of the total health expenditure, 64.7% is household health expenditure while 60.5% is from out-of-pocket expenditure (OOPE). It has been reported that almost 60% of the total OOPE is for outpatient care alone.[1]
The PM-JAY was introduced with the aim to reduce this OOPE. It is a publicly financed health insurance scheme to cover the socioeconomically deprived rural and selected occupational categories of the urban population. It aims to cover nearly 40% of the country's population, i.e., nearly 100 million households and 500 million people across the country.[1] The scheme aims to provide health coverage of Rs. 5,00,000/- through impaneled hospitals.[3] The complete implementation of this program will make it the world's largest government-funded health protection mission.[4]
Karnataka alone has around 1,41,238 impaneled hospitals,[5] of which 24 are in the Mysore district.[6] As of December 2021, approximately 10.73 crore families, i.e., 50 crore individuals have benefitted from this scheme. In Karnataka, almost 62,09,073 families have been enrolled into this scheme.[5]
The government aims to provide health coverage of Rs. 5 lakh per family per year on a floater basis (where the insurance covers the entire family rather than an individual).[7] Beneficiaries will include those families listed under the socioeconomic caste census database with no limit to age or number of family members. With the help of this scheme, the beneficiaries can avail of free treatment at all public and impaneled private hospitals. Services that will be available at the impaneled private hospitals would include:
Secondary and tertiary care hospitalizationsMedical care packages to cover the cost of surgery, day-care treatments, cost of medicine, and investigations[4]It is a national portable scheme, i.e., the services under this scheme can be availed across the country.[4]
During the COVID-19 pandemic, there was a sudden rise in the need for medical care and hospitalizations. This led to greater unexpected OOPE toward health during the pandemic. Hence, this study was undertaken to assess the coverage of the Ayushman Bharat program among the people residing in the urban slum of Mysuru and to assess the extent to which the program was reducing the OOPE toward health-care expenses.
Objectives
To assess the coverage of PM-JAY beneficiariesTo assess if the PM-JAY program has reduced the OOPE. MethodsThis was a cross-sectional, door-to-door study conducted between June and July 2021. One hundred and four participants residing in the urban health center area of Mysore were included in the study. A convenient sampling technique was used to select the participants. The participants who were willing to participate were included in the study. No incentives or monetary benefits were offered to them.
The questions were read out to them, and their responses were noted in a semi-structured questionnaire. The participants were asked to show their Ayushman Bharat health cards to confirm if they actually held these cards. None of their names or phone numbers were collected hence ensuring the anonymity of the participant identity.
QuestionnaireThe questionnaire consisted of the following sections:
Sociodemographic details: Includes age, sex, education, and occupation of the person being interviewedAbout Ayushman Bharat: Monthly per capita income, whether they had an insurance card, source of the card, the reason for admission to health-care facilities in the last 12 months (if any), types of health care availed in the past 12 months, total expenditure on health care in the past year, total OOPE on health care in past one year, sources of the OOPE, and the reason for the OOPE (e.g. Consultation fees/cost of medicine/investigations, etc.).The data collected were entered in MS Excel 2019 and analyzed using Statistical Package for the Social Science (SPSS), Windows version 26.0 (IBM Corp. released 2019. IBM SPSS Statistics for Armonk, NY, USA). analysis was done for demographic variables and represented as percentages. Mean and percentages were used for analysis. Tables and charts were used wherever necessary.
ResultsA total of 104 participants were interviewed for this study. The mean age of the participants was 42.1 ± 15.94 years. Females comprised 73% of our study population. The various occupations of the participants can be summarized as follows:
We found that majority of the study participants, 59% were unemployed or had lost their jobs due to the pandemic. Thirteen percentage of the participants were skilled workers while 10% each were employed as unskilled or clerks/shop owners. The remainder of 8% saw 4% of them employed as professionals while another 4% were retired individuals.
Upon evaluation of the education level of the study participants, we found that majority of the participants (24%) had a minimum high school education while another 20% were illiterate. Eighteen percentage of the study population had received a minimum of middle school education and 15% of them were graduates.
It was found that the average per capita income of 57.7% of the participants was less than Rs. 10,000/- per month.
Only 38 (33%) of the members had PM-JAY cards while 59 (56.73%) did not have any insurance. Of those who had the card, 40% had obtained it from a health worker, 27.5% from a government office, and 32.5% had got it from a government hospital.
Among the 38 participants having the card, 30 (78.95%) had used it in the past year. The average health expenditure was 29,006/- among the PM-JAY card holders. The average OOPE after availing of the insurance was Rs. 25,873/- (past 1 year). Fifty-nine (56.73%) did not have any health insurance. Among these participants, it was found that the average health expenditure in the past year was Rs. 4958/- and the OOPE was Rs. 4077/-. For 31 of the 59, the OOPE was spent from their savings. Finally, for the 7 (6.7%) who had health insurance other than PM-JAY, the OOPE toward health was Rs. 12,000/- against an original amount of Rs. 15,014/-.
From [Table 1], we find that majority of the participants with the PM-JAY used their savings to pay for the OOPE toward health care. The average expenditure from their savings was Rs. 15,208/-. It was further noted that the cause for OOPE was the consultation fees and cost of medicines for all the cardholders and noncardholders.
Table 1: Sources of the out-of-pocket expenditure among the Pradhan Mantri Jan Arogya Yojana cardholders[Table 2] is a summary of the frequency of hospital admissions among PM-JAY cardholders in the past year.
Table 2: Frequency of hospital admissions among the Pradhan Mantri Jan Arogya Yojana cardholders[Figure 1] shows the various causes for hospital admissions among the study participants.
In the present study population, it was found that among the PM-JAY card holders, the average OOPE for the various hospital admissions was Rs. 20,426/- while the OOPE for noncard holders/other insurance holders was Rs. 4,918/-. This discrepancy in the figures could be attributed to the fact that the PM-JAY cardholders used the hospital admission facilities more than the rest of the population.
DiscussionThe present study was undertaken soon after the 2nd lockdown of COVID-19 to assess the coverage of the PM-JAY scheme of the Government, an initiative to reduce the OOPE of the people toward health care. One hundred and four participants residing in the urban slum area of Mysore were interviewed for this study. Among the participants, 73% were females. The higher proportion of females interviewed was because the interview was carried out during the daytime when most of the male members of the family are out for their duty.
Fifty-nine percentage of the participants were unemployed or had lost their jobs during the pandemic. Among the study participants, 24% of them had received education up to high school, i.e., Classes 9 and 10 while another 20% were illiterate.
The present study found that only 33% of the participants had PM-JAY cards, while 51.3% of them did not have any medical insurance. A similar study conducted by Vishnu Priya Sriee et al. in Tamil Nadu among 300 households showed only 42.33% of the households were covered by the scheme.[2] However, a study conducted by Ravindra Harish et al. in Kerala showed that nearly 74% of their study population were PM-JAY card holders. They attribute this coverage to the campaigns and activities undertaken by the local self-government to increase the enrolment of the people.[8]
In the present study, among the card holders, 30 (78.95%) had availed the services in the past year, of which nearly 83% of the card holders had spent an additional amount toward health care with an average OOPE of Rs. 15,208/-. Vishnu Priya Sriee et al. found that among the households with the PM-JAY card, only 10% had spent an additional amount on health care in the past year.
A study conducted by Uma Vasudevan in Puducherry showed that 85.5% of the urban study population had availed either outpatient (OP)/inpatient (IP)/pharmacy services during their study period. Nearly 65.8% of these expenses led to OOPE for an amount of Rs. 4,824/-. Seventy-six percentage of these OOPE was toward pharmacy expenses and another 14% was from the doctors' consultation fees.[9] The present study also shows similar results. In the current study, 35 (59.32%) of the noncard holders had availed OP/IP/pharmacy services in the past year. Among these, 52.54% had to incur OOPE for an amount of Rs. 4077/- from their savings, and all amount was spent toward pharmacy/consultation expenses.
Strengths
There are only a handful of studies done in India to evaluate the coverage of the PM-JAY schemeIn addition, since this study was undertaken in the postlockdown period, we were able to interview a greater number of individuals who had contact with the health-care facility in the recent past.Limitations
The data collection was done during working hours and hence most of the households were unavailable for an interviewThe sample size used to collect the data was small. Further studies with larger sample sizes need to be undertakenFuture studies can also try to evaluate the causes for the unavailability of the PM-JAY cards. ConclusionAfter nearly 6 years since the inception of the PM-JAY program, the coverage of the scheme is still inadequate. Despite the huge burden of health expenses arising from the COVID-19 pandemic, coverage, and awareness about the scheme among the people remains scarce. The local government bodies and health workers need to take the initiatives to identify such families and ensure that they avail of this scheme to reduce the OOPE toward health care in future.
Financial support and sponsorship
None.
Conflicts of interest
There are no conflicts of interest.
References
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