12

CHAPTER
Health Policy & Health
Insurance
12.1 HEALTH POLICY e) The Policy seeks to ensure improved access
and affordability of quality secondary and
a) The National Health Policy, 2017 seeks tertiary care services through a combination
to strengthen the role of Government for of public hospitals and strategic purchasing
holistic development of the health sector for in healthcare deficit areas from accredited
attainment of highest possible health and non­ governmental healthcare providers,
well-being to all across all ages. achieve significant reduction in out of
b) The policy advocates that the primary pocket expenditure due to healthcare costs,
healthcare is sought to be made more reinforce trust in public healthcare system
comprehensive covering preventive, and influence operation and growth of
promotive, curative, palliative, geriatric and private healthcare industry as well as medical
rehabilitative care. It focuses on a patient technologies in alignment with public health
centric thrust with focus on continuum of goals.
care, making public health care system f) The Policy supports pluralism and advocates
predictable, efficient, affordable and access to AYUSH remedies through co-
effective, with a comprehensive package of location in public health facilities and
services and products that meet immediate recognizes the need to nurture AYUSH
health care needs of most people. systems of medicine.
c) Progressively achieving Universal Health g) The policy adopts a holistic approach
Coverage by assuring availability of addressing infrastructure and human
free, comprehensive primary health care resource gaps along with leveraging digital
services and continuum of care, for all technology in strengthening the health
aspects of reproductive, maternal, child and systems. The policy further recommends
adolescent health and for the most prevalent compliance to right of patients to access
communicable, non-communicable and information about their condition and
occupational diseases in the population is treatment, maintaining adequate standards
one of the key objective of this policy. of diagnosis and treatment and developing
d) The Policy also advocates for engagement standard guidelines of care applicable
with private sector for critical gap filling both to public and private sector. Towards
for achieving national health goals, through providing speedy resolution of disputes and
inter-alia collaboration for strategic complaints, the policy has recommended for
purchasing, capacity building, awareness setting up of a separate empowered medical
generation, disaster management, skill tribunal.
development programmes, etc. h) To ensure quality of care, the policy

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recommends that public hospitals and to address heterogeneity in micro-nutrient

facilities undergo periodic measurements adequacy across regions in the country with
and certifications of levels of quality. focus on the more vulnerable sections of the
It recognizes development of standard population. It further, recommends focused
guidelines of care and grading of clinical interventions on high risk communities and
establishments and adoption of standard recommends for strengthening the women’s
treatment guidelines. The policy accordingly access to healthcare needs, by making
recommends establishing National public hospitals more women friendly and
Healthcare Standards Organization for ensuring that the staff have orientation to
maintaining adequate standards of diagnosis gender–sensitivity issues. Additionally, the
and treatment. policy recommends that health care to the
i) For attracting and retaining doctors in remote survivors/ victims need to be provided free
areas, the policy recommends financial and and with dignity in the public and private
non-financial incentives, creating medical sector. The policy also provides greater focus
colleges in rural areas; preference to students on occupational health- physical, chemical,
from under-serviced areas, realigning and other workplace hazards. Work-sites
pedagogy and curriculum to suit rural health and institutions would be encouraged and
needs, mandatory rural postings, etc. It also monitored to ensure safe health practices,
recognises establishing cadres like nurse accident prevention, besides providing
practitioner and public health nurses to preventive and promotive healthcare
increase their availability in most needed services.
areas. The policy recommends development
l) Towards addressing the healthcare needs
of a cadre of mid-level care providers as a
of geriatric population in rural areas, it
complementary human resource strategy for
recommends that primary healthcare to be
expansion of primary care from selective
comprehensive which includes geriatric
care to comprehensive care. Additionally, it
care, palliative care and rehabilitative care
proposes for a planned expansion of allied
technical skills as a key policy direction and services and recognizes the growing need
also creation of a Public Health Management for palliative and rehabilitative care for
Cadre for better public health management. all geriatric illnesses and advocates the
continuity of care across all levels.
j) The policy also seeks to address health
security and make in India for drugs and m) Towards urban health, the policy lays
devices. It also seeks to align other policies emphasis on addressing the primary health
for medical devices and equipment with care needs of the urban population with
public health goals. special focus on poor populations living in
listed and unlisted slums, other vulnerable
k) Towards addressing the health needs of populations.
the vulnerable groups, the National Health
Policy has situation specific measures in n) NHP 2017 builds on the progress made since
provisioning and delivery of services to the last NHP 2002. And, it also set specific
take care of special health needs of tribal quantitative and time bound goals and targets
and socially vulnerable population groups. related to health status, programme impact,
Towards this, the policy advocates for Health Systems Performance, and health
research and validation of tribal medicines system strengthening to be achieved in the
and envisions for a systematic approach health sector for enabling achievement of its

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goal of attainment of highest possible level • Improve accessibility – To enhance access

of health and well-being for all at all ages. to medical care along a continuum of care.
Through the network of empaneled public
12.2 AYUSHMAN BHARAT - PRADHAN and private hospitals, responsibility will rest
MANTRI JAN AROGYA YOJANA with supply side especially in the private
Introduction sector.

Ayushman Bharat - Pradhan Mantri Jan Arogya • Quality of care – To encourage healthcare
Yojana (PMJAY), launched on 23.09.2018, providers to improve the quality of care
provides a health cover of up to Rs. 5 lakhs per and services through standard treatment
family per year, for secondary and tertiary care protocols. Payment through the private
hospitalization. Around 10.74 crore vulnerable sector and beneficiary feedback mechanism
families (approximately 50 crore beneficiaries) will further propel healthcare providers to
are entitled for cashless and paperless access to improve the quality of their services.
services at the point of service. PMJAY is one Key Features
of the largest fully Government-financed health
protection schemes of the world. • Health cover of up to Rs. 5,00,000 per
family per year, for secondary and tertiary
Objectives care hospitalization through a network of
• Improve affordability – To enable the bottom Empanelled Health Care Providers (EHCP).
40 per cent of the population to afford and • No cap on family size, age or gender.
access secondary and tertiary care including
pre-hospitalisation and post-hospitalisation • Cashless access to services for the beneficiary
expenses. at the point of service.

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• All pre–existing conditions are covered. has now been restructured into National Health
The benefit cover includes pre & post Authority, which is an attached office of Ministry
hospitalization expenses. of Health and Family Welfare. To implement the
scheme at the State level, States have formed State
• Benefits are portable across the country in all Health Agencies (SHAs) in the form of a society/
empanelled hospitals. trust.
• Services include about 1,390 procedures Status (as on 31.3.2019) since launch of scheme
covering treatment, food, drugs and supplies, i.e. 23rd September, 2018
and diagnostics services.
• 33 States/ UTs have signed the MoU with
• PMJAY covers up to 3 days of pre- NHA.
hospitalisation and 15 days of post- • Out of the total target beneficiary of 10.74
hospitalisation expenses such as diagnostics crore Families spread across the country,
and medicines. 2.84 crore e-cards were issued.
Organizational Structure • 17.96 lakh beneficiaries availed the benefits
At the Central level, National Health Agency of the scheme since its inception.
(NHA) was set up as a society under the • A network of hospitals has been developed
Societies Registration Act, 1860 for managing across implementing States/UTs by
the implementation of PMJAY. In pursuance of empaneling 15,223 public & private hospitals
the Cabinet decision, the National Health Agency under the scheme.

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Rickshaw Pullers, Rag Pickers and Auto/Taxi

drivers). The Scheme was transferred to Ministry
of Health & Family Welfare on “as is where is”
basis with effect from 01.04.2015.
Each family enrolled in the scheme was entitled
to hospitalization benefits of upto INR 30,000
per annum in Government as well as empanelled
private hospitals. Transportation Cost of Rs. 100
per visit was also paid to the beneficiary family,
subject to maximum ceiling of Rs. 1000/- per
year. The Scheme was implemented at state
level through a contractual arrangement between
insurance companies and State Government
represented by the State Nodal Agency (SNA).
The funding of the scheme is on the sharing pattern
of 60:40 between the Centre and the State and
90:10 for North-eastern and Himalayan States. In
respect of Union Territories without legislature, the
Central Government share is 100% and for Union
Territories with legislature, the sharing pattern
• National call centre operating through toll is 60:40. 1516 treatment packages were covered
free number 14555/1800111565 received under RSBY.
around 36.5 lakh calls. During the year 2018-19, the RSBY scheme
• PMJAY mobile application has been installed was implemented in 12 States/UTs, across 204
by more than 2.71 lakh users. Districts with a target of around 4.19 crore
families, covering around 2.74 crore families
• More than 94 lakh users have checked their (65.45% of the total target). A network of more
entitlement status through mera.pmjay.gov. than seven thousand hospitals was developed by
in. empaneling 3812 private hospitals and 3385 public
hospitals under RSBY scheme.
12.2.1 Rashtriya Swasthya Bima Yojana (RSBY)
and Senior Citizens Health Insurance With the launch of Ayushman Bharat – Pradhan
Scheme (SCHIS) Mantri Jan Arogya Yojana, RSBY scheme has
been subsumed in it.
Rashtriya Swasthya Bima Yojana (RSBY) was a
centrally sponsored scheme that was implemented Senior Citizen Health Insurance Scheme
by Ministry of Labour & Employment (MoLE) (SCHIS)
since 2008, under the Unorganized Workers’
Social Security Act 2008 to provide health SCHIS which provided insurance cover to senior
insurance coverage to Below Poverty Line (BPL) citizens as a top-up over the existing RSBY
families and 11 other categories of Unorganized Scheme, has been implemented w.e.f. 01.04.2016.
Workers(UOWs) (MGNREGA Workers, This scheme provided an additional annual
Construction Workers, Domestic workers, coverage of Rs. 30,000/- per senior citizen in the
Sanitation Workers, Mine Workers, licensed eligible RSBY beneficiary family. RSBY provided
Railway Porters, Street Vendors, Beedi Workers, a health insurance cover of Rs. 30,000/- which

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was also available to senior citizens once they use Oncology- 49) were covered under SCHIS, in
SCHIS coverage of Rs. 30,000/. If in any RSBY addition to 1516 packages under RSBY. Approval
enrolled family, there were more than one senior was accorded to eight States namely Assam,
citizen, then the additional cover was in multiple Gujarat, Karnataka, Kerala, Meghalaya, Nagaland,
of Rs. 30,000/- per senior citizen. Tripura and West Bengal for implementation of
SCHIS.
211 treatment packages (Cardiology -17, Cardio
Thoracic Surgery- 18, Cardio Vascular Surgery- With the launch of Ayushman Bharat – Pradhan
18, Neuro Surgery- 5, Polytrauma & Repair- Mantri Jan Arogya Yojana, SCHIS has been
7, Burns-8, Surgical Oncology- 89, Medical subsumed in it.

206 ANNUAL REPORT I 2018-19