Pradhan Mantri Jan Arogya Yojana (PMJAY): Key Issues to Address in Jammu and Kashmir

By Ummar Jamal 

The Pradhan Mantri Jan Arogya Yojana (PMJAY), also known as Ayushman Bharat Yojana, stands as one of the most ambitious health insurance initiatives launched by the Government of India. Aimed at providing financial protection to vulnerable and economically weaker sections of society during medical emergencies, the scheme promises to cover over 500 million people with a health insurance coverage of up to ₹5 lakh per family per year for secondary and tertiary care hospitalization.

While the scheme is envisioned to be a game-changer in the Indian healthcare landscape, its implementation in the Union Territory (UT) of Jammu and Kashmir reveals several shortcomings. These challenges, if left unaddressed, threaten to undermine the scheme’s potential to serve those who need it the most.

The Aim of the Scheme

The primary objective of PMJAY is to ensure that the economically vulnerable sections of society do not suffer due to the financial burden of healthcare costs. By providing cashless and paperless access to services, the scheme aims to reduce out-of-pocket expenditures for the poor, thereby preventing the economic downfall of families due to medical emergencies. The scheme covers a wide range of services including over 1,500 medical procedures, which are provided through a network of public and private hospitals that have been empanelled under the scheme.

Shortcomings in Jammu & Kashmir

Despite the comprehensive nature of PMJAY, its implementation in Jammu and Kashmir has faced significant hurdles. A major issue is the reluctance of private hospitals to fully participate in the scheme. Many leading private hospitals in Srinagar, such as Shifa Hospital, Florence Hospital, and Khyber Institute, have not been covering a wide range of surgeries under PMJAY. This reluctance has led to a situation where many poor patients, who hold the Golden Card (a card issued under PMJAY to eligible beneficiaries), are often denied treatment at these private hospitals.

The refusal of these hospitals to provide a full range of services under the scheme severely compromises its effectiveness. Patients who are turned away face significant difficulties in accessing necessary medical care, which directly contradicts the very purpose of the scheme.

Government Delayed Funding: A Core Issue

The reluctance of private hospitals to fully participate in PMJAY in Jammu and Kashmir can be traced back to delayed payments from the government. According to reports, empanelled private hospitals and dialysis centers in Jammu and Kashmir do not receive payments on time. This delay has created a financial strain on these hospitals, many of which are already operating on tight budgets.

On 13 august, the Srinagar branch of the Jammu and Kashmir Empanelled Private Dialysis Centres and Hospital Association met with the Deputy Commissioner of Srinagar to request emergency funds, as payments have been pending since March 15. The centres, under the Ayushman Bharat Scheme (AB-PMJAY), have not been paid for services since March 14, 2024, due to a dispute between the State Health Agency and the insurance company. Despite assurances in April that the issue would be resolved by early May, no action has been taken, according to an association spokesperson.

In a letter to the Chief Secretary of Jammu and Kashmir written in the month of June this year the association of empanelled private hospitals expressed their inability to continue providing services under the scheme beyond May 2024 unless payments were released. The letter highlighted that these hospitals had exhausted their funds and could not continue offering services under PMJAY without receiving the due payments. Despite this, these hospitals have continued to provide services, but they have reached a point where sustaining these services without government payments is no longer feasible.

The delayed payments have not only discouraged private hospitals from fully participating in the scheme but have also led to a decline in the quality of services offered under PMJAY. Hospitals that are struggling to manage their finances are less likely to invest in necessary medical infrastructure or hire additional staff, both of which are crucial for providing quality healthcare services.

Flaws in Empanelment and Coverage

Another significant challenge with the implementation of PMJAY in Jammu and Kashmir is the limited range of surgeries and medical procedures covered under the scheme. While about 133 private hospitals have been empanelled under the scheme, the fact that many crucial surgeries are not covered has reduced the scheme’s overall impact. Patients requiring specialized surgeries often find themselves in a situation where their Golden Card is not honored, leaving them with no choice but to either forgo the necessary treatment or bear the expenses out of pocket.

This limitation in coverage not only defeats the purpose of providing financial protection to vulnerable sections but also erodes trust in the scheme. If beneficiaries perceive that the scheme does not cover the treatments they need, they are less likely to rely on it, and the intended benefits of PMJAY will remain unachieved.

The Way Forward

To ensure the successful implementation of PMJAY in Jammu and Kashmir, several steps need to be taken to address the current shortcomings. The government must prioritize the timely disbursement of funds to empanelled private hospitals. Ensuring that payments are made on time will encourage these hospitals to continue providing services under the scheme and will prevent the financial strain that currently hinders their full participation. Moreover, the government should revisit the list of surgeries and medical procedures covered under PMJAY in Jammu and Kashmir. By expanding the range of treatments covered, the scheme can offer more comprehensive healthcare services to beneficiaries and prevent situations where patients are turned away due to lack of coverage.

The government should work closely with private hospitals to address their concerns and build a stronger partnership. This could involve setting up a more streamlined payment process, offering incentives for hospitals that provide a wider range of services under PMJAY, and ensuring that the administrative burden on these hospitals is minimized. There should be a robust system in place to monitor the implementation of PMJAY in Jammu and Kashmir. Regular audits and reviews can help identify gaps in service delivery and ensure that empanelled hospitals are fulfilling their obligations under the scheme. Additionally, establishing accountability mechanisms for delayed payments can prevent future disruptions in the scheme’s implementation.

Efforts should be made to educate the beneficiaries of PMJAY about the scope and limitations of the scheme. Clear communication regarding what is covered under the scheme and the process for accessing services can empower patients and reduce the instances of denied treatment.

Tailpiece

The Pradhan Mantri Jan Arogya Yojana has the potential to revolutionize healthcare access for the economically weaker sections of society in India. However, the scheme’s success hinges on its effective implementation, particularly in regions like Jammu and Kashmir where healthcare infrastructure and access are already under strain. By addressing the issues of delayed payments and limited coverage, the government must ensure that PMJAY lives up to its promise of providing universal health coverage to those who need it most.

Views expressed in the article are the author’s own and do not necessarily represent the editorial stance of Kashmir Observer

• The author is a Kashmir based columnist. He tweets at ummar_jamal and can be reached at [email protected]

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