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MC Exclusive: Private hospitals’ body bats for PMJAY coverage for all men above 80, all women above 60

If implemented, it will ensure PMJAY coverage for an additional 7.5 crore population in India.

October 31, 2022 / 11:33 AM IST
(Illustration by Suneesh K)

(Illustration by Suneesh K)


India’s largest network of private hospitals has sought expansion of the government's flagship health insurance scheme, Ayushman Bharat Pradhan Mantri Jan Aarogya Yojana (PMJAY), to include all women above 60 years of age and all men over 80 years.

The Association of Healthcare Providers of India (AHPI), along with Vayah Vikas, a Bengaluru-based organisation that works for the welfare of elderly care, has written to the Union finance ministry with the suggestion.

“In our experience, elderly men and women across income groups need hospitalisation coverage the most and are among the most vulnerable part of the Indian population whose healthcare needs require urgent intervention,” Girdhar J Gyani, director general of the AHPI, told Moneycontrol.

PMJAY is the largest health assurance scheme in the world of its kind, which aims at providing a health cover of Rs 5 lakh per family per year for secondary and tertiary care hospitalisation to over 10.74 crore poor and vulnerable families, or approximately 50 crore beneficiaries, that form the bottom 40 percent of the Indian population.

The households included in the scheme, launched in 2018, are based on the deprivation and occupational criteria of Socio-Economic Caste Census 2011 (SECC 2011) for rural and urban areas respectively.

As per estimates, there are nearly 10.4 crore people above 60 years of age in India — 5.3 crore women and 5.1 crore men — and the AHPI recommendation, if fulfilled, could bring nearly 7.5 crore of them under the ambit of PMJAY.

Broadening the PMJAY coverage

There are a total of 1,673 health benefit packages across various specialities that can be availed at about 23,000 hospitals empanelled under the programme.

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Gyani said by making the recommendation, the network of hospitals was asking the government to fulfil its commitment of expanding the PMJAY coverage.

“It has been indicated on several occasions by senior government authorities that the government is looking to bring nearly 70 percent of the Indian population under the coverage of PMJAY and it can be ensured by measures like the one we are suggesting,” Gyani said.

On their part, the National Health Authority (NHA) that operationalises PMJAY and the Union health ministry officials said the fate of the recommendation may depend on the financial review of the proposal.

“In the past, there have been talks to include the missing middle — the chunk of the population not covered under any health insurance coverage — under PMJAY but not much has moved on that front, mainly owing to the financial considerations,” a senior NHA official conceded.

A health ministry official said the finance ministry will have a final say on whether more beneficiaries can be included under PMJAY.

Only recently, the government announced that all transgender people, who are registered with it, can avail the benefit of the health insurance scheme, making them the first group outside the BPL households to become beneficiaries of the scheme.

A step towards universal health coverage

Economists Pritam Datta and Chetana Chaudhuri, who are associated with the National Institute of Public Finance and Policy in Delhi, underlined that the 60 years+ female population and 80 years+ male population is set to gradually increase to 9 percent, which would be roughly 13.1 crore population in 2036.

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“This would lead to a significant increase in coverage, which is currently limited to mainly BPL population,” said Datta. “This is a welcome step towards universal health coverage.”

As per the NSSO 75th round data, about 6.7 percent of the male population and 8.3 percent of the female population are reporting ailments (all age brackets) and in the 60+ age group, the reporting was significantly high with 27.5 percent among the male population and 27.9 percent among the female population.

For ailments that are covered under PMJAY specifically, there are 85 hospitalisation cases per thousand people in 60+ years age-bracket (96 for male, 75 for female) while the figure is 144 per thousand population for 80 years+ age-bracket (180 for male, 114 for female), according to the NSSO 75th round data. However, the hospitalisation figure is only 29 cases per thousand people for all age-brackets.

“The inclusion would also increase the claim amount significantly, requiring additional resources to finance it,” said Datta.

He added that extending PMJAY to the older population would bring a significant volume of the population under government-sponsored social security schemes but to increase the actual utilisation of services, the government requires strengthening the health system.
Sumi Sukanya Dutta
first published: Oct 31, 2022 11:33 am