Problem Statements

Catastrophic health expenses push more than 60 million people into poverty every year in India. Currently the Indian healthcare delivery system is marred by the high costs of devices and services, and lacking in cost standardization across service providers.. Some of the sub-challenges to address the wider challenge of bringing down the cost of health services are:

  • What are the ways to bring down the cost of diagnosis and diagnostics?
  • How a one-stop shop (an online platform) for hospitals to procure drugs/medicines, implants, instruments etc be created to ensure ease in procurement and to encourage buying decisions based on price, quality, availability and peer reviews?
  • How can empanelled hospitals seamlessly outsource services that are not available at the point of care, in order to ensure cashless treatment is given to the beneficiaries especially pre and post hospitalization?

With the advent of Ayushman Bharat-PMJAY, the hospitalisation rate of the bottom 40% of the population is expected to rise from the current 2.45% to 2.75% translating into about 1.7 crore patients per year. Considering there is a natural preference towards quality care, this new demand needs to be matched by high quality supply of care as the current network remains comprising mainly of unregulated private providers with a handful of islands of excellence concentrated in the metropolitan cities and already under severe pressure. Further, this scenario is characterised by lack of quality standards and/or standard treatment protocols for serious illnesses and monitoring mechanism for services whose quality differs from provider to provider.

Some of the sub-challenges to address the wider challenge of ensuring quality of care/health services are:
  • How can we improve the quality of care at the point of service while maintaining and improving cost of care?
  • How can we reduce infection rate at hospitals? How do we bring down the anti-bacterial resistance?
  • How can we build a technological solution that would help measure and track the quality of care?
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Reaching out to 10 crore families spread across the country out of which more than 8 crore are in the rural areas is one of the most important areas of opportunity as well as challenge for Ayushman Bharat PMJAY.

However, lack of awareness among those living in the rural areas and small towns and information asymmetry regarding the health, diseases, treatment, can come in the way of increasing the demand for healthcare or provide resistance to change in healthcare-seeking behaviour among the poor and vulnerable sections of citizens. We will need to increase the reach, awareness and access of healthcare service delivery manifold especially in the small towns and rural areas where the supply of providers is low. Augmenting individual and collective capacities and efficiencies of driving PM-JAY will need to be complemented with innovative mechanisms to raise beneficiary awareness so that the benefits of the scheme reach the last man standing in the queue

Some of the sub-challenges to address the wider challenge of maximising beneficiary awareness are:
  • How can we reach 8 crore families living in more than 7 lakh villages of the country with the message of Ayushman Bharat PMJAY?
  • How can we empower more than 10 crore target families across the country from a rights-based approach to secondary and tertiary care for serious illnesses?
  • How do we change the healthcare-seeking behaviour of the bottom 40 per cent of the population that currently either procrastinates treatment to avoid large healthcare bills or falls down the spiral of indebtedness and poverty in its bid to fund catastrophic healthcare episodes that it cannot afford?
  • How to use call centres/develop on-the-ground vernacular solutions to reach out to beneficiaries in remotest of taluks/blocks/villages?
  • How can we leverage the reach of local partners and influencers to increase awareness (online & offline)?
  • How to enhance beneficiary participation in Health Assurance and Continuum of Care?

The existing beneficiary chain is characterised by an absence of a upward-downward referral system which leads to longer beneficiary cycle and higher operational costs. Information asymmetry between doctors and beneficiaries, and lack of information therapy for the beneficiaries often leads to low adherence to the treatment and follow-up care. Limited resources in vernacular medium to solve beneficiary queries coupled with limited capacity on grievance redressal leads to intensification and prolonging of patient distress and continuation of low quality services in the absence of continued feedback.

Ayushman Bharat aims to undertake path breaking interventions to holistically address health. The Government is working on integrating primary care with secondary and tertiary care with a focus on providing a continuum of care covering preventive, promotive, curative, and ambulatory care.

Some of the sub-challenges to address the wider challenge of pre and post-treatment engagement are:
  • How to enhance beneficiary participation continuum of care?
  • How can we ensure adherence to medication post-discharge for better health outcomes?
  • How can we build a system to take care of upward and downward referrals and ensure smooth transition from primary care to secondary/tertiary care and follow-up care?

PMJAY relies heavily on the development of a robust data platform to effectively capture all critical data elements and ensure its secure collection, management, storage and exchange. It is also essential to enrich the data by collating more information in a structured format across different entities and stakeholders such as providers, patients etc to ensure its completeness and accuracy.

One of the key challenges observed in this regard is that patients often do not have access to their complete medical records which limits the ability to share their data with clinicians on a real-time basis. Creation of a personal health records architecture would enable better treatment decisions by the doctor and increased efficiency in care especially in times of emergency.

The second challenge is with regard to ensuring data security and privacy during storage, processing standardization and exchange across different entities such as State health agencies, medical auditors and National Health Authority (NHA). Currently, the collection, receipt, storage, handling and transfer of sensitive personal data or information in electronic form is subject to the Information Technology Rules 2011, under the Information Technology Act 2000. From a healthcare perspective, this covers information relating to physical, physiological and mental health conditions, sexual orientation as well as medical records and history. Additionally, the lack of interoperability of health records between hospitals, clinics and diagnostic centres, and in extreme cases, even between two departments of the same organization poses as a big challenge.

Some of the sub-challenges to ensure that the data quality, content and its privacy and security can be enhanced are:
  • Development of a secure and standardized Personal health records architecture for data storage, processing and exchange.
  • Creation of national data repositories in a structured format such as patient registries, doctor registry, Healthcare infrastructure registry.
  • Setting up a secure, easy to use, interoperable and robust platform for data storage, encryption and exchange.
  • Sharing patient and Claims data securely across different parties located in remote locations, data encryption.

The health workforce and its expansion is one of the most critical ingredients for achieving universal health coverage. India’s healthcare system as it stands today is inadequate to service 500 million additional people that Ayushman Bharat PM-JAY aims to cover. PM-JAY will lead to demand for 1.3 crore additional bed days, nearly 43,000 additional hospital beds, more than 5,000 additional doctors and more than 20,000 additional nurses.

Further, with existing workforce and resources, there are knowledge gaps at various levels of service delivery and scheme process. Doctors who graduated decades ago may be in need of upgradation of their knowledge and skills keeping up with the latest medical research and technology. Paramedics in the country are under-trained and under-utilised and need capacity-building trainings from time to time.

To tackle these challenges, we need focused solutions for training and capacity building of frontline workers as well as clinical decision support systems to aid doctors to make faster and better decisions. Tailored tools for the local context and multi-year investments in training, capacity building, and evaluation could help address the needs of a vast population.

Some of the sub-challenges to address the wider challenge of human resource are:
  • How to build and maximise capacities of treating doctors?
  • How to build and maximise capacities of paramedics?

Globally, it is estimated that $260 billion(180 billion euros)—or approximately 6% of global health care spending—is lost to fraud each year. World over healthcare schemes and insurance programs are prone to integrity violations due the very nature of healthcare - asymmetry of information, provider induced demand and malpractices, ghost policy holders, fake beneficiaries etc. with serious implications for health outcomes besides financial waste. The PM-JAY Anti-Fraud framework as laid out in Anti-fraud Guidelines 2018, aims to detect, prevent and deter fraudulent and abusive malpractices under the scheme. It would be imperative for a scheme of this magnitude and complexity to have robust anti-fraud solutions deployed real time.

Some of the sub-challenges to address the wider challenge of fraud and Abuse Control:
  • How to Leverage AI/ ML solutions for Fraud detection and prevention?
  • How to identify fraud in real time and ensure its prompt investigation at the point of care?
  • How to provide real time alerts to state anti-fraud units on potential suspect claims for prompt review?