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Review Article
India’s National Health Protection Scheme: A Preview
Reema Mukherjee, Manisha Arora1

Department of Community India has recently announced the “Ayushman Bharat–National Health Protection

Abstract
Medicine, Armed Forces
Medical College, Pune,
Scheme (AB‑NHPS),” one of the largest government health insurance schemes
Maharashtra, 1Department of in the world. The scheme aims to provide quality health care to the poor and
Community Medicine, Army vulnerable families, a step forward toward the government’s commitment on
College of Medical Sciences, universal health care. The beneficiary households under the AB‑NHPS will be
New Delhi, India based on the deprivation and occupation status of the family, drawn from the
Socioeconomic and Caste Census database. The scheme will take care of all the
secondary health care and most of the tertiary health care procedures. The road
map envisaged for the implementation of the scheme consists of number of
challenges such as funding, acceptance by the states, exclusion of primary health
care, and outpatient expenditure from the scheme. We conclude that successful
implementation of the said scheme will require robust planning, stringent
regulations, simplified processes, and continuous monitoring using advanced
technological E‑health platforms.
Received: 08‑07‑2018
Accepted: 13‑08‑2018 Keywords: Ayushman Bharat, challenges, health insurance, scheme

Introduction birth anniversary, as announced by the hon'ble

A fter seven decades of self‑governing independence,
India is yet to provide its people with a successful
and widely accessible health protection program.
A step in that direction, “The National Health
Protection Scheme,” touted as one of the largest
government‑sponsored health insurance schemes in the
world, was announced by the finance minister during
the budget speech in parliament. The union cabinet
under the prime minister approved the launch of this
scheme meant to benefit more than 10 crore poor and
vulnerable families, targeting 50 crore individuals,
with a family cover of Rs 5 lakhs per family per year.
[1]
The National Health Policy 2017 aimed at providing
universal health care and quality services to all at an
affordable cost, which was in line with the Sustainable
Development Goal 3 of universal health care. The
National Health Protection Scheme (NHPS) is an
ambitious project of the government of India, aimed at
providing quality health care to the poor and vulnerable
families, and achieving its commitment on universal
health care. The Pradhan Mantri Jan Arogya Abhiyaan
(Ayushman Bharat) will be rolled out on 25 September
,2018 on the occasion of Pandit Deendayal Upadhyay’s
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Prime Minister on 15 August 2018 independence
day speech. An official website 'abnhpm.gov.in' has
been launched by the government of India for the
mission. Ayushman Bharat‑National Health Protection
Mission (AB‑NHPM) will subsume the on‑going
centrally sponsored schemes – Rashtriya Swasthya
Bima Yojana (RSBY) and the senior citizen health
insurance scheme. However, despite the RSBY having
functioning for more than a decade now, the verdict on
the effectiveness of this government‑sponsored health
insurance scheme is at best mixed;[2] in this backdrop
will the NHPM succeed where the RSBY could not,
or is the ambitious NHPM merely old wine in a new
bottle? This paper outlines the details of the NHPM,
as available from public documents and MoHFW press
releases, and also some of the problems envisaged in
its implementation.
Address for correspondence: Dr. Manisha Arora,
Department of Community Medicine, Army College of Medical
Sciences, Brar Square, Near Base Hospital, Delhi Cantonment,
New Delhi ‑ 110 010, India.
E‑mail: manishaandarora@gmail.com
This is an open access journal, and articles are distributed under the terms of the Creative
Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows others to
remix, tweak, and build upon the work non‑commercially, as long as appropriate credit is
given and the new creations are licensed under the identical terms.
For reprints contact: reprints@medknow.com

DOI:
10.4103/mjdrdypu.mjdrdypu_109_18 How to cite this article: Mukherjee R, Arora M. India's national health
protection scheme: A preview. Med J DY Patil Vidyapeeth 2018;11:385-8.

© 2018 Medical Journal of Dr. D.Y. Patil Vidyapeeth | Published by Wolters Kluwer - Medknow 385
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Mukherjee and Arora: National Health Protection Scheme
Ayushman Bharat: How Will it Work
Beneficiaries
Beneficiary households under the AB‑NHPS will be
based on the deprivation and occupation status of the
family, drawn from the Socioeconomic and Caste
Census database. The scheme will cover roughly
10 crore families.[1,3] In rural areas, families having
only one room with kucha walls and kucha roof;
families having no adult member between the age
of 16 and 59 years; female‑headed households with
no adult male member between the age of 16 and
59 years, disabled member, and no able bodied adult
member in the family; SC/ST households; and landless
households deriving major part of their income from
manual casual labor are included in this scheme. This
is roughly 7.5 crores of the total 18 crores of the rural
Indian population. Further, families having any one
of the following criteria: households without shelter,
destitute, living on alms, manual scavenger families,
primitive tribal groups, and legally released bonded
labor are automatically included under the scheme.
These families account for an additional 0.16 crore rural
beneficiaries of this scheme. For urban areas, 11 defined
occupational categories are entitled under the scheme.
Thus, of the 6.52 crore urban households, around 1.92
crores get included in the scheme. Finally, 9.91 crore
households stand to be beneficiaries under the NHPS,
which includes the 0.22 crores who are covered under
the RSBY scheme.
Benefits
The NHPS will take care of almost all secondary care
and most of the tertiary care procedures. It is proposed
to set up 1,50,000 health and wellness centers, from
within the subcenters and primary health centers to take
care of the primary health‑care element. To ensure that
the umbrella of health care includes everybody, there
will be no cap on family size and age in the scheme,
unlike the RSBY. Priority will be given to girl child,
women and and senior citizens. The benefit cover will
also include pre and post-hospitalization expenses,
as these were identified as one of the important
out‑of‑pocket expenditures (OOPs) in literature
reviewing the impact of RSBY. All preexisting
conditions will be covered under the policy. A  defined
transport allowance per hospitalization is also proposed
to be paid to the beneficiary.
The beneficiaries can avail benefits in both the public
and empaneled private facilities. All public hospitals
in the states implementing AB‑NHPM will be deemed
empaneled for the scheme. Hospitals belonging to
Employee State Insurance Corporation may also
be empaneled. Private hospitals will be empaneled
386 Medical Journal of Dr. D.Y. Patil Vidyapeeth  ¦  Volume 11  ¦  Issue 5  ¦  September-October 2018
online based on the defined criteria. To control costs,
the payments for treatment will be done on package
rate, and these will be decided by the government.
The package rates will include all the costs associated
with treatment. For beneficiaries, it will be a
cashless, paperless transaction. Keeping in view the
state‑specific requirements, states/UTs will have
the flexibility to modify these rates within a limited
bandwidth.[1]
Implementation
At the center or the apex, it is proposed to set up
AB‑NHPM council. This will be chaired by the Union
Health and Family Welfare Minister. It is also proposed
to have an AB‑NHPM Governing Board, which will be
jointly chaired by Secretary (Health and Family Welfare)
and Member (Health), NITI Aayog. It is proposed to
establish an AB‑NHPM agency (AB‑NHPMA) to manage
the AB‑NHPM at the operational level in the form of
a society. AB‑NHPMA will be headed by a full‑time
CEO of the level of secretary/additional Secretary to the
government of India. Under this apex, the body will be
the state health agency (SHA).It is proposed to set up a
structure at the district level too. States would be given
the option of rolling out NHPS with either a trust‑based
model (where states themselves set up a trust which
will hold and administer the funds) or through private
insurance companies. However, certain reports claim
that the government would encourage the states to go
for a trust model.[4,5] To provide a seamless experience
to the beneficiary, an Ayushman Mitra(AM), a certified
frontline health service professional shall be present at
each of the Empanelled Health Care Provider (EHCP)
and shall serve as a first contact point for beneficiaries,
(abnhpm.gov.in).
Funding
The premium per family is expected to be roughly around
Rs 1000–1200/year. This cost is to be borne by the center
and the state. The scheme will be financed by the general
taxation and there will be no earmarked funds especially for
this scheme.[3,4] The contribution of the center and the state
toward the premium will be in the ratio of 60:40 in all states
except the northeastern and Himalayan states (viz. Jammu
and Kashmir,Himachal Pradesh and Uttarakhand), where
the center will contribute in the ratio 90:10. As per the NITI
Aayog estimates, 5000–6000 crores would be required for
this scheme, and the government has allocated 2000 crores
in the current budget.[6] To ensure that the funds reach SHA
on time, the transfer of funds from the central government
through AB‑NHPMA to State Health Agencies may be
done through an escrow account directly. The state must
contribute its matching share of grants within the defined
time frame.
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Mukherjee and Arora: National Health Protection Scheme
Timelines
After announcement of Ayushman Bharat, the
implementation has followed tight timelines. Six
working groups were constituted to put together
experiences drawn from the RSBY, along with global
best practices, and inputs from states running their own
health insurance schemes to make recommendations
for the NHPS. Based on these recommendations,
broad operational guidelines have been laid down in
the fields of beneficiary identification, empanelment of
hospitals, grievance redressal, claim settlement etc. The
first Health and Wellness Centre was launched by the
Hon’ble Prime Minister at Jangla, Bijapur, Chhatisgarh
on 14 April 2018. The National Health Agency (NHA)
was constituted for the effective implementation of
AB-NHPM and established as a society on 11 May
2018, (abnhpm.gov.in). The official date for roll-out of
Ayushman Bharat has been announced.
The road ahead
In a country where around 63 million people are pushed
into poverty due to health‑care expenses, NHPS could
be an effective approach to ensure universal health
coverage. Some of the problems envisaged in the
implementation of this program are predominantly the
funding, acceptance by the states, exclusion of primary
health care and outpatient expenditure from the scheme,
problems regarding awareness of the scheme among
its beneficiaries who are automatically included under
the ambit of scheme, and the best model to provide
health‑care insurance to be used in the implementation
of the program. However, critics are skeptical about this
new scheme being proposed by the government and cite
the apparent failure of RSBY, which despite now running
for almost a decade has shown to be ineffective in
reducing OOP expenditures with an average claim ratio
of only around 33%. RSBY also left almost 40% of its
beneficiaries uncovered.[2,7] The most important reason
for this was lack of good quality care. In most of the
northern states, health care was being provided mainly
through empaneled private hospitals and clinics due to
the abysmal state of the public health infrastructure in
these states. In case stringent empanelment norms were
followed, even these private hospitals would not have
been empaneled, as these were substandard and offered
poor quality of care. This coupled with illiteracy and
poor awareness and lack of any regulatory mechanism
to control these private hospitals, which overtreated
the patients, led to RSBY having almost no impact on
OOP in these states, despite the government spending
money.[2,7] The only clear gainers seemed to be the
insurance company and the private hospitals. However,
in the southern states, which have implemented robust
Medical Journal of Dr. D.Y. Patil Vidyapeeth  ¦  Volume 11  ¦  Issue 5  ¦  September-October 2018
health insurance schemes of their own, analysis showed
that these states have managed to reduce OOP.
Most reviews of RSBY have divulged that the poor
avoid hospitalization due to the associated indirect costs
and loss of wages. Most of the expenditure incurred
in illness is over OPD treatment, drug, and diagnostics,
and these account for two‑third of the OOP expenditure
as against hospitalization which accounts only for the
remaining one‑third of the expenditure. The burden of
outpatient expenditures that account for the bulk of OOP
health care spending is mostly unaffected and utilization
of outpatient care may even have increased on account
of RSBY.[2] Thus, some of the issues that need to be
addressed while implementing NHPS are as follows:
first, services to be covered and standard management
guidelines for different diseases will have to be defined.
Second, safeguards and regulations will need to be
co‑opted to avoid unnecessary admissions/procedures
and overtreatment. Review of the RBSY scheme showed
that even for illness that could be treated on an OPD
basis, private clinics resorted to admitting the patients
resulting in unnecessary admissions on one hand, loss of
wages for the poor on the other and credit on the RBSY
was used up and thus not available for more significant
illnesses.[8] Thus, the need for stringent regulatory
mechanisms cannot be overemphasized. Third,studies
indicate that 65% of the health‑care expenditure in
the country is for outpatient care, which are primarily
OOP expenses. If the final goal is comprehensive health
care, then effective and quality primary health care is
of paramount importance. If there is one lesson to be
learnt from the successful universal health coverage of
Thailand, then it is the importance of investing in robust
primary health infrastructure, in achieving the goal of
health care for all. Through setting up of 1,50,000 health
and wellness centers, as announced by the government,
is a big initiative and it must be implemented effectively,
as this will determine and guide the further utilization
of secondary and tertiary health‑care services provided
under the ambit of NHPS.[9] This specifically assumes
importance in the light of the fact that the poor prefer
to avoid hospitalization due to the associated indirect
cost and loss of earning capacity and, therefore, depend
on outpatient care and primary health services for their
health needs. Without the backing of these effective
primary health‑care measures, the aim of NHPS will
be defeated despite large financial investments into the
same.
Finally, there are inherent challenges pertaining to the
national wide implementation of the scheme which
includes getting the various stakeholders including the
state governments on a common agreeable platform and
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Mukherjee and Arora: National Health Protection Scheme
a requirement to work on prevention of possible misuse
of the system.[4,10]
Conclusion
We must realize that implementation of such schemes
requires strong planning, stringent regulations, simple
and efficient processes, and continuous monitoring using
advanced technological E‑health platforms. Success
of NHPS will depend on a resolute political will,
administrative dynamism, and a missionary zeal to fulfill
its goals. Implementation failures can not only result in
an exponential rise in costs of such schemes but also
put a strain on future allocations as well toward the
health‑care sector.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
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