A study on impact of AB-PMJAY on rural population of Uttar Pradesh

Introduction

In India, healthcare expenditure constitutes 3.8% of the gross domestic product (GDP), with out-of-pocket expenses making up 58.78%. According to the National Sample Survey Office (NSSO) 75th round report, approximately 55% of the Indian populace (rural: 52% and urban: 61%) utilizes healthcare services from the private sector. In rural regions, nearly INR 15,937, and in urban areas, INR 22,031 are incurred as out-of-pocket medical costs for hospitalization [National Health Authority 2021] [1] . Healthcare expenses often lead many families into debt, as a significant portion of the Indian population belongs to the middle or lower socio-economic classes. India, a developing nation with a growing population of 1.4 billion [Worldometer: India population (2022)] [18] , sees Bihar as one of its most densely populated states/UTs [Census of India Website]. Bihar ranks among the least effective states in India regarding healthcare service provision, as indicated by various health metrics [NITI Aayog: INDIA 2015-16:] [3] . The percentage of families living below the poverty line in Bihar stands at 52.2% [Ministry of Statistics and Programme Implementation 2022] [4] . Numerous healthcare models exist, with the out-of-pocket model being the most common in underdeveloped regions and countries lacking the financial means to establish a medical system akin to the other three models previously mentioned. The affluent receive specialized medical care, while the impoverished do not unless they can secure the necessary funds to afford it [Vera Whole Health 2022] [5] . A high-level meeting convened by the United Nations proposed the establishment of universal health coverage to address the inequities in healthcare costs and the disparities in access to health services [Watkins et al. 2017] [6] . The current movement advocating for universal health coverage (UHC) emerged in response to the increasing global awareness of challenges such as restricted access to healthcare, inadequate treatment, and substantial financial risks [Watkins et al. 2017] [6] . In an effort to mitigate healthcare expenditures and ensure sufficient health services, the Indian government, encompassing both state and central authorities, has launched various health security initiatives, including Ayushman Bharat, a scheme entirely funded by the central government [National Health Authority 2021] [1] . This initiative was officially launched in Ranchi on September 23, 2018, by the esteemed Prime Minister of India. The objective of realizing the vision of universal health coverage is to guarantee that no individual is overlooked [National Health Authority 2021] [1] . Ayushman Bharat stands as one of the principal programs designed to offer financial protection for accessing secondary and tertiary healthcare services. This scheme comprises two main components: the health and wellness center and the Pradhan Mantri Jan Arogya Yojana (PMJAY). PMJAY is recognized as the largest public-funded health insurance initiative globally, catering to both rural and urban populations in India. The primary goal of PMJAY is to alleviate catastrophic out-of-pocket expenses, provide extensive coverage in a timely manner, and enhance the quality of prolonged hospital stays [Press Information Bureau 2022] [7] . The awareness level of PMJAY in the rural areas of Bihar was found to be only 6.7% [Dash U, Muraleedharan VR]. While other individual studies in India also reported a low level of awareness [Kusuma et al., 2018] [9] . There is a dearth of literature in the community-level assessment of the awareness of Ayushman Bharat-PMJAY in India. Very limited studies have assessed PMJAY at the community level [Sriee et al., 2021 and V.Pugazhenthi 2021] [10] . As per data from the government of Bihar, in the year 2020, only 50% of the population was eligible for Ayushman Bharat [Bihar Swasthya Suraksha Samiti 2022] [12] . It has been nearly three years since the implementation of Ayushman Bharat-PMJAY in Bihar, which signifies that there will be a change in the level of awareness. Hence, this study is intended to explore the utilization and awareness of Ayushman Bharat-PMJAY in a selected rural area of Bihar. In India, out-of-pocket expenses account for 59.18% of healthcare spending, which makes for 3.8% of GDP. About 56% of Indians rely on private healthcare services, with outof-pocket hospitalization expenditures average INR 16,658 in rural regions and INR 23,011 in urban settings, according to the National Sample Survey Office's (NSSO) 75th round report (National Health Authority 2021) [1] . In light of India's growing population of 1.48 billion, this financial strain drives many households into debt, especially those in the middle and lower socioeconomic groups (Census of India Website 2022) [2] . A startling 37.68% of households in Uttar Pradesh lived below the poverty line in 2022-2023, making it one of the states with the worst healthcare systems. Due to a shortage of funding for the establishment of comprehensive healthcare systems, the out-of-pocket payment model is prevalent in these emerging regions. According to Watkins et al. (2017) [6] , this strategy frequently leads to an imbalance in which the impoverished population remains underserved unless they can afford care, whereas wealthier persons may obtain high-quality medical treatment. In order to reduce healthcare cost disparities and increase access to healthcare services, the UN has promoted universal health coverage, or UHC. Global awareness of problems including poor accessibility, subpar care, and substantial financial concerns related to medical costs gave rise to the UHC movement. [Press Information Bureau, 2022] [7] . The Indian government launched a number of health security initiatives, most notably the federal governmentfunded Ayushman Bharat project, to address these problems. Ayushman Bharat, which the Prime Minister introduced in Ranchi on September 23, 2018, seeks to provide universal health coverage so that no one is denied access to essential medical treatment. Health and wellness centers and the Pradhan Mantri Jan Arogya Yojana (PMJAY), the largest publicly financed health insurance program in the world serving both rural and urban populations, are the two main elements of this program. PMJAY's main objectives are to reduce catastrophic out-ofpocket costs, offer prompt coverage, and lengthen hospital stays. Studies on PMJAY awareness in rural Uttar Pradesh provide a mixed picture: some report low awareness (over 50%), some report moderate awareness (between 20 and 30%), and some propose two-Studies reveal a mixed picture of PMJAY awareness in rural Uttar Pradesh: some find poor awareness (above 50%), others note moderate awareness (between 20 and 30%), and some suggest two-thirds are aware. However, despite health workers and media campaigns, utilization remains low (between 1.3% and 15%) due to lack of information, card possession, and comprehension of benefits. Lack of cards, unclear eligibility, and a lack of knowledge about how to use it are the main problems; health professionals and special programs are important sources of information. [Policy Bazar: Niti Aayog 2023 Report] [14] .

Objectives

To find out the awareness level of AB-PMJAY regarding utilization

Methodology

This study employed a cross-sectional design to assess knowledge, awareness, and practices regarding the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) among the population of Uttar Pradesh. The study was conducted over a period of five months (November 2021 to March 2022). A simple random sampling method was used to select beneficiary families from rural areas of Uttar Pradesh under the PMJAY scheme. The survey data was collected through face-to-face interviews or written questionnaires, a common primary data collection method for gathering information directly from the source. It has been used to obtain quantitative or qualitative information to understand the research topic.

First stage: Uttar Pradesh state were selected purposively as the respondent belong to the same region. Second stage: Among total 75 districts of Uttar Pradesh state each 9 th District were selected by random sampling method. Third stage: From each selected district 185 households who utilized services under PMJAY mission were selected purposively. Fourth stage one person were selected as a respondent from each household. According to the sample size, responses were collected from a total of 1646 respondents. A total of 38 questionnaires were printed and distributed directly to the respondents. In this survey, some individuals did not fill out the printed questionnaires correctly, resulting in the exclusion of three participants. 1643 individuals completed the questionnaires correctly, and their responses were deemed usable and valid for the survey. This represented an 85% response rate for the entire survey. Therefore, the sample size used for this study is 1643. The collected data were entered into Microsoft Excel 2019 and analysed using SPSS version 30. Descriptive statistics, including frequencies and percentages, were computed. A T-test was performed to assess associations between categorical variables, with a p value.

Result and Discussion

The reporting and explanation of empirical data gathered in accordance with the study's suggested objectives are covered in this chapter. The researcher further simplifies the objectives into a number of subheadings. The following is a presentation and discussion of the outcomes of the statistical analysis of the data.

Overview of Ayushman Bharath Yojana

A total of 1643 participants took part in the study from urban areas of Uttar Pradesh. Table 1 is showing the socio demographic characteristics of the study participants in rural as well as urban area. Healthcare providers were also a significant source of information for beneficiaries. Based on survey of available information, the distribution of respondents' suggestions for those without an Ayushman card typically falls into several key areas, reflecting a mix of official guidance, alternative options, and practical advice. The primary suggestions include: N/A (78.7%) and create awareness about AB-PMJAY ormal education (17.3%) followed by No Suggestion (3.3%), Where and how card be used (0.6%) in table 5. The present study examined the source of information about the benefits of the AB-PMJAY card. The statement describes a breakdown of survey responses, indicating that the vast majority of respondents had (51.7%) and CSC (31.3%) followed by Empannled hospital (16.7%) and N/A (0.2%) table 6. The Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) scheme primarily focuses on covering hospitalisation expenses for secondary and tertiary care, while generally excluding most outpatient department (OPD) treatments. The statistics provided (Hospital 89.2%, OPD 8.8%, Other 2%) broadly reflect this intended focus table 8. The scheme's core design is to protect vulnerable families from catastrophic financial expenditures associated with major hospital stays, which is why the vast majority of claims are for in-patient care. Determining the distribution of respondents based on their nearest health insurance participating hospital requires collecting specific location data from respondents and health facilities. Similarly finding was reported in table 9 shows that majority of respondents were nearest health participating hospital CHC (83.5%), (District hospital 9.5%) and Other (5.6%) while Private Empanelled Hospital (1.4%). 10] . Hospitals were identified and humiliated for misconduct in a study. [Sriee et al., 2021] [10] .

According to survey results and field observations, health professionals' effective awareness efforts and specific initiatives to inform beneficiaries of how and where to take advantage of the scheme's advantages are primarily responsible for higher use in rural regions. Urban regions did not exhibit this immediate awareness. The lack of appropriate instruction regarding the plan hinders the use of AB by beneficiaries in both locations.-PMJAY. Only by raising beneficiaries' knowledge and implementing appropriate oversight and governance can these problems be resolved.

Conclusion

Based on survey findings and field observations, the successful awareness campaigns and targeted initiatives by health professionals to educate beneficiaries on how and where to utilize the benefits of the scheme are chiefly responsible for the increased usage in rural areas. In contrast, urban areas did not demonstrate this level of immediate awareness. Rural beneficiaries faced challenges in obtaining sufficient information about the program, which impedes their utilization of AB.-PMJAY.

References

1. National Health Authority. About Pradhan Mantri Jan Arogya Yojana (PM-JAY). Available from: https://pmjay.gov.in/about/pmjay. Accessed Oct 22, 2021.
2. Office of the Registrar General & Census Commissioner, India. Census of India website. Available from: https://censusindia.gov.in. Accessed Mar 8, 2022.
3. NITI Aayog. India: National multidimensional poverty index baseline report based on NFHS-4 (2015-16). Available from: https://www.niti.gov.in/node/2271. Accessed Feb 14, 2022.
4. Ministry of Statistics and Programme Implementation. Homepage. Available from: https://www.mospi.gov.in. Accessed Jul 16, 2022.
5. Vera Whole Health. Global healthcare: Four major national models and how they work. Available from: https://www.verawholehealth.com/blog/globalhealthcare-4-major-national-models-and-how-theywork. Accessed Feb 15, 2022.
6. Watkins DA, Jamison DT, Mills A, et al. Universal health coverage and essential packages of care. In: Jamison DT, Gelband H, editors. Disease Control Priorities: Improving Health and Reducing Poverty. Washington (DC): World Bank; 2017.
7. Press Information Bureau. Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (AB-PMJAY). Available from: https://pib.gov.in/Pressreleaseshare.aspx?PRID = 1546948. Accessed Oct 16, 2022.
8. Kusuma YS, Pal M, Babu BV. Health insurance: Awareness, utilization, and its determinants among the urban poor in Delhi, India. J Epidemiol Glob Health. 2018;8:69-76. doi:10.2991/j.jegh.2018.09.004.
9. Sriee GVV, Maiya GR. Coverage, utilization, and impact of Ayushman Bharat scheme among the rural field practice area of Saveetha Medical College and Hospital, Chennai. J Fam Med Prim Care. 2021;10:1171-1176. doi:10.4103/jfmpc.jfmpc_1789_20.
10. Pugazhenthi VP. A study on awareness on AB-PMJAY for treatment of diseases with special reference to cancer care in Thanjavur district of Tamil Nadu. 2021. doi:10.36713/epra6426.
11. Bihar Swasthya Suraksha Samiti. Ayushman BharatBihar. Available from: https://biswass.bihar.gov.in. Accessed May 13, 2022.
12. NITI Aayog. The long road to universal health coverage. Available from: https://www.niti.gov.in/longroad-universal-health-coverage. Accessed Oct 17, 2023. The Wire. Cases of fraud begin to emerge as Ayushman Bharat touches 30 lakh people. Available from: https://thewire.in/health/ayushman-bharat-uttarakhandgovernment-hospital-fraud. Accessed Oct 17, 2023.
13. The Times of India. 111 hospitals linked to fraud in Ayushman Bharat scheme 'named and shamed'. Available from: https://timesofindia.indiatimes.com/india/name-shamestrategy-against-errant-hospitals-to-prevent-pmjayfrauds/articleshow/71379683.cms. Accessed Oct 17, 2023.