Abstract
Ayushman Bharat scheme is a National Health Protection Scheme introduced on September 23, 2018 by the government of India. The study was done to estimate the awareness and utilization of the Ayushman Bharat scheme in the urban and rural beneficiaries of Gautam Buddha Nagar. A comparative cross sectional study was conducted in the field practice areas of the Department of Community Medicine, Gautam Buddha Nagar, Uttar Pradesh among 224 households. Simple random sampling was done, and data was collected using a semi-structured questionnaire. Our study found that around 8.9% and 18.8% of beneficiaries in urban and rural areas, respectively were aware of the benefits of the scheme. The study also reported that only 8% of beneficiaries in urban areas have utilized the benefits of the scheme while 15.2% of beneficiaries in rural areas have utilized the benefits in rural area. Creating good awareness campaigns, special drives, and working toward quality assurance in both the public and private sectors will help beneficiaries get the best out of this dynamic healthcare scheme.
Keywords: Awareness, Ayushman Bharat, Pradhan Mantri Jan Arogya Yojana, utilization
INTRODUCTION
Public sector hospitals in India are overburdened and underfunded and their utilization varies widely.[1,2] In a country where the average household income varies between Rs 5000 and 10,000 a month,[3] it is impossible to imagine poor people being able to afford even the most basic services from a private hospital. In rural or urban areas, people are making payments either by taking loans or by selling their assets during hospital admissions.[4] In India, the health profile report released by WHO in 2014 shows that because of high out-of-pocket (OOP) expenditure, annually 3.2% of Indians fall below the poverty line.[5]
The Government of India announced AB-PMJAY on September 23, 2018. The Socio-Economic Caste Census (SECC) 2011 data showed occupational categories of urban worker families and impoverished, rural families as the target audience for this initiative. This initiative would cover almost 50 crore individuals, including 8.03 crore families in rural areas and 2.33 crore families in metropolitan areas.[6] For secondary and tertiary care hospitalization, AB-PMJAY would offer a defined benefit cover of Rs. 5 lakh per family (on a family floater basis) every year.[1,7,8]
Its awareness and utilization remain out of reach of the beneficiaries as cases of fraud start to emerge all over the country. Staff in government and private hospitals have reportedly been acting in a nexus that exploited specific rules of the scheme.[9,10,11] These events are not only because of inadequate infrastructural facilities but also because of a lack of awareness among the targeted population.
To reduce the risk of exclusion, kiosks have also been established at empaneled hospitals to facilitate on-the-spot registration to ensure that no one who is entitled to benefit from the AB-PMJAY is denied hospital care.[12] According to the report by the Confederation of Indian Industry (CII) and Boston Consulting Group (BCG) titled “Health Insurance Vision 2025,” about two-thirds of the households eligible under the AB-PMJAY have not enrolled under the health insurance scheme. The report has also stated that about 59% of the households in India are without any health insurance coverage. In the case of less than Rs. 5 lakh segment, about 74% of the people do not have health insurance. Low awareness of health insurance among people is cited as one of the biggest reasons for the low takers of health insurance plans in India, including AB-PMJAY.[13,14]
One of the most dependable ways to give the covered family financial protection is through a health insurance plan. Since there is little information available about this new plan, a comparative cross-sectional study across Gautam Buddha Nagar’s rural and urban areas has been conducted to assess awareness, utilization, and availability of AB-PMJAY.
SUBJECTS AND METHODS
A comparative cross-sectional study has been conducted among beneficiaries coming under the Ayushman Bharat Scheme in the rural and urban field practice area (RHTC and UHTC) of the Department of Community Medicine of a medical college in NCR from July to August 2021. By using the formula n = 4 p*q/L2, assuming awareness to be 50%, 7% absolute error, and considering a 10% loss to follow-up, the sample size came out to be 224.
Four out of eight Villages and four out of eight colonies among the rural and urban field practice areas, respectively were selected by simple random sampling. A total of 28 households from each village and each colony falling under deprived rural families and identified occupational categories of urban workers’ families as per the latest Socio-Economic Caste Census (SECC)[7] data were selected. A line listing was done with the help of medico-social workers to identify the population falling under deprived SECC. Adults above 18 years of age were informed about the study. One member was selected randomly from each household using a simple lottery method from among the willing members, and informed consent was taken and a semi-structured questionnaire was filled out by the investigator.
A semi-structured questionnaire containing information about demographic data, awareness about the scheme, utilization of services, availability of services, and factors affecting the utilization [Annexure 1].
Descriptive statistics (frequency and percentage) were used to analyze the demographic characteristics, awareness, utilization, availability, and factors affecting utilization regarding AB-PMJAY. Ethical approval was taken from the Institutional Ethics Committee (Ref. No. SU/SMS &R/76-A/2020/44).
RESULTS
A total of 224 participants took part in the study from both rural and urban areas.
Table 1 is showing the sociodemographic characterstics of the study participants in rural as well as urban area.
Table 1.
Distribution of study subjects according to their socio-demographic characteristics. n=112 for each place
| Characteristics | Urban (n) (%) | Rural (n) (%) |
|---|---|---|
| Gender | ||
| Male | 68 (60.7) | 76 (67.9) |
| Female | 44 (39.3) | 36 (32.1) |
| Age (in years) | ||
| 18–38 | 38 (33.9) | 32 (28.6) |
| 39–58 | 67 (59.8) | 61 (54.4) |
| 59–78 | 07 (6.3) | 19 (17.0) |
| Religion | ||
| Hindu | 96 (85.7) | 104 (92.9) |
| Muslim | 16 (14.3) | 08 (7.1) |
| Caste | ||
| General | 22 (19.6) | 26 (23.2) |
| OBC | 78 (69.6) | 58 (51.8) |
| SC/ST | 12 (10.8) | 28 (25.0) |
| Education Status | ||
| Illiterate | 11 (9.8) | 17 (15.1) |
| Primary School | 15 (13.3) | 19 (17) |
| Middle School | 28 (25.1) | 30 (26.8) |
| High School | 27 (24.1) | 18 (16.1) |
| Intermediate | 18 (16.1) | 19 (16.9) |
| Graduate | 13 (11.6) | 09 (8.1) |
In urban areas, the majority of the respondents were male (60.7%), in the age group of 38–58 years (59.8), Hindu by religion (85.7%), OBC by caste (69.6%), married (89.3%), and literate (90.2%).
In rural areas, the majority of the respondents were male (67.9%), in the age group of 38–58 years (54.4%), Hindu by religion (92.9%), OBC by caste (51.8%), married (93.8), and literate (84.9%).
In urban areas, out of 112 beneficiaries interviewed, 10 (8.9%) beneficiaries were aware of the benefits of the scheme, and 09 (8%) beneficiaries were aware of the services that come under AB-PMJAY as shown in Table 2. Around two-thirds of them (36.7%) came to know about the scheme at either CHC/District Hospital/Private Hospital and CSCs/kiosks/PHCs/CHCs are the main place for registration for approximately half of them that is 52 (46.4%).
Table 2.
Awareness about PM-JAY among the beneficiaries in urban and rural areas. n=112 for each place
| Characteristics | Urban (n) (%) | Rural (n) (%) |
|---|---|---|
| No. of beneficiaries aware of the benefits of the scheme | ||
| Yes | 10 (8.9) | 21 (18.8) |
| No | 102 (91.1) | 91 (81.2) |
| No. of beneficiaries aware of how to avail the services | ||
| Yes | 09 (8.0) | 16 (14.3) |
| No | 103 (92.0) | 96 (85.7) |
| Source of information about the scheme | ||
| TV/Radio/Newspaper/Internet | 28 (25.1) | 10 (8.9) |
| Friend/Relative | 32 (28.6) | 09 (8.0) |
| Health Worker/Arogya Mitra/letters through mail | 11 (9.6) | 76 (67.9) |
| CHC/District Hospital/Private Hospital | 41 (36.7) | 17 (15.2) |
| Place of registration | ||
| CSCs/Kiosks/PHCs/CHCs | 52 (46.4) | 20 (17.9) |
| Empaneled Hospital | 48 (42.9) | 19 (16.9) |
| Registered during a special drive | 12 (10.7) | 73 (65.2) |
Similarly in rural areas, out of 112 beneficiaries interviewed, 21 (18.8%) beneficiaries were aware of the benefits of the scheme, and 16 (14.3) beneficiaries were aware of how to avail of the services which come under AB-PMJAY as shown in Table 2. Two-thirds (67.9%) of them came to know about the scheme through Health workers/Arogya Mitra/letters through mail and a maximum number of beneficiaries 73 (65.2) got registered during the special drive regarding AB-PMJAY.
Utilization of services under the scheme by the beneficiaries is summarized in Table 3.
Table 3.
Utilization of services under the scheme by the study participants in urban and rural areas. n=112 for each place
| Characteristics | Urban (n) (%) (n=112) |
Rural (n) (%) (n=112) |
|---|---|---|
| No. of beneficiaries who have utilized the benefits of the scheme | ||
| Yes | 09 (8.0) | 17 (15.2) |
| No | 103 (92.0) | 95 (84.8) |
| Type of Health facility visited by beneficiary | ||
| Public Hospital | 5 (4.4) | 8 (7.1) |
| Private Non-Profit Hospital | 2 (1.8) | 5 (4.4) |
| Private for-profit Hospital | 2 (1.8) | 4 (3.5) |
| Haven’t utilized benefits | 103 (92.0) | 95 (85.0) |
| Reason for choosing the particular hospital | ||
| Near to home | 1 (0.9) | 5 (4.4) |
| Suggested by someone | 2 (1.8) | 4 (3.5) |
| Referred by doctor | 2 (1.8) | 4 (3.5) |
| Always visit the same hospital | 4 (3.5) | 3 (2.7) |
| No other hospital in the area | 0 (00) | 1 (0.9) |
| Haven’t utilized benefits | 103 (92.0) | 95 (85.0) |
| Benefits under the scheme utilized by beneficiary | ||
| Medical Treatment/medical consumables | 3 (2.7) | 8 (7.1) |
| Diagnostic/lab benefits | 2 (1.8) | 1 (0.8) |
| Non intensive/intensive care services | 4 (3.5) | 8 (7.1) |
| Have not utilized benefits | 103 (92.0) | 95 (85.0) |
In the urban areas, few of them (8.0%) have utilized the benefits of the scheme and among them, the majority that is 5 (4.4%) visited the public hospital. Most of the beneficiaries 4 (3.5%) went to the hospital to which they usually go and a maximum of them that is 4 (3.5%) have utilized non-intensive/intensive care services under the scheme.
In the rural area, 17 (15.2%) beneficiaries have utilized the benefits of the scheme and among them, the majority that is 8 (7.1%) visited public hospitals. Most of the beneficiaries that is 5 (4.4%) preferred the hospital which is near to their home and the maximum of them that is 8 (7.1%) have utilized non-intensive/intensive care services and medical treatment under the scheme.
DISCUSSION
The study investigated the awareness and utilization of Ayushman Bharat Yojna among the entitled beneficiaries of urban and rural areas of Gautam Buddha Nagar District. Though insurance schemes to provide healthcare are not a new concept in India, the level of awareness and knowledge about AB-PMJAY is not yet high particularly in urban areas. The study shed light on the unmet needs of beneficiaries of the scheme in the urban and rural areas by investigating the reasons for not availing the scheme when needed.
The findings in the study reflect ignorance about AB-PMJAY were the most important reasons for less utilization of the schemes. This trend is also seen in the other studies conducted in different parts of the country.[15] A study conducted in the states of Haryana and Bihar showed similar results. The utilization of schemes in both urban and rural areas remains poor. It is important to address the issues faced by the beneficiaries, particularly in the initial stages of the scheme, otherwise, patient satisfaction from the scheme remains poor. By making the procedure easy and understandable, we can enhance the utilization of the scheme by the beneficiaries.
Another area of concern is low awareness regarding the payment procedure in the scheme. This study showed that few beneficiaries had to make co-payments at the hospital despite being covered under the scheme. Certain hospitals and people take advantage of beneficiaries due to their lack of knowledge and awareness. This has also been reported from several parts of the country.[9,10,11,15] In a report, hospitals were named and shamed for malpractice.[10,15]
Based on the survey findings and observations from the field, more utilization in rural areas is mainly because of good awareness campaigns and special drives conducted by the health workers to make beneficiaries aware of how and where to utilize the benefits of the scheme. This prompt awareness was not seen in urban areas. Beneficiaries in both areas could not get proper guidance regarding the scheme which hampers the utilization of AB-PMJAY.
These issues can only be managed by increasing awareness among the beneficiaries and by proper monitoring and governance.
Conflicts of interest
There are no conflicts of interest.
Acknowledgment
We thank all the household and community members for their participation and support.
ANNEXURE-1
SURVEY FORM
SOCIO-DEMOGRAPHIC CHARACTERISTICS
1. Name :
2. Age in completed years:
3. Gender : M/F/Others :
4. Address :
5. Marital status : Married/ Unmarried/ Divorced/ Widowed
6. Religion : Hindu/Muslim/Sikh/others
7. Caste : General/OBC/SC-ST
8. Education : Illiterate/Primary/Middle/Secondary Higher Secondary/Graduation/PG
9. Type of family : Nuclear/Extended/ 3-Generation
10. Ownership of house : Own/ Rented
11. Migration Duration. : Within last 10 years/ More than 10 years
12. Type of house : Kuchha/semi-pakka/pakka
13. No. of family members :
14. Socio-economic status (Modified Kuppuswamy Scale 2019):
a. Education of Head of Family:
o Professional degree (7)
o Graduate or postgraduate (6)
o Intermediate or post high school diploma (5)
o High school certificate (4)
o Middle school certificate (3)
o Primary school certificate (2)
o Illiterate (1)
b. Occupation of Head of Family:
o Professionals (white collar) (10)
o Semi-professional (6)
o Clerical, shop owners/farm (5)
o Skilled Workers (4)
o Semi skilled worker (3)
o Unskilled worker (2)
o Unemployed (1)
c. Total Monthly Income of the Family:
d. Total Score:
e. Socioeconomic Class:
f. Mobile no.
AWARENESS ABOUT SCHEME
15. How did you first hear about the scheme
a. TV/ Radio/ Newspaper/ Internet b. Friend/ Relative c. Health worker/others
16. How cards were made?
................................
.................................
17. Do you know the benefits of the scheme
a. Yes, please enumerate................................................................
................................................................
b. Don’t know
18. Do you know how and where to avail the scheme
a. Yes b. No
19. Any other insurance scheme with which you are registered ?
a. Yes, name of scheme................................................................
b. No
UTILIZATION OF SERVICES
20. Have you utilized the benefits of the scheme a. Yes b. No
21. Which health facility you visited.
a. Public hospital b. Private for profit hospital c. Private for non profit hospital
22. Reason for choosing the particular hospital
a. Near to home b. Reputation of hospital is good c. Suggested by relatives and friends
d. Referred by doctor e. Always go to this hospital f. No other hospital
g. Other reason
23. What benefit under the scheme have you utilized
a. Medical examination/ consultation/ treatment b. Medicine/ medical consumables
c. Diagnostic/ lab benefits d. Accommodation/ food services
e. Non intensive/ intensive care services
24. How many days patient was admitted a. 1 b. 2 c. 3 d. >3
25. Number of times benefits availed a. 1 b. 2 c. 3 d. >3
26. Number of family members who got benefit a. 1 b. 2 c. 3 d. >3
27. Did the hospital provided any food during the treatment
a. Yes, please rate the quality out of 10..........................................
b. No
28. Did the hospital provided any transportation facility
a. Yes, please specify....................................................................
b. No
AVAILABILITY OF SERVICES
29. How easy was it to register for the scheme
a. Very easy b. Easy c. Moderate d. Hard e. Don’t remember.
30. How easy was it to avail the services
a. Very Easy b. Easy c. Moderate d. Hard e. Don’t remember
31. Did you get help from Arogya Mitra in availing scheme a. Yes b. No
32. Was there a separate help desk for the scheme at the hospital a. Yes b. No c. Don’t remember
33. Was the staff at the help desk of the scheme polite and helpful a. Yes b. No
34. Was the family told about the procedure of availing scheme a. Yes b. No
35. Were the finger prints taken for verification/ registration
a. Yes, whose finger print was taken..............................................
b. No
36. Distance at which services were available
a. < 2 km / <15 mind b. 2-5 km / 15-30 mins c. 5-10 km / 30 mins - 1 hr
d. >10km / >1 hr e. Don’t know
37. How long did the patient had to wait before he/she was attended by the staff a. 5-15 mins b. 15-30 mins c. 30-60 mins d. >60 mins
38. How many services needed by you were available at the hospital
a. All of the services
b. Most of the services
c. Only few services
d. No service was available
FACTORS AFFECTING UTILIZATION
39. Did the hospital asked money from you, if yes please specify how much amount was shortfall in the card from the package/treatment rate
a. Yes, How much was reimbursement......................................................
b. No
40. Reason of not availing the scheme
a. Individual level difficulties
i. No service available in the area
ii. Money for transport was needed
iii. Nobody to guide
b. System level difficulties
i. Facility needed by me was not in the package
ii. Problem in enrollment of data
iii. Use of scheme discouraged by the hospital
c. Services Not needed
41. Will you try to avail scheme again
a. Yes
b. No
OPINION OF BENEFICIARY
42. Do you need any improvement in the scheme, if yes please specify
a. Yes,......................................................................................
......................................................................................
......................................................................................
......................................................................................
b. No
43. Where will you prefer your treatment
a. Private sector
b. Public sector
44. How would you rate the scheme (5 point likert scale)
a. Very Unsatisfied (1)
b. Unsatisfied (2)
c. Neutral (3)
d. Satisfied (4)
e. Very satisfied (5)
45. Will you recommend the scheme to your contacts
a. Yes
b. No
Funding Statement
Nil.
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