Lok Sabha Question No. 2044 (UNSTARRED), answered on 2021-07-30
Subject: Survey on Implementation of AB-PMJAY
Ministry: HEALTH AND FAMILY WELFARE
Asked by: Sunil Kumar Pintu

- a): Yes.
- b): A summary of the findings from the survey is at Annexure - I.
- c): The state-wise  (including  Bihar)  number  of  such  hospitals  in  the  country,  against  whom allegations  of  denial  of  treatment  under  AB-PMJAY  have  been  reported  by  beneficiaries despite  being  empanelled  under  the  scheme  is  given  at Annexure II .  The  district  wise number  of  hospitals  in  Bihar  against  whom  allegations  related  to  denial  of  treatment  was reported under AB-PMJAY is given at Annexure - III.
- d): To  ensure  that  disputes  and  grievances  related  to  denial  of  treatment  or  demanding  of money  by  hospitals,  and  any  other  types  of  grievances  involving  beneficiaries,  healthcare providers and other stakeholders under AB-PMJAY are resolved in an efficient, transparent and time-bound manner, National Health Authority has developed Grievance Redressal Guidelines and put in place a Central Grievance Redressal Management System (CGRMS).

## GOVERNMENT OF INDIA MINISTRY OF HEALTH AND FAMILY WELFARE DEPARTMENT OF HEALTH AND FAMILY WELFARE

## LOK SABHA UNSTARRED QUESTION NO. 2044 TO BE ANSWERED ON 30 TH JULY, 2021

## SURVEY ON IMPLEMENTATION OF AB-PMJAY

## 2044. SHRI SUNIL KUMAR PINTU:

Will the Minister of HEALTH AND FAMILY WELFARE be pleased to state:

- (a) whether the Government has recently conducted any survey regarding implementation of Ayushman Bharat Yojana;
- (b)  if so, the outcome thereof;
- (c)    the  number  of  such  private  hospitals in  the  country,  location-wise  particularly  in Bihar which are refusing proper treatment to the cardholders under this scheme despite being empanelled under the Scheme; and
- (d)    the  details  of  measures  taken/being  taken  for  ensuring  proper  treatment  of Ayushman cardholders along with the action taken against such erring hospitals?

## ANSWER

## THE MINISTER OF STATE IN THE MINISTRY OF HEALTH AND FAMILY WELFARE (DR. BHARATI PRAVIN PAWAR)

Grievance Redressal under AB-PMJAY has a three-tier system at District, State, and National Level.  At  each  level,  there  is  a  dedicated  nodal  officer  viz.  District  Grievance  Nodal  Officer (DGNO), State Grievance Nodal Officer (SGNO) and National Grievance Nodal Officer (NGNO). Also, at each level, there is a committee formed viz. District Grievance Redressal Committee (DGRC)  at  district  level,  State  Grievance  Redressal Committee  (SGRC)  at  state  level  and National Grievance Redressal Committee (NGRC) at national level to address the grievances.

An IT-enabled and web-based grievance redressal system has been developed which enables a person to register a grievance on the portal https://grievance.pmjay.gov.in or https://cgrms.pmjay.gov.in. Also, citizens can lodge grievance through national call centre 14555 or through mail, letter, fax etc., which will be acknowledged, recorded, escalated & resolved as per procedure laid down in grievance redressal guidelines. Any grievance regarding denial of treatment by an empanelled hospital which is registered by beneficiaries at the time of admission  and  before  discharge  are  considered  as  SOS  grievances  and  Turn  Around Time of 6 working hours has been defined to resolve these types of grievances.

Complaints  or  grievances  received  through  any  medium  are  immediately  assigned  to respective  Grievance Nodal Officer designated  at  State  and  district  level  for  necessary action .  The concerned officer will  take  necessary  action to resolve  the case  either through direct channel or placing it before the committee.

The State  & district  level  authority  connect  with  the  concerned  hospital  against  which  the grievance has been raised. They also connect with the beneficiary to understand the nature of the  grievance.  Based  on  the  information collected from  the  beneficiary  and  the  hospital, the issue is resolved. It is ensured that the treatment is provided to the beneficiary.

Many  times,  complaints filed  by  the  beneficiary  in  this  regard  are found  to  be  incorrect e.g. beneficiaries due to lack of information demand services related to such speciality for which the hospital is not empanelled under the scheme, or grievance is lodged against denial of services against hospitals which are either not empanelled, or have been suspended or de-empanelled. Such grievances are dropped.

Other grievances which are found to be genuine are resolved and it is ensured that beneficiary is provided treatment by the empanelled hospital. However, if the hospital denies providing the treatment  as  per  the  established  procedure &  protocol  under  Ayushman  Bharat-PMJAY, necessary action  including  suspension  and de-empanelment of hospital is  undertaken  by  the respective State Health Agency.

As on 27 th July 2021, 2107 grievances related to denial of services have been received from the launch of the scheme, of which 1995  grievances have been resolved.

## Gist of findings and recommendations from the valuation

| Year of Evaluation                                      | Details of Independent Evaluation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               | Details of Independent Evaluation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                |
|---------------------------------------------------------|-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
|                                                         | Major Findings                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  | Recommendations                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  |
| Year of Demand Side Evaluation: 2019 (Household Survey) | High levels of awareness in terms of knowing about PM- JAY but there are still possibilities to further improve knowledge about various aspects of the scheme. There was high satisfaction with the entire verification process which was reported as part of registration experience. Overall, a small proportion of the sample size of respondents reported hospitalization. Satisfaction with the services received was generally very high among all individuals. Certain respondents did report incurring Out of Pocket Expenditure during hospitalization | a) Further strategies to increase awareness about the scheme features can become an enabler for ensuring even more effective access to healthcare. b) Additional efforts are required to be channelled towards understanding and addressing potential gaps in accessing healthcare services to ensure that all beneficiaries in need of specialized care receive adequate care. c) Replicating experiences from other settings, solutions are being actively sought to integrate insurance navigators, i.e. dedicated staff to guide and assist beneficiaries from verification of eligibility process to registration with the scheme to the hospitalization experience d) Detailed facility-based assessments may be carried out to investigate instances of OOPE and identify strategies to address them e) A seamless Complaints and Grievance system is to be put in place. |

|                                                          | Major Findings                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          | Recommendations                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     |
|----------------------------------------------------------|-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| Year of Demand Side Evaluation: 2019 (Hospitals' Survey) | non-empanelled hospitals fulfilled criteria of 24x7 availability of at least 1 doctor, 1 nurse, pharmacy, and obstetric and new-born care providers Majority of hospitals reported increase in patient load Many respondents opined that the increased awareness and increased health seeking behaviour among beneficiaries were important achievements, coupled with greater access to proper medical treatment especially for poor patients. This was especially highlighted in the states of Bihar, Chhattisgarh, Kerala, and Uttar Pradesh. Other achievements pertinent for beneficiaries include better beneficiary satisfaction, better outcomes due to better equipped hospitals and the portability of services across states. | a) Empanelment of accredited hospitals and/or strategies designed to encourage hospitals to undergo accreditation as a means of ensuring adherence to higher quality standards b) Cost structures are investigated to ensure the adequacy of the current treatment packages and related case- based rates, and apply changes if required c) An in-depth exploration of the reasons for Out Of Pocket Expenditure in patients utilizing services under PMJAY may be conducted, including before and during hospitalization d) Increased awareness generation and promotional activities are carried out among beneficiaries, so that they are aware of their entitlements, understand and comply to PMJAY specific documentation, verification and hospitalization requirements and are empowered to utilize services through PMJAY. |

## Annexure- II

## State-wise details of hospitals where allegations related to denial of treatment were reported under AB-PMJAY

| State             |   Grievance Related To Denial Treatment |
|-------------------|-----------------------------------------|
| Andhra Pradesh    |                                       1 |
| Assam             |                                      13 |
| Bihar             |                                     214 |
| Chandigarh        |                                       9 |
| Chhattisgarh      |                                      38 |
| Daman And Diu     |                                       1 |
| Gujarat           |                                      60 |
| Haryana           |                                     266 |
| Himachal Pradesh  |                                       3 |
| Jammu And Kashmir |                                      61 |
| Jharkhand         |                                     253 |
| Karnataka         |                                      48 |
| Kerala            |                                      21 |
| Madhya Pradesh    |                                     274 |
| Maharashtra       |                                      51 |
| Manipur           |                                      11 |
| Meghalaya         |                                       1 |
| Nagaland          |                                       2 |
| NCT Of Delhi      |                                       6 |
| NHCP*             |                                      25 |
| Punjab            |                                      35 |
| Rajasthan         |                                       6 |
| Sikkim            |                                       2 |
| Tamil Nadu        |                                      24 |
| Tripura           |                                       1 |
| Uttar Pradesh     |                                     593 |
| Uttarakhand       |                                      87 |
| West Bengal       |                                       1 |

## Annexure-III

## District wise number of hospitals in Bihar against whom allegations related to denial of treatment  was reported under AB PM-JAY

Out  of  the  214 grievances  received  in  Bihar, 170  grievances  were  against  denial  of treatment  in  Private  Hospitals.  Out  of  the  170  grievances, 159  were  resolved, 2 grievances were withdrawn and 9 are being resolved.

| District Name   |   No. of complaints |   Resolved/Closed |   Withdrawn |   In process |
|-----------------|---------------------|-------------------|-------------|--------------|
| Aurangabad      |                   1 |                 1 |           0 |            0 |
| Begusarai       |                   6 |                 5 |           0 |            1 |
| Bhagalpur       |                   9 |                 9 |           0 |            0 |
| Bhojpur         |                   7 |                 6 |           0 |            1 |
| Darbhanga       |                  36 |                35 |           0 |            1 |
| Gaya            |                   1 |                 1 |           0 |            0 |
| Jamui           |                   2 |                 2 |           0 |            0 |
| Jehanabad       |                   1 |                 1 |           0 |            0 |
| Katihar         |                   6 |                 6 |           0 |            0 |
| Korba           |                   1 |                 1 |           0 |            0 |
| Madhepura       |                   1 |                 1 |           0 |            0 |
| Madhubani       |                   4 |                 4 |           0 |            0 |
| Muzaffarpur     |                  16 |                16 |           0 |            0 |
| Nalanda         |                   8 |                 6 |           0 |            2 |
| Nawada          |                   1 |                 1 |           0 |            0 |
| Palamu          |                   2 |                 1 |           0 |            1 |
| Patna           |                  37 |                33 |           2 |            2 |
| Purnia          |                  15 |                15 |           0 |            0 |
| Ranchi          |                   1 |                 1 |           0 |            0 |
| Rohtas          |                   1 |                 1 |           0 |            0 |
| Saharsa         |                   1 |                 0 |           0 |            1 |
| Saran           |                   5 |                 5 |           0 |            0 |
| Sitamarhi       |                   5 |                 5 |           0 |            0 |
| Siwan           |                   1 |                 1 |           0 |            0 |
| Vaishali        |                   2 |                 2 |           0 |            0 |
| Total           |                 170 |               159 |           2 |            9 |