Research Design:
The research adopts a qualitative approach to gain an in-depth understanding of the importance of golden cards among seriously ill patients in the Kashmir region. Qualitative research allows for a nuanced exploration of human experiences and perceptions, making it well-suited for this study.
Sampling Technique:
A purposive sampling technique was employed to select a cohort of 20 seriously ill participants. Purposive sampling enables the selection participants who possess relevant and rich information about the phenomenon under investigation, ensuring the study's focus on the target population. [Insert Table 1 here]
Table 1
Demographic and background characteristics of participants (n = 20)
Serial Number | Age | Gender | Marital Status | Disease | Work Status | Health Status |
1 | 45 | Male | Married | Back Disc | Employed | Not Cured |
2 | 82 | Female | Widowed | Problem in Eyes | Unemployed | Partially Cured |
3 | 55 | Male | Married | Cataracts | Retired | Cured |
4 | 40 | Female | Married | Cancer | Employed | Not Cured |
5 | 68 | Male | Widowed | Arthritis | Retired | Cured |
6 | 31 | Female | Single | Gallbladder stones | Employed | Partially Cured |
7 | 60 | Male | Married | Heart Disease | Retired | Partially Cured |
8 | 35 | Female | Married | Asthma | Employed | Cured |
9 | 50 | Male | Married | Kidney Disease | Employed | Partially Cured |
10 | 42 | Female | Divorced | Prostrate | Unemployed | Cured |
11 | 48 | Male | Married | Cancer | Employed | Not Cured |
12 | 28 | Female | Single | Migraine | Employed | Not Cured |
13 | 70 | Male | Widowed | Osteoporosis | Retired | Cured |
14 | 78 | Female | Married | Eye problem | Pensionary | Partially Cured |
15 | 56 | Male | Married | Pulmonary Disease | Employed | Partially Cured |
16 | 33 | Female | Married | Surgery in Leg | Unemployed | Cured |
17 | 62 | Male | Married | Stroke | Retired | Partially Cured |
18 | 29 | Female | Single | Anemia | Employed | Cured |
19 | 47 | Male | Married | Liver Disease | Employed | Not Cured |
20 | 55 | Female | Married | Rheumatoid Arthritis | Employed | Partially Cured |
Data Collection:
Data were acquired through the administration of semi-structured interviews from the 16th of February, 2023, to the 23rd of May, 2023. Semi-structured interviews balance flexibility and structure, allowing for a comprehensive exploration of the research topic while ensuring consistency in data collection. The interviews were conducted face-to-face to establish rapport and encourage participants to share their perspectives openly.
Participant Recruitment:
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Inclusion Criteria: Participants were required to meet specific inclusion criteria, including possessing the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) golden cards.
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Recruitment Process: Potential participants were identified through two key identifiers in the Kashmir region. They were contacted, provided information about the study, and invited to participate voluntarily.
- Informed Consent: Prior to participation, participants were provided with informed consent forms explaining the study's purpose, procedures, risks, and benefits. Oral informed consent was obtained from all participants.
Data Collection Instrument:
A semi-structured interview schedule was developed, consisting of open-ended questions and prompts designed to explore participants' perceptions of the importance of golden cards in accessing healthcare services and the issues they faced despite having these cards. The interview schedule was pretested to ensure clarity and relevance.
Data Collection Procedure:
- Interviews were conducted by trained researchers with experience in qualitative research and sensitivity to the participants' conditions.
- Interviews took place in a private and comfortable setting, chosen by the participants to ensure their comfort and confidentiality.
- Each interview was audio-recorded with the participant's consent, and detailed field notes were taken to capture non-verbal cues and contextual information.
Data Analysis:
Data analysis was carried out following Colaizzi's technique of data analysis, which involves the following steps:
- Familiarisation: Researchers immersed themselves in the data to gain a holistic understanding.
- Significant Statements: Key statements and phrases related to the importance of golden cards were extracted.
- Formulating Meanings: Researchers identified underlying meanings and concepts in the significant statements.
- Cluster Themes: Themes were clustered and organised based on similarities and patterns. Although many different themes emerged, only two were considered for this study.
- Developing an Exhaustive Description: A comprehensive description of each theme was developed.
- Validation: Findings were validated through member checking and expert consultation.
Ethical Considerations:
Confidentiality and anonymity of participants were strictly maintained throughout the study, and participants were assured of their right to withdraw at any time without any question. Allocation of pseudo-names further strengthened the privacy of the participants of the study.
Findings
Despite their noble intentions, government-sponsored social welfare programs often grapple with systemic deficiencies, notably fraud, abuse (Kim and Maroulis 2018), claims processing, and timeliness issues. These challenges underscore the inherent limitations of such initiatives. The issue of fraud and abuse within social welfare programs constitutes a substantial impediment to their efficacy (Swan, Cullity and Roche 2008). Inadequate checks and balances and a dearth of vigilant oversight have created an environment ripe for unscrupulous individuals and entities to exploit these programs for personal gain. The diversion of resources away from deserving beneficiaries represents a fiscal concern and a moral one (Kapur and Nangia 2015), as it compromises such programs' very purpose and ethos. In addition, the erosion of public trust in the government's ability to judiciously manage taxpayer funds reverberates as a disconcerting consequence (Lamm 2003).
Conversely, the labyrinthine processes associated with claims processing, characterised by bureaucratic convolution, onerous documentation, and protracted waiting times, present a formidable impediment to the efficacy of these social welfare initiatives. Cumbersome procedures deter eligible individuals from availing themselves of the support they qualify for and engender an environment of inefficiency that hinders the timely delivery of much-needed assistance. This inertia in claims processing does not merely result in delayed support but, more profoundly, engenders disillusionment and frustration among beneficiaries, thereby undermining the very objectives of these programs.
Addressing these intractable issues necessitates a comprehensive and systemic overhaul of social welfare programs. Heightened vigilance in fraud detection and prevention mechanisms, alongside fortifying oversight structures, is pivotal (Othman et al. 2015). Instituting stringent penalties for fraudulent activities is integral to deterring unscrupulous actors and ensuring that resources are appropriately channelled to the deserving. Moreover, streamlining claims processing procedures, harnessing technological innovations to expedite adjudication (Vithal 2004), and establishing unequivocal timelines for the disbursement of benefits are vital steps toward enhancing the timeliness and, consequently, the overall efficacy of these programs.
Fraud and Abuse
Fraud in government schemes is a multifaceted phenomenon characterised by deliberately manipulating or misappropriating public resources and funds for personal gain or other illicit purposes (Obuah 2010). This intricate issue often arises due to various factors, including bureaucratic inefficiencies, inadequate oversight mechanisms, and the inherent complexity of government programs. In some instances, corrupt officials exploit discretionary powers to divert funds earmarked for the intended beneficiaries to their own pockets. Additionally, collusion between public servants and private sector actors, such as contractors or suppliers, can facilitate fraud through bid rigging, inflated invoicing, or kickback arrangements (Sohail and Cavill 2008). The opacity of government operations and the lack of transparency can create fertile ground for fraudulent activities to flourish, as it becomes challenging for citizens and oversight bodies to detect and report malfeasance (Mackey and Cuomo 2020). To combat this pervasive problem effectively, it is imperative to implement robust accountability measures, promote transparency, and bolster the capacity of government agencies to detect and prevent fraud. Addressing fraud in government schemes is crucial for safeguarding public resources and upholding the trust and integrity of the state's service delivery apparatus, ultimately ensuring that these programs fulfil their intended social and economic objectives. The fraud and abuse in PM-JAY have taken different forms, as evident from the following narrations of the multiple participants. Participant 7 narrated:
I felt breathless. My wife arranged an auto rickshaw immediately, and we headed to Khyber Hospital. Some 4 to 5 tests were conducted. The tests cost around 12 thousand rupees. I was told you have had a massive heart attack and immediately need heart surgery. All my family members became helpless and worried when they heard, "Heart attack!". My caretakers agreed to surgery to save my life. My wife presented a golden card, hoping that government schemes might finally be of any use. However, the golden card was rejected, and she was told that golden cards are not accepted here. My son-in-law was made to sign a document that read that full cash would be paid once the surgery was completed. All this happened in a brief time. We could not move to some other hospital as I was already in the cabin, so I could decide but little. After the surgery, I had to pay One lac and eighty thousand rupees for a heart stent and some thirty thousand rupees as additional hospital charges.
It can be seen that erstwhile empanelled hospitals that no longer accept the golden cards should have put a banner or sign saying so in explicit terms. But they instead seem to conceal it, and it is only later that the patient can make little decisions that the information is revealed. The narration of participant 6 makes the case clearer:
At the entrance of Florence Hospital, a big banner read, "Golden Cards are Accepted Here". But in reality, it is a hoax. I was having stones in my gallbladder. I went to Doctor Chalkoo, who told me to remove them immediately as they might lead to other serious problems. He told us to come to Florence on a particular date. We went there with a golden card with hope. However, to our disbelief, we were told by the hospital administration that this particular doctor (Dr Chlakoo, in this case) does not accept payment through Golden Card, and we need to pay in cash instead. We were left puzzled, and at the same time, I was experiencing excruciating pain, and I was a new mother. So, time was very important for me. Then, my husband managed to get forty thousand rupees, and I was operated upon. Besides forty thousand rupees for the operation, an additional three thousand for room rent for one night in the hospital and medicine worth eight thousand were other financial burdens. So, having or not having a golden card was the same. I have never heard of someone benefitting from a golden card in our clan.
Venting out frustration and despair after facing a similar situation, participant 16 relatedly said:
The juxtaposition of relief and apprehension was palpable. On the one hand, there was the profound relief of having survived the medical ordeal, knowing that the kidney removal was necessary for my well-being. On the other hand, the financial burden cast a shadow over this relief, reminding us of the practical challenges that awaited us upon leaving the hospital.
The scale and complexity of AB-PMJAY make it susceptible to fraud. The program covers a vast population, making oversight challenging. The involvement of multiple stakeholders, including state governments, insurance companies, and healthcare providers, creates opportunities for fraudulent practices and collusion. The absence of robust identity verification at the point of service delivery exacerbates these issues. AB-PMJAY faces significant fraud and abuse issues (Bharat 2018), which, if left unaddressed, can compromise the program's integrity and hinder its goal of providing healthcare access to vulnerable populations in India. Addressing these challenges through robust monitoring and technological solutions is crucial to the program's success (ibid). Efforts to address fraud include the National Health Authority's use of data analytics and technology to enhance transparency and detect fraud. Capacity-building initiatives for healthcare providers and beneficiary awareness campaigns are also in place to mitigate these challenges.
Claims Processing and Timeliness
The delayed processing of claims is a primary challenge within the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY). These delays, often attributed to administrative bottlenecks and bureaucratic intricacies, have significant repercussions (Sawant and Luhar 2022). They lead to protracted waiting periods for beneficiaries and healthcare providers awaiting reimbursement, directly contravening the program's fundamental objectives. The core purpose of AB-PMJAY is to provide timely financial support for medical expenses to vulnerable populations. When claims processing is sluggish, beneficiaries and healthcare providers must grapple with financial hardships, counteracting the intended safety net the scheme provides. Issues related to the accuracy and transparency of claim processing compound the challenges. Errors manifest in multiple forms, including erroneous eligibility determinations, misclassification of medical procedures, and insufficient documentation. Though often unintentional, these errors generate disputes and, in certain instances, lead to outright denial of claims (WHO 2022). Such discrepancies undermine the beneficiaries' trust in the system and place them at a distinct disadvantage. Beneficiaries are forced into the complex and time-consuming appeals process to rectify these errors, further exacerbating their financial and emotional burdens. Although many participants highly appreciated the PM-JAY scheme, they were concerned about the time complexities. The narration of participant 2 [This participant spoke on behalf of his grandmother] makes the case clear:
My grandmother was having problems with her eyes. She was unable to see anymore. On investigation, doctors found that she had cataracts in her eyes and referred us to an eye hospital in Srinagar. We went there with a golden card. After a few enquiries and documentation, we were told you would be called after a few days for cataract removal surgery. Days turned into months, and we did not get any response from the authorities. The cost for such surgery is about thirty to fifty thousand rupees. It is a huge amount, so we could not do it without having a golden card. I repeatedly went to the hospital nearly 80 km from home and pleaded with them to fast-forward our case. They used to say that no doctor was available yet. Finally, after three months, my grandmother was operated upon, and the cataract was successfully removed. We also got medicine and eye drops for post-surgical recovery, free of cost. If we did not have a golden card, it would not have been possible for us to do the much-needed surgery.
The family had a Golden card, which enabled them to access the expensive cataract-removal surgery, which would have otherwise been financially out of reach. However, despite having the card, they faced significant delays in receiving medical attention, enduring three months before the surgery finally took place. The Golden Card was instrumental in making the surgery and post-surgical treatment affordable for them. They might not have been able to afford the much-needed procedure without the card.
Standing in the rain, a group of people accompanying patients at SMHS hospital, Srinagar, were agitating and raising slogans. To hear their concerns, the researchers came to know their viewpoints through participants 11 and 12:
We have patiently waited here since 9 a.m.; the clock now reads 3 p.m. It is important to note that each of us holds a valid golden card, which entitles us to healthcare benefits under the PMJAY program. However, we are enduring an extended wait due to the unavailability of essential medications at the PMJAY-affiliated pharmacies. Despite our best efforts to access the necessary treatment, the pharmacy staff has advised us to purchase these vital medications from external sources. Regrettably, this is impossible for us, given our financial constraints. Our patients are growing increasingly distressed, and time is of the essence. Their health hangs in the balance, and any further delay could have dire consequences. We beseech the authorities to consider the gravity of this situation. If our patients suffer harm or, heaven forbid, succumb to their conditions while waiting for the medications they require, will the government accept responsibility for these unfortunate outcomes?
The above narration exposes many issues: Firstly, a group of individuals has been patiently waiting since 9 a.m., and it is now 3 p.m., signifying an extensive wait for medical assistance. Secondly, it has highlighted that each group member possesses a valid Golden card, which should grant them access to healthcare benefits under the PMJAY program, including free medication. However, there is a problem with the unavailability of essential medications at pharmacies affiliated with the PMJAY program. In response, the pharmacy staff advises the patients to purchase these crucial medications from external sources. Regrettably, given their apparent financial constraints, this option is financially unfeasible for the group. The urgency of the matter becomes increasingly evident as the patients' conditions worsen. Time is of the essence, and the patient's health hangs precariously in the balance. Any further delay in accessing the necessary medications could have dire and potentially life-threatening consequences. Furthermore, the allied complexities in obtaining a golden card are not easy. According to participant 15:
I was made to update my Aadhaar to obtain a coveted golden card. However, my initial attempts were thwarted as the Aadhar machine failed to recognise my fingerprints, adding a layer of frustration to the process. Undeterred, I persevered and submitted the required documents, patiently waiting for a solution from the indifferent officials who managed the Aadhar centre. Finally, after some deliberation and effort, a pathway to update my Aadhaar card was discovered. With my updated Aadhaar card, I eagerly acquired my golden card. However, this endeavour was a labyrinthine experience filled with complexities and uncertainty. To compound matters, unsettling rumours have surfaced, suggesting that numerous hospitals might not accept this golden card, leaving me pondering the purpose of the considerable effort and inconvenience I endured. In retrospect, the difficult journey to obtain the golden card has left me questioning whether the benefits of this endeavour truly outweighed the challenges and uncertainties I encountered along the way.
The regional disparities in healthcare infrastructure across India are pivotal in influencing the timeliness of claims processing. Uneven distribution of healthcare resources and personnel, primarily concentrated in urban areas, translates into prolonged claims processing times in underserved and remote regions. Beneficiaries in these areas encounter substantial delays due to limited access to healthcare facilities and providers, amplifying pre-existing healthcare delivery disparities. Consequently, the well-intentioned promise of equitable healthcare access remains unrealised in these regions, which is at the heart of AB-PMJAY.