India, a nation of over 1.4 billion people, has long grappled with disparities in healthcare access and affordability. Recognizing the urgent need to provide quality healthcare to its vast population, the Government of India launched Ayushman Bharat – Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) in 2018. Commonly referred to as Ayushman Bharat Insurance, this scheme is the world’s largest government-funded healthcare program, aiming to ensure that no Indian is denied medical treatment due to lack of financial resources.
Background and Inception
Ayushman Bharat was announced by Prime Minister Narendra Modi in 2018 as part of the government’s vision to move from sectoral and segmented health services to a comprehensive need-based healthcare service. The program is structured on two pillars:
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Health and Wellness Centres (HWCs): These are upgraded primary health centers designed to deliver comprehensive primary healthcare, including free essential drugs and diagnostic services.
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Pradhan Mantri Jan Arogya Yojana (PMJAY): The second pillar, PMJAY, focuses on secondary and tertiary healthcare services through a health insurance cover.
This article focuses primarily on Ayushman Bharat Insurance, officially PMJAY, which is a flagship health assurance scheme.
Key Features of Ayushman Bharat Insurance (PMJAY)
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Coverage of ₹5 Lakh Per Family Per Year: Each eligible family is entitled to a health insurance cover of ₹5 lakh annually for secondary and tertiary hospitalization across public and empanelled private hospitals.
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Target Beneficiaries: The scheme is targeted at the bottom 40% of the Indian population, covering over 50 crore individuals from economically weaker sections. Beneficiaries are selected based on Socio-Economic Caste Census (SECC) 2011 data.
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Cashless and Paperless Access: Patients can receive treatment without paying upfront at any of the empanelled hospitals under the scheme.
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Pan-India Portability: Beneficiaries can avail services across India, regardless of their place of registration or treatment.
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Wide Range of Treatments Covered: The scheme covers 25 specialities including cardiology, oncology, orthopaedics, and more. It includes pre- and post-hospitalization expenses, diagnostics, and medicines.
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Empanelled Hospitals: Both public and private hospitals can be part of the network, increasing access and choices for patients.
Implementation and Governance
PMJAY is implemented by the National Health Authority (NHA) at the central level and by State Health Agencies (SHAs) at the state level. States have the flexibility to implement the scheme through:
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Insurance Model
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Trust Model
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Mixed Model
This flexibility ensures adaptability to local administrative capacities and existing insurance infrastructure.
Achievements and Impact
Since its launch, Ayushman Bharat Insurance has made significant strides in improving access to healthcare for millions of Indians:
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Crores of Beneficiaries: Over 5 crore hospital admissions have been facilitated under the scheme since its inception.
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Women Empowerment: Nearly 50% of PMJAY cardholders are women, empowering them with direct access to healthcare services.
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Reduced Out-of-Pocket Expenditure: By providing cashless treatment, the scheme significantly reduces catastrophic healthcare expenses, a major cause of poverty in India.
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Strengthening Infrastructure: The scheme has indirectly contributed to infrastructure upgrades in hospitals, especially in Tier 2 and Tier 3 cities, to meet empanelment standards.
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Digital Transformation: The creation of the Ayushman Bharat Digital Mission (ABDM) is helping in digitizing health records and improving service delivery.
Challenges and Criticisms
Despite its massive scale and intent, Ayushman Bharat Insurance faces several challenges:
1. Inadequate Awareness
Many eligible beneficiaries are still unaware of the scheme or how to access its benefits. There is a need for stronger information, education, and communication (IEC) campaigns.
2. Quality of Care
While private hospitals have participated actively, there have been concerns regarding the quality and consistency of care offered under the scheme, especially in rural and underserved regions.
3. Fraud and Abuse
There have been instances of fraudulent claims, ghost beneficiaries, and unethical practices by certain healthcare providers. The government has been working to tighten auditing mechanisms and use technology to prevent such issues.
4. Sustainability and Funding
With rising healthcare costs and increasing enrolment, ensuring sustainable funding remains a concern. Regular budgetary allocations and public-private partnerships are being explored to address this.
5. Limited Coverage Scope
Critics argue that the scheme focuses mainly on hospitalization and not enough on preventive care, diagnostics, and outpatient services, which form a significant portion of health expenditures.
Future Outlook and Reforms
The government is committed to strengthening Ayushman Bharat Insurance as a cornerstone of India’s healthcare delivery system. Some of the notable future plans and reforms include:
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Expansion of Beneficiary Base: Efforts are underway to include more families beyond SECC 2011 data, potentially moving toward universal health coverage.
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Integration with Digital Health Infrastructure: Through the Ayushman Bharat Digital Mission (ABDM), the government aims to create a unified digital health ecosystem with electronic health records (EHRs), digital health IDs, and real-time claim processing.
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Greater Emphasis on Preventive Care: There is a growing shift in focus toward early detection and prevention through health and wellness centers, aiming to reduce the disease burden.
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Enhanced Hospital Network: Steps are being taken to increase the number of empanelled hospitals, especially in remote areas, to improve accessibility.
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Public-Private Partnerships: Strategic collaborations with private insurers, technology providers, and healthcare institutions are being encouraged to improve reach and efficiency.
Conclusion
Ayushman Bharat Insurance is a transformative initiative that seeks to bring dignity, security, and better health outcomes to India’s most vulnerable populations. While it is still a work in progress with areas that require attention, it has already made a profound impact on the lives of millions.
In a country where out-of-pocket expenses often push families into poverty, Ayushman Bharat represents a bold and visionary step toward achieving universal health coverage. If implemented with efficiency, transparency, and inclusivity, it has the potential to become a global model for public healthcare delivery.