Ayushman Bharat: UPSC Indian Society Guide to India’s Health Scheme

Ayushman Bharat is the Government of India's flagship initiative to achieve Universal Health Coverage (UHC) and realise the Sustainable Development Goal commitment to "leave no one behind". Launched in 2018 as recommended by the National Health Policy, 2017, Ayushman Bharat combines primary care (Health and Wellness Centres) with the world's largest health assurance scheme (PM-JAY). For UPSC GS-II (welfare, health) and GS-I (social issues) aspirants, it is a must-know programme.

Conceptual Framework: Why UHC Matters

Health is a prerequisite for development. India's challenges:

• Out-of-pocket (OOP) health expenditure stood at 62.6% in 2014-15; fell to 39.4% by 2019-20 (National Health Accounts).
• Catastrophic health costs push 55 million Indians into poverty annually (WHO-World Bank).
• WHO recommends every country invest at least 4% of GDP on health.
• India's public health expenditure: 1.84% of GDP (2021-22) — target of 2.5% by 2025 under NHP 2017.

Ayushman Bharat addresses UHC across three domains: availability, accessibility, affordability.

Architecture of Ayushman Bharat

Ayushman Bharat has two inter-related components:

1. Health and Wellness Centres (HWCs) — now Ayushman Arogya Mandirs

• Transformation of existing Sub-Centres and Primary Health Centres into comprehensive primary care units.
• Target of 1,50,000 HWCs announced in February 2018.
• By 2024, over 1.76 lakh Ayushman Arogya Mandirs operational.
• Services include:
• Maternal and child health
• Non-communicable diseases (hypertension, diabetes, cancer screening)
• Mental health
• Eye care, oral care
• Free essential drugs and diagnostics

2. Pradhan Mantri Jan Arogya Yojana (PM-JAY)

• World's largest health assurance scheme.
• Health cover of Rs 5 lakh per family per year for secondary and tertiary care hospitalisation.
• Covers approximately 55 crore beneficiaries (12.37 crore families).
• Public and private empanelled hospitals — over 29,000 by 2024.
• Cashless, paperless, portable across states.
• Beneficiaries identified from SECC 2011 deprivation indicators.
• No cap on family size, age, or gender.
• Covers 1,949 medical procedures across 27 specialties.
• Pre-hospitalisation and post-hospitalisation expenses included.

India's Situation: Impact So Far

By 2024:

Significance

• Reduction in catastrophic health expenditure: OOP declined from 62.6% to 39.4% partly due to PM-JAY.
• Expanded private sector access: Poor beneficiaries can access private hospitals earlier unavailable.
• Portable coverage: Migrants covered across states.
• Gender equity: Women constitute nearly half of beneficiaries — significant given India's gender-skewed health-seeking patterns.
• NCD focus: HWCs tackle India's NCD burden (heart disease, diabetes, cancer).
• Digital backbone: Interoperable with Ayushman Bharat Digital Mission (ABHA ID).

Challenges

Exclusion Errors

• SECC 2011 is outdated: Many deserving households missed; welfare lists being revised via Awaas Plus and state data.
• Caste classification errors in SECC (~40 lakh entries).

Asymmetric Federalism

• Several states (Kerala, Tamil Nadu, Andhra Pradesh) expanded coverage at own cost.
• Cash-strapped states (Bihar, Jharkhand) depend heavily on Centre.

Ghost Beneficiaries and Fraud

• CAG Report (2023): Fraudulent registration of ~7.5 lakh beneficiaries under a single phone number.
• Invalid names, duplicate IDs, unrealistic dates of birth in beneficiary databases.
• Upcoding, dead patient admissions, double billing.

Cost and Payment Delays

• PM-JAY rates kept as guidelines — big hospitals often reject patients; smaller hospitals absorb losses.
• Payment backlogs to hospitals lead to service rejection or rationing.

Inequity in Access

• Empanelment gaps in remote areas (Northeast, Leh, hill districts).
• Connectivity issues in conflict zones (Kashmir, LWE-affected districts).
• Poor beneficiaries with rare or unlisted conditions excluded.

Implementation

• Low share of total health spending: PM-JAY < 2.5% of total health expenditure.
• Uneven State Health Agency (SHA) formation — some states delayed.
• Parallel transaction systems → beneficiary overlap with state schemes.
• Public financial management system (PFMS) non-compliance.

Government Schemes and Institutional Framework

Suggestions for Improvement

Systemic Reforms

• Consolidate government healthcare spending and clear payment backlogs.
• Provide every beneficiary with an Ayushman Card — NHA targets 100% coverage.
• Form SHAs and fraud cells in states where lacking.
• Address upcoding, dead-patient billing, double charging through AI-powered audits.
• Move toward unified transaction management system across state and central schemes.

IMA Recommendations

• Government hospitals (already free) should be excluded from PM-JAY scope; direct funding preferred.
• Move away from insurance-based healthcare delivery due to administrative costs and profit motive of insurers.

Towards 'Sampann Bharat'

• Invest in preventive and promotive health alongside curative.
• Strengthen primary care via Ayushman Arogya Mandirs.
• Integrate mental health, elderly care, women's health comprehensively.

Latest Developments (2024-26)

• PM-JAY 70+ extension (October 2024): Cabinet approved extension of PM-JAY to all citizens aged 70 years and above, irrespective of income. Adds 6 crore elderly to the scheme.
• Ayushman Arogya Mandirs: By 2024, over 1.76 lakh centres operational; offering non-communicable disease screening, tele-consultation.
• ABDM progress: Over 67 crore ABHA IDs issued; 3.3 lakh health facilities registered on Health Facility Registry.
• Rs 1 lakh crore authorisation milestone (2024): PM-JAY crossed Rs 1 lakh crore worth of hospital admissions.
• 2024 Lok Sabha elections: Health became a key campaign issue; INDIA bloc proposed Rs 25 lakh coverage; NDA committed to expand Ayushman Bharat.
• Caste census data: Bihar 2023 survey showed higher OOP health burden on OBC/EBC households — reinforcing case for PM-JAY expansion.
• MPI 2024 (NITI Aayog): Maternal and child health indicators improved, partly attributable to Ayushman Arogya Mandirs.
• SDG India Index 2023-24: SDG 3 (Good Health) composite score improved; Kerala leads, Bihar lags.
• National Health Accounts 2019-20: OOP share of total health expenditure fell to 39.4% from 48.21% in 2018-19.
• Private hospital strike threats (2023-24): Over package rate revisions; NHA revised 120+ package rates upward.
• Women's Reservation Act, 2023 implementation (pending) expected to increase legislative attention to women's health.

UPSC Relevance

• Prelims: PM-JAY eligibility, HWCs, NHA, SECC 2011.
• GS-II: Welfare schemes, health policy, governance.
• GS-III: Inclusive growth, human resource development.
• Essay: "Universal health coverage: from promise to practice."

Your answer should:

1. Explain Ayushman Bharat's two components — HWCs and PM-JAY.
2. Cite scale metrics — 35+ crore cards, 7.5 crore admissions, Rs 1 lakh crore value.
3. Assess successes — reduced OOP, expanded access, gender equity.
4. Acknowledge challenges — fraud, payment delays, asymmetric federalism, exclusion errors.
5. Argue for primary care strengthening, not just tertiary insurance coverage.
6. Link to Ayushman Bharat Digital Mission as enabling infrastructure.

Universal health coverage is less about the scheme than about the civilisational commitment behind it: no family should go bankrupt when a child falls ill. Ayushman Bharat moved India several steps closer to 'Swasth Bharat' and, eventually, 'Sampann Bharat'. The next phase must match coverage width with care depth.

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