Ayushman Bharat & the National Health Mission

Overview

Ayushman Bharat, launched in September 2018, is the world's largest government-funded health insurance scheme. It aims to provide health coverage of ₹5 lakh per family per year to over 10 crore (100 million) poor and vulnerable families — approximately 50 crore (500 million) beneficiaries, or 40% of India's population. The scheme represents a paradigm shift from India's historically fragmented, out-of-pocket health financing model toward a more systematic, insurance-based approach to universal health coverage (UHC).

Ayushman Bharat has two pillars: PM-JAY (Pradhan Mantri Jan Arogya Yojana), which provides secondary and tertiary care insurance; and Health and Wellness Centres (HWCs), which deliver comprehensive primary care. The scheme is complemented by the National Health Mission (NHM), which continues to fund infrastructure, human resources, and disease control programs, and by the ABHA digital health ID system, which aims to create interoperable electronic health records for all citizens.

Whether Ayushman Bharat will achieve its ambitious goals — and whether it will do so equitably — remains one of the most important questions in Indian health policy.

PM-JAY: Pradhan Mantri Jan Arogya Yojana

PM-JAY is the insurance component of Ayushman Bharat. It provides cashless coverage for listed secondary and tertiary care procedures at empaneled public and private hospitals.

• Eligibility: Based on the Socio-Economic Caste Census (SECC) 2011, which identified deprived rural households and occupational categories of urban workers. The scheme is fully funded by the central government, with states contributing a share (60:40 for general states, 90:10 for northeastern states).
• Benefits: ₹5 lakh per family per year for medical and surgical procedures across 25 specialties, including cardiology, oncology, nephrology, and orthopaedics. Pre-existing diseases are covered from day one. There is no cap on family size or age.
• Empanelment: Both public and private hospitals can be empaneled. As of 2024, over 25,000 hospitals are empaneled under PM-JAY, with roughly equal numbers in public and private sectors. However, empanelment does not guarantee quality — many private hospitals have been accused of fraudulent claims and unnecessary procedures.
• Package rates: The government fixes procedure rates, which are often lower than market rates. This has led to complaints from private hospitals that the rates are unsustainable, and from patients that empaneled hospitals refuse PM-JAY beneficiaries or demand top-up payments.
• Claims: Over 6 crore hospital admissions have been authorized under PM-JAY since its launch, with a claims amount of over ₹80,000 crore. The average claim size is ₹15,000–20,000.

ABHA: Ayushman Bharat Health Account

The Ayushman Bharat Health Account (ABHA) is a 14-digit unique health identifier that aims to create a unified digital health infrastructure for India. Every citizen can create an ABHA number and link their health records to it.

• Purpose: ABHA enables the creation of longitudinal health records that follow the patient across providers and states. The vision is that a patient in Kerala can access their health history when they visit a hospital in Delhi, eliminating the need to carry paper records and reducing duplication of tests.
• Consent framework: The National Digital Health Mission (NDHM), now part of ABHA, promises a consent-based system where patients control who can access their data. However, critics have raised concerns about data privacy, the security of centralized health records, and the potential for exclusion of those without digital literacy or smartphone access.
• Adoption: As of 2024, over 60 crore ABHA numbers have been created. However, actual usage — the linking of health records and their retrieval across providers — remains limited. Many health facilities are not yet integrated into the digital ecosystem.

National Health Mission (NHM)

The National Health Mission (launched in 2005 as the National Rural Health Mission, expanded to urban areas in 2013) is the backbone of India's public health system. It provides funding for:

• Infrastructure: Construction and renovation of PHCs, CHCs, and sub-centres
• Human resources: Salaries of ASHAs, auxiliary nurse-midwives (ANMs), doctors, and specialists; incentives for rural service
• Disease control programmes: National Vector Borne Disease Control Programme (malaria, dengue, kala-azar), Revised National Tuberculosis Control Programme (RNTCP), National Leprosy Eradication Programme, Integrated Disease Surveillance Programme (IDSP)
• Maternal and child health: Janani Suraksha Yojana (institutional delivery incentives), Janani Shishu Suraksha Karyakram (free maternal and child care), Rashtriya Bal Swasthya Karyakram (child health screening)
• Family planning: Free contraceptives, sterilization camps, counselling
• Immunization: Universal Immunization Programme (UIP) — one of the world's largest, reaching 26 million infants annually

The NHM is implemented through State Health Missions, giving states flexibility in how they use central funds. However, this flexibility also leads to wide variation in performance. Kerala and Tamil Nadu consistently outperform Bihar and Uttar Pradesh on NHM indicators.

Pradhan Mantri Bhartiya Jan Aushadhi Pariyojana (PMBJP)

The Jan Aushadhi scheme provides quality generic medicines at affordable prices through dedicated Jan Aushadhi Kendras. As of 2024, there are over 10,000 such stores across India, offering over 1,700 medicines and 300 surgical items at 50–90% below market rates.

• Impact: The scheme has reduced out-of-pocket expenditure on medicines, particularly for chronic diseases (diabetes, hypertension, cardiovascular conditions) where drug costs can be prohibitive.
• Challenges: Many Jan Aushadhi stores face supply shortages. Doctors in private practice often do not prescribe generic medicines, preferring branded alternatives. Public awareness of the scheme remains limited in rural areas.

Critiques and Challenges

Ayushman Bharat has been praised for its ambition but criticized on multiple grounds:

• Exclusion errors: The SECC 2011 database is outdated. Many eligible families are not listed, while some ineligible families have been included. States have complained about the rigidity of central eligibility criteria.
• Supply-side constraints: PM-JAY creates demand for hospital care, but the supply of quality hospitals — especially in rural and underserved areas — has not kept pace. Beneficiaries often cannot find empaneled hospitals nearby.
• Quality concerns: Empaneled private hospitals have been accused of fraud, unnecessary procedures, and overcharging. The monitoring and grievance redressal mechanisms are weak.
• Neglect of primary care: Critics argue that PM-JAY's focus on tertiary care insurance distracts from the more fundamental need to strengthen primary health care. Insurance does not prevent disease; public health infrastructure does.
• Cost escalation: The scheme's budget has grown rapidly. In FY2024–25, PM-JAY was allocated ₹7,500 crore, but actual expenditure has often exceeded allocation. Sustainability of funding is a concern.
• Digital divide: ABHA and digital health records assume a level of digital literacy and connectivity that does not exist for millions of Indians. The risk of exclusion is significant.

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