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Pradhan Mantri Jan Arogya Yojana: Largest Health Assurance Scheme in The World

The Pradhan Mantri Jan Arogya Yojana (PMJAY) stands out as a crucial endeavour within the field of public health policy in an era marked by changing healthcare landscapes and an increasing emphasis on universal health coverage (Government of India). PMJAY has attracted attention as a revolutionary programme. It was established with the goal of delivering accessible and affordable healthcare to millions of underprivileged people throughout India (Government of India, 2018). This case study explores the many facets of PMJAY, including its origins, implementation methods, effects on healthcare delivery, difficulties encountered, and its role in shaping the nation’s healthcare trajectory. 

India’s economy has emerged as one of the top three fastest-growing economies in the world for the past few decades, drawing attention from throughout the globe (World Bank, 2021). However, despite achieving outstanding progress in several areas, India is still categorised as a Lower Middle-Income Country (LMIC) by the World Bank, mostly because of its uneven socioeconomic and health indicators (World Bank, 2018). Keeping in mind the then-existing healthcare system, the government of India initiated the PMJAY scheme. 

Health Infrastructure In India

Health Infrastructure In India

Since 1947, the state-sponsored health system in India has gone through four major phases that can be distinguished (Rao, 2019): 

Phase 1 (1947-1965): The creation of a basic health infrastructure, emphasising primary care and preventative services, was the focus during this time. An important factor in the development of this stage was the 1946 Bhore Committee Report. The Indian government made substantial investments in the construction of hospitals, primary health centres, and rural health posts. 

Phase 2 (1965-1980): During this period, family planning programmes were expanded, and the focus moved to maternal and child health. Notably, several disease prevention initiatives were started, such as the smallpox and malaria eradication programmes.  

Phase 3 (1980–2000): As a result of the government’s focus on economic development, public health spending fell throughout this phase. Nevertheless, major achievements were made, including the rollout of the National Rural Health Mission (NRHM) and the implementation of the Universal Immunisation Programme (UIP). 

Phase 4 (since 2000): The current phase is characterised by a renewed focus on public health, which is reflected in increasing government healthcare spending and the introduction of numerous innovative projects. A goal for a more just and effective healthcare system was set forth in the National Health Policy of 2002 (Ministry of Health and Family Welfare, 2002).  

Further, India health spending patterns 1995-2014, were depicted in Figure 1. Certainly, comparing India’s health spending patterns from 1995 to 2014 based on Out-of-Pocket Expenditure (OOPE) as a percentage of total expenditure on health and Government expenditure on health as a percentage of total expenditure on health can provide valuable insights. During this period, India likely witnessed a significant reliance on Out-of-Pocket Expenditure (OOPE) for healthcare. OOPE as a percentage of total expenditure on health reflects the proportion of healthcare costs that individuals and households had to pay directly. A high OOPE percentage suggests that a substantial burden was placed on individuals for healthcare expenses, potentially leading to financial hardships for many. On the other hand, Government expenditure on health as a percentage of total expenditure on health indicates the contribution of public funds towards healthcare. A lower percentage here signifies a less substantial role of the government in providing healthcare services and financial protection to the population. Comparing these two percentages over the years can show whether India’s healthcare system was becoming more inclusive and government-supported or if it continued to rely heavily on individual payments. Ideally, a decrease in OOPE as a percentage of total expenditure on health and an increase in government spending on health would reflect progress towards a more accessible and equitable healthcare system. 

Figure 1: India Health Spending Patterns 1995-2014 
Source: NHA 
Overview of PMJAY: A Scheme To Revolutionize Healthcare

Overview of PMJAY: A Scheme To Revolutionize Healthcare

In alignment with the vision outlined in the National Health Policy 2017, the Union Budget 2018-19 heralded the introduction of ‘Ayushman Bharat’ to promote a healthier India. The Government of India introduced two pivotal initiatives within the healthcare sector as part of Ayushman Bharat, aiming to bring about transformative changes in healthcare delivery across primary, secondary, and tertiary care systems. These initiatives encompass preventive measures as well as health promotion strategies. The key features of PMJAY are illustrated in Figure 2. The government’s objective is to not only enhance overall health but also to prevent wage loss, financial hardships, and job-related setbacks while propelling the growth of the healthcare industry. 

Through these measures, the Indian healthcare landscape is on the cusp of a significant transformation towards achieving Universal Health Coverage (UHC). It is projected that approximately 20 crore (80%) families will benefit from the comprehensive coverage provided by AB-PMJAY, which will be supplemented by private insurance schemes and other government-funded health programs like CGHS, ESIS, Railways, and ECHS. In a significant address, Prime Minister Narendra Modi, along with Cabinet member Dr. Harsh Vardhan, highlighted that the inaugural year (2018) of Ayushman Bharat Yojana has already alleviated the suffering of more than 50 crore economically disadvantaged individuals in India. 

The PMJAY healthcare programme is an entitlement-based programme with no formal enrolment requirements (National Health Authority). 10.74 crore families are expected to be covered, including 8.20 crore living in rural areas and 2.33 crore in urban areas as per the latest SECC data. The most recent data available shows that these households are still the focus of the program’s coverage efforts.  

The programme identifies targeted low-income and underprivileged rural families using information from the most recent Socio-Economic Caste Census (SECC) (National Health Authority, 2023). This information comprises 11 occupational categories of urban workers’ families in addition to categories like D1, D2, D3, D4, D5, and D7 (National Health Authority). The coverage also extends to families that had previously signed up for the Rashtriya Swasthya Bima Yojna (RSBY), even though they do not belong to the SECC’s target groups (National Health Authority). There is no cap on family size and age in the scheme and an Aadhar card is not mandatory. One would only need to establish one’s identity to avail of benefits under the scheme which can also be done through an election ID card or ration card (TOI, 2018). 

States are still required to map and cover AB-PMJAY beneficiaries even if their populations exceed those on the benefit list (National Health Authority, 2023). At empanelled healthcare providers, Common Service Centres (CSCs), and other approved locations made possible by the State Health Agency (SHA), beneficiaries can get an AB-PMJAY e-card printed with a unique ID. The NHA specifies the requirements for beneficiary identification, the method for creating an e-card, and other elements of beneficiary administration. 


Figure 2: Key features of PMJAY  
Genesis: Unveiling PMJAY

Genesis: Unveiling PMJAY

A significant portion of the population lacks access to a thorough national health protection system in a nation rich in stakeholders advancing global development. In response, the Pradhan Mantri Jan Arogya Yojana (PMJAY) was launched by the Indian government. the Ayushman Bharat The flagship health insurance programme, Pradhan Mantri Jan Arogya Yojana (AB PMJAY), was introduced on September 23, 2018, by Prime Minister Narendra Damodardas Modi in Ranchi. An important step towards achieving universal health coverage, this effort intends to offer comprehensive healthcare services to economically vulnerable segments of society (Ministry of Health and Family Welfare, 2018).  

The country’s top health insurance programme, PMJAY, is a transformative step towards obtaining universal health coverage and has grown to become the largest government-sponsored healthcare scheme in the world (Prime Minister of India, Mr Modi). The PM in his inaugural speech at Ranchi stated that the total number of beneficiaries from AB is more than the population of America, Canada and Mexico combined. The PM urged the people to memorize the helpline number of AB, 14555. According to health ministry officials, the 71st round of the National Sample Survey Organization (NSSO) revealed that 85.9 per cent of rural households and 82 per cent of urban households have no access to healthcare insurance/assurance. With a focus on economically disadvantaged families in both urban and rural India, each enrolled family is entitled to an annual health cover of Rs. 5 lakhs for secondary and tertiary hospitalisation, regardless of size or member age. This program’s scope has been expanded through the merger with the previous administration’s Rashtriya Swasthya Bima Yojna (Ministry of Health and Family Welfare, 2019).  

In keeping with the Universal Health Coverage (UHC) tenet, PMJAY works to guarantee that everyone has access to high-quality healthcare services that include curative, treatment, rehabilitative, and palliative care at an affordable price. Access, quality, and financial protection are the three main facets of the idea. To achieve the other Sustainable Development Goals, India is committed to provide Universal Health Care for everyone by 2030. By lowering out-of-pocket healthcare costs, it seeks to lessen the financial burden on society’s most economically disadvantaged individuals (World Health Organisation). 

The demographic composition of India makes these initiatives more urgent. More than 20% of the population still makes less than $1.9 per day despite significant economic improvement. The “triple burden of disease”— communicable diseases, non-communicable diseases (NCDs), and injuries—threatens India’s population increase in the 15–35-year-old age bracket, suggesting a rare opportunity for sustained economic growth. The extended and expanding need for healthcare services stems from this complex epidemiological condition (World Bank, 2018).  

The supply and demand sides of India’s healthcare system are both problematic. While the bulk of private healthcare providers is small, unregulated, and located in urban centers, the private sector accounts for over 70% of healthcare visits and 50% of hospital beds, creating a gap in services for the underprivileged population. In addition, due to India’s enormous population, public sector hospitals experience financial hardships, an inadequate number of resources, and a staffing deficit (World Health Organisation, 2017).  

Beneficiaries Under PMJAY

Beneficiaries Under PMJAY

Beneficiaries of the PMJAY are chosen in accordance with predetermined standards. These standards are different for urban and rural areas: 

  1. For Rural Areas: 
    Beneficiaries are selected from deprived households that meet at least one of six deprivation criteria (National Health Authority): 
    1. Only one room with kuccha walls and kuccha roof (D1).
    2. No adult member between the age of 16 to 59 (D2). 
    3. Female-headed households with no adult male member between the age of 16 to 59 (D3). 
    4. Disabled member and no able-bodied adult member (D4). 
    5. SC/ST households (D5). 
    6. Landless households deriving a major part of their income from manual casual labor (D7). Households without shelter, destitute/living on alms, manual scavenger families, primitive tribal groups, legally released bonded labour. 
  2. For Urban Areas:
    Beneficiaries in urban areas are selected based on their occupation (National Health Authority). The eligible occupational categories include: 
    1. Rag picker.
    2. Beggar. 
    3. Domestic worker. 
    4. Street vendor/cobbler/hawker/other service provider working on streets. 
    5. Construction worker/plumber/mason/labor/painter/welder/security guard/coolie and other head-load workers. 
    6. Sweeper/sanitation worker/mali. 
    7. Home-based worker/artisan/handicrafts worker/tailor. 
    8. Transport worker/driver/conductor/helper to drivers and conductors/cart puller/rickshaw puller. 
    9. Shop worker/assistant/peon in small establishments/helper/delivery assistant/attendant/waiter/electrician/mechanic/assembler/repair worker/washer-man/chowkidar. 
The Underlying Purpose Of PMJAY

The Underlying Purpose Of PMJAY

India’s healthcare system was facing a number of pressing issues prior to the launch of the PMJAY, underscoring the urgent need for a transformative intervention. 

  1. Heightened Healthcare Demand: 

    India’s enormous population, which surpassed 1.35 billion in 2018, cemented its status as the second-most populated country in the world. This demographic was distinguished by a sizeable young component, which made up 66.43 percent of the total population (ages 15–64) and 6.18 percent of those 65 and older. India’s population dividend period, marked by a significant increase in the working-age population, began in 2018 and is expected to last until 2055, a remarkable 37 years after it commenced (KPMG Report). However, this demographic advantage was accompanied by the expectation of an ageing population, which the KPMG Report predicts will grow from 6.176 percent in 2018 to a considerable 19 percent by 2050. 

  2.  Healthcare Expenditure Challenges:   
    India’s healthcare spending environment was difficult. The country ranked last among the BRIC countries in terms of total health expenditure as a proportion of GDP in 2018. It was only 4.2 percent. Pre-PMJAY health expenditure landscape in different economies are depicted in figure 3. As a percentage of GDP, government expenditure on health was at 1.13 percent in 2014–15 and very slightly increased to 1.18 percent in 2015–16. However, analysts argued that there need be a major increase to reach a 2.5 percent GDP allocation by 2025, especially in light of the fact that the global average health spending (% of GDP) was much higher in 2016 at 10.2 percent (World Bank Report, 2018). 

  3. Figure 3: Pre-PMJAY Health Expenditure Landscape in Different Economies (Adapted from World Bank Report, 2018) 

  4. Changing Disease Profile 

    NCDs now account for a significant portion of mortality in India, up from 37.1 percent in 1990 to 61.8 percent in 2016. Due to this worrying trend, NCDs currently make up a sizable 55% of all ailments in the country. Regrettably, approximately 23% of India’s population is now at risk of premature death as a result of these non-communicable diseases. Global Incidence of Deaths from Non-communicable Diseases are shown in figure 4. 

    The fact that a sizable portion of district hospitals lack the necessary medical resources to adequately treat non-communicable diseases is particularly alarming. As a result, a sizeable percentage of those suffering from these diseases rely heavily on private institutions for their healthcare, highlighting a significant difference in the availability of quality medical care.  

  5. Figure 4: Global Incidence of Deaths from Non-communicable Diseases (Adapted from World Bank Report, 2018)

  6.  Catastrophic Healthcare OOPE 

    In India’s healthcare system, catastrophic out-of-pocket expenses (OOPE) are still a major source of concern. Individuals directly bear the burden of 62.6 percent of the nation’s overall health expenditures through out-of-pocket expenses. Households and individuals are subject to a significant financial burden as a result, which affects their general economic well-being (Kruk et al., 2009). According to statistics, 17.3% of people spend more than 10% of their household’s overall spending on healthcare (National Sample Survey Organisation, 2014). This enormous financial load has negative effects. Due to these exorbitant healthcare costs, around 5.5 crore (55 million) Indians are forced into poverty each year. 3.8 crore (38 million) people—a figure that is even more startling—find themselves living below the poverty line due just to the price of buying essential pharmaceuticals.  

    PM-JAY’s coverage of approximately 90% of medical out-of-pocket (OOP) costs among the covered populations, as indicated by Gruber et al. in 2022, underscores its effectiveness in providing financial protection. This level of coverage becomes even more substantial when considering the potential for national adoption, aligning with the exemplary performance of the best-performing states. PM-JAY’s ability to safeguard individuals and families from catastrophic health expenditures is thus greatly enhanced. 

  7. Health Indices 

    India’s health indicators have significantly improved in recent years. A critical measure of maternal health, the Maternal Mortality Ratio (MMR), has significantly decreased by 77 percent, going from 556 deaths per 100,000 live births in 1990 to 130 per 100,000 live births in 2016. This development has pushed India’s MMR below the Millennium Development Goals (MDGs) objective and puts the nation on track to meet the Sustainable Development Goals (SDGs) target of achieving an MMR below 70 by 2030. 

    Additionally, India’s Infant Mortality Rate (IMR) has shown encouraging developments. The number of deaths per 1,000 live births decreased from 42 in 2012 to 33 in 2017, indicating improvements in paediatric healthcare. In addition, India’s life expectancy has significantly increased. Male life expectancy climbed from 62.3 to 67.3 years during the course of a decade, from 2001 to 2005 to 2011 to 2015, while female life expectancy went from 63.9 to 69.6 years. 

  8. Indicator 




    Maternal mortality ratio 



    77% reduction 

    Infant mortality ratio 




    Life expectancy (males) 



    +5 years 

    Life expectancy (females) 



    +5.7 years 

    Table 1: Health Indices Before PMJAY (Source: KPMG Report 2018)

  9. Health Infrastructure 
    The healthcare infrastructure in India faces numerous difficulties. It has the lowest hospital bed density among the BRIC countries, with just 1 bed per 1,000 people. Notably, the private sector accounts for a sizable number of hospitalisation cases, holding a 63 percent majority share of hospital beds (rural: 58.1 percent and urban: 68.0 percent). Due to a lack of both healthcare staff and physical facilities, 79 percent of urban residents and 72 percent of rural residents, respectively, seek outpatient services from the private sector. Similar to this, 58 percent of rural inhabitants and 68 percent of urban residents choose inpatient care provided by the private sector. 
  10. Indicator 


    Hospital beds per 1,000 population 

    Private sector share of hospital beds 


    Share of hospitalized cases –rural 


    Share of hospitalized cases –urban 


    Percentage seeking out patient- rural 


    Percentage seeking out patient- urban 


    Percentage seeking in patient- rural 


    Percentage seeking in patient- urban 


    Table 2: Health Infrastructure Before PMJAY 
    (Source: KPMG Report, 2018) 

  11. Healthcare Workforce 

    Significant challenges are presented by the healthcare worker situation in India. The nation has the lowest ratio of doctors per 10,000 people among the BRIC countries, at about 0.7. This shortage is especially problematic because only one-third of India’s population, or around 44.2 crore people, who live in metropolitan areas, are served by 74% of the country’s doctors. Additionally, there is a severe lack of medical specialists in Primary Health Centres (PHCs), with a reported shortage of 3,027 doctors as of March 31, 2017. 

  12. Indicator 


    Physician per 1000 population 


    Percentage of doctors serving 1/3 population 


    Urban population covered by doctors 


    Shortfall of doctors at PHC 


    Table 3: Health Workforce Before PMJAY 
    (Source: KPMG Report, 2018) 

  13.  Disparity in Health Status Across States  

    In India, there is a considerable disparity in the health of the various states. The best-performing state received a score that was more than 2.5 times higher than the least-performing state in the category of larger states, indicating a considerable disparity in overall Health Index ratings. With a stellar aggregate score of 74.01, Kerala stands out as the best performer among the Larger States. With a substantially lower overall score of 28.61, Uttar Pradesh stands out as the state performing the worst. 

    The Health Index scores ranged from 38.51 in Nagaland, which indicates worse health standards, to 74.97 in Mizoram, which indicates relatively better health standards, when looking at the Smaller States. Similar discrepancies were seen between the Union Territories (UTs), where the Health Index values ranged from 41.66 in Daman and Diu to 63.62 in Chandigarh. 



Smaller State 


Overall Health Index Score 

Best Performing 




Least Performing 




Larger State 


Overall Health Index Score 

Best Performing 




Least Performing 

Uttar Pradesh 



Union Territories 


Overall Health Index Score 

Best Performing 




Least Performing 

Daman and Diu 



Table 4: Health Spending in Different States  
(Source: National Health Authority, 2018) 

Legislative Process Of The PMJAY

Legislative Process Of The PMJAY

The PMJAY Ayushman Bharat initiative’s legislative implementation process involved a number of clearly defined stages and the following significant developments: 

  1. Initiation and Inauguration (September 2018) 
    The PMJAY Ayushman Bharat initiative was inaugurated by the Government of India on September 23, 2018. It was created as a ground-breaking government-funded healthcare initiative to meet the medical needs of economically disadvantaged groups. 
  2. Cabinet Endorsement (March 2018) 
    After initiation, the scheme underwent a crucial phase of endorsement by the Cabinet. This phase laid the groundwork for the scheme’s execution by meticulously outlining and finalising the plan’s financial allocation.
  3.  Parliamentary Scrutiny (2018) 
    After receiving Cabinet approval, the plan was brought before the parliamentary body for close examination and review. The Parliament’s deliberations and discussions allowed for a thorough analysis of the scheme’s complexities, funding mechanisms, and legislative elements. Members of Parliament had a chance to improve it through this procedure as well.  
  4. Resource Allocation 
    Careful resource allocation, a crucial component approved through the annual budgetary process, was essential to the scheme’s realisation. 
  5. Legal Framework 
    To enable the seamless integration of the plan into the healthcare environment, specific legal aspects and laws were modified or developed as the framework took shape. Based on the initiative’s precise criteria, several regulations were created. 
  6. Operational Guidelines 
    After the scheme’s parliamentary approval, operational guidelines were later developed. The detailed operating procedures for its administration and implementation were specified in these instructions. 
  7. State Collaboration 
    The federal government signed Memorandums of Understanding (MoUs) with the states and union territories, involving their active participation. These MoUs promoted cooperation and shared accountability during the implementation of the programme. 
  8. Registration and Empanelment 
    The procedures for registration and empanelment facilitated the execution of the scheme. In order to participate in PMJAY, medical institutions and healthcare professionals have to register and be verified. 
  9. Beneficiary Identification 
    The careful identification of beneficiaries was a pillar of the effort. This was achieved by skilfully combining information from the Socio-Economic Caste Census (SECC) with other relevant factors, assuring the targeted distribution of benefits. 
  10. E-card Distribution 
    In order to simplify access, e-cards were given to beneficiaries, giving them the tools, they needed to fully take use of the program’s benefits. 
  11. Implementation and Monitoring 
    Careful implementation and ongoing monitoring laid the foundation for the scheme’s realisation and continued efficacy, ensuring its seamless integration and its capacity to achieve its intended goal at the grassroots level. 
PMJAY Structure

PMJAY Structure

To ensure the proper operation of the Pradhan Mantri Jan Arogya Yojana (PMJAY), a number of crucial components form its structural foundation. 

At the core of this structure is the Pradhan Mantri Jan Arogya Trust (PMJAT), which acts as the implementing agency. PMJAY is in charge of overseeing and carrying out PMJAY, making sure that its benefits are delivered without delay to eligible families. The State Health Agency (SHA), which operates at the state level, is in charge of managing the actual application of PMJAY. This entails locating and authenticating beneficiaries, registering hospitals, keeping an eye on medical services, and making sure benefits are distributed promptly throughout the state. State governments are crucial to PMJAY because they raise awareness of the programme, mobilise funding, and make it easier for SHA and PMJAT to work together. They intervene as well to handle any problems that may come up during implementation. Another important element is the hospitals and healthcare providers, who are in charge of giving PMJAY beneficiaries access to high-quality medical care. To take part in the programme, these organisations and service providers must register with the SHA. By providing insurance coverage to PMJAY beneficiaries, the involved insurance companies play a significant role. They also manage the complex process of adjudicating insurance claims and making sure that payments are quickly paid to qualified persons. Lastly, PMJAY’s technology foundation is a powerful IT platform. The smooth operation of the programme is ensured by this platform, which streamlines procedures such beneficiary registration, hospital enrolment, claims processing, and benefit payments (National Health Authority, 2023). 

Implementation Model Of PMJAY

Implementation Model Of PMJAY

Different models are used by different Indian states to implement their health assurance and insurance programmes (Figure 5). Some decide to work with insurance providers, while others administer and carry out these programmes themselves within their own borders. States can choose their preferred implementation approach thanks to the flexibility provided by PM-JAY, which takes into account that they have various degrees of preparation and capacity to execute such initiatives. The assurance/trust model, the insurance model, or both may be used by states to implement their policies (National Health Authority, 2023). This adaptable approach enables states to align their healthcare programs with their unique circumstances and requirements. 

Modes of Implementation (# States/UTs) 

% of Beneficiary covered 

Trust (23) 


Hybrid (3) 


Insurance (7) 


Table 5: Mode of Implementation of PMJAY Source: NHA Annual Report 2021-22

Trust and Assurance Model

When implementing PM-JAY, states mostly use the Trust and Assurance Model. This concept avoids the involvement of insurance firms by having the State Health Agency (SHA) supervise and carry out the plan directly. With the SHA paying healthcare providers directly, this strategy places the financial risk of implementing the plan on the government. The SHA may use an Implementation Support Agency (ISA) for claim administration and related tasks even if an insurance company is not involved. The SHA takes on specialised activities such hospital empanelment, beneficiary identification, claims management, audits, and other pertinent tasks in addition to day-to-day management and administration of the programme (National Health Authority, 2023).

Insurance Model

As an alternative, the Insurance Model calls for the SHA to hold a bidding process in order to choose an insurance company that will be in charge of managing PM-JAY inside the State. Families who qualify pay an insurance company premium for the policy’s protection, which is established using market rates. The insurance provider then oversees the processing of claims and provider payments. According to this concept, the insurance company bears the financial risk related to the scheme’s implementation. The program’s provisions set a cap on the portion of premiums that insurance firms may keep for profits and overhead costs in order to prevent excessive profits (National Health Authority, 2023). This makes sure that the primary goal is still to provide the targeted beneficiaries with healthcare benefits.

Figure 5: States implementing different models. 
(Source: KPMG Report in association with ASSOCHAM) 

Mode of Implementation 

Public (row percentage) 

Private for Profit (row percentage) 

Private Not for Profit (row percentage) 

Total EHCFs (column percentages) 

Trust Mode 

6988 (57%) 

4796 (39%) 

454 (4%) 

12238 (60.4%) 

Hybrid Mode 

3419 (55%) 

2695 (43%) 

158 (3%) 

6272 (30.9%) 

Insurance Mode 

811 (52%) 

644 (41%) 

115 (7%) 

1570 (7.7%) 

Table 6: Overall distribution of PMJAY empanelment by mode of implementation and sector(Source: Empanelment of health care facilities under Ayushman Bharat ) 

Key Initiatives Envisioned For Effective Implementation PMJAY

Implementation Model Key Initiatives Envisioned For Effective Implementation PMJAY

The successful implementation of AB-PMJAY has been improved via the deployment of key measures. These programmes demonstrate a dedication to the program’s ongoing improvement. The National Health Authority (NHA) has taken the initiative to solve a variety of issues, putting special emphasis on crucial areas including data analytics and fraud management, package pricing, the participation of private hospitals, and programme awareness raising. 

Strengthening the Workforce for Implementation 

In order to create a technological platform for the prevention, control, screening, and management of Non-Communicable Diseases (NCDs), the Ministry of Health and Family Welfare teamed up with a trust and a computer technology business in June 2018. With the use of this platform, the AB-PMJAY programme and health and wellness centres will be effectively connected, ensuring a smooth continuum of care.  

Improving Screening Mechanisms 

In order to accelerate the adoption of AB-PMJAY and include more private hospitals, the NHA joined with the NATHEALTH-Healthcare Federation of India in February 2019. The NHA has also signed Memorandums of Understanding (MoUs) with organisations like the Railway Board, Coal India, North Municipal Corporation, and New Delhi Municipal Council to appoint PSUs and National Healthcare providers (NHCPs) under Ayushman Bharat. 

 Expanding the Network of AB-PMJAY Providers 

A Memorandum of Understanding (MoU) was signed in June 2019 with the Quality Control of India (QCI) to offer accredited hospitals digital certification. To ensure hospitals meet the certification requirements, the NHA has created three levels of phased quality certifications: Bronze, Silver, and Gold. Different criteria, financial incentives, and leverage are offered by these levels to empanelled hospitals that have received NQAS/NABH certification. Notably, three hospitals in October 2019 were awarded gold certificates. 

Enhancing Quality of Care 

In January 2019, the NHA published detailed grievance redressal rules with an emphasis on resolving grievances from all parties within the allotted timeframes. In addition, a new portal with an enhanced user interface was launched, giving features like standardised drop-down menus, auto-fetching beneficiary information, and a list of accredited hospitals. As of 2023, the PMJAY has achieved remarkable progress in providing seamless access to healthcare services. It has significantly expanded the reach of quality care by enlisting a network of 28,000 empanelled hospitals, which notably includes over 12,650 private hospitals (Figure 6). This comprehensive network has played a pivotal role in diminishing barriers to healthcare access, making quality medical services readily available to a broad spectrum of the population. 

Figure 6: Expanded the reach of quality care 
(Source: NHA, May 2023) 
Expenditure On PMJAY

Expenditure On PMJAY

In the Budget Estimates (BEs) for the Financial Year (FY) 2021-22, the Government of India (GoI) allocated ₹6,400 crore to PMJAY, which remained consistent with the FY 2020-21 BEs but marked a significant increase from the Revised Estimates (REs) of the previous year (Figure 7). In FY 2020-21, until 20th November 2020, GoI had released only ₹1,032 crore, accounting for 33 percent of the year’s REs. The COVID-19 pandemic had notable impacts on PMJAY, with a 64 percent decrease in the number of claims filed between 11th to 18th March 2020 and 25th March to 1st April 2020. On 4th April 2020, packages for COVID-19 testing and treatment were introduced. As of 15th July 2020, approximately 58 percent of all households in India were covered under PMJAY, with an additional 8 percent covered by state schemes. In FY 2020-21, GoI allocated ₹1,600 crore to Health and Wellness Centers (HWCs), with ₹431 crore expended by September 2020. HWCs were not engaged in COVID-19 tasks, and the pandemic did not disrupt their operationalization. As of 20th November 2020, 50,069 HWCs were operational, representing 65 percent of the cumulative target for FY 2020-21. There was a significant surge in HWC footfall, with 2,672 lakh people visiting HWCs across India as of October 2020, which was more than three times the total footfall recorded the previous year (Source: National Council of Applied Economic Research) (Figure 8). 

The estimated expenditure on the Pradhan Mantri Jan Arogya Yojana (PMJAY) for the financial year 2023 is projected to be ₹1.5 lakh crore (Source: National Council of Applied Economic Research) (Figure 9). 

Figure 7: Year-wise Details of Funds Allocated and Released under AB-PMJAY from 2018-19 to 2022-23 

Figure 8: Expenditure for PMJAY over different years 
(Source: National Council of Applied Economic Research). 

Figure 9: Change in Expenditure on PMJAY over different years 
(Source: National Council of Applied Economic Research) 

Scheme Convergence Under PMJAY

Scheme Convergence Under PMJAY

For beneficiaries of various healthcare programmes, including those run by the central and state governments, public sector undertakings (PSUs)/autonomous bodies, the National Health Authority (NHA) has started a scheme convergence under Ayushman Bharat-PMJAY to provide cashless medical treatment. These beneficiaries include staff members, retirees, their dependents, and vulnerable groups who require medical assistance from the government. The scheme convergence intends to enable digital healthcare, increase access through empanelled health care organisations (HCOs), improve grievance redressal, improve service quality, and prevent fraud. The following programmes have been added to NHA’s convergence platform: 

Ayushman CAPF Scheme 

  • Launched by the Ministry of Home Affairs and NHA. 
  • Provides cashless healthcare services to Central Armed Police Force (CAPF) personnel and their dependents. 
  • Covers seven categories of forces, including Assam Rifles, Border Security Force, and others. 
  • Utilizes the existing network of empanelled HCOs under AB PM-JAY and CGHS for cashless medical services. 
  • Beneficiaries can access various medical facilities without financial limits. 
  • Allows online reimbursement. 
  • NHA has processed 1.32 lakh claims on its IT platform. 
  • Over 35 lakh Ayushman CAPF cards printed, with Aadhaar authentication for a significant portion

Building and Other Construction Workers (BoCW) 

  • Collaboration between the National Health Authority and Ministry of Labour and Employment. 
  • Implemented in select states/union territories, including Bihar, Chandigarh, Nagaland, and Uttar Pradesh. 
  • Offers medical coverage of INR 5 lakhs per BoCW family annually with portability for treatment in any state. 
  • Over four lakh beneficiaries verified for enrollment. 

Central Government Health Scheme (CGHS) 

  • Revamped to provide cashless and paperless healthcare benefits to pensioners and their dependents. 
  • Onboarded onto NHA’s IT platform in June 2021. 
  • Operates across 74 cities in 24 CGHS zones. 
  • Covers 45 specialties and 1853 procedures/packages. 
  • Comprehensive coverage without exclusions, co-payments, deductibles, or annual limits. 
  • Facilitated 35.4 lakh claims of CGHS beneficiaries on the IT platform. 
  • 1851 CGHS empanelled HCOs provide cashless benefits. 

Employees’ State Insurance Scheme (ESIS) 

  • Extended health-benefit packages of AB PM-JAY to ESIS beneficiaries. 
  • Partnership between NHA and Employees’ State Insurance Corporation (ESIC). 
  • Provides medical benefits with no annual coverage ceiling. 
  • Includes all HBPs of AB PM-JAY and offers portability for treatment in any state. 
  • Over three thousand beneficiaries verified, with 1400+ preauthorizations raised for treatment. 

Health Minister’s Discretionary Grant (HMDG) 

  • Provided by the Ministry of Health and Family Welfare, Government of India to poor patients with an annual family income up to INR 125,000/- and below. 
  • Financial assistance up to a maximum of INR 125,000/- for hospitalization/treatment in government hospitals. 
  • NHA’s IT platform is customized for efficient application processing. 
  • Facilitated verification of 662 beneficiaries and 179 preauthorization requests since its launch on NHA’s IT platform in June 2021. 
PMJAY Quality Certification

PMJAY Quality Certification

The Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB PMJAY) Quality Certification programme was introduced by the NHA in partnership with the Quality Council of India (QCI) with the goal of assessing and assuring the quality of healthcare services provided by hospitals participating in the scheme. It is a vital component to ensure that beneficiaries receive high-quality and safe healthcare services This strategic alliance aims to hasten the accreditation procedure for hospitals while also raising the standard of medical care. Quality certification helps in enhancing patient satisfaction, improving healthcare standards, and building trust in the healthcare system. 

Collaboration with the Quality Council of India (QCI) 

The NHA, responsible for implementing PMJAY, has collaborated with the Quality Council of India (QCI) to establish a comprehensive quality certification process. QCI is a government body known for its expertise in assessing and certifying the quality standards of various sectors, including healthcare. This collaboration brings in QCI’s experience and credibility to the healthcare sector under PMJAY. The main goal is to create a network of healthcare providers dedicated to offering high-quality services while following industry standards. Together, NHA and QCI have created a straightforward and effective system for hospital certification. The NHA has decided to benefit from QCI’s proven methods, breadth of knowledge, and reputation for reliability in hospital certification. A technology platform is used to assist both desktop and on-site examinations as part of the certification procedure, which also involves hospital registration, document uploading, and the payment of modest fees. This approach supports the Digital India goal. 

Certification Process and Levels 

The quality certification process under PMJAY involves several key steps: 

Registration: Hospitals interested in obtaining quality certification register for the process. 

Document Upload: Hospitals are required to upload relevant documents and information related to their healthcare services. 

Submission of Nominal Fees: A nominal fee is submitted as part of the certification process. 

Desktop and On-Site Assessment: The assessment includes both desktop review and on-site evaluation of the hospital’s infrastructure, processes, and healthcare delivery standards. 

Technology Platform: The certification process utilizes a technology platform for efficient and standardized assessment. 

The certification levels under PMJAY include (Figure:10): 

  • Gold: The highest level of certification, indicating exemplary healthcare standards and practices. 
  • Silver: Hospitals meeting the required quality standards but not at the gold level. 
  • Bronze: Hospitals meeting the basic quality standards. 

The NHA also intends to provide incentives to certified hospitals in the form of higher reimbursement rates, in keeping with the current policy of rewarding recognised institutions. This strategy tries to get more hospitals to apply for accreditation. The three levels of the AB PMJAY Quality Certification are Gold, Silver, and Bronze, with Gold being the highest degree of certification that can be obtained under this initiative. 

Incentives for Certified Hospitals 

To encourage hospitals to participate in the quality certification process, NHA has introduced incentives for certified hospitals. These incentives include Higher Reimbursement Rates, certified hospitals receive higher reimbursement rates for the healthcare services provided to PMJAY beneficiaries. This financial incentive aims to attract more hospitals to apply for certification. Quality certification is a pivotal aspect of PMJAY, ensuring that beneficiaries receive healthcare services of high standards. The collaboration with QCI, a structured certification process, and incentives for hospitals contribute to the continuous improvement of healthcare quality under PMJAY. 

Figure 10: Three tier quality certification 
(Source: National Authority of India ) 
International Views On PMJAY

PMJAY Quality Certification

A notable illustration of India’s dedication to developing global healthcare is the Pradhan Mantri Jan Arogya Yojana (PMJAY). As the biggest health assurance programme in the world, PMJAY has attracted attention and recognition on a global scale. Experts, policymakers, and global health organisations are all interested in and optimistic about it as a result of its deployment and success. The PMJAY programme has been praised by the World Bank as being innovative and ambitious because of its potential to revolutionise Indian healthcare. The PMJAY programme has received praise from the World Health Organisation (WHO) for its ability to significantly improve the lives of millions of people. 

Many nations aiming to achieve universal health coverage (UHC) and lessen healthcare inequities look to PMJAY as a model. UHC is feasible in even the most populous and diverse nations thanks to its creative approach to providing financial security to disadvantaged individuals and its wide network of accredited hospitals. The programme demonstrates how digital solutions may shape the future of healthcare accessible through the use of technology for beneficiary identification, cashless transactions, and effective claim processing.  

According to a report in Mint dated August 28, 2023, Dutch officials recently visited the offices of the NHA. This visit occurred in the context of the Netherlands’ plans to introduce a digital genetic passport for its citizens. The purpose of this genetic passport is to identify Dutch citizens based on their susceptibility to hereditary diseases. This initiative highlights the growing interest in utilizing genetic information for healthcare purposes and raises discussions about privacy and data security. 

At the G20 Health Ministers’ Meeting in Gandhinagar, India, held on August 20, 2023, the Chief of the World Health Organization (WHO), Tedros Adhanom Ghebreyesus, commended India’s Ayushman Bharat Scheme for its remarkable efforts in achieving Universal Health Coverage. He highlighted the significance of promoting digital health as a valuable tool to enhance healthcare accessibility, especially in remote areas and among those with limited financial means. Ghebreyesus praised India’s leadership in the digital health sector and cited Ayushman Bharat as an example where community health workers effectively connected with doctors remotely, showcasing the potential for global application of similar digital healthcare technologies. “WHO has always supported Ayushman Bharat. We believe that countries should invest in primary healthcare and India is doing that. I am glad that I got the opportunity to visit here. India has done its best to fight COVID-19,” as per WHO Director-General, Dr. Tedros. 

Additionally, PMJAY emphasises the significance of public-private partnerships in increasing access to healthcare. PMJAY has expanded its network and given its clients a variety of healthcare service options by bringing in commercial healthcare providers. Other nations looking to work with the private sector to improve their healthcare systems can learn a lot from this strategy. In essence, PMJAY plays a part in advancing healthcare around the world outside of India. It motivates governments to seek comprehensive healthcare reforms, use technology, and cultivate alliances that can close healthcare disparities and enhance population wellbeing. PMJAY is a shining example of innovation and a monument to the transformative potential of global healthcare efforts as the world works towards the goal of universal health coverage. 

Impact Of PMJAY: Catalyzing Healthcare Transformation

Impact Of PMJAY: Catalyzing Healthcare Transformation

The Government of India’s premier health reform initiative is called PMJAY was introduced in 2018 (Figure 11) to give the nation’s lowest and most vulnerable citizens access to high-quality healthcare. The objective of PMJAY includes a comprehensive cashless healthcare system for secondary and tertiary care hospitalisation, with coverage for over 500 million people by 2030. “For India, Health is a service and never commerce alone” as per Dr Mansukh Mandaviya, Minister of Health and Family Welfare (17 August 2023). The programme, which is currently in use in 33 States/UTs across the country, covers a wide spectrum of illnesses, from common maladies like diabetes and hypertension to serious conditions like cancer and cardiac problems. Additionally, the PMJAY programme facilitates comprehensive medical care by paying for pre- and post-hospitalization costs including as diagnostic tests, drugs, and follow-up care (National Health Authority, May 2023).  

Figure 11: PMJAY milestones 
(Source: National Health Authority; 
Figure 12: Reforms under PMJAY 
(Adapted from PMJAY, National Health Authority) 

Beyond healthcare provision, PMJAY emphasises the value of preventative care and works to promote a culture of wellness and health consciousness. The initiative’s growth trajectory serves as a symbol of its dedication to promoting public welfare. Initiated with the intention of offering health insurance coverage for up to Rs. 5 lakh per family per year, PMJAY has steadily increased its reach to include more states and Union Territories (National Health Authority, 2021) (Figure 18). This inclusive strategy has been instrumental in ensuring that a larger population has access to high-quality healthcare. 

Beneficiaries’ testimonials, like that of Kusumvati Dev from Gorakhpur, highlight the transformational effects of PMJAY. The effectiveness of the campaign is demonstrated by the woman’s successful knee replacement surgery with the Prime Minister’s card support (Ministry of Health and Family Welfare, 2023). Due to a lack of money, Dharampal from Haryana would not have been able to get his hip replacement done if it had not been for AB-PMJAY. He thanks the government for introducing him to this scheme, which has been a lifesaver,” as per Dharampal, an Ayushman Bharat PMJAY beneficiary (Ministry of Health & Family Welfare, August 2023). Till July 31, 2023, over 54 million beneficiaries across the country have availed of free hospitalization benefits worth Rs 66,400 crore so far. AB PMJAY towards achieving Antyodaya, refer Figure 13, an average of 95 beneficiaries are being identified per minute.  

Figure 13: AB PMJAY towards achieving Antyodaya 
 Source: NHA, 2023 

Strategic actions to improve benefits and accessibility have marked PMJAY’s evolution. Access to healthcare has been made easier by programmes like the PMJAY e-card. The year-wise progress of AB PMAY card generation is depicted in figures 14 & and 15. Additionally, the programme has expanded its assistance to include serious illnesses, providing financial aid for families dealing with formidable medical issues (National Health Authority, 2023). The overall number of Ayushman cards created till 30 August 2023 was 24,73,77,758. The State/UT-wise details of the cards created are depicted in Figure 17. The top 5 states covering beneficiaries under the PMJAY scheme: Madhya Pradesh – 3.59 Crore; Uttar Pradesh – 2.94 Crore; Chhattisgarh- 1.93 Crore; Gujarat – 1.77 Crore; Assam – 1.56 Crore (Figure 16). 

Figure 14: Year-wise progress of AB PMJAY cards generation 
Source: NHA, 2023 

Figure 15: Ayushman Card Generation Trend 
Source: (August 2023) 

Figure 16: Top 5 states with the highest number of Ayushman cards 
Source: NHA, 2023 
Figure 17: Ayushman card created State/UT-wise 
Source: (August 2023) 

The partnership between PMJAY and healthcare professionals is essential to its success. The initiative has made vital financial contributions, demonstrating its dedication to supporting the healthcare ecosystem. In addition, steps have been taken to preserve the standard of medical care, fostering all-around well-being (Ministry of Health and Family Welfare, 2021).  

As of August 21, 2023, the NHA has recognized AOI Babina Speciality Hospital in Imphal as one of the best-performing hospitals for its commendable contributions to the application and promotion of the AB-PMJAY scheme, under the Government of India’s initiatives. This acknowledgement underscores the hospital’s dedication to the successful implementation and advocacy of the AB-PMJAY scheme. 

PMJAY’s implementation has brought about a revolutionary change in India’s healthcare system. This large-scale healthcare project has had numerous significant effects that are changing the healthcare ecology in the country. Some of the major effects of PMJAY to highlight just how profound an impact it has had on millions of Indians’ access to healthcare, financial stability, and general well-being are as follows: 

Improved Healthcare Access 

PMJAY has significantly improved the availability of high-quality healthcare services for millions of previously underserved people.  

For instance, Mrs Anjali, who lives in a remote village in Jharkhand, was able to receive a life-saving heart operation at a neighbouring renowned hospital because of PMJAY, which her family would not have been able to afford otherwise (Source: Twitter Post of NHA, 2023). 

Figure 18: Number of Eligible Families as per SECC 2011 

Note: RAJYA SABHA SESSION – 259 UNSTARRED QUESTION No 1524. ANSWERED ON, 14TH March 2023. States/UT of Odisha, West Bengal and Delhi are not implementing AB-PMJAY.

Financial Protection 

PMJAY was touted to play a significant role in enabling better protection from health-related financial risk. For one, the scheme targeted a broader range of beneficiaries, including more poor and vulnerable households that were identified based on deprivation and occupational criteria in the Socio-Economic Caste Census 2011 (NHA) (Figure 20). The scheme’s financial coverage was expanded more than sixteen-fold from 30,000 rupees in RSBY to 5,00,000 rupees. Another significant feature of PMJAY is that it does not impose an upper limit on the number of members in a household, ensuring that nobody gets excluded. The transition from RSBY to PMJAY has thus resulted in better coverage, made evident by the increase in the enrolment of beneficiaries (Figure 19) and the number of empanelled hospitals (Figure 21 and 22).  

By paying for medical bills, PMJAY serves as a strong financial safety net, preventing families from spiralling into debt to pay for healthcare. As an illustration, take Mr. Rajesh, a daily wage worker in Uttar Pradesh, who underwent emergency surgery after a road accident. PMJAY paid for his hospitalisation and operation, easing the financial strain on his family. 

Figure 19: State/UTs-wise Details of Percentage Eligible Beneficiaries Issued Ayushman Card under AB-PMJAY from 2019-20 to 2021-22 

Note: RAJYA SABHA SESSION – 258 UNSTARRED QUESTION No 1563. Data Figures are in Number/ in Rupees. Additional 3 crore Ayushman cards have been verified by States using their own IT system. The co-branded Ayushman Cards have been issued to State scheme beneficiaries which have been converged with AB-PMJAY. Therefore, number of Ayushman Cards issued in few States is more than number of eligible individuals from SECC database. Ayushman Bharat – Pradhan Mantri Jan Arogya Yojana (AB-PMJAY). 

Figure 20: Hospitals Empanelled 
Source: (31 August 2023) 
Figure 21: State/UTs-wise Detail of Authorized Hospital Admissions under AB-PMJAY from 2018-19 to 2022-23 

Note: RAJYA SABHA SESSION – 257 STARRED QUESTION No 146. Data Figures are in Number. NA – Not Available. Note – Above List Does Not Include the State/UT of West Bengal, Odisha and NCT of Delhi as they are not Implementing the Scheme.

Reduction in Out-of-Pocket Expenses 

The scheme considerably lessens the financial strain of paying for medical treatments, prescriptions, and procedures out of pocket.  

A child’s congenital heart defect surgery was funded by PMJAY for a family in a tribal area of Odisha, alleviating their financial burden (Source: Economic Times). 

 Empowerment of Women 

PMJAY supports women’s empowerment by ensuring they receive essential medical treatment without having financial constraints compromise their health. The PMJAY has had a positive impact on the empowerment of women by providing them with better access to healthcare services. It has contributed to improved health outcomes, financial security, and overall well-being for women, enabling them to lead healthier and more productive lives (Figure 22 and 23). 

For instance, Ms. Sunita, a single mother from rural Bihar, may receive chemotherapy for cancer while still being able to look after her kids. 

Figure 22: Ayushman Cards Created- Gender Distribution 
Source: (31 August 2023) 
Figure 23: Authorized Hospital Admissions- Gender Distribution (31 August 2023) 
Source: (31 August 2023) 

Reduced Infant Mortality 

By providing prompt medical care, PMJAY’s coverage of maternity and neonatal healthcare has resulted in a decrease in infant mortality rates.  

Through PMJAY, a low-income family in a Rajasthani village benefited from complete maternity care, which led to a healthy delivery and the child’s well-being (Source: Jagran Josh Survey). 

Preventive Care 

Preventive care is given top priority by PMJAY, encouraging beneficiaries to seek early disease diagnosis and treatment. Under PMJAY, Mr. Ramesh, a farmer in Karnataka, underwent routine health examinations. An early diagnosis of diabetes enabled him to manage the condition effectively, averting potential complications. These impacts highlight the scheme’s effectiveness in improving healthcare access, offering financial protection, and promoting preventive care, ultimately enhancing the well-being of vulnerable populations. 

Challenges Of PMJAY

Challenges Of PMJAY

The Pradhan Mantri Jan Arogya Yojana (PMJAY) has several important obstacles that call for improvement. First off, there is a noticeable lack of satisfaction among private healthcare professionals who take part in PMJAY. Many of them believe that private insurance plans are more successful and effective than public insurance plans. The programme also addresses the crucial problem of a weak healthcare infrastructure, which restricts access to high-quality medical care. The effective delivery of healthcare is impeded by this inadequate infrastructure. Dr. Aisha Rahman, a healthcare policy expert, emphasises the inadequateness of health resources and infrastructure by pointing out that access to high-quality healthcare is still a major concern because of the underdeveloped healthcare infrastructure. 

In addition, the gaps in healthcare coverage between urban and rural areas continue to be a problem for PMJAY. Urban communities frequently gain more from the programme than their rural counterparts, which raises questions about equal access to healthcare. Alarmingly, despite a number of provisions, advocates are increasingly of the opinion that healthcare disparities have been increasing, underlining the necessity of closing these gaps. Urban areas receive more benefits than rural ones when it comes to healthcare coverage, according to Professor Rajesh Gupta, an advocate for health equity. 

The underutilization of PMJAY’s budgeted funding is also a cause for concern. The effectiveness of the programme and its ability to effectively reach all eligible beneficiaries may be limited by this underutilization. According to Dr. Sanjay Patel, a public health economist, underutilization of budgeted money can reduce the program’s effectiveness. To successfully meet its aim of offering affordable, high-quality healthcare to all Indian citizens, PMJAY must go through ongoing changes and reforms in order to overcome these obstacles. 

Moreover, the strategic integration of technology and data analytics is indispensable for expediting procedures, curbing fraudulent activities, and enhancing the overall efficacy of the program. During the 5th National Anti-Fraud Workshop, jointly organized by the National Health Authority (NHA) and the World Bank in New Delhi, several key figures discussed pivotal aspects of this endeavour. Shri Rohit Dev Jha, Joint Director at NHA, delivered insights into the evolving roles of NHA and SHA (State Health Agencies) in the realm of fraud control. Additionally, Ms. Latha Ganapathy, Director at NHA, Shri Vipin Kumar Singh, Director of the National Network of Anti-Fraud Units (NNAFU) at NHA, and Ms. Roohi Khann, Joint Director at NNHA, presented their valuable recommendations regarding trigger-based due diligence, actions against non-compliant entities, and other pertinent challenges. Shri Ghayas Uddin Ahmed, the Financial Advisor at NHA, provided an overview of the current status of fraud and abuse control under PMJAY and introduced new initiatives undertaken to bolster these efforts. These collaborative discussions underline the ongoing commitment to fortifying fraud prevention measures within the healthcare system. 

To overcome these challenges, it is imperative for PMJAY to undergo continuous improvements and reforms, ensuring that it can successfully fulfil its mission of providing accessible and quality healthcare to all Indian citizens.  

In August 2023, media allegations that suggested problems in the audit of the Ayushman Bharat-PMJAY health insurance scheme were rejected by the government, which deemed them inaccurate and misleading. In a performance audit, the Comptroller and Auditor General of India (CAG) had raised a concern about beneficiaries who had previously been marked as “dead” in the system but were still receiving care under the programme. In total, 3,903 similar claims involving 3,446 patients were found during the audit, and hospitals received Rs 6.97 crore. 

The government made it clear that hospitals might submit a pre-authorization request three days in advance, which is frequently required in circumstances involving poor connectivity or crises. Pre-authorization requests have occasionally been denied because individuals died while receiving treatment, giving rise to the same admission and death dates. These deaths were likewise reported by hospitals, showing that there was no attempt to cheat the system. Regarding the same patient receiving treatment in two hospitals simultaneously, Ayushman Card holders, particularly children up to 5 years of age, can utilize the card in different hospitals, depending on their specific medical needs. 

The cell phone number is not a required field for beneficiary verification, hence reports suggesting that one mobile number is linked to several beneficiaries were disregarded. Despite the fact that mobile numbers were first collected without OTP-based validation, adjustments were subsequently implemented to acquire valid mobile numbers. The CAG report on the AB PM-JAY from September 2018 to March 2021 was presented in the Monsoon Session of 2023, according to the government, reinforcing its dedication to openness and accountability in the program’s execution. 


Future Directions And Sustainability Of PMJAY

Future Directions And Sustainability Of PMJAY

Several future orientations and sustainability measures become clearer as the Pradhan Mantri Jan Arogya Yojana (PMJAY) develops. First, there is an increasing focus on broadening the scope of the programme to accommodate more beneficiaries. To guarantee that every eligible person is covered, this calls for raising awareness and organising enrolment efforts. Additionally, utilising technology and data analytics will be essential for speeding processes, reducing fraud, and improving the program’s overall effectiveness. The ability of PMJAY to keep expenses under control while maintaining the calibre of healthcare services is directly related to its long-term viability. To ensure fair pricing, this calls for ongoing agreements with healthcare providers. The success of PMJAY also hinges on the creation of a strong feedback system that enables beneficiaries to share their successes and difficulties, ultimately leading to programme improvements. The private sector’s active participation is another crucial aspect of sustainability. Collaborations with private healthcare providers can assist widen the network of hospitals having empanelled status, increasing beneficiaries’ access to care. Public-private collaborations can also spur innovation in healthcare delivery, improving the system’s efficiency. 

In the long run, PMJAY hopes to lessen the burden of non-communicable diseases and improve the general health and well-being of the populace. The programme to stop the rising tide of chronic illnesses will include preventive healthcare measures and health promotion efforts. Political commitment and continuous funding are also essential to sustainability. For PMJAY to succeed moving forward, the government must continue to prioritise it and provide enough funds. Expanding coverage, utilising technology, and encouraging preventative healthcare are some of PMJAY’s prospects. Cost management, private sector involvement, and continuous political and financial backing are all necessary for sustainability. By addressing these issues, PMJAY is well-positioned to significantly alter the state of Indian healthcare for years to come. 



In conclusion, the Pradhan Mantri Jan Arogya Yojana (PMJAY) stands as a pioneering and ambitious initiative in the global pursuit of Universal Health Coverage (UHC). As one recognizes the complex challenge of ensuring health for all, it becomes evident that government efforts alone cannot accomplish this monumental task. PMJAY has brought this realization to the forefront, prompting a shift towards collaboration with the private sector. With a vast portion of the world’s population having limited access to healthcare, the need for both investment and expertise becomes paramount. 

If one must envision a scenario where every country without UHC matches the health spending per capita of the average OECD nation, it will require an astronomical increase in global healthcare spending. This, however, appears to be an unrealistic approach. Instead, nations are exploring innovative partnerships with the private sector. These collaborations not only aid in building essential healthcare infrastructure but also pave the way for highly efficient service delivery models that can ensure the long-term affordability of healthcare. 

Across continents, from Asia to Latin America, the Middle East to Africa, there is a growing interest and ambition to engage the private health sector at nearly every stage of the UHC journey. PMJAY, as the world’s largest health assurance scheme, exemplifies the potential of such partnerships. However, it is also evident that the road ahead for PMJAY requires unwavering dedication and substantial support to realize its noble objectives. The pursuit of ‘Health for All’ is a collective endeavour that calls for continued innovation, collaboration, and the commitment of nations to transform the landscape of global healthcare. 

Policymakers around the world now understand that the government alone cannot drive the UHC agenda. With 88 per cent of the global population consuming just 27 per cent of its healthcare resources, the challenge is one of both investment and expertise. If every country without UHC were to increase health spending per capita to the average OECD level, by 2030 the world would be spending USD27 trillion extra on healthcare — a 400 per cent increase in total worldwide health spending today. This seems unrealistic. Instead, countries are looking at how private sector partners can help to not only build up the necessary infrastructure for UHC but also develop innovative, ultra-efficient models of service delivery that can make the costs affordable over the long term. Across Asia but also Latin America, the Middle East and Africa, there is interest and ambition to use the private health sector at almost every stage of the UHC journey. Clearly, the current progress for Ayushman Bharat entails a substantial drive and larger support to realise the objectives of the initiative and eventually provide ‘Health for All’. 




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