About 63 million people in India fall below the poverty line each year because of healthcare costs. Ayushman Bharat, the “most important Government welfare scheme underway in India today”, according to Minister of State for Health and Family Welfare SP Singh Baghel, set out to remedy this by providing 120 million families with health insurance cover up to Rs 5 lakh under the Pradhan Mantri Jan Arogya Yojana, also known as PM-JAY.
In addition, a network of health and welfare centres aims to provide preventive and primary healthcare services to the people. In five years, the health insurance arm of the scheme has reached about 56% of all eligible beneficiaries. However, there are not enough empanelled hospitals for the registered beneficiaries, and out of pocket expenditure on health remains high, according to studies from different states.
The Pradhan Mantri Jan Aarogya Yojana programme was launched five years ago on September 23, 2018, by Prime Minister Narendra Modi. A digital records-keeping arm called Ayushman Bharat Digital Mission was launched in September 2021.
The National Health Authority, an autonomous body headed by the Minister of Health and Family Welfare that implements the insurance scheme, has provided over 253 million people health cards, according to its dashboard as of October 5. IndiaSpend takes a look at the biggest health insurance scheme in the world and whether it has been a success.
Empanelled hospitals not enough
Health and welfare centres are different from primary health centres, according to Sudha Shree Chandrashekar, an advisor at the Health Systems Transformation Platform, a non-profit that works with the central and state governments to improve healthcare delivery. “HWC goes much beyond PHCs, the scope of activity has expanded to include things like NCDs [non-communicable diseases], mental health etc – moving from healthcare to health (prevention, early care, health education), staffing has changed – the approach is more holistic,” they said.
Some existing primary health and sub-centres were converted into health and welfare centres to deliver comprehensive primary healthcare including maternal and child health services, diagnostic services and free essential drugs, as per the Pradhan Mantri Jan Aarogya Yojana website.
About 150,000 health and welfare centres have been operationalised as of December 2022, as per government data.
The Pradhan Mantri Jan Aarogya Yojana also has 27,252 hospitals or empanelled healthcare providers, according to its dashboard, where beneficiaries can avail of cashless services. However, the number of active empanelled healthcare providers is significantly less: only 19,756 were active in the last six months.
But this number is too small for the number of people eligible for the scheme in several states, as an August 2023 Comptroller and Auditor General Report report points out based on data from November 2022. For instance, Assam’s 349 empanelled healthcare providers amount to two hospitals for every 100,000 people, as per the latest data from the National Health Authority dashboard.
In Andaman and Nicobar Islands, Assam, Maharashtra, Jharkhand, Haryana and Meghalaya, the empanelled healthcare providers did not provide all the services they are supposed to provide under the scheme, noted the Comptroller and Auditor General report.
Eligible population
Pradhan Mantri Jan Aarogya Yojana, which subsumed the older health insurance scheme Rashtriya Swasthya Bima Yojana, covers the poorest 40% of the households. Eligible households are selected on the basis of the socio-economic caste census (an enumeration exercise which ranks rural households based on access to health, housing, etc.) and occupational criteria (households that rely on begging, rag-picking, domestic work, etc. for their livelihood in urban areas).
Some states, like Uttarakhand, Karnataka and Himachal Pradesh, have gone beyond the eligibility criteria and provided healthcare to more people, said Dr Chandrasekhar from the Health Systems Transformation Platform. This is why some states have more than 100% enrollment in the programme. IndiaSpend has also reached out to the National Health Authority to understand why this is the case, and will update the story when we receive a response.
So far, about half of the people eligible are covered by the health insurance scheme.
Scheme usage
The number of hospitalisations per 100,000 Ayushman cards issued is highest in Tamil Nadu, with over 179,003 hospitalisations for every 100,000 people enrolled, as per the dashboard. Kerala has the second highest utilisation rate with 74,280 hospitalisations for every 100,000 cards issued, followed by Rajasthan (52,168) and Karnataka (41,089).
Among the bigger states, Assam has the lowest utilisation of the insurance scheme with 5,292 hospitalisations for every 100,000 beneficiaries. In Uttar Pradesh, there were 2.6 million hospitalisations since the scheme was rolled out, which translates to 7,928 hospitalisations for every 100,000 people enrolled.
Costs remain high
High cost of healthcare forced people to sell assets, as IndiaSpend reported in March 2023.
The scheme does not cover the cost of out-patient consultations. Therefore, beneficiaries have to get referrals from government or private doctors for procedures, which they use at empanelled healthcare providers, according to Ravi Singh (26), a social worker with Agrasar, a non-profit that helps citizens procure the documentation required for Ayushman Bharat cards.
“We (Agrasar) asked 5,000 people with Ayushman Bharat cards about their experience. About seven or eight of them had been admitted, and none of them exceeded the coverage amount,” he added.
Reducing out-of-pocket expenditure on health is one of the objectives of the scheme. Yet, studies from different states reveal that out-of-pocket expenditure is still high.
About 87.9% of people dipped into their savings for health expenses, 11.3% borrowed from friends and relatives, while 0.3% utilised health insurance, found a 2023 study by the National Council of Applied Economic Research which surveyed four states, Odisha, Maharashtra, Punjab and Uttar Pradesh.
During the Covid-19 pandemic, enrolment in a public or privately funded health insurance did not decrease out-of-pocket expenditure, found a 2022 study. Another study found that although the availability of health insurance increased the chances of healthcare utilisation, it did not protect against financial risks. Enrolment in Pradhan Mantri Jan Aarogya Yojana or any other health insurance scheme did not increase the chances of institutional delivery or reduction in out-of-pocket expenditure, found this analysis of data from the National Family Health Survey 2019-20.
The targeted nature of the scheme does not take into account the social gradient, said Rama Baru, a health policy specialist and professor at the Centre for Social Medicine and Community Health at the Jawaharlal Nehru University in New Delhi. “When you set a threshold and target people based on some criteria, you are excluding people who are just above the threshold. But that person can fall below the poverty line too,” she told IndiaSpend, adding that targeted schemes break social cohesion in communities. Instead, the focus should be on universal health care based on progressive taxation, she said.
IndiaSpend has reached out to the Ministry of Health and Family Welfare to comment on the enrollment, empanelment of hospitals and the expenditure incurred per person. This story will be updated when they respond.
This article first appeared on IndiaSpend, a data-driven and public-interest journalism non-profit.
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