Ayushman Bharat - A vision for universal health that still needs healing

When Prime Minister Narendra Modi launched Ayushman Bharat – Pradhan Mantri Jan Arogya Yojana (PM-JAY) on September 23, 2018, it marked a historic step toward universal health care in India. For a nation long plagued by high out-of-pocket health expenditures, unequal access, and the crushing burden of medical debt, Ayushman Bharat promised a new dawn of affordable, inclusive, and accountable healthcare for the poor.

The need for Ayushman Bharat

India’s public health system has struggled for decades. Barely 1.2% of GDP was being spent on healthcare when the scheme was introduced. Millions of families fell into poverty every year due to medical expenses. According to National Health Accounts, nearly 65% of healthcare spending was borne directly by households. Rural India, where nearly 70% of the population lives, suffered the worst limited hospitals, shortage of doctors, and poor infrastructure.

Ayushman Bharat emerged as a response to this structural inequality. The idea was not only to provide insurance but to build a comprehensive healthcare ecosystem from the village level upward.

How the programme operates

Ayushman Bharat rests on two main pillars:

1. Health and Wellness Centres (HWCs): Over 1.6 lakh sub-centres and primary health centres are being upgraded into HWCs to provide preventive, promotive, and basic curative care close to home. These centres offer services for maternal health, child care, non-communicable diseases, and essential drugs aiming to shift the focus from illness to wellness.

2. Pradhan Mantri Jan Arogya Yojana (PM-JAY): This insurance-based component provides coverage of up to ₹5 lakh per family per year for secondary and tertiary hospitalisation to over 50 crore citizens, based on the Socio-Economic and Caste Census (SECC) data. The beneficiaries can avail cashless treatment at both public and empanelled private hospitals across India.

The National Health Authority (NHA) administers PM-JAY, while states can implement it through State Health Agencies. Hospitals are reimbursed directly through an online transaction system, ensuring transparency and minimizing corruption.

Achievements and success stories

In just seven years, Ayushman Bharat has touched millions. Over 6 crore hospital admissions have been authorized under PM-JAY, covering treatments ranging from cardiac surgeries to cancer therapies that were once out of reach for the poor. Women and elderly citizens form a major portion of beneficiaries. Health and Wellness Centres have expanded basic healthcare access to the remotest corners in tribal belts, hilly terrains, and rural areas where doctors were once scarce. For many poor families, the “golden card” under PM-JAY has become a lifeline, offering them the dignity of treatment without financial ruin.

The digital backbone of the scheme through the Ayushman Bharat Digital Mission has also been a significant step. Electronic Health Records (EHRs), unique health IDs, and interoperability between hospitals are helping create a new digital health ecosystem.

Challenges and Shortcomings

Despite its scale and ambition, Ayushman Bharat is not free from flaws. Implementation across states remains uneven. Southern states like Tamil Nadu and Kerala had already established strong health insurance frameworks before PM-JAY; their integration was smoother. But in states with weak health systems Bihar, Jharkhand, and parts of the Northeast the rollout has been patchy. Another challenge lies in hospital empanelment. Many private hospitals hesitate to join the scheme due to low reimbursement rates and delayed payments. There have been complaints of hospitals denying services or demanding under-the-table payments. Fraudulent claims and misuse of beneficiary cards have occasionally marred the programme’s reputation.

Moreover, preventive healthcare, the very foundation of HWCs, often gets overshadowed by curative services. Human resource shortages, inadequate medical supplies, and limited diagnostic facilities continue to plague rural centres.

Measuring success: Quantity vs Quality

While the numbers look impressive on paper, quality of care remains inconsistent. Many HWCs operate with one or two staff members; doctors are absent, and digital infrastructure is weak. The focus has been more on coverage rather than outcomes of how healthy beneficiaries actually become after treatment. Also, the scheme covers hospitalisation but not outpatient expenses, which constitute a significant portion of household medical costs. Thus, the financial protection remains partial.

Suggestions for improvement

1. Strengthen Primary Care: More investment in HWCs is crucial. These centres must be equipped with diagnostic tools, adequate staff, and digital support. Preventive and community health awareness must be expanded.

2. Revisit Package Rates: Reimbursement rates to hospitals should be periodically revised to reflect current treatment costs and ensure private sector participation without compromising quality.

3. Curb Fraud and Leakage: Stronger audit mechanisms, biometric verification, and AI-based fraud detection can minimize misuse.

4. Integrate with Other Health Missions: Ayushman Bharat should be aligned with maternal health, nutrition, and disease-control programmes for holistic impact.

5. Focus on Health Outcomes: Evaluation should not stop at counting hospitalisations; it should measure recovery rates, patient satisfaction, and reduction in catastrophic expenditure.

6. Expand Coverage Gradually: Inclusion of outpatient care and chronic disease management in the insurance net would make the system more comprehensive.

A step in the right direction

Ayushman Bharat is undoubtedly a landmark initiative, one that reflects India’s commitment to the principle that “healthcare is not a privilege, but a right.” It represents the largest government-funded health insurance scheme in the world, and despite its flaws, it has laid a solid foundation for universal health coverage.

However, as India’s economy grows and its population ages, the expectations from this programme will only rise. For Ayushman Bharat to truly live up to its promise, it must evolve from being just a financial support system to becoming a transformative public health movement.

If implemented with renewed energy, transparency, and focus on grassroots strengthening, Ayushman Bharat could well become the backbone of a healthier, more equitable India — a nation where no one fears illness for lack of money, and where wellness becomes a shared national goal