India, a nation with a population of over 1.4 billion, faces significant challenges in providing equitable and affordable healthcare to all its citizens. Addressing this pressing need, the Government of India launched one of the world’s largest publicly funded health insurance schemes: Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PMJAY). Introduced in 2018, PMJAY is a landmark initiative aimed at achieving Universal Health Coverage (UHC) by providing health insurance to the most vulnerable segments of the population.
Background and Launch
PMJAY was launched on September 23, 2018, by Prime Minister Narendra Modi in Ranchi, Jharkhand. It is a crucial component of the larger Ayushman Bharat scheme, which was announced in the Union Budget 2018–19. Ayushman Bharat is a two-pronged initiative: first, to establish Health and Wellness Centres (HWCs) to deliver comprehensive primary healthcare, and second, to implement PMJAY, which addresses secondary and tertiary healthcare needs.
Objectives of PMJAY
The primary objectives of PMJAY are:
-
To reduce the financial burden on poor and vulnerable groups due to hospitalization and medical emergencies.
-
To improve access to quality healthcare services across the country, especially for those who are underserved.
-
To promote equity in healthcare by offering free treatment to the economically disadvantaged.
-
To strengthen the public health infrastructure by incentivizing both public and private hospitals to provide services to PMJAY beneficiaries.
Key Features
PMJAY has several unique features that set it apart from other health schemes in India:
-
Coverage of ₹5 lakh per family per year for secondary and tertiary hospitalization.
-
Covers over 10 crore families (approximately 50 crore individuals), making it the largest such scheme globally.
-
No enrollment required; eligibility is determined based on the Socio-Economic and Caste Census (SECC) 2011 data.
-
Cashless and paperless access to healthcare services at the point of service in both public and empaneled private hospitals.
-
Portability of benefits across the country, enabling beneficiaries to access treatment anywhere in India.
-
3 days pre-hospitalization and 15 days post-hospitalization expenses covered, including diagnostics and medicines.
Eligibility Criteria
Unlike traditional insurance schemes, PMJAY does not require any premium from the beneficiaries. Eligibility is based on deprivation and occupational criteria in rural and urban areas, as identified in SECC 2011. Some of the eligible groups include:
-
Households without any adult male member aged between 16 and 59.
-
Families with only one room with kucha walls and roof.
-
Manual scavenger families.
-
Landless households earning a major part of their income from manual labor.
In urban areas, eligibility extends to workers in 11 occupational categories, such as rag pickers, domestic workers, street vendors, construction workers, etc.
Implementation and Governance
PMJAY is implemented by the National Health Authority (NHA) at the central level and State Health Agencies (SHAs) at the state level. The scheme operates under a hybrid model, where states can choose to implement it through insurance companies, a trust model, or a mix of both.
Empaneled hospitals are rigorously screened and are required to meet defined quality criteria. The scheme also integrates an IT platform, making it a technology-driven initiative. Beneficiaries receive an e-card, which enables them to access treatment in any empaneled hospital nationwide.
Achievements and Impact
Since its launch, PMJAY has made significant strides in improving healthcare access in India:
-
As of 2024, over 5 crore hospital admissions have been recorded under the scheme.
-
The scheme has saved billions of rupees in out-of-pocket expenditure for beneficiaries.
-
Over 27,000 hospitals, including more than 10,000 private ones, have been empaneled under PMJAY.
-
The scheme has helped boost the healthcare infrastructure in Tier II and Tier III cities by encouraging private sector participation.
-
It has led to increased health-seeking behavior, especially among the poor, for serious illnesses like cancer, cardiac diseases, and orthopedic surgeries.
Challenges
Despite its widespread acclaim, PMJAY also faces several challenges:
-
Awareness Gaps: A large number of eligible beneficiaries remain unaware of their entitlements under the scheme.
-
Infrastructure Deficits: In many remote areas, the lack of quality healthcare infrastructure limits the effectiveness of the scheme.
-
Fraudulent Claims: There have been instances of hospitals engaging in fraudulent billing practices, prompting the need for stricter audits.
-
Manpower Shortages: India faces a chronic shortage of trained healthcare professionals, especially in rural areas.
-
State-Level Variations: Implementation varies widely across states, leading to inconsistencies in service delivery.
Government Initiatives to Strengthen PMJAY
Recognizing the challenges, the government has undertaken several measures:
-
Awareness Campaigns: ‘Arogya Mela’ and ‘Ayushman Bharat Pakhwada’ initiatives have been launched to spread awareness.
-
Hospital Empanelment Modules: Revisions have been made to improve hospital empanelment and prevent malpractices.
-
IT Enhancements: Use of AI and data analytics for claim adjudication and fraud detection.
-
Health IDs under ABDM: Integration with the Ayushman Bharat Digital Mission (ABDM) aims to create digital health records for citizens.
-
Training and Capacity Building: Efforts are being made to train Ayushman Mitras and hospital staff to improve patient support and scheme management.
Future Prospects
The long-term vision of PMJAY is to lay the foundation for a robust, inclusive, and sustainable health system in India. Key areas for development include:
-
Expansion of beneficiary base to include middle-income households not covered under any scheme.
-
Strengthening primary care through integration with Health and Wellness Centres.
-
Enhancing private sector participation through incentives and transparent processes.
-
Better monitoring and evaluation mechanisms to ensure quality and accountability.
The Ayushman Arogya Mandirs, a rebranding of HWCs, are expected to further bridge the gap between primary and secondary healthcare, providing a continuum of care under Ayushman Bharat.
Conclusion
Ayushman Bharat PMJAY is a transformative health initiative that seeks to redefine the healthcare landscape in India. By providing financial protection and improving access to quality care for millions, it is a giant leap toward achieving Universal Health Coverage. While challenges persist, the scheme has already laid a strong foundation for a healthier and more equitable India.
Its success will depend on continued political will, active participation from states, robust governance mechanisms, and integration with broader health sector reforms. If implemented effectively, PMJAY has the potential to become a global model for large-scale health insurance programs, especially in developing countries with similar socio-economic challenges.