The northern states of India, those with the highest number of Ayushman cardholders, have recorded the lowest number of hospital admissions under the Ayushman Bharat scheme. Uttar Pradesh, with a staggering 51 million Ayushman cards, has seen only 2.8 million hospital admissions. Similarly, Madhya Pradesh, with 40.2 million cards, and Bihar, with 35.6 million cards, have reported just 3.35 million and a mere 778,000 admissions, respectively. The reasons behind this anomaly remain unclear, but they coincide with weaker healthcare systems in these states.
Meanwhile, four of the top five states in terms of authorised hospital admissions under the Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) are from the southern region. Leading the pack is Tamil Nadu with 9.05 million hospital admissions since the scheme’s inception. Karnataka follows with 6.60 million, Kerala with 5.46 million, and Andhra Pradesh with 4.96 million, according to the PMJAY dashboard. Rajasthan is the only northern state in the top five, recording 5.74 million admissions. This dominance by southern states highlights the widespread utilisation of the scheme in that region.
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Poor healthcare infrastructure in northern states
This contrast becomes more striking, considering Tamil Nadu and Kerala have far fewer Ayushman cards but significantly higher hospital admissions. For instance, Karnataka and Andhra Pradesh are the top southern states in terms of card issuance, yet they rank eighth and tenth on a national level, further emphasising the discrepancy between card creation and actual usage in northern states.
The consistent underperformance of states like Uttar Pradesh and Bihar has been evident since the inception of the scheme. Despite the Union government urging these states to improve their performance and raise awareness, challenges persist. A key issue is the lack of healthcare infrastructure —both states have very few public and private hospitals empanelled under the scheme. Of the 20,905 empanelled hospitals nationwide, only 9,905 are private hospitals. This shortage becomes even more glaring in times of crisis.
For example, during the Covid-19 pandemic, only 19 people in Bihar, with a population of over 110 million, sought treatment through the Ayushman Bharat Scheme. In Jharkhand, 1,419 people availed treatment, and in Uttar Pradesh, just 975 received care, with only 1,538 tests conducted under the scheme.
Southern states prioritise tertiary care
In contrast, states with stronger public health infrastructures, like Andhra Pradesh and Tamil Nadu, have effectively utilised PMJAY funds for tertiary care. Maharashtra, where three-quarters of empanelled hospitals are private, follows a similar trend, with the scheme subsidising major medical expenses as originally intended.
In states with weaker healthcare systems such as Uttar Pradesh and Bihar, PMJAY primarily covers secondary care, underscoring the lack of capacity and infrastructure to address more complex medical needs. These states allocate more funds to secondary care procedures due to their underdeveloped healthcare systems.
Role of private sector in healthcare
The dominance of private hospitals in the scheme also points to an imbalance in healthcare infrastructure. Despite 58% of empanelled hospitals being government-run, two-thirds of the funds spent under PMJAY have gone to private hospitals. To address this, the government must incentivise private sector investments in states like Uttar Pradesh and Bihar, while also ramping up public infrastructure spending.
One of the scheme’s limitations has been its lower penetration in smaller cities and towns across most states, especially outside the southern region. Unlike southern states, where primary and secondary public healthcare is relatively robust, other regions lack the necessary infrastructure to meet growing demand. Strengthening these foundational levels of care is crucial to reducing the burden on tertiary care facilities and ensuring the scheme’s success nationwide.
Lessons from global models
Looking at international examples, Thailand’s focus on strengthening its primary healthcare system, including reallocating funds from urban hospitals to build rural healthcare facilities, contributed to the country’s achievement of universal health coverage.
In contrast, the United States’ reliance on insurance-based healthcare has led to skyrocketing costs— a path India seems to be treading with PMJAY. To avoid similar outcomes, India must shift focus toward bolstering its primary healthcare system.
Launched in 2018, PMJAY is the world’s largest publicly funded health insurance scheme, offering health coverage of up to ₹5 lakh per family per year for secondary and tertiary care hospitalisation. The scheme aims to provide healthcare access to over 550 million individuals, covering 123.4 million families identified as deprived in the socio-economic caste census.
While over 356 million people now hold Ayushman cards, and more than 68 million hospitalisations worth ₹90,204 crore have been covered, there remains a significant gap in utilisation across different regions. To bridge this gap, especially in northern states, the government must focus on improving healthcare infrastructure and making the scheme more accessible to the masses.