The implementation of the expanded Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PM-JAY) has been slower than expected. Despite the Union government’s announcement in September to extend health insurance coverage to all individuals aged 70 and above, only 1.87 million people from this age group have registered as of November — just 3% of the estimated 60 million target group.
India is experiencing a demographic shift, with its elderly population steadily rising. According to the 2011 Census, 3.3% of India’s 1.2 billion people were aged 70 and above. Current estimates place this figure at 4.1% of the 1.45 billion population, and by 2050, the elderly are expected to account for over 20% of the population. This demographic transition highlights the need for robust state support, as medical expenses for the elderly are significantly higher. Ayushman Bharat 2.0, with its promise of Rs 5 lakh annual health insurance coverage for senior citizens, seeks to address this growing need. However, the low uptake of the scheme highlights the urgency of addressing implementation challenges.
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Challenges to Ayushman Bharat outreach
Healthcare professionals emphasise the importance of targeted awareness campaigns, simplified onboarding processes, and stronger outreach initiatives. The low registration numbers can partly be attributed to a lack of awareness among the elderly and their families. Additionally, the model code of conduct in election-bound states like Maharashtra and Jharkhand may have slowed progress.
States have shown varying rates of success. Madhya Pradesh leads with 709,200 registrations but has achieved only one-fifth of its 3.4 million target. Kerala, with 396,522 registrations, came second, but its elderly population—projected to reach 5.8 million by 2050—suggests much more needs to be done. In contrast, Uttar Pradesh, despite having an elderly population of over 18 million, lags with just 255,318 new registrations.
PM-JAY: Persistent problems
Ayushman Bharat, launched in 2018, is India’s flagship healthcare programme aimed at achieving universal health coverage. It comprises two components: health and wellness centres and the PM-JAY scheme. Under the expanded PM-JAY, every individual aged 70 or older is entitled to Rs 5 lakh in annual health insurance, in addition to the Rs 5 lakh coverage provided to their family members.
To date, 36 crore Ayushman cards have been issued, and over 6.8 crore individuals have received treatment at empanelled hospitals. However, the scheme has faced criticism, particularly from empanelled hospitals that report significant delays in claim payments. Nearly 43% of these hospitals are private, and many are scaling back their participation due to financial constraints and overburdened capacities. For example, in Bihar, there are over 10,000 families per empanelled healthcare provider, creating an untenable situation.
The success of PM-JAY depends on strengthening public sector healthcare infrastructure. Many private hospitals, perceived as superior to government facilities, are overwhelmed due to patient preference, exacerbating disparities. States like Uttar Pradesh also highlight the issue of inactive empanelled hospitals, with 39% inactive since empanelment. Addressing state performance disparities requires thorough research and action. In regions where healthcare infrastructure is sparse or inactive, efforts must focus on building and operationalising facilities.
Revisiting the insurance model
Experts argue for a redesign of the current insurance model to improve healthcare access and quality. A system that integrates payer and provider roles, with performance-based funding, could better incentivise high-quality care. Countries like Thailand, Turkey, Vietnam, and Uruguay have successfully implemented UHC through such models. India’s out-of-pocket health expenditure remains alarmingly high at 47-50%, compared to the global average. While Ayushman Bharat has the potential to reduce this burden, its current design may fall short of addressing the twin goals of minimising out-of-pocket costs and ensuring quality care.
To realise its full potential, Ayushman Bharat must prioritise raising awareness and educating communities about the scheme to increase registrations. Simplifying enrolmentprocesses and improving access to the scheme will be critical in overcoming barriers. Infrastructure development must also be accelerated to address disparities between states and regions, ensuring that healthcare facilities are available and operational in underserved areas.
Additionally, revisiting the insurance model and introducing performance-based funding can help incentivise better quality care and align public and private healthcare systems more effectively. Countries with successful UHC models have demonstrated the importance of such integration. India has made strides in reducing out-of-pocket health expenditure, but with current levels still hovering at 47-50%, more needs to be done to make healthcare accessible and affordable.
Ayushman Bharat holds the promise of transforming India’s healthcare landscape. However, its success depends on addressing these systemic challenges and implementing reforms to ensure that it fulfils its ambitious goals. Only then can India move closer to achieving universal health coverage.