Ayushman Bharat: Grand Promises, Harsh Reality on the Ground

Ayushman Bharat: Promises vs. Real-World Impact

Imran Haider, a 30-year-old native of Bijnor in Uttar Pradesh, works in an event management firm. Despite his mother possessing an Ayushman Bharat card for the past four to five years, Imran asserts that she has never received any aid through the scheme. "My mother has had this card for years, but whenever we try to use it, we are either turned away or told that the benefits do not apply," Imran claimed, expressing his frustration with the system.

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The Ayushman Bharat Yojana was launched with the ambitious goal of providing free health insurance coverage to low-income earners across India. Positioned as a key element of the Indian government's National Health Policy, the program aimed to cover roughly the bottom 50% of the population. Announced in the 2018 Union budget and approved by the Union Council of Ministers shortly thereafter, the scheme was heralded as a game-changer in addressing the nation's healthcare crisis.

During his Independence Day speech in 2018, Prime Minister Narendra Modi declared that the Ayushman Bharat Yojana would be a landmark initiative, promising health coverage to 10 crore households, or approximately 50 crore individuals. The program offers a cover of ₹5 lakh per family per year for medical treatment in empaneled hospitals, encompassing both public and private institutions. It is designed to be inclusive, with no restrictions on family size, age, or gender, and covers all pre-existing medical conditions.

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However, despite its promising framework, the scheme's real-world impact remains questionable. Our investigation has uncovered significant discrepancies between the scheme's objectives and its implementation. While the Indian government described how over six crore citizens were pushed into poverty annually due to out-of-pocket medical expenses, the question now arises: is the Ayushman Bharat Yojana truly serving its intended purpose?

The challenges begin with access; many eligible families struggle to even obtain the card. For those who do manage to secure it, accessing the promised services remains a formidable challenge. This disconnect between policy and practice raises concerns about the efficacy of the program and whether it is genuinely alleviating the healthcare burden on India's most vulnerable populations.

Jag Mohan's Struggle: A Tale of Unfulfilled Promises

Jag Mohan, a resident of Madhya Pradesh, is one of the many who hold an Ayushman Bharat card, but his experience reveals the stark gap between the scheme's promises and its actual delivery. Despite his wife suffering from severe ailments, Jag Mohan has been forced to pay out-of-pocket for her treatment. "I have taken my wife to many hospitals, showing them the card, but they don't accept it," he laments. "Some say this card isn't valid at their hospital, while others acknowledge it but never reimburse us. All this time, I've been paying from my own pocket."

When questioned about the government's assurance that the Ayushman Bharat scheme offers ₹5 lakh in coverage per family per year for treatment at empaneled hospitals, including both public and private institutions, Jag Mohan expressed his frustration. "I know the government has been claiming that, but so far I haven't received even a single rupee from these empaneled hospitals," he said. "For instance, my wife needs medicines costing around ₹2,000 to ₹3,000, which I have to buy myself now, with no hope of reimbursement. She has been suffering from kidney stones—there are about eight to nine stones in both her kidneys. We had an operation done in Gwalior about seven to eight years ago, but now the stones have returned, and this time in both kidneys."

Jag Mohan's plight reveals the harsh realities faced by many who are meant to benefit from the scheme. "I am a labourer, and for the past two months, I haven't been able to work because I've been tending to my wife. With no income, how am I supposed to pay these huge bills? We've been going from one hospital to another, but we're very poor and staying on rent in Delhi," he said, his voice heavy with despair.

Private Sector Gaps and Misuse

While the scheme was designed to offer a safety net by covering medical expenses at both public and private hospitals, the reality is fraught with significant challenges. Although many government hospitals have integrated into the program, a notable number of private corporate hospitals remain outside its ambit. These private institutions argue that even with government subsidies, they cannot sustain their specialised services at the reduced rates mandated by the scheme.

Further complicating matters, there have been alarming reports of misuse within the scheme. Investigations have revealed that some private hospitals exploit the system by submitting fraudulent medical bills. In several cases, surgeries have been claimed to be performed on patients who had already been discharged, and dialysis treatments have been billed from hospitals lacking the necessary kidney transplant facilities. These deceptive practices undermine the integrity of the scheme and place additional burdens on those it is intended to help.

The gap between the scheme’s objectives and its execution exposes the pressing need for stringent oversight and accountability to ensure that it fulfils its promise of accessible and affordable healthcare. Dr. Nikhil Balram, a medical officer at a primary health centre in Bihar, highlights a significant disparity in how the scheme is experienced across different healthcare sectors. He notes that while both private and government hospitals receive similar financial backing under the scheme, the perception of better facilities in private hospitals leads to complications. 

“It is true that some private hospitals offer better facilities compared to certain government hospitals. In such cases, we have seen that people opt private hospitals and then when private hospitals do not cooperate then it becomes an issue,” Dr. Balram acknowledges. “However, the problem also arises when government hospitals themselves do not accept the card. In such cases, patients should ideally file a complaint.”

Our investigation reveals the harsh reality faced by many impoverished individuals holding Ayushman Bharat cards. These people, already struggling to meet basic needs, often lack awareness of their rights and the process for filing complaints. The expectation that they will themselves navigate the complexities of the healthcare system to address grievances is impractical. The systemic inefficiencies and lack of cooperation from both private and government institutions increase their challenges, undermining the scheme's intended benefits and leaving vulnerable populations in a precarious situation.

Dr. Balram sheds light on another critical issue plaguing the scheme—widespread unawareness about private hospital inclusion. Despite the scheme's promise to cover both public and private hospitals, many people remain uninformed about the availability of private facilities under the program. “Awareness has always been a significant problem,” Dr. Balram observes. “The program’s advertisement is inadequate. The names of empaneled hospitals should be prominently published in government advertisements so that people are aware they can access these facilities.”

Dr. Balram also highlights issues related to card issuance and beneficiary lists. Even when individuals possess the necessary documents, they often struggle to obtain their Ayushman Bharat cards. Government surveys list beneficiaries, but discrepancies in these lists leave many unsure of their status and options. “When names are not listed following surveys, people are left confused about where to turn for help,” he explains. “The government must ensure these surveys are conducted regularly and establish initiatives at the block level to help people access support and address their grievances.”

Gurpal is another senior citizen we encountered during the course of this investigation. Like many others, he also possesses an Ayushman Bharat card but has found himself moving from pillar to post in a futile attempt to access the promised benefits. Despite being entitled to coverage under the scheme, Gurpal’s experience is marred by a series of obstacles that reflect the larger systemic issues plaguing the program.

Much like other beneficiaries we spoke to, Gurpal’s frustration stems from the fact that his card, which should guarantee him access to essential healthcare services, has been rendered almost useless by bureaucratic inefficiencies and non-cooperation from empaneled hospitals. Despite visiting several healthcare facilities, Gurpal has repeatedly been turned away, with hospitals citing various reasons for not honouring his health card.

For many senior citizens like Gurpal, navigating the complexities of the healthcare system is challenging enough without the added burden of fighting for their entitled benefits. The promise of the scheme to provide free medical treatment remains elusive for him, leaving him to bear the brunt of healthcare costs out of his own pocket—a situation that is both financially draining and emotionally taxing.

Controversies Surrounding the Scheme

Despite the scheme’s ambitious goals, it has faced several controversies. Critics argue that the program’s rollout has been plagued by many implementation-related challenges, including issues with the identification of eligible beneficiaries and difficulties in coordination among various state and central agencies. These hurdles have often led to delays in service delivery and hindered the scheme's effectiveness in reaching those most in need.

Another major point of contention is the quality of care provided under the program. While the scheme promises financial protection against high medical expenses, concerns have been raised about the adequacy of coverage and the standard of services offered by empaneled hospitals. Reports suggest that some private hospitals, eager to capitalise on the scheme, are compromising on the quality of care to reduce costs, which could undermine the very purpose of providing accessible and high-quality healthcare.

Moreover, there have been debates about the financial sustainability of the scheme. Critics argue that the funding model, which relies on a mix of central and state contributions, might not be sufficient to sustain long-term operations, especially in the face of rising healthcare costs. The scheme’s critics have also questioned the adequacy of the reimbursement rates provided to hospitals, which could potentially deter them from offering comprehensive services. These financial and operational concerns cast doubt on whether the scheme can maintain its promise of universal health coverage in the long run.

Safdarjung Hospital Staff Confronted 

During the course of the story, The Probe team visited Safdarjung Hospital. We observed firsthand the difficulties many beneficiaries face when trying to claim reimbursement under the scheme. We saw numerous impoverished patients moving from one counter to another, struggling to get their claims processed. A significant issue arose when we discovered that several cards, which beneficiaries presented as valid, were being rejected by hospital staff as invalid.

When our reporter approached a counter staff member about one such rejection, the staffer initially insisted that the card was invalid to the beneficiary. However, under further questioning, the staff abruptly changed their stance and acknowledged the card as valid. In another instance, a different card was dismissed as invalid. Confronted with these inconsistencies, we inquired about the criteria used to determine the validity of the cards. The counter staff explained that they simply input the card numbers into a database, and if the number did not appear, the card was deemed invalid.

This database-driven approach raises serious concerns. Beneficiaries presented us with their cards, asserting that they were valid and should entitle them to the benefits promised by the government. Yet, the discrepancies and lack of transparency in the validation process suggest systemic flaws that undermine the scheme’s objective of providing reliable and accessible healthcare to those in need. 

Coverage Gaps and Funding Shortfalls

Dr. Anant Phadke, a prominent health activist, provides a critical perspective on the program, revealing several fundamental issues that hinder its effectiveness. According to Dr. Phadke, the scheme’s coverage is limited to high-tech procedures that are often prohibitively expensive in the Indian context. “The scheme primarily covers advanced procedures that, by their nature, are costly,” Dr. Phadke explains. “In the Indian healthcare landscape, this means that only a small fraction of patients—about 3 to 5 percent—actually benefit from hospitalisation under the scheme.”

Dr. Phadke further highlights a stark reality: the majority of patients, approximately 95 percent, face significant out-of-pocket expenses for treatments not covered by the scheme. For impoverished families, even basic medicines for simple illnesses are beyond their reach. This financial strain is increased by insufficient funding for the program. “To adequately cover 50 crore individuals, the government would need to allocate around ₹30,000 crores annually,” Dr. Phadke asserts. “However, the current budget stands at only about ₹7,000 crores, up from ₹6,400 crores previously. This severe underfunding is a central issue.”

The low funding levels are causing substantial implementation problems, according to Dr. Phadke. “The fundamental flaw in the program is its narrow focus on high-end medical procedures while neglecting most of the health issues that people face,” he argues. “If the government genuinely intends to make a difference, it must increase funding significantly to ensure the program benefits those in need.”

The Probe has approached the Ayushman Bharat authorities for a detailed response to the concerns raised. The story will be updated when we receive a response from the authorities. However, the government has revealed that under the PMJAY, more than 34.6 crore Ayushman cards have been created; over 29,000 hospitals have been empaneled; 33 States/UTs have been covered; more than 7 crore hospitalisations have taken place; over ₹94,000 crore has been spent so far on hospitalizations; and more than 11 lakh treatments have been provided under portability.

Exclusionary Practices in the Ayushman Bharat Scheme

The requirement to link the cards with Aadhaar numbers has ignited a huge controversy, raising concerns about its role as an exclusionary measure rather than a means of empowerment. The central issue revolves around the stipulation that beneficiaries must connect their health cards to their Aadhaar numbers to access the scheme’s benefits. This requirement has led to accusations that Aadhaar is being utilised as a barrier, preventing eligible individuals from receiving necessary healthcare services.

Critics argue that the Aadhaar linkage process creates substantial hurdles for many beneficiaries. For individuals who either do not possess an Aadhaar card or face difficulties in linking their Aadhaar with their Ayushman Bharat card, the process becomes an insurmountable obstacle. In rural and remote areas, where a large portion of the scheme’s beneficiaries reside, access to Aadhaar registration centres is often limited. Additionally, the process of linking Aadhaar can be complex, time-consuming, and fraught with bureaucratic challenges, further compounding the difficulties faced by these individuals.

Instances of discrepancies and errors in Aadhaar data have heightened the issue. Mismatches between the information in the Aadhaar database and the details recorded in the Ayushman Bharat system have led to many cards being erroneously flagged as invalid. Such data mismatches result in eligible individuals being unjustly excluded from accessing healthcare services, despite their entitlement under the scheme. 

The exclusionary impact of this linkage requirement highlights a critical flaw in the implementation of the scheme. Rather than facilitating access to healthcare, the Aadhaar linkage process has become a formidable obstacle for many, casting doubt on the scheme’s ability to deliver on its promise of equitable health coverage for all.

Ayushman Bharat is undoubtedly a noble initiative, aiming to provide much-needed healthcare coverage to millions of low-income and marginalised individuals across India. The scheme's ambitious goal of offering free medical treatment to those who need it most is commendable, and on paper, it appears to be a game-changer in the country's healthcare landscape. However, despite its promising framework, the program is struggling to deliver its intended benefits to the people who need them the most. 

The primary issue lies in the inadequate funding allocated to the scheme. The inadequacy of funding has led to several systemic issues that hinder the scheme's effectiveness. Hospitals, both public and private, often lack the necessary resources to fully participate in the program. As a result, many beneficiaries are turned away or provided with substandard care. The lack of adequate compensation for hospitals also discourages private healthcare providers from participating, further limiting access for those in need.

Until and unless the government significantly increases the funding for Ayushman Bharat, these challenges will persist. The scheme will continue to fall short of its potential, and low-income and marginalised groups will remain trapped in a cycle of frustration and unmet healthcare needs.

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