PATIENTS accessing private facilities under Pradhan Mantri Jan Arogya Yojana (PMJAY) had to incur on an average Rs 53,965 Out-of-Pocket Expenditure (OOPE) per hospitalisation on medicine, transport and diagnostics services, reveals an evaluation study commissioned by the NITI Aayog.
The study, conducted by the IQVIA Consulting and Information Services India Pvt. Ltd., was recently submitted to the NITI Aayog’s Development Monitoring and Evaluation Office (DEMO). It covers all centrally sponsored schemes of the health sector, including the PM-JAY.
Schemes’ appraisal
The findings of the study are crucial in view of the government’s appraisal of functioning of various schemes ahead of their continuation for the 16th Finance Commission period beginning April 1, 2026. Emails seeking comments from the NITI Aayog and the Ministry of Health and Family Welfare did not elicit a response.
As per the report, a survey was conducted among a total sample of 2,283 households across 13 states and Union Territories, of which a majority of 1,489 (65%) households were covered by some form of health insurance while 794 (35%) had no insurance cover. Among those with health insurance coverage, most (1,380 households) were covered under government-sponsored schemes, while a smaller proportion, 81 (5%), were covered under private insurance plans.
Among those covered under government schemes, a majority were PMJAY (1,156 households) beneficiaries. During the survey it was found that a total of 1,201 families’ members were hospitalised during the last five years, representing 23% of all individuals included in the survey.
As per the findings of the survey, 35% of those covered under PMJAY had not incurred any sort of OOPE during hospitalisation while the remaining 65% had to pay for medicine, transport and diagnostics services.
The patients accessing private facilities under PMJAY had to incur on an average OOPE of Rs 53,965 per hospitalisation. In public facilities, the patients incurred on an average OOPE of Rs 21,827 per hospitalisation, said the study.
Thus, in private hospitals, patients under PMJAY had to spend more than double OOPE as compared to the public hospitals, it said.
As per the study, the average OOPE was Rs 34,790 compared with Rs 38,084 for those not insured, suggesting PMJAY patients incurred Rs 3,294 less on an average compared with those not insured under any insurance scheme.
As far as non-insured patients are concerned, they incurred an OOPE of Rs 74,847 per hospitalisation in private facilities compared to Rs 11,146 in public facilities.
“Despite coverage of pre and post-hospitalisation care, beneficiaries continue to incur OOPE for medicines and diagnostics. Those visiting public hospitals often face higher travel and medicine costs, whereas overall OOPE remains higher in private hospitals primarily driven by expenses on medicines, diagnostics and patient transport. It is acknowledged that transport cost is not covered under the scheme,” noted the study.
The PMJAY, which is a flagship scheme under the Centre’s Ayushman Bharat scheme, was launched on September 23, 2018 with a total outlay of Rs 40,112 crore for a period of five years 2019–20 to 2024–25. The scheme is touted as the “world’s largest” health assurance scheme, aimed to provide health coverage of Rs 5 lakh per family per year for secondary and tertiary care hospitalisation.
The government’s target is to cover over 12 crores families (about 55 crore individuals) under this scheme. The scheme provides cashless health services related to 1,961 procedures across 27 medical specialities.
In September 2024, the PMJAY was expanded to cover all senior citizens aged 70 and above, irrespective of their socio-economic status.
In govt facilities, out-of-pocket expenses on average Rs 21,827 
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