Opinion Five years of Narendra Modi’s Ayushman Bharat: A report card, a reality check

There are also significant barriers to enrollment. The beneficiaries are asked to provide documents like entitlement letter from the PM, Aadhaar, Ration, PAN cards. Further, matching of names in the SECC list, Aadhaar and ration cards is a must for registration. These onerous requirements of proof of identity often act as a barrier to accessing Modi’s “free” health cover. Besides, enrollment in PM-JAY is not free for the poor, as is claimed. Informal payment ranging from Rs 100 to Rs 200 per person is universal in slums, though it does not ensure the issuance of card, as in this example. Manish Kumar, a daily wage earner from Uttar Pradesh, told his story about not receiving the smart card despite paying Rs 200 to the enrolling agents. Clearly, the enrolment processes did not take structural issues into account.

Another major concern is the exclusion of the poorest of the poor from the PM-JAY beneficiary list. For instance, Lakshmi, a domestic worker staying in Purania crossing slum in a Kaccha house with roofs and walls made of bamboo and plastic sheets for decades for decades, found her family of eight missing from the list. A frontline health worker, involved in PM-JAY enrolment activity in the state says, “Bechare Jo jhopodpatti wale hai, unka naam nehi aya he, but those who are rich or having government jobs, their names have come”.

The programme data also confirms that the penetration of PM-JAY amongst the poor is relatively insignificant. Notably, PM-JAY targets the bottom 40% of the population (roughly 58 crore) based on the Socio Economic and Caste Census database (SECC 2011). As of August 2023, 24 crore PM-JAY cards were issued, which implies that after five years of implementation, almost three-fifths of the target (58 per cent) population is still outside the ambit of PM-JAY. Further, according to the National Family Health Survey 2019-21 data, at national level, of the households that reported to have at least one member covered by the publicly-funded health insurance schemes, less than a third (32 per cent) were from the poorer category, whereas two-thirds were actually drawn from the richest 60 per cent of the households (Figure1).

Enrollment share of households covered under PM-JAY and state schemes in 2019-21 by wealth quintile.

States’ experience

The poor’s lower access to PM-JAY is evident in states too. Take the case of Bihar and Uttar Pradesh, where almost half of India’s poor live. Even after three years of PM-JAY’s implementation, the proportion of households with at least one member covered by the publicly-funded health insurance scheme was only 14 per cent in Uttar Pradesh in 2021 and 15 per cent in Bihar in 2019-20. Besides low enrollment, the targeting performance was dismal in most states including the ones that are implementing state schemes in conjunction with PM-JAY to get to universal coverage. Gujarat is a case in point, where the enrolment rate was lowest in the poorest quintile, and the leakage to the non-poor was as high as 73 per cent (Table1).

The issue of limited reach and high exclusion errors is partly the result of the mechanism used for reaching the target population in PM-JAY. Additionally, insufficient attention is paid to even enroll those listed on the beneficiary list. Many favour the policy solution of expanding eligibility and moving towards universal coverage to minimise the exclusion problem. However, aside from the exclusion issues, insurance-based commercialised healthcare systems have inherent flaws, and the recent report of the Comptroller and Auditor General pointing to large-scale corruption in PM-JAY reaffirmed it. Importantly, the budgetary allocation on PM-JAY went up by 360 per cent in the last five years. Policymakers must recognise the limitations of the so-called “strategic purchasing” strategy to accelerate progress towards UHC. Instead of further experimenting with this type of health insurance/healthcare model, which leads to wasteful spending, it would be far less challenging to strengthen the existing public healthcare system.

The writer is Associate Professor and Chairperson, Centre for Health Policy, Planning and Management, TISS