Opinion More funds for Ayushman Bharat won’t help those who need the scheme the most

Such inordinately low funding cannot generate any significant impacts. Moreover, the most recent HCES data (2022-23) reveals PMJAY’s dismal performance. In the last five years, only 20 per cent of households in the country have been covered by PMJAY. Moreover, a disconcerting pattern in enrollment was noticed: Of those covered by AB, three-fifths were from the top 60 per cent of households, and two-thirds (67 per cent) from advanced castes, while Adivasi and Dalit communities accounted for 33 per cent of the registered households. Additionally, the coverage varies enormously across India, with the lowest (less than 6 per cent) recorded in the three most populous states: Uttar Pradesh, Bihar and Maharashtra. And the average number of enrollees from registered households was also the lowest in those states. This implies that in UP, where the average is only 2.5, most members of an average family (with 5.1 members) were excluded from the programme. Notably, since AB was introduced, all three states have been predominantly governed by the party that has also been in power at the Centre. On the other hand, the states ruled by opposition political parties seem to have performed better in terms of reaching the eligible population. West Bengal stands out with a household coverage of 72.3 per cent through Swasthya Sathi (SS), averaging 3.5 enrollees per household (in a household size of 3.8), surpassing all states in achieving UHC. The point to be noted is that in West Bengal, where everyone is eligible for SS hospitalisation cover, the enrollment was highest (73 per cent), further confirming that the universal system is better at dealing with exclusion errors than targeted interventions.

The scheme’s impact was found to be quite limited in addressing the hospital care requirements of the needy. Poorer individuals have worse health status than wealthier ones because of poor nutrition and unhealthy living environments. Yet, only 12 per cent of households in the bottom 40 per cent consumption expenditure group reported any hospitalisation, compared to 23 per cent of households in the top 60 per cent. Moreover, only 7 per cent of households in the bottom 40 per cent that required hospitalisation received benefits from AB. In other words, AB could not be of any use to 93 per cent of poorer households whose members needed hospital treatment in 2022-23.

Besides dismal utilisation of benefits, AB/PFHIPs also reveal a pro-rich bias. The top three expenditure quintiles constitute the majority of AB beneficiaries, while marginalised groups such as Dalits and Adivasis make up only 32 per cent of those benefiting from AB. These findings closely correspond with our field observations. For instance, a fisherman in Thiruvananthapuram whose mother, Maria, is a stroke survivor, stated, “It hasn’t even been a year since my mother fell ill, and we have already spent a lot — around Rs 60,000 in just one month. We were unaware of any health insurance options.” Likewise, a casual worker from Palghar, Maharashtra, said, “My mother-in-law is suffering from paralysis and requires medication. Expenses can reach up to 3,000 rupees per month. I showed my yellow-coloured ration (BPL) card, but they told me that I would have to pay. No one listens to us.” I tried to find out if AB could at least protect the users from the financial consequences of hospitalisations. It turned out that more than half of them faced catastrophic financial losses, despite receiving AB’s benefits.

The analysis provides key insights into the workings of the scheme. Firstly, AB benefits mainly go to the better-off and it largely failed to target the bottom of the economic pyramid. As a result, low-income households continue to rely on out-of-pocket (OOP) payments and skimp on treatment. Secondly, most beneficiaries end up incurring high OOP hospital expenses. Also, private providers believe that PMJAY’s reimbursement rates are too low, often leading to extra billing for beneficiaries. Furthermore, AB is designed in a way that offers limited financial protection against the cost of care. Its coverage is shallow and does not include physician visits, diagnostic tests, or medications, forcing patients to shoulder most of the treatment expenses. Unfortunately, the Union Budget does not address any of these critical questions. The overall allocation to health accounted for only 2 per cent of total government expenditure in FY26. This is way below the 8 per cent mark set for the states, considered to be essential to raise public health spending to 2.5 per cent of GDP by 2025. Achieving this target is vital for making substantial progress toward UHC, as envisaged by the National Health Policy of 2017.

Worryingly, budgetary provisions for the National Health Mission decreased in real terms from the previous year. As a percentage of GDP, the Centre’s allocation is only 0.31 per cent of GDP in FY26, which implies that India, in all likelihood, will miss the 2025 target and thereby further delay the realisation of UHC.

The writer is chairperson, Centre for Health Policy, Planning and Management, Tata Institute of Social Sciences, Mumbai