Blitz Bureau
NEW DELHI: When West Bengal signed its memorandum with the National Health Authority (NHA) in June this year, Ayushman Bharat achieved what no earlier national health effort had managed: A presence in all 28 states and eight Union territories. With Delhi having joined a year earlier, the Pradhan Mantri Jan Arogya Yojana (PM-JAY) — the insurance pillar of the programme — became genuinely pan-Indian. Eight years after Prime Minister Narendra Modi launched it from Ranchi in September 2018, the scheme stands among the most ambitious public-health undertakings anywhere in the world, and a cornerstone of India’s march toward universal health coverage.
A record of historic scale
The numbers behind the milestone are formidable. More than 43 crore Ayushman cards have been created, and PM-JAY has authorised over 11.6 crore hospital admissions worth roughly ₹1.73 lakh crore, across a network of 36,081 empanelled hospitals. The primary-care pillar, the Ayushman Arogya Mandirs, now exceeds 1.81 lakh centres offering screening, teleconsultation and free essential care close to home.
The Ayushman Bharat Digital Mission has crossed 90 crore health accounts — arguably the largest digital health infrastructure on earth — while the Ayushman Vay Vandana cover, extended in 2024 to every citizen above 70, has already reached lakhs of elderly households. Most tellingly, India’s out-of-pocket health expenditure has fallen from 62.6 per cent in 2014-15 to 39.4 per cent in 2021-22 — a decline that reflects real relief for families for whom a single hospitalisation once meant debt.
That every State and Union territory now participates is itself a quiet triumph of cooperative federalism. Health is a state subject, and bringing governments across the political spectrum onto a common platform took patient negotiation and shared purpose. For the ordinary citizen the significance is immediate: an Ayushman card issued in one state can, in principle, be used at an empanelled hospital in another, offering portable protection to migrant workers and travelling families who were long the most exposed to medical uncertainty.
India’s out-of-pocket health expenditure has fallen from 62.6 per cent in 2014-15 to 39.4 per cent in 2021-22 — a decline that reflects real relief for families for whom a single hospitalisation once meant debt.
Success brings the next task
These are achievements of historic scale, and they establish Ayushman Bharat as a durable pillar of India’s welfare architecture. Yet the very success of the programme now brings its next task into focus. Any initiative expanding at this velocity naturally encounters areas that call for refinement — and it is a measure of the scheme’s institutional maturity that many are already being addressed, calmly and methodically, even as enrolment continues to climb.
One such area is the timeliness of payments to hospitals. As claims have multiplied, reimbursement cycles have in places lengthened, prompting some private providers to scale back participation. Recognising this, the Government has rolled out the National Health Claims Exchange (NHCX), a digital gateway that standardises and speeds up claim settlement, complemented by a regulatory push for near-instant cashless approvals. As these systems mature and connect more insurers and hospitals, the friction that has strained provider cash flows is expected to ease, keeping the private sector — which handles a large share of treatments — firmly within the fold.
Closely linked is the question of package rates. To keep empanelled hospitals, especially in smaller towns, financially engaged, the NHA has periodically revised its Health Benefit Package; the 2024 iteration expanded to 1,961 procedures with upward rate revisions for 350 of them. Institutionalising such reviews, so that rates track medical costs predictably, would further strengthen provider confidence and participation.
Extending protection
A third dimension concerns the depth of financial protection. PM-JAY covers hospitalisation, yet a substantial share of household health spending goes on medicines and outpatient care. Here, complementary programmes are quietly filling the gap. Ayushman Arogya Mandirs dispense free essential drugs and diagnostics, while the network of Jan Aushadhi Kendras — now exceeding 19,500 outlets offering generics 50 to 80 per cent cheaper — brings affordable medicine within reach of rural and urban families alike, serving an estimated 10 to 12 lakh people a day. Weaving these strands more tightly into the Ayushman Bharat fold would extend protection across the full continuum of care.
The programme’s reach is also shaped by the availability of trained personnel. Specialist positions in rural health centres remain to be filled in large numbers — a challenge the Union Government is meeting through an ambitious expansion of medical education, with a commitment to 75,000 new medical seats over five years and capacity already rising past 1.18 lakh MBBS places.
Complemented by Community Health Officers and a growing volume of teleconsultations, this build-out is steadily deepening the workforce. Pairing it with focused incentives for rural service would help ensure that the facilities the state has created under the PM-ABHIM infrastructure mission are matched by the doctors and specialists to run them.
Guarding the integrity of the scheme has been another priority, and one where the response has been notably robust. The NHA has established a National Anti-Fraud Unit that deploys advanced analytics — machine learning, image recognition and Aadhaar-based biometric verification — to protect scheme funds and ensure that every rupee reaches genuine beneficiaries. Such safeguards, strengthened continuously, are what allow a programme of this size to command public trust as it grows.
Reaching the missing middle
Finally, there is the opportunity to widen coverage further. PM-JAY was designed for the economically weakest, and commercial insurance serves the organised sector; between them lies a large self-employed and informal-sector population — often described as the “missing middle” — that could benefit from an affordable, contributory option. The universal extension of the Vay Vandana cover to all senior citizens points encouragingly in this direction, and NITI Aayog’s blueprint for covering this segment offers a ready template for the next step toward truly universal protection.
Taken together, these are not the failings of a struggling programme but the refinements befitting a maturing one. The pattern is consistent and reassuring: as each pressure point has emerged, an institutional response has followed. The system is demonstrably responsive; the task now is to accelerate and sequence these reforms so that the promise is realised in full.
The way forward
The advisory that emerges is straightforward. First, timely settlement of hospital claims should be treated as a firm commitment, with NHCX-enabled automation backed by clear timelines. Second, package rates merit a transparent, periodic revision mechanism linked to actual costs. Third, financial protection should progressively extend to outpatient and pharmaceutical expenses, scaling the Arogya Mandir and Jan Aushadhi networks in tandem. Fourth, the missing-middle population deserves a dedicated, low-cost insurance pathway. Fifth, rural workforce deployment should advance in step with medical-seat expansion. And underpinning all of these, a steady rise in public health spending toward the National Health Policy’s 2.5 per cent-of-GDP goal would give the reforms the fiscal room they need to succeed.
None of this diminishes what has been accomplished. Ayushman Bharat has widened India’s health safety net further than any programme before it, and in doing so has changed the calculus of illness for hundreds of millions. The next phase is about consolidation — ensuring that reach translates into resilience, and that a card in every eligible hand is matched by quality care within every citizen’s grasp. With the institutional will already evident and the reform machinery already in motion, that vision is well within reach.
Deepening the promise
Ayushman Bharat has achieved remarkable breadth — near-universal enrolment, a nationwide hospital network, and a sharp fall in out-of-pocket costs. The next frontier is depth, and three linked questions will define the programme’s second phase. Can financial protection extend beyond hospitalisation to the medicines and outpatient care on which families still spend the most? Can the large “missing middle” — households too well-off for PM-JAY yet stretched by private insurance — be brought under an affordable, contributory cover? And can the health workforce, particularly rural specialists, grow fast enough to staff the facilities now in place? Encouragingly, each is already being addressed — through Jan Aushadhi and the Arogya Mandirs, the universal Vay Vandana extension for senior citizens, and a major expansion of medical seats. The task ahead is to accelerate and connect these efforts, supported by a steady rise in public health spending toward the 2.5 per cent-of-GDP benchmark. These are challenges of success, not failure — the work of converting a landmark in access into a lasting guarantee of care for every Indian.