Seven Years of Ayushman Bharat

₹1.48 Lakh Crore in Cashless Care Over Seven Years — But Is Ayushman Bharat Delivering Equitably?

On September 24, 2025, Ayushman Bharat marked its seventh anniversary, celebrated as the world’s largest government-funded health assurance scheme. With over ₹1.48 lakh crore dispensed for 10.3 crore hospital admissions under the Pradhan Mantri Jan Arogya Yojana (PM-JAY), its scale is incontestable. Out-of-pocket health expenditure has dropped from 63% to 39%, signaling a step towards relieving the financial strain historically borne by Indian households. Yet, beneath these headline figures lies a critical debate on regional disparities, implementation bottlenecks, and unfulfilled promises in comprehensive primary care.

Institutional Framework and Ambitious Scope

Ayushman Bharat finds its legislative rooting in the National Health Policy, 2017, launching officially in September 2018, from Ranchi. Structured as a two-pronged initiative, it integrates:

• PM-JAY: Aiming to cover 55 crore individuals from economically vulnerable households, it provides ₹5 lakh per family annually for secondary and tertiary hospital treatments. Beneficiaries, identified through SECC 2011 data, enjoy portable, paperless access at both public and empanelled private hospitals nationwide.
• Ayushman Bharat Health and Wellness Centres (AB-HWCs): Tasked with converting 1.5 lakh sub-centres and primary health centres into HWCs, this program focuses on preventive and promotive care, addressing maternal health, child health, non-communicable diseases, and essential diagnostics.

Budgetary allocations have soared, with the government’s health expenditure increasing from 29% to 48% of total health spending. Yet, this rise masks uneven absorption in states struggling with infrastructure deficits and human resource constraints.

Expanding Access, Yet Facing Institutional Gaps

The past seven years saw significant expansion. New provisions extended PM-JAY benefits to gig workers, senior citizens through the Ayushman Vay Vandana Card, and even grassroots health workers like ASHA and Anganwadi workers. The Ayushman Bharat Digital Mission (ABDM), launched in 2021, further added a technological layer to healthcare, creating unique health IDs for citizens under the ABHA framework.

However, numbers alone do not address critical questions of healthcare quality and systemic bottlenecks. National Quality Assurance Standards (NQAS) frameworks remain inconsistently applied across states, with audit reports showing gaps in patient satisfaction and hospital accountability. The irony is clear: a scheme intended to build confidence in public healthcare is disproportionately reliant on private sector empanelment, with for-profit hospitals cornering a significant share of reimbursements.

Regional Disparities — India’s Unequal Healthcare Landscape

Despite its portable benefits, Ayushman Bharat replicates enduring interstate inequities. Tamil Nadu and Kerala, states with robust public healthcare networks, utilize PM-JAY funds far more effectively than Bihar or Uttar Pradesh, where infrastructure inadequacies undermine access. This amplifies geographical healthcare inequalities rather than mitigating them.

Funding utilization ratios reveal troubling patterns: northeastern states consistently fall short in absorbing allocated funds, raising questions about local governance capacity. Meanwhile, chronic vacancies in AB-HWCs across rural India hinder preventive care efforts, a cornerstone of the scheme.

Lessons from Thailand’s Universal Coverage Scheme

Thailand’s Universal Coverage Scheme (UCS), launched in 2002, demonstrates stark contrasts with Ayushman Bharat. By offering free comprehensive medical care—including out-patient services—to all citizens, irrespective of income group, it bypasses exclusion errors inherent in means-testing models like SECC 2011. Crucially, Thailand built UCS upon an extensive community-level primary care infrastructure, ensuring equal access nationwide.

India, by comparison, faces persistent gaps in primary health capacity. While HWCs aim to bridge those gaps, the coverage remains uneven, and workforce shortages plague overburdened rural areas.

What Remains Unresolved?

Metrics for success must look beyond hospital admissions. Is preventive care reducing disease burden? Are out-of-pocket expenses genuinely declining across all income groups, or marginally for targeted beneficiaries? What remains absent is clear data on health outcomes under PM-JAY, particularly for non-communicable diseases, which now account for the majority of mortality in India.

Political and fiscal tensions persist. The Centre-State relationship, often fraught in federal schemes, complicates fund disbursement and monitoring. Despite financing escalations, corruption risks and fund diversion in local administration threaten larger policy objectives.

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