Introduction

In a country as vast and unequal as India, healthcare access is a measure not just of policy success but of social justice. Launched with the vision of achieving Universal Health Coverage (UHC), Ayushman Bharat–Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) has emerged as one of the largest public health insurance schemes in the world. But as the National Health Authority’s (NHA) Annual Report 2024–25 reveals, this success story is layered with contradictions—between public and private sectors, access and equity, vision and reality.

Ayushman Bharat: An Overview

Launched in 2018, Ayushman Bharat has two key components:

1. Pradhan Mantri Jan Arogya Yojana (PMJAY): Provides ₹5 lakh per family per year for secondary and tertiary care.
2. Ayushman Arogya Mandirs (AAMs): Formerly Health and Wellness Centres, these aim to deliver comprehensive primary healthcare, including screening, diagnostics, and non-communicable disease management.

The scheme covers around 55 crore people (the poorest 40%), based on SECC 2011 data and legacy RSBY lists. Over 35 crore Ayushman cards have been issued, with nearly half to women.

Key Insights from the NHA Report (2024–25)

• Private Hospital Dominance: Though only 45% of the 31,000+ empanelled hospitals are private, they conducted 52% of hospitalisations and claimed 66% of the ₹1.29 lakh crore treatment cost.
• Top Treatments: Haemodialysis (14%), fever (4%), gastroenteritis, and animal bites have seen high usage. General medicine, ophthalmology, and general surgery top specialties in 2024–25.
• Patient Mobility: Ayushman Bharat’s portability allows cross-state treatment. Chandigarh (19%), UP (13%), and Gujarat (11%) are top in-migration destinations. States with high out-migration include UP, MP, and Bihar.
• Digital Progress:
  • ABHA (Ayushman Bharat Health Account): 14-digit ID linked to health records.
  • 60% of Indians have ABHA numbers, with 50 crore health records already linked.
  • 38% of health facilities and 26% of health personnel are registered.

Successes and Gains

• Financial Protection: 21% reduction in out-of-pocket health expenditure (OOPE), and an 8% drop in health-related emergency loans.
• Gender Inclusion: Women hold 49% of Ayushman cards, with 3.6 crore hospitalizations availed.
• District Hospital Revenue: An estimated annual net benefit of $26 million, potentially rising to $41.8 million.

Structural Challenges to UHC

Despite these achievements, deep-rooted issues challenge the goal of “Health for All”:

1. Low Public Health Spending

India spends just 1.84% of GDP on public health, below the 2.5% target set by the National Health Policy 2017. This underfunding weakens infrastructure and shifts burden to private providers.

2. Urban Bias & Workforce Shortage

Doctors and specialists are concentrated in urban private sectors, leaving rural areas underserved. There’s also a chronic shortage of trained paramedical and community health workers.

3. Neglect of Primary and Outpatient Care

While Ayushman Bharat covers hospitalisation, it neglects primary care, diagnostics, and OPD services, which form the bulk of healthcare needs and OOPE.

4. Private Sector Overdependence

Private hospitals dominate despite the scheme being government-led. This raises concerns over profit-driven motives, overcharging, and variable quality of care.

5. The “Missing Middle”

Those not poor enough for government schemes or rich enough for private insurance—the “missing middle”—remain uncovered. They form a significant portion of India’s informal workforce.

Sociological Reflections: Health as a Social Contract

Sociologists have long emphasized the role of healthcare in maintaining social order and justice. Talcott Parsons, in his theory of the sick role, viewed health as a societal function that sustains productivity and stability. From this lens, a failing health system erodes not just well-being but social cohesion.

Michel Foucault’s ideas on biopower are also relevant—governments manage populations through healthcare, surveillance, and control over bodies. The digital expansion under Ayushman Bharat (via ABHA) offers empowerment, but also raises ethical concerns about data privacy and access.

Meanwhile, Indian sociologist D. Banerji critiqued India’s health model for its “urban elite orientation”, arguing that public health should be people-centric and not hospital-centric—a critique that still resonates.

The Way Forward: Building Real Universal Health Coverage

To make UHC a reality, India must go beyond insurance cards and focus on systemic reforms:

• Raise Public Health Spending to 2.5% of GDP with a strong focus on primary care (AAMs) and preventive services.
• Expand Coverage to include OPD services, medicines, diagnostics, and the missing middle population.
• Strengthen the Workforce by training and incentivizing rural health workers, expanding medical colleges, and supporting community-level care.
• Leverage Digital Tools like telemedicine, ABHA, and health apps to extend specialist care into remote areas.
• Regulate Private Sector through strict enforcement of the Clinical Establishments Act, quality audits, and patient rights charters.

Conclusion

Ayushman Bharat–PMJAY is a milestone in India’s journey toward Universal Health Coverage. It has empowered millions and reduced financial vulnerability—but it also reveals a stark reality: the public health system remains weak, and private players dominate a scheme meant for the poor.

If health is a human right and not a privilege, India must urgently shift from hospitalisation-led insurance to community-based wellness, from patchwork coverage to comprehensive care. Only then can Ayushman Bharat truly live up to its name—a “blessed India” where no one is left behind.