The Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (PM-JAY), launched in 2018, is a landmark healthcare initiative by the Indian government to provide free health coverage to over 100 million vulnerable families. According to the Ministry of Health and Family Welfare, 30 crore Ayushman Cards were created under AB-PMJAY. Additionally, the scheme's 6.2 crore free hospital admissions have saved more than 1.25 lakh crore of out-of-pocket expenditure for poor and vulnerable populations. It covers Rs. 5 lakhs per family annually for secondary and tertiary care hospitalization to over 12 crores of poor and vulnerable families (approximately 55 crore beneficiaries) that form the bottom 40 percent of the Indian population.

 

The government healthcare expenditure has remained constant, a minor share at around 3.8 percent of India's GDP. Even within the formal space, 58.78 percent are covered as out-of-pocket expenditures. This scheme's success depends entirely on its beneficiaries’ awareness and understanding of its benefits. However,  there is still a lack of awareness among eligible beneficiaries regarding their entitlements despite outreach efforts at every level because of various socio-economic and informational barriers. Bihar is among India's worst-performing states in providing health care services, as reflected by the National Multidimensional Poverty Index Baseline Report--based on NFHS-4 (2015-16). According to the Ministry of Statistics and Programme Implementation, the percent of families residing below the poverty line is 52.2 in Bihar. Based on a rural case study of the National Library of Medicine, awareness of this scheme was around 68.6 percent, while actual utilization amongst the eligible stands at a poor 1.3 percent. This disparity shows an important difference between awareness and proper engagement with the schemes, as most beneficiaries of the scheme heard about it through mass media and community outreach programs, but there was a substantial gap in understanding the detailed benefits and the enrolment process.

 

As per the National Sample Survey Office (NSSO) 75th round report, about 55 percent of the Indian population avail of healthcare services from the private sector. The challenges in spreading awareness are multifaceted, including low literacy rates, limited media reach in rural areas, and bureaucratic complexities. Data-driven strategies will facilitate awareness and eradicate fraudulence due to the efficient outreach and analytical work on various issues. Utilizing digital platforms and community health workers like accredited social health activists (ASHA) and Anganwadi workers (AWW) can improve information dissemination. Utilizing data analytics to identify demographics and regions with low awareness can help tailor outreach campaigns, and by analysing socio-economic data, the government can focus efforts on areas where eligible populations may not be fully informed about PM-JAY benefits. Several studies have highlighted the positive impact of AB-PMJAY on improving healthcare access and reducing financial barriers. A significant increase in hospitalization rates among eligible households is observed, indicating enhanced access to healthcare services. Additionally, the scheme has increased healthcare utilization, particularly in rural and underserved areas.

 

However, the implementation of ABPMJAY also faces several challenges. There are concerns about the quality of care provided under the scheme, with reports of disparities in service provision between public and private healthcare providers. Private hospitals are sometimes accused of prioritizing profit over patient care, leading to concerns about over-treatment or under-provision of services for cost savings, whereas public hospitals often face challenges such as inadequate infrastructure, lack of advanced medical equipment, and insufficient healthcare staff. This can lead to lower quality of care and longer patient waiting times. Furthermore, the scheme's financial sustainability is under scrutiny, given the high costs associated with its comprehensive coverage.

 

To address these issues, data on community health needs can guide the people, addressing specific local concerns. Further, we should focus more on enhancing the regulatory framework to ensure quality care, increasing the participation of private healthcare providers, and exploring innovative financing mechanisms. These platforms can offer real-time updates on eligibility, benefits, and enrollment processes, thus enhancing public knowledge without costing much. Continued monitoring and evaluation are crucial to ensuring that AB-PMJAY achieves its objectives of providing equitable and affordable healthcare to the most vulnerable populations, who can fully benefit from the healthcare services provided under this ambitious program. Increasing awareness and understanding of PM-JAY among beneficiaries is crucial for maximizing the scheme's impact.

 

Besides these, fraudulent activities within the scheme are yet another major concern. The scheme has faced significant challenges with fraud, with approximately 3.42 lakh fraud cases identified as of December 2024, including unnecessary surgeries and inflated claims. In December 2024, it was reported that two patients died after undergoing unnecessary angioplasty at Khyati Multispecialty Hospital in Ahmedabad. Investigations revealed that the hospital had been involved in fraudulent practices, leading to its de-empanelment from PMJAY. There was also a scam involving the creation of fake beneficiary cards, implicating a former general manager of PMJAY in Gujarat and directors of Khyati Hospital. They exploited technical vulnerabilities to approve ineligible beneficiaries for the scheme. And the list goes on.

 

However, advanced analytics can identify fraudulent claims by analysing patterns in service utilization. The Government of India uses Artificial Intelligence (AI) and Machine Learning (ML) technologies to detect suspicious transactions / potential frauds under Ayushman Bharat - Pradhan Mantri Jan Arogya Yojana (AB-PMJAY). These technologies prevent, detect, and deter healthcare fraud during the scheme implementation and help ensure appropriate treatment for eligible beneficiaries. This includes mandatory documentation for claims and biometric verification of beneficiaries at hospitals. Moreover, the National Health Authority (NHA) has proposed a 'name and shame' policy for fraudsters, intending to publicly disclose the names and photographs of individuals found guilty of defrauding the scheme. Besides these measures, hospitals and individuals found guilty of fraud face severe penalties, including financial restitution and de-empanelment from the scheme. For instance, after audits revealed fraudulent practices, Khyati Hospital was barred from providing services.

 

Implementing real-time analytics enables continuous monitoring of claims and hospital activities. This approach helps identify fraud before it reaches a higher level, thus efficiently allocating resources. In implementation, realising benefits towards AB-PMJAY through these strategies shall ensure the desired improvement in accessing healthcare services in equal measure.

 

Fraud within the PMJAY scheme poses significant challenges to its integrity and effectiveness in providing healthcare to vulnerable populations. However, through robust monitoring mechanisms, technological advancements, public accountability measures, and strict offender penalties, the government is actively working to mitigate these issues and ensure that the scheme's benefits reach genuine beneficiaries. Through education and enforcement by analytics, PM-JAY can reach its target audience more effectively while preventing abuse and making healthcare financing sustainable in India.