ESSAY

The Ayushman Bharat Pradhan Mantri Jan

Arogya Yojana and the path to universal
health coverage in India: Overcoming the
challenges of stewardship and governance
Blake J. Angell ID1*, Shankar Prinja ID2, Anadi Gupt ID3, Vivekanand Jha ID4,5,
Stephen Jan ID1

1 The George Institute for Global Health, University of New South Wales, Sydney, Australia, 2 School of
Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India, 3 National
Health Mission, Government of Himachal Pradesh, Shimla, Himachal Pradesh, India, 4 The George Institute
for Global Health, University of New South Wales, New Delhi, India, 5 University of Oxford, Oxford, United
Kingdom

* bangell@georgeinstitute.org.au
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a1111111111 Summary points
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• Public spending on healthcare in India is amongst the lowest in the world at just over
1% of gross domestic product (GDP), and the Indian health system is characterised by
substantial shortcomings relating to workforce, infrastructure, and the quality and avail-
ability of services.
OPEN ACCESS
• The Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY), approved by
Citation: Angell BJ, Prinja S, Gupt A, Jha V, Jan S
(2019) The Ayushman Bharat Pradhan Mantri Jan the Indian government in March 2018, is an ambitious reform to the Indian health sys-
Arogya Yojana and the path to universal health tem that seeks to provide financial health protection for 500 million of the most vulnera-
coverage in India: Overcoming the challenges of ble Indians and halt the slide of the 50–60 million Indians who fall into poverty annually
stewardship and governance. PLoS Med 16(3): as a result of medical-related expenditure.
e1002759. https://doi.org/10.1371/journal.
pmed.1002759 • There is a need for wide reforms across public and private providers of care if India is to
Published: March 7, 2019
meet its stated aims of providing universal health coverage (UHC) for its population.
The success of the program will rely on a reformed and adequately resourced public sec-
Copyright: © 2019 Angell et al. This is an open
tor to lead implementation, delivery, and monitoring of the scheme.
access article distributed under the terms of the
Creative Commons Attribution License, which • While there are significant challenges facing the program, by providing the impetus for
permits unrestricted use, distribution, and system-wide reform, AB-PMJAY presents the nation with a chance to tackle long-term
reproduction in any medium, provided the original
and embedded shortcomings in governance, quality control, and stewardship and to
author and source are credited.
accelerate India’s progress towards the stated goal of UHC provision.
Funding: No specific funding was received for this
work. • Implementation and ongoing operation of the program need to be carefully monitored
to ensure that it is meeting its aims in a sustainable manner and that negative unin-
Competing interests: The authors have declared
that no competing interests exist. tended consequences are avoided.

Abbreviations: AB-PMJAY, Ayushman Bharat

Pradhan Mantri Jan Arogya Yojana; GDP, gross
domestic product; UHC, universal health coverage.

Provenance: Not commissioned, externally peer

reviewed.

PLOS Medicine | https://doi.org/10.1371/journal.pmed.1002759 March 7, 2019 1/6

 Introduction
Successive Indian national governments have stated a commitment to achieving universal
health coverage (UHC). In spite of this, UHC remains an elusive aim, and the Indian health
system continues to be characterised by substantial shortcomings relating to workforce, infra-
structure, and the quality and availability of services. Public expenditure on healthcare in India
remains at levels amongst the lowest in the world. The government of India approved the
Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) in March 2018 and has
hailed the program as a historic step towards achieving UHC in India. The scheme aims to
publicly fund the healthcare of up to 500 million people and, if it lives up to its potential, repre-
sents a unique opportunity to institutionalise quality healthcare free at the point of service for
the most marginalised Indians, improving the health of the population and drastically reduc-
ing or eliminating medical-related impoverishment. While many have already questioned the
likelihood of successful implementation of the AB-PMJAY, the vast ambition of the program
presents an opportunity to pursue the systemic reform that India requires to meet its UHC
aims. This will require an injection of resources into a chronically underfunded health system,
but this must be accompanied by a focus on the interrelated issues of governance, quality con-
trol, and stewardship if the scheme is to sustainably accelerate India towards UHC.

The policy context

The Indian health system comprises a complex mix of various levels of government decision
makers and providers, private companies, and other nongovernment service providers. The
country has a chronic shortage of doctors and other healthcare providers, who tend to be con-
centrated in the urban centres, leaving large parts of the country underserved [1,2]. Notwith-
standing increases in real terms over recent decades, government expenditure on health in
India ranks amongst the lowest in the world at a little over 1% of GDP [3]. Consequently, the
system depends heavily on out-of-pocket payments charged to patients at the point of care.
Such payments limit access to care and have a disproportionate economic impact on the poor
[4]. Impoverishment in India as a result of healthcare costs is common for patients and their
families, with an estimated 50–60 million people pushed into poverty each year as a result of
medical-related expenditure [5].
A raft of policies have been implemented by state and national governments over recent
decades to improve healthcare coverage in India [2]. Most notably, the National Rural Health
Mission was established in 2005 [6] by the central government to provide universal access to
care for rural residents, which was then joined by the National Urban Health Mission to create
the National Health Mission in 2014 [7]. These policy initiatives were accompanied by an
increase in health system infrastructure such as community and primary healthcare centres
[2]. Along with a number of state and national schemes such as the Rashtriya Swasthya Bima
Yojana launched in 2007 that covered hospital expenses of up to INR 30,000 (approximately
US$420) for families living below the poverty line, it was estimated that, by 2010, up to 25% of
India’s population had some level of financial protection for healthcare costs [8]. While these
and similar schemes have been accompanied by ambitious mandates, in many cases their
impact on financial risk protection has been limited by insufficient resourcing and coverage
gaps [2,8–13].

Modicare and UHC

In this context, the cabinet of the Indian government approved the ambitious AB-PMJAY in
March, 2018. The scheme, colloquially referred to as “Modicare” after Indian Prime Minister
Narendra Modi, aims to build on existing schemes to provide publicly funded health insurance

PLOS Medicine | https://doi.org/10.1371/journal.pmed.1002759 March 7, 2019 2/6

 cover of up to 500,000 Indian rupees (over US$7,000) per family per year to about 100 million
families (500 million people, 40% of India’s population) [14,15]. The scheme builds on the pre-
vious programs outlined above (for example, the National Health Mission still forms the basis
of primary care under the new program [16]) and has been designed to be implemented to
either take over or operate alongside state-based programs, but has a broader remit in terms of
the services covered and the amount of coverage that each individual is entitled to. The govern-
ment has so far allocated 100 billion rupees (almost US$1.5 billion) to the program for 2018–
2019 and 2019–2020 [14]. Currently, the country spends about US$64 per person on health-
care, two-thirds of which is privately financed by user fees [17]. As such, current UHC initia-
tives in India centred on AB-PMJAY alongside state-based programs such as those in Andhra
Pradesh, Telangana, Tamil Nadu, Karnataka, and Kerala represent, as a whole, one of the most
ambitious ever health and, one could argue, poverty-alleviation programs ever launched.
Details of AB-PMJAY initially emerged in a piecemeal way via government press releases
and media interviews [18–20]. More recently, government guidelines for implementing differ-
ent parts of the scheme have been released [15,16]. Eligibility for the scheme is determined
based on deprivation criteria measured in the 2011 Socio-Economic Caste Census. There is no
limit to the number of family members covered, and benefits will eventually be India-wide (if
all states and union territories sign up to the program). This means that a beneficiary will be
allowed to take cashless benefits from any public or empanelled private hospital across the
country. State health authorities will lead the implementation of the AB-PMJAY, and states are
free to continue to provide existing programs alongside the national program or integrate
them with the new scheme. States will also be able to choose their own operating model to
either use the expenditure to pay a private insurance provider to cover services, provide ser-
vices directly (as elected by Chandigarh and Andhra Pradesh, for example), or a mix of the two
(as in Gujarat and Tamil Nadu) [20]. Expenditure under the program will also be shared
between the central and state governments in a prespecified ratio depending on the legislative
arrangements and relative wealth of the states, with the Indian government covering between
60%–100% of expenditure [18,20]. A pilot of the program, involving only public hospitals, was
launched in August 2018 across 110 districts in 14 states and union territories, with a large
number of private hospitals having since been empanelled under the program [21].

The challenges of governance and stewardship

UHC aims to ensure access to quality essential healthcare services and medicines for popula-
tions without exposing them to the risk of financial hardship [22]. Progress towards UHC must
be seen in light of the severe challenges facing the Indian system. The country is beset by defi-
ciencies in the resources available to fund healthcare, the skilled workforce and infrastructure
available to provide care, and oversight of healthcare provision. Private providers have become
the dominant provider of care in India, and thus UHC is unlikely to be achieved without
engagement with this sector [2,23,24]. The profit motive that drives the behaviour of these pro-
viders, however, has led to concerns that services may be encouraged to sometimes act against
the public interest. Regulation and oversight of these providers in low- and middle-income
nations is often poor. There is evidence from across low- and middle-income countries that pri-
vate providers more frequently deviate from evidence-based practice, have poorer patient out-
comes, and are more likely to provide unnecessary testing and treatment [25], and the data that
do exist from India have mirrored these findings [26]. At the same time, public providers in
India have been shown to face significant governance challenges as well, with services shown to
be rife with absenteeism, of poor quality, and nonexistent in many areas of care. Corruption at
all levels of the system from doctor training to investment decisions remains an issue [2].

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 Policy interventions to progress India towards UHC need to factor in these difficulties and
make tangible inroads into overcoming them. Institutional inefficiencies, common in health
systems across the world, are often difficult to change once embedded because change often cre-
ates winners and losers. The size and scope of the announced program, however, presents some-
thing of an opportunity to overcome some of this fragmentation and set India onto an optimal
path to UHC if it is able to constructively work to overcome these challenges. Fundamental to
doing so will be ensuring appropriate governance and quality of the healthcare provided to the
population. Few details have emerged as to how the interrelated issues of governance, monitor-
ing, and accountability will be managed under the scheme to progress India towards successful
implementation of AB-PMJAY and ultimately UHC. As new services are provided and coverage
increased, successful implementation will require a parallel concerted push towards quality
assurance, appropriate governance, and appropriate referral pathways in both public and pri-
vate healthcare providers. Given the importance of private providers in India, there is a need to
strengthen the stewardship function of the government to monitor the provision of care from
these providers. This could occur in a number of ways, such as through the development of
robust referral pathways for patients, quality audits of providers, incentives to improve the effi-
ciency and quality of care, strategic purchasing, and a general strengthening of the capacity of
the public sector to effectively contract with and regulate the private sector.

Conclusion
The AB-PMJAY offers a unique opportunity to improve the health of hundreds of millions of
Indians and eliminate a major source of poverty afflicting the nation. There are, however, sub-
stantial challenges that need to be overcome to enable these benefits to be realised by the
Indian population and ensure that the scheme makes a sustainable contribution to the prog-
ress of India towards UHC. UHC has become a key guiding target for health systems around
the world under the Sustainable Development Goals to improve the health of the global popu-
lation and overcome the scourge of medical-related impoverishment. The success of UHC is
measured by the access of health services across the population, the types of services that are
available, and the financial protection offered to the population. While there are obvious
resource constraints in implementing AB-PMJAY, the success—or otherwise—of the scheme
in making progress across these three measures will also depend on overcoming a number of
existing and interrelated structural deficiencies of the Indian system such as issues of public
and private sector governance, stewardship, quality control, and health system organisation.
To do so will require careful monitoring of the implementation of the program to track prog-
ress against key budgetary, service, and financial-protection measures and guard against unin-
tended consequences. In many cases, current arrangements in these areas can be seen to be a
product of vested interests and a system that is not designed to reward positive change. Alter-
ing these incentives to promote universal and quality care for all Indians will require wide-
spread reform, intervention, and leadership across all levels of the Indian system. Thus, whilst
these weaknesses pose a threat to the ability of proposed reforms to meet their ambitious
objectives, by providing the impetus for systemic reform, AB-PMJAY presents the nation with
a chance to tackle long-term and embedded shortcomings in governance, quality control, and
stewardship.

References
1. Sachan D. India looks to a new course to fix rural doctor shortage. Lancet 2013; 382 (9899):e10. PMID:
24137656

PLOS Medicine | https://doi.org/10.1371/journal.pmed.1002759 March 7, 2019 4/6

 2. Patel V, Parikh R, Nandraj S, Balasubramaniam P, Narayan K, Paul VK, et al. Assuring health coverage
for all in India. Lancet. 2015; 386 (10011):2422–35. https://doi.org/10.1016/S0140-6736(15)00955-1
PMID: 26700532
3. Central Bureau of Health Intelligence. National Health Profile India 2018. 2018 [Available from: http://
www.cbhidghs.nic.in/index1.php?lang=1&level=2&sublinkid=88&lid=1138. Cited 22 October 2018].
4. Lagarde M, Palmer N. The impact of user fees on access to health services in low-and middle-income
countries. Cochrane Database Syst Rev. 2011; 13(4):CD009094.
5. Selvaraj S, Farooqui HH, Karan A. Quantifying the financial burden of households’ out-of-pocket pay-
ments on medicines in India: a repeated cross-sectional analysis of National Sample Survey data,
1994–2014. BMJ Open 2018; 8(5): e018020. https://doi.org/10.1136/bmjopen-2017-018020 PMID:
29858403
6. Ministry of Health and Family Welfare. Framework of implementation for National Rural Health Mission
2005–12. The Government of India. 2005 [available: http://www.nhm.gov.in/nhm/nrhm/nrhm-
framework-for-implementation.html. Cited October 19 2018].
7. Ministry of Health and Family Welfare. National Health Mission 2018 [available from: http://nhm.gov.in/
accessed 22 October 2018].
8. La Forgia G, Nagpal S. Government-sponsored health insurance in India: Are you covered? The World
Bank; 2012.
9. Devadasan N, Criel B, Van Damme W, Ranson K, Van der Stuyft P. Indian community health insurance
schemes provide partial protection against catastrophic health expenditure. BMC Health Serv Res.
2007; 7(1):43. https://doi.org/10.1186/1472-6963-7-43 PMID: 17362506
10. Karan A, Yip W, Mahal A. Extending health insurance to the poor in India: An impact evaluation of Rash-
triya Swasthya Bima Yojana on out of pocket spending for healthcare. Soc Sci Med. 2017; 181:83–92.
https://doi.org/10.1016/j.socscimed.2017.03.053 PMID: 28376358
11. Singh P, Kumar V. Insurance coverage under different health schemes in Uttar Pradesh, India. Clin Epi-
demiol Glob Health. 2017; 5(1):33–9. https://doi.org/10.1016/j.cegh.2016.03.002.
12. Selvaraj S, Karan AK. Why Publicly-Financed Health Insurance Schemes Are Ineffective in Providing
Financial Risk Protection. Econ Political Wkly. 2012; 47(11):60–8.
13. Rathi P, Mukherji A, Sen G. Rashtriya Swasthya Bima Yojana: Evaluating Utilisation, Roll-out and Per-
ceptions in Amaravati District, Maharashtra. Econ Political Wkly. 2012; 47(39):57–64.
14. Government of India. Ayushman Bharat—National Health Protection Mission 2018. Available from:
https://www.india.gov.in/spotlight/ayushman-bharat-national-health-protection-mission [accessed 22
October 2018].
15. Ministry of Health and Family Welfare. Operational Guidelines on Ayushman Bharat National Health
Protection Mission. 2018 [cited 12 October 2018] Available from https://ayushmanbharatharyana.in/
assets/pdfs/AB-NHPM%20Operational%20Guidelines%20June%202018.pdf.
16. National Health Systems Resource Centre. Operational Guidelines, Health and Wellness Centres for
Comprehensive Primary Health Care. 2018 [cited 12 October 2018] Available from http://nhsrcindia.
org/sites/default/files/Operational%20Guidelines%20For%20Comprehensive%20Primary%20Health%
20Care%20through%20Health%20and%20Wellness%20Centers.pdf.
17. World Health Organisation. Health financing profile 2017, India. New Delhi: 2017 [cited 20 August
2018]: available from https://apps.who.int/iris/bitstream/handle/10665/259642/HFP-IND.pdf?
sequence=1&isAllowed=y.
18. Cabinet approves Ayushman Bharat–National Health Protection Mission [Internet]. Delhi; 2018 [cited
20 August 2018]. Available from: http://pib.nic.in/newsite/PrintRelease.aspx?relid=177816
19. Sharma A, Raghavan P. Ayushman Bharat scheme launch on Sept 25. The Economic Times. 2018
Aug 16.
20. Ghosh A. Health cover scheme: Who, how. The Indian Express. 2018 June 14; available https://
indianexpress.com/article/explained/national-health-mission-ayushman-bharat-health-mission-jp-
nada-health-budget-5216382/ [cited August 20 2018].
21. Lancet The. India’s mega health reforms: treatment for half a billion. Lancet. 2018; 392(10148):614.
https://doi.org/10.1016/S0140-6736(18)31936-6
22. World Health Organisation. Universal Health Coverage (UHC) Factsheet 2018. Available from: http://
www.who.int/news-room/fact-sheets/detail/universal-health-coverage-(uhc) [accessed 22 October
2018].
23. Rao PH. The private health sector in India: a framework for improving the quality of care. ASCI Journal
of Management 2012; 41(2):14–39.

PLOS Medicine | https://doi.org/10.1371/journal.pmed.1002759 March 7, 2019 5/6

 24. Sengupta A, Nundy S. The private health sector in India. BMJ. 2005; 331(7526):1157–58. https://doi.
org/10.1136/bmj.331.7526.1157 PMID: 16293815
25. Basu S, Andrews J, Kishore S, Panjabi R, Stuckler D. Comparative performance of private and public
healthcare systems in low-and middle-income countries: a systematic review. PLoS Med. 2012; 9(6):
e1001244. https://doi.org/10.1371/journal.pmed.1001244 PMID: 22723748
26. Das J, Holla A, Das V, Mohanan M, Tabak D, Chan B. In urban and rural India, a standardized patient
study showed low levels of provider training and huge quality gaps. Health Aff. 2012; 31(12):2774–84.

PLOS Medicine | https://doi.org/10.1371/journal.pmed.1002759 March 7, 2019 6/6