A Critical Analysis of the World’s Largest Publicly Funded Health Insurance Program: India’s Ayushman Bharat

Rajesh Kamath, Helmut Brand


Background: Launched in September 2018, the ABPMJAY is the world’s largest publicly funded health insurance (PFHI) program with population coverage of 500 million. A systematic review was conducted. Methods: A comprehensive literature search was conducted in four databases: PubMed, Web of Science, Scopus, and Google Scholar. The literature search was conducted with the search terms: “Ayushman Bharat OR ABPMJAY OR modicare AND RSBY.” The search was set to title and abstract. Gray literature and government websites were also searched for relevant documents. A total of 881 documents were identified (PubMed: 53, Web of Science: 46, Scopus: 97, Google Scholar: 681, government websites: two, and gray literature: two). Fifty‑two duplicates were identified. After the elimination of the duplicates, 829 unique documents were identified. These 829 unique citations were then subjected to a review of title and abstract independently by 2 reviewers. Six‑hundred and ninety‑two articles were rejected after review of title and abstract. One‑hundred and thirty‑seven articles were screened for full text independently by two reviewers. Sixty‑six articles were rejected after review of the full text. Disagreements were resolved by discussion. Seventy‑one unique articles were included in the final review. To attain the objective of the study, which is to critically analyze and provide an overview of Ayushman Bharat, a narrative synthesis was performed. Results: Seven themes were identified from the review: (1) health and wellness centers (HWCs); (2) out‑of‑pocket health expenditure (OOPHE); (3) fraud; (4) upcoding and provision of unnecessary medical care; (5) moving focus away from primary care; (6) coverage; and (7) lop‑sided access, exclusion at the periphery, and brain drain. There is very little impact evidence of the ABPMJAY available. Conclusions: The government could plan impact evaluation studies in every state that the ABPMJAY is functional in. Any high‑quality feedback generated might enable the National Health Authority, the government body leading and coordinating the ABPMJAY, to take necessary steps operationally and advice the government on strategy. Another concern is that the ABPMJAY PFHI might negatively impact the ongoing process of continuous strengthening and development of the government health‑care system at all levels—primary, secondary, and tertiary. Continual recalibration and course corrections on the basis of high‑quality feedback might enable ABPMJAY reduce catastrophic OOPHE for 500 million Indians. This is more than 6% of humanity: the largest block of people served by a single PFHI in history.


ABPMJAY; Ayushman Bharat; modicare; publicly funded health insurance (PFHI); RSBY; universal health care

Full Text:



Ramani KV, Mavalankar D. Health system in India:

Opportunities and challenges for improvements. J Health Organ

Manag 2006;20:560‑72.

Powell‑Jackson T, Acharya A, Mills A. An assessment of

the quality of primary health care in India. Econ Polit Wkly


India urban population, 1960‑2021. Knoema. Available from:

https://knoema.com/atlas/India/Urban‑population. [Last accessed

on 2022 Jul 21].

Ghuman BS, Mehta A. Health care services in India: Problems

and prospects. International Conference on the Asian Social

Protection in Comparative Perspective. Singapore: National

University of Singapore; 2009. p. 7‑9

Bandyopadhyay S, Sen K. Challenges of Rasthryia Swasthya

Bima Yojana (RSBY) in West Bengal, India: An exploratory

study. Int J Health Plann Manag 2018;33:294‑308.

GV VPS, Maiya GR. Coverage, utilization, and impact of

Ayushman Bharat scheme among the rural field practice area of

Saveetha Medical College and Hospital, Chennai. J Family Med

Prim Care 2021;10:1171‑6.

Joseph J, Sankar DH, Nambiar D. Empanelment of health care

facilities under Ayushman Bharat Pradhan Mantri Jan Arogya

Yojana (AB PM‑JAY) in India. PloS One 2021;16:e0251814.

ABDM components. NHA. Official website Ayushman Bharat

Digital Mission. Available from: https://abdm.gov.in/.

www.ETHealthworld.com. Budget 2020: Healthcare gets

Rs 69,000 crore; Rs 6,400 crore for Ayushman Bharat‑et

healthworld. ETHealthworld.com 2020.

Lahariya C. ‘Ayushman Bharat’program and universal health

coverage in India. Indian Pediatr 2018;55:495‑506.

Ved RR, Gupta G, Singh S. India’s health and wellness centres:

Realizing universal health coverage through comprehensive

primary health care. WHO South East Asia J Public Health


Lahariya C. ‘More, better, faster & sustained’: Strengthen

primary health care to advance universal health coverage. Indian

J Med Res 2019;149:433‑6.

Bajpai N, Wadhwa M. Health and Wellness Centres:

Expanding Access to Comprehensive Primary Health Care

in India. Academic Commons 2019. Available from: https://


Chatterjee P. India launches Ayushman Bharat’s secondary care

component. Lancet 2018;392:997.

Kumar R. Universal health coverage–Time to dismantle vertical

public health programs in India. J Family Med Prim Care


Keshri VR, Gupta SS. Ayushman bharat and road to universal

health coverage in India. J Mahatma Gandhi Inst Med Sci


Gupta R. Universal healthcare ahoy. RUHS J Health Sci


Bhargava B, Paul VK. Informing NCD control efforts in India on

the eve of Ayushman Bharat. Lancet 2022;399:e17‑9.

Jain N. Modinomics=Corporatonomics Part IV: Modi’s Budgets

and the Social Sectors: Health. Lokayat. 2019. Available from:



Das S, Jha AK. Getting coverage right for 500 million Indians.

N Engl J Med 2019;380:2287‑9.

Choudhury M, Tripathi S, Dubey JD. Experiences with

government sponsored health insurance schemes in Indian

states: A fiscal perspective. NIPFP Working Paper Series. New

Delh: National Institute of Public Finance and Policy; 2019.

Available from: https://www.nipfp.org.in/media/medialibrary


Garg S, Bebarta KK, Tripathi N. Performance of India’s national

publicly funded health insurance scheme, Pradhan Mantri Jan

Arogaya Yojana (PMJAY), in improving access and financial

protection for hospital care: Findings from household surveys

in Chhattisgarh state. BMC Public Health 2020;20:1‑0. doi:


Karan A, Yip W, Mahal A. Extending health insurance to the

poor in India: An impact evaluation of Rashtriya Swasthya Bima

Yojana on out of pocket spending for healthcare. Soc Sci Med


Garg S, Chowdhury S, Sundararaman T. Utilisation and financial

protection for hospital care under publicly funded health

insurance in three states in Southern India. BMC Health Serv

Res 2019;19:1‑1.

Sangar S, Dutt V, Thakur R. Burden of out‑of‑pocket

health expenditure and its impoverishment impact in India:

Evidence from national sample survey. J Asian Public Policy


Azam M. Does social health insurance reduce financial burden?

Panel data evidence from India. World Dev 2018;102:1‑7.

Gupt A, Kaur P, Kamraj P, Murthy BN. Out of pocket

expenditure for hospitalization among below poverty line

households in district Solan, Himachal Pradesh, India, 2013.

PloS One 2016;11:e0149824.

Devadasan N, Seshadri T, Trivedi M, Criel B. Promoting

universal financial protection: Evidence from the Rashtriya

Swasthya Bima Yojana (RSBY) in Gujarat, India. Health Res

Policy Syst 2013;11:1‑8. doi: 10.1186/1478‑4505‑11‑29.

Rao M, Katyal A, Singh PV, Samarth A, Bergkvist S,

Kancharla M, et al. Changes in addressing inequalities in access to hospital care in Andhra Pradesh and Maharashtra

states of India: A difference‑in‑differences study using repeated

cross‑sectional surveys. BMJ Open 2014;4:e004471.

Nandi S, Schneider H, Dixit P. Hospital utilization and out of

pocket expenditure in public and private sectors under the

universal government health insurance scheme in Chhattisgarh

State, India: Lessons for universal health coverage. PLoS One


Virk AK, Atun R. Towards universal health coverage in India:

A historical examination of the genesis of Rashtriya Swasthya

Bima Yojana–The health insurance scheme for low‑income

groups. Public Health 2015;129:810‑7.

Prinja S, Bahuguna P, Gupta I, Chowdhury S, Trivedi M. Role

of insurance in determining utilization of healthcare and financial

risk protection in India. PloS One 2019;14:e0211793.

Philip NE, Kannan S, Sarma SP. Utilization of comprehensive

health insurance scheme, Kerala: A comparative study of insured

and uninsured below‑poverty‑line households. Asia Pac J Public

Health 2016;28 (1_Suppl):77S‑85S.

Khetrapal S, Acharya A, Mills A. Assessment of the

public‑private‑partnerships model of a national health insurance

scheme in India. Soc Sci Med 2019;243:112634.

Maurya D. Understanding public health insurance in

India: A design perspective. Int J Health Plann Manag


Gopichandran V. Ayushman Bharat National health protection

scheme: An ethical analysis. Asian Bioeth Rev 2019;11:69‑80.

Khan SA. Hurdles to implementation one year on Ayushman

Bharat. Econ Polit Wkly 2019;54. Available from: https://www.


Goel S, Sharan S. Tightening the performance screws on

Ayushman Bharat. The Hindu‑Business Line. 2017. Available



Paul V. Ayushman Bharat Pradhan Mantri Jan Arogya

Yojana (AB PMJAY): Hope for millions and exciting new

prospects for Neuro‑Healthcare. Neurol India 2019;67:1186‑7.

Pareek M. Ayushman Bharat‑National Health Protection Mission

a way towards Universal Health Cover by reaching the bottom

of the pyramid to be a game changer or non‑starter. Int J Adv

Innov Res 2018;7:1‑10. doi: 10.5281/zenodo. 1411497.

Maurya D, Ramesh M. Program design, implementation and

performance: The case of social health insurance in India. Health

Econ Policy Law 2019;14:487‑508.

ABPMJAY beneficiary empowerment guidebook March 2019.

Ayushman bharat — Long live private healthcare. Econ Polit

Wkly 2018;53:8.

Sundararaman T. Ayushman Bharat: Hopes and fears. Int J

Health Syst Implement Res 2018;2:1‑5.

Bagcchi S. Doctors criticise India’s” ill conceived” launch

of publicly funded health insurance scheme. BMJ Br Med

J (Online) 2018;360:k1448. doi: 10.1136/bmj.k1448.

Bharat A. Designing India’s national healthcare protection:

Challenges and opportunities. Perspectives 2018. Available

from: https://www.ideasforindia.in/topics/social‑identity/

designing -india -s- national- healthcare‑protection challenges‑and‑opportunities.html.

Saxena N, Singh P, Mishra A. A qualitative comparative analysis

of healthcare Supply–Demand side barriers under the publicly

funded health insurance scheme in India. Indian J Public Health


Morton M, Nagpal S, Sadanandan R, Bauhoff S. India’s largest

hospital insurance program faces challenges in using claims data

to measure quality. Health Aff 2016;35:1792‑9.

Kumar R. Achieving universal health coverage in India: The

need for multisectoral public health action. Indian J Community

Med 2020;45:1‑2. doi: 10.4103/ijcm.IJCM_61_19.

Kumar R. Universal health coverage–Time to dismantle vertical

public health programs in India. J Family Med Prim Care


Mukherjee R, Arora M. India’s national health protection

scheme: A preview. Med J Dr D Y Patil Vidyapeeth 2018;11:385.

Sethi S, Sharma P, Kumar A, Singh N, Kishore J. ‘Ayushman

Bharat is a boon for the country’: Against the motion. Int J Prev

Curative Community Med 2019;5:36‑40.

Mukhopadhyay I, Sinha D. Painting a picture of Ill‑health. In:

Azad, Chakraborty S, Raman S, Sinha D, editors. Quantum

Leap in the Wrong Direction. Orient Black Swan Hyderabad,

India; 2019.

Sharma SD. Health care for India’s 500 million. Harvard Public

Health Rev 2018;18:1‑4. Available from: https://www.jstor.org/


Pande A. Ayushman Bharat and the trivialisation of healthcare.

The Hindu Centre for Politics and Public Policy 2019. Available

from: https://www.thehinducentre.com/the‑arena/current‑issues/


Sundararaman T. Ayushman Bharat: Hopes and fears. Int J

Health Syst Implement Res 2018;2:1‑5.

Chaudhuri S. Ayushman Bharat: Accessible healthcare or cause

for concern for the welfare state?

Ghosh SM, Qadeer I. Pradhan Mantri Jan Arogya Yojana:

A paper tiger. Soc Change 2019;49:136‑43.

Angell BJ, Prinja S, Gupt A, Jha V, Jan S. The Ayushman

Bharat Pradhan Mantri Jan Arogya Yojana and the path to

universal health coverage in India: Overcoming the challenges of

stewardship and governance. PLoS Med 2019;16:e1002759.

Dror DM, Vellakkal S. Is RSBY India’s platform to implementing

universal hospital insurance? Indian J Med Res 2012;135:56‑63.

Thakur H. Study of awareness, enrollment, and utilization of

Rashtriya Swasthya Bima Yojana (national health insurance

scheme) in Maharashtra, India. Front Public Health 2016;3:282.

doi: 10.3389/fpubh. 2015.00282.

Sarwa A, Aggarwal AK, Prinja S. Local elected

leaders (“Panchayat”) can Play key role for enrolment under

National Health Protection Mission (NHPM) under ‘Ayushman

Bharat’: Lessons learnt from Rashtriya Swasth Bima

Yojna (RSBY) implementation. Int J Health Syst Implement

Res 2018;2:39‑48.

Taneja PK, Taneja S. Rashtriya Swasthya Bima

Yojana (RSBY) for universal health coverage. Asian J Manag

Cases 2016;13:108‑24.

Malhi R, Goel D, Gambhir RS, Brar P, Behal D, Bhardwaj A.

Rashtriya Swasthya Bima Yojana (RSBY) and outpatient

coverage. J Family Med Prim Care 2020;9:459‑64.

Kusuma YS, Pal M, Babu BV. Health insurance: Awareness,

utilization, and its determinants among the urban poor in Delhi,

India. J Epidemiol Global Health 2018;8:69‑76.

Nandi S, Dasgupta R, Garg S, Sinha D, Sahu S, Mahobe R.

Uncovering coverage: Utilisation of the universal health

insurance scheme, Chhattisgarh by women in slums of Raipur.

Indian J Gender Stud 2016;23:43‑68.

Karpagam S, Vasan A, Seethappa V. Falling through the gaps:

Women accessing care under health insurance schemes in

Karnataka. Indian J Gend Stud 2016;23:69‑86.

Singh OP. Insurance for mental illness: Government schemes must show the way. Indian J Psychiatry 2019;61:113‑4.

Trivedi M, Saxena DB. Third angle of RSBY: Service providers’

perspective to RSBY‑operational issues in Gujarat. J Family Med

Prim Care 2013;2:169‑72.

Mozumdar A, Aruldas K, Jain A, Reichenbach L. Understanding

the use of India’s National Health Insurance Scheme for family

planning and reproductive health services in Uttar Pradesh. Int J

Health Plann Manag 2018;33:823‑35.

Bandyopadhyay S, Sen K. Challenges of Rasthryia Swasthya

Bima Yojana (RSBY) in West Bengal, India: An exploratory

study. Int J Health Plann Manag 2018;33:294‑308.

Nandi A, Holtzman EP, Malani A, Laxminarayan R. The need

for better evidence to evaluate the health & economic benefits

of India’s Rashtriya Swasthya Bima Yojana. Indian J Med Res


Naib P, Nigam R, Gautam K, Goel H. Cataract Management

under Ayushman Bharat Pradhan Mantri Jan Arogya Yojana.

Available from: https://www.readkong.com/page/cataractmanagement-under‑ayushman‑bharat-pradhan‑mantri‑2877247.

Nandi A, Ashok A, Laxminarayan R. The socioeconomic and

institutional determinants of participation in India’s health

insurance scheme for the poor. PloS One 2013;8:e66296.

Dutta S, Lahiri K. Is provision of healthcare sufficient to ensure

better access? An exploration of the scope for public‑private

partnership in India. Int J Health Policy Manag 2015;4:467‑74.

Prinja S, Sharma A, Gupta I, Chowdhury S, Trivedi M.

Designing a framework for benefit packages. Econ Polit Wkly


Choudhury M, Datta P. Private Hospitals in Health Insurance

Network in India: A Reflection for Implementation of Ayushman

Bharat. 2019. Working Papers id: 13009, eSocialSciences.

Available from: https://ideas.repec.org/p/ess/wpaper/id13009.html.

Pandey N, Jha S, Rai V. Key drivers for adopting universal

health system: Patient insights from central India. Anvesha


Kaur S, Jain N, Bhatnagar PC. Early trends from utilization of

oncology services: Insights from Ayushman Bharat Pradhan

Mantri Jan Arogya Yojana (PM‑JAY). Working Paper 004.

Available from: https://www.pmjay.gov.in/sites/default/

files/2019‑11/Working% 20paper‑4%20% 281%29.pdf.

Hooda SK. With inadequate health infrastructure, Can

Ayushman Bharat really work? 2018. Available from:





Events. HWC. Available from: http://ab‑hwc.nhp.gov.

in/. [Lastaccessed on 2022 Jun 19].

Sundararaman T. In new health and Wellness Centres, India has

a good plan for primary care – backed by Little Action. Scroll.

in. 2018. Available from: https://scroll.in/pulse/870405/in‑newhealth-and-wellness-centres-india‑has‑a‑good‑plan‑for‑primary‑ca


Press Trust of India | New Delhi. Ayushman scheme will

cover drugs, diagnostic expenses pre and post hospitalisation:

Nadda. Business Standard. 2018. Available from: https://www.



Press Trust of India | New Delhi. Ayushman Bharat saw 51% fall in

average weekly claims amid lockdown: Report. Business‑standard.

com. 2022. Available from: https://www.business‑standard.


Mookerji N. Expecting a rebound in health services: Ayushman

Bharat CEO Indu Bhushan. Business‑standard.com. Available fr

om: https://www.business‑standard.com/article/economy‑policy/