BharatNotes Framework: The Ayushman Bharat Umbrella
Launched by Prime Minister Narendra Modi on 23 September 2018 from Ranchi, Ayushman Bharat (AB) is India's flagship programme aimed at operationalising the National Health Policy, 2017 commitment to Universal Health Coverage (UHC). It is the world's largest government-funded health assurance programme.
The scheme rests on a continuum-of-care philosophy — combining comprehensive primary healthcare at the community level with secondary and tertiary hospitalisation cover for the poor and vulnerable, stitched together by a digital health backbone.
| Pillar | What it does |
|---|---|
| Ayushman Arogya Mandirs (AAMs) | Primary healthcare — erstwhile Health & Wellness Centres, renamed 26 Nov 2023 |
| PM Jan Arogya Yojana (PMJAY) | ₹5 lakh secondary/tertiary hospitalisation cover |
| Ayushman Vay Vandana (AB PM-JAY 70+) | Extension — all senior citizens 70+ regardless of income (launched 29 Oct 2024) |
| Ayushman Bharat Digital Mission (ABDM) | Digital health ID (ABHA) and interoperability stack (launched 27 Sept 2021) |
| PM–ABHIM | Pradhan Mantri Ayushman Bharat Health Infrastructure Mission — public health infrastructure (launched Oct 2021) |
Implementing agency: National Health Authority (NHA), an autonomous body under the Ministry of Health and Family Welfare.
PMJAY — The Core Insurance Scheme
Pradhan Mantri Jan Arogya Yojana (PMJAY) is the world's largest fully government-funded health assurance scheme, providing a cashless, paperless hospitalisation cover.
| Feature | Detail |
|---|---|
| Launched | 23 September 2018 |
| Cover | ₹5 lakh per family per year — on a family floater basis |
| Cover type | Covers secondary and tertiary hospitalisation; ~2,000 procedures across 27 specialties; includes 3 days pre-hospitalisation and 15 days post-hospitalisation expenses |
| No restriction | No cap on family size, age, or gender; no waiting period for pre-existing conditions from Day 1 |
| Portability | Beneficiary in any state can avail treatment in any empanelled hospital across India |
| Implementing agency | National Health Authority (NHA) at Centre; State Health Agencies (SHAs) at State level |
Eligibility — Beneficiary Identification
PMJAY uses the Socio-Economic Caste Census (SECC) 2011 as the primary identification database (no enrolment — entitlement-based).
| Rural (7 deprivation criteria — at least 1 required) | Urban (11 occupational categories) |
|---|---|
| Only one room with kuccha walls and kuccha roof | Ragpicker, beggar |
| No adult member aged 16–59 | Domestic worker, street vendor |
| Female-headed household with no adult male 16–59 | Construction worker, plumber, mason, labour, painter |
| Disabled member, no able-bodied adult | Sweeper, sanitation worker, mali |
| SC/ST households | Home-based artisan, handicraft worker, tailor |
| Landless households dependent on manual labour | Transport worker — driver, conductor, cart puller |
| Destitute, living on alms; manual scavenger; primitive tribal group; legally released bonded labour (auto-included) | Shop worker, peon, delivery assistant, waiter |
Expansions beyond SECC 2011:
- All ASHAs, Anganwadi Workers (AWWs), and Anganwadi Helpers (AWHs) and their families (announced Sept 2024; operationalised alongside 70+ extension)
- All senior citizens aged 70 and above via Ayushman Vay Vandana (Oct 2024)
Coverage Numbers (as of 2025–26)
| Metric | Figure |
|---|---|
| Ayushman cards issued (cumulative) | 36.9 crore+ (as of 24 March 2025) |
| Empanelled hospitals | 32,320 (as of 15 October 2025) |
| Private empanelled hospitals | 15,733+ (as of 31 December 2025) |
| Hospital admissions authorised (cumulative) | 9.84 crore+ (till June 2025); 11.69 crore (Feb 2026) |
| Treatment amount authorised (cumulative) | ₹1.40 lakh crore+ (till June 2025) |
| States/UTs implementing | 35 out of 36 (Odisha joined Jan 2025; Delhi joined April 2025) |
States and the Opt-Out Story
Initially, several states declined PMJAY citing preference for their own schemes or federal concerns over branding and cost-sharing.
| State | Status (as of April 2026) |
|---|---|
| Odisha | Signed MoU with NHA on 13 January 2025; became 34th State/UT to implement |
| Delhi | Signed MoU on 5 April 2025 (post-Assembly elections); became 35th State/UT |
| West Bengal | Remains outside PMJAY — initially joined, later withdrew; operates its own Swasthya Sathi scheme |
Ayushman Vay Vandana Yojana — The 70+ Extension
A landmark expansion converting PMJAY from a poverty-targeted scheme toward a life-stage universal entitlement for the elderly.
| Feature | Detail |
|---|---|
| Launched | 29 October 2024 (Dhanteras) by PM Modi |
| Eligibility | All citizens aged 70 years and above, irrespective of socio-economic status |
| Identification | Aadhaar-based age verification; distinct Ayushman Vay Vandana Card |
| Cover | ₹5 lakh additional top-up per year exclusively for elderly members in families already covered by PMJAY; a fresh ₹5 lakh family floater for elderly in families not under PMJAY |
| Target population | Approximately 6 crore senior citizens in ~4.5 crore families |
| Choice | Beneficiaries already covered under CGHS, ECHS, or Ayushman CAPF must choose between existing cover or shift to Vay Vandana |
Performance in Year One (Oct 2024 – Oct 2025)
| Metric | Figure |
|---|---|
| Vay Vandana Cards issued | 86 lakh+ (as of Oct 2025); 9.60 million+ (as of Nov 2025) |
| Treatments availed in first year | ~7 lakh |
| Treatment value in first year | ₹1,471 crore |
Ayushman Bharat Digital Mission (ABDM)
Launched: 27 September 2021 (nationwide) — creates a federated digital health ecosystem ("UPI moment for health"). Based on the National Digital Health Blueprint (NDHB) recommendations.
The ABDM Building Blocks
| Component | Function |
|---|---|
| ABHA (Ayushman Bharat Health Account) | 14-digit unique Health ID; patient-controlled, consent-based access to longitudinal health records |
| Healthcare Professionals Registry (HPR) | Single source of truth for all doctors, nurses, allied health professionals |
| Health Facility Registry (HFR) | Repository of public and private health facilities (hospitals, labs, pharmacies, clinics) |
| Unified Health Interface (UHI) | Open protocol enabling interoperability between patient apps and health service providers (akin to UPI for payments) |
| Drug Registry & Health Claims Exchange (HCX) | Standardised drug codes; API-based insurance claim settlement |
ABDM Dashboard — Key Metrics
| Metric | As of Feb 2025 | As of Jan 2026 |
|---|---|---|
| ABHA created | 73.98 crore | 84.79 crore+ |
| Health records linked to ABHA | 49.06 crore | 82.69 crore |
| Health Facilities on HFR | 3.63 lakh | 4.51 lakh |
| Healthcare Professionals on HPR | 5.64 lakh | 7.61 lakh |
| Facilities using ABDM-enabled software | 1.59 lakh | — |
Key principle: ABDM is consent-based and federated — no central database of health records. The patient owns the ABHA ID and grants specific consents for data sharing through the Consent Manager architecture.
Ayushman Arogya Mandirs (AAMs) — Primary Healthcare
Renamed from Health and Wellness Centres (HWCs) on 26 November 2023 (during 74th Constitution Day week). Built by upgrading Sub-Centres and Primary Health Centres under NHM.
Expanded Service Package — 12 Services
| # | Service |
|---|---|
| 1 | Care in pregnancy and childbirth |
| 2 | Neonatal and infant healthcare |
| 3 | Childhood and adolescent healthcare |
| 4 | Family planning, contraceptive services, other reproductive healthcare |
| 5 | Management of communicable diseases — National Health Programmes |
| 6 | Management of common infectious and acute simple illnesses |
| 7 | Screening, prevention, control and management of NCDs (hypertension, diabetes, 3 common cancers — oral, breast, cervical) |
| 8 | Basic oral health care |
| 9 | Elderly and palliative healthcare |
| 10 | Emergency medical services and trauma |
| 11 | Screening and basic mental health services |
| 12 | Basic ENT and ophthalmology services |
Achievement vs Target
| Metric | Figure |
|---|---|
| Original target | 1.5 lakh AAMs by end of 2022 (later rolled forward) |
| Operationalised (Dec 2023) | 1,63,402 |
| Operationalised (30 Nov 2025) | 1,81,873 — target exceeded |
| NCD screenings (cumulative) | 55.66 crore hypertension, 48.44 crore diabetes (till Dec 2023) |
Institutional Architecture
| Tier | Body | Role |
|---|---|---|
| Centre | National Health Authority (NHA) | Apex body; policy, IT platform, National Anti-Fraud Unit (NAFU), hospital empanelment standards |
| State | State Health Agencies (SHAs) | Implementation, hospital empanelment, claim settlement, grievance redressal |
| District | District Implementation Units | Ground-level awareness, card issuance, audit |
| Hospital | Empanelled Health Care Providers (EHCPs) | Treatment delivery; Pradhan Mantri Arogya Mitras (PMAMs) stationed at hospitals to assist beneficiaries |
Empanelment standards: NHA prescribes minimum criteria (beds, specialists, diagnostic facilities, NABH accreditation preferred). Rates follow Health Benefit Packages (HBP 2022) revised periodically.
Funding Architecture
| Element | Detail |
|---|---|
| Sharing pattern (general states) | 60:40 (Centre : State) |
| NE states and Himalayan states | 90:10 (Centre : State) |
| Union Territories without legislature | 100% by Centre |
| UTs with legislature (Delhi, Puducherry, J&K) | 60:40 |
Union Budget 2025–26 Allocations
| Head | Allocation |
|---|---|
| Ministry of Health & Family Welfare (total) | ₹99,859 crore |
| PMJAY (AB-PMJAY) | ₹9,406 crore — ~29% increase over BE 2024-25 |
| Revised Estimate FY 2025-26 (MoHFW) | Basis for FY26-27 which saw ~10% rise to ₹1,06,530.42 crore |
Cumulative Expenditure (PMJAY)
Cumulative government expenditure on free treatment under AB-PMJAY has crossed ₹81,979 crore (as per latest parliamentary replies, 2025), against cumulative authorised value of ₹1.40 lakh crore — reflecting the difference between authorised and actually paid claim amounts.
Challenges and Criticism
| # | Challenge | Evidence / Data |
|---|---|---|
| 1 | Low private hospital participation in some states | Private empanelment concentrated in a few states (Maharashtra, Gujarat, Karnataka, Tamil Nadu); package rates seen as financially unviable by corporate chains |
| 2 | Fraud and abuse | 2.7 lakh claims worth ₹562.4 crore found non-admissible; 3.56 lakh claims worth ₹643 crore rejected; 3.42 lakh fraud cases detected; 56,000+ unnecessary surgeries flagged |
| 3 | Punitive action still scaling | 1,114 hospitals de-empanelled; 1,504 penalised for ₹122 crore; 549 suspended |
| 4 | Claim rejection & settlement delays | Private hospitals cite delayed reimbursement cycles; SAFUs often under-staffed |
| 5 | Quality of care disparity | NABH-accredited hospitals remain a minority; variable outcomes across districts |
| 6 | Health workforce shortage | AAMs often staffed by Community Health Officers (CHOs) alone; specialist gap in CHCs |
| 7 | Out-of-Pocket Expenditure (OOPE) still high | OOPE fell from 62.6% (2014-15) to ~39.4% (2021-22 NHA data), but still well above WHO benchmark of 15–20% |
| 8 | Exclusion errors | SECC 2011 is 14 years old; economic status of households has changed; reliance on stale database excludes genuine poor and includes ineligible |
| 9 | West Bengal hold-out | Beneficiaries from WB denied portability benefits enjoyed elsewhere |
| 10 | Federal friction in branding | Several states initially sought dual branding; NHA policy tightened |
NAFU technology stack: Deploys 57 tools including rule-based triggers, machine learning algorithms, fuzzy logic, image classification and de-duplication to auto-flag suspicious claims.
Key Terms
- PMJAY (Pradhan Mantri Jan Arogya Yojana): The ₹5 lakh hospitalisation cover arm of Ayushman Bharat; entitlement-based on SECC 2011.
- ABHA (Ayushman Bharat Health Account): 14-digit unique health ID enabling patient-controlled longitudinal health records under ABDM.
- AAM (Ayushman Arogya Mandir): Renamed Health and Wellness Centre (2023); delivers 12-service Comprehensive Primary Health Care package.
- NHA (National Health Authority): Apex implementing body for PMJAY and ABDM; autonomous entity under MoHFW.
- SECC 2011: Socio-Economic Caste Census, 2011 — database identifying deprived households; primary eligibility basis for PMJAY.
- EHCP (Empanelled Health Care Provider): Public or private hospital enrolled to deliver PMJAY treatments at notified Health Benefit Package rates.
- UHC (Universal Health Coverage): Principle that all individuals receive needed health services without financial hardship — SDG Target 3.8.
- OOPE (Out-of-Pocket Expenditure): Direct payments by individuals for health services at the time of use; key indicator of catastrophic health spending.
- NAFU (National Anti-Fraud Unit): NHA's central anti-fraud cell deploying AI/ML triggers, backed by State Anti-Fraud Units (SAFUs).
- PMAM (Pradhan Mantri Arogya Mitra): Hospital-stationed facilitator who verifies beneficiaries, assists admission, and supports claim processing.
Beyond the Book — Analytical Perspectives
1. NITI Aayog UHC Vision. The Health System for a New India: Building Blocks report (2019) laid the template of publicly financed, privately delivered UHC that PMJAY operationalises — essentially a strategic purchasing model, not a nationalised NHS-style system.
2. Lancet and BMJ evidence on OOPE. Peer-reviewed studies document a drop in catastrophic health expenditure (CHE) among PMJAY beneficiaries — though effect size varies by state capacity. National Health Accounts 2021–22 place OOPE at 39.4% of Total Health Expenditure, down from 62.6% in 2014–15.
3. Comparison with Obamacare (Affordable Care Act, US). Obamacare mandates individuals to buy private insurance with subsidies; PMJAY is a purely government-funded entitlement. PMJAY covers ~40% of India's population (poorest plus 70+) at zero premium; ACA expanded coverage to ~20 million Americans through a mix of Medicaid expansion and marketplace subsidies.
4. Strategic purchasing vs price controls. PMJAY's Health Benefit Package (HBP) rates are often lower than CGHS rates — critics argue this creates a two-tier care system. Proponents point to bulk-purchasing efficiency gains.
5. ABDM as public digital infrastructure. Like UPI and Aadhaar, ABDM is architected as a Digital Public Good (DPG) — open APIs, federated data, consent manager, no central database. This contrasts with China's centralised model and the EU's decentralised EHR approach.
6. Feminisation of enrolment. Roughly 49% of Ayushman cards are held by women; women account for ~48% of authorised hospital admissions — higher than women's share in general private insurance, suggesting PMJAY reduces gender gap in healthcare access.
Recent Developments (2024–2026)
Expansion to Senior Citizens (70+) — October 2024
The Union Cabinet on 29 October 2024 universalised AB-PMJAY coverage to all Indians aged 70 years and above, irrespective of income. Approximately 6 crore senior citizens across 4.5 crore families now receive ₹5 lakh annual hospitalisation cover under the "Ayushman Vay Vandana Card." Senior citizens in already-enrolled families receive an additional top-up of ₹5 lakh specifically for themselves. By January 2025, over 40 lakh senior citizens had enrolled.
This marks a shift from income-targeted to age-targeted entitlement — the first such universalisation of a health benefit in India. The AB-PMJAY budget was raised from ₹7,300 crore (2024–25) to ₹9,406 crore (2025–26). Total Ayushman cards issued surpassed 36.9 crore by March 2025. The ASHA/AWW/AWH expansion (March 2024) added 37 lakh frontline health workers and their families to the scheme's coverage.
UPSC angle: Prelims — AB-PMJAY expansion to 70+ (October 2024); Ayushman Vay Vandana Card; 36.9 crore cards total; ASHA/AWW expansion March 2024. Mains (GS2) — universalism vs targeting in health insurance; elderly demographic challenge; integration of frontline workers in health security.
ABDM Progress — 80 Crore ABHA IDs (2024)
The Ayushman Bharat Digital Mission (ABDM) — launched nationally in September 2021 — crossed 80 crore Ayushman Bharat Health Account (ABHA) unique health IDs by 2024. ABHA is a 14-digit digital health ID enabling patients to voluntarily link and share their health records with providers. The Health Information Exchange and Consent Manager (HI-EM) platform, ABHA app, and Ayushman Bharat Health Records (ABHR) framework are now operational.
In December 2024, the National Health Authority (NHA) reported 382 million Health Records (facility-linked doctor visits, prescriptions, and lab results) linked to ABHA IDs. The number of healthcare facilities registered on the NHA's Health Facility Registry crossed 2.1 lakh. The ABDM's open API architecture (Digital Public Good model) enables private EMR software vendors and hospital systems to integrate with the national health data ecosystem.
UPSC angle: Prelims — ABDM: launched September 2021; ABHA (14-digit health ID); 80 crore IDs (2024); Health Facility Registry 2.1 lakh. Mains (GS2) — digital health infrastructure as public good; data privacy and consent architecture (Puttaswamy judgment); comparison with NHS England's NHS App.
PMJAY Claims Data and Fraud Control (2024)
As of early 2025, AB-PMJAY has facilitated over 7.7 crore hospital admissions worth approximately ₹1.08 lakh crore since launch in September 2018. Average annual claim hospitalisation has been approximately 1.5–1.7 crore beneficiaries since 2021. The National Anti-Fraud Unit (NAFU) — PMJAY's AI-driven fraud detection system — uses 57 tools (including ML, fuzzy logic, image classification) to flag suspicious claims.
NAFU detected and prevented fraudulent claims worth over ₹700 crore in 2023–24. Key fraud patterns include: ghost patients, duplicate billing, upcoding (claiming for higher-cost procedures than performed), and empanelled hospitals conducting unnecessary procedures. CAG's audit noted that fraud prevention mechanisms, while improving, require strengthening — with recommended claims settlement timelines often breached in several states.
UPSC angle: Prelims — PMJAY: 7.7 crore admissions; NAFU (fraud detection); NHA as implementing body. Mains (GS2) — moral hazard in health insurance; AI in welfare governance; state-centre fund-sharing mechanism; SECC 2011 age of data as eligibility limitation.
Ayushman Vay Vandana — 93 Lakh Senior Cards Issued (October 2025)
By October 2025, over 93 lakh Ayushman Vay Vandana Cards had been issued to senior citizens aged 70 years and above across states and Union Territories — up from 40 lakh reported in January 2025. As of 31 October 2025, the scheme had authorised 7.89 lakh hospital admissions under the senior citizen category, amounting to healthcare services valued at approximately ₹1,741 crore across implementing states and UTs.
The Vay Vandana extension remains the only universalised (income-irrespective) component of AB-PMJAY. The gap between the target of ~6 crore eligible seniors and the 93 lakh cards issued reflects continuing awareness gaps, especially in rural areas. The NHA has partnered with ASHA workers and Common Service Centres (CSCs) for on-the-spot card generation to accelerate enrolment.
The national total of Ayushman cards (all categories combined) stands at approximately 36.9 crore as of March 2025, making AB-PMJAY the world's largest health assurance scheme by beneficiary count.
UPSC angle: Prelims — Ayushman Vay Vandana: October 2024 launch, 70+, all income levels, ₹5 lakh cover; 93 lakh cards (October 2025); 7.89 lakh admissions (October 2025). Mains (GS2) — universal vs targeted health coverage; elderly healthcare challenge; implementation gaps in senior citizen outreach.
Exam Strategy
Mains question templates:
- "Examine how Ayushman Bharat contributes to achieving SDG 3 (Good Health and Well-being). What are the residual gaps?" — Tie PMJAY + AAM + ABDM to SDG 3.8 (UHC) and SDG 3.4 (NCDs).
- "Ayushman Bharat is the world's largest health assurance scheme but has limitations in achieving UHC. Discuss." — Use OOPE data, exclusion errors, WB opt-out, private hospital concentration.
- "Discuss the significance of the Ayushman Bharat Digital Mission in transforming India's health system." — Emphasise federated architecture, ABHA numbers, UHI as "UPI for health".
- "Ayushman Vay Vandana marks a shift from poverty-targeted to life-stage universal health entitlement in India. Evaluate."
NFHS-5 linkages: Use NFHS-5 data on hypertension (24% men, 21% women), diabetes (16% adults), institutional deliveries (88.6%) to argue both need and scope for AAMs.
High-yield Prelims facts:
- Launched: 23 September 2018 (Ranchi); five pillars structure
- PMJAY: ₹5 lakh family floater; SECC 2011 basis; no enrolment (entitlement)
- Vay Vandana: 29 October 2024; all 70+; ~6 crore seniors
- ABDM: 27 September 2021 nationwide; ABHA = 14-digit ID
- AAMs: Renamed 26 November 2023; 12-service package
- NHA is autonomous under MoHFW; State level = SHA
- Funding: 60:40 (general), 90:10 (NE/Himalayan), 100% (UT without legislature)
- Budget 2025-26 PMJAY allocation: ₹9,406 crore
- West Bengal is the only state outside PMJAY (as of April 2026)
Cross-link: For latest PMJAY expansion announcements, ABHA rollout updates, and Union Budget health allocations, see Ujiyari.com.
