No Stitch In Time

On April 14, 2018, Ambedkar Jayanti, Prime Minister Narendra Modi inaugurated the first Health and Wellness Centre (HWC) under his government’s ambitious Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PM-JAY) in the village of Jangla, located in Bhairamgarh block of Chhattisgarh’s Bijapur district. The official National Health Authority website calls Ayushman Bharat PM-JAY, also known as the Ayushman Card Scheme,  the ‘largest publicly funded health assurance scheme in the world’. Under the scheme, an underprivileged family holding an Ayushman card is eligible to receive a health cover of five lakh rupees per year per family from the government.  

However, six years since the celebrated inauguration, the Jangla HWC remains severely underutilised. On an April afternoon in 2024, Geeteshwari, its community health officer told Object, “Only 13 percent of the people from seven surrounding villages have utilised the centre for primary care. Two hundred Ayushman Cards are ready and waiting in the HWC for distribution to beneficiaries. But nobody wants the Ayushman card.” 

Object visited the neighbouring villages of Potanar, Bardala, Bangoli, Mana, Badetungali, and Kodripal in April 2024 and learnt that out of 50,178 people, only 480 were issued Ayushman cards. Through our investigation, we discovered that for the villagers of Bijapur district, acquiring an Ayushman card was hindered by severe poverty, infrastructural barriers, and the threat of Naxal violence.

“A MAJORITY OF villagers here do not have a mobile phone,” shared Sukli, the health assistant at the HWC who works as a liaison between the villagers and the health centres. “In order to obtain an Ayushman card, the potential beneficiary needs to possess an Aadhaar card. Now, a One Time Pin (OTP) on one’s mobile phone is a mandatory verification for an Aadhaar card. So, since most of them don’t have mobile phones, they don’t have Aadhaar cards.” 

Dasri Korsa, the mukhiya (chief) of the village Badetungali, said, “In the early days of Aadhaar enrolment, when mobile numbers weren't required, a few villagers managed to get their Aadhaar cards. But that’s no longer the case.” 

Speaking to the villagers all through April this year, Object learnt that even if someone did have a mobile phone, most villages  did not have a sufficient number of network towers. 

While the severe poverty in these areas plays a significant role in cutting off access to amenities like mobile phones, according to Badetungali’s deputy sarpanch Payku Lekam, there are deeper issues at play. Most villages in Bastar and Bijapur fall under the ‘Red Corridor’  or areas affected by Maoist-Naxalite activity. 

Lekam emphasised that while the poor in other parts of the country might prioritise buying a mobile phone despite being unable to afford a meal, as it was “essential for daily life”, the situation in villages like Badetungali, deep inside Naxal-affected areas, was different.  “Villagers fear keeping phones, as Maoists, suspecting they're being used to inform authorities, often seize them,” he said. “The villagers here in Bastar are like footballs—caught between the distrust of security forces and the Maoists. That's why they're afraid to keep mobile phones.”

Caught in the crossfire of conflicting forces, the villagers remain deprived of basic healthcare and access to the government's lifeline scheme Ayushman Bharat.

THIS ONGOING FINANCIAL struggle highlights broader issues within the scheme’s evolution. Atul Singhania, secretary of the Association of Healthcare Providers India (AHPI), Chhattisgarh, said, “The changing governments in Chhattisgarh were more concerned with rebranding and renaming the scheme than updating its policies and data.” 

Singhania detailed the chronology of these changes.

In 2010, under the leadership of Prime Minister Manmohan Singh, the central government introduced the 'National Health Insurance Scheme' across all Indian states. This initiative was aimed at providing health coverage to families identified under the Below Poverty Line (BPL) data maintained by the Planning Commission, targeting the most vulnerable populations.

The National Health Insurance Scheme demonstrated notable success, prompting the Bharatiya Janata Party (BJP)-led Dr Raman Singh’s government in Chhattisgarh to expand and rename the scheme in 2015. The new name 'Mukhyamantri Swasthya Bima Yojana' extended coverage to include not only BPL families but also those categorised as 'Above Poverty Line' (APL) to broaden the scope of the beneficiaries.

Following this, in 2018, the Modi government launched the Pradhan Mantri Jan-Arogya Yojana (PMJAY) under the Ayushman Bharat initiative. 

But in 2019, with the transition to the Congress-led Bhupesh Baghel government in Chhattisgarh, the state government pulled out of the Ayushman  Bharat banner and introduced a healthcare scheme named Khubchand Baghel Swasthya Sahayata Yojna, which used ration cards instead of Ayushman cards.

After the BJP government came back to power in Chhattisgarh at the end of 2023, it reversed this decision and reintroduced Ayushman cards. 

The changes in the Ayushman Bharat scheme under different state administrations have impacted both its execution and effectiveness. 

A critical issue that has emerged from this pendulation is the inclusion of APL families in a scheme originally designed for BPL families. AHPI secretary Singhania pointed out that while the scheme initially benefited BPL families, the addition of APL families led to a surge in beneficiaries. This sudden increase exacerbated financial pressures on hospitals, resulting in delays and complications with payments, further complicating the scheme’s overall effectiveness. “The scheme’s payment structure, where the Centre contributes 60 percent and the state government 40 percent, exacerbates these issues,” noted Dr Gupta. 

Chhattisgarh’s public health minister  Jaiswal,  however, said that while the Centre covers 60 percent of costs for BPL beneficiaries, the state is solely responsible for APL cases, intensifying the financial strain. He criticised the previous Baghel government for mismanaging the Ayushman budget. “The former government failed to arrange proper revenue. Funds meant for Ayushman were diverted to activities like farmer bonuses, leaving us with the challenge of paying hospitals and for medical equipment,” said Jaiswal, adding that election-related delays had worsened the situation.

Object reached out to former health minister T. S. Singh Deo, who rejected Jaiswal’s claims, stating, “Hospitals often misuse Ayushman by inflating bills—like showing the same CT scan multiple times. Third-party investigations are necessary to catch these issues, which delays payments. The problem isn't misallocation of Ayushman funds, but the need for thorough verification.”

“In this tug-of-war between the state government and the Centre and their respective negligence, the hospitals incur losses,” Singhania observed.

BEYOND NEGLIGENCE, THE scheme needs work at its inception—primarily, that it was not crafted based on a comprehensive medical understanding of diseases, according to Dr Dave.  “It was a lifeline for the underprivileged,” he said. “But the programme would have been far more effective if treatment costs were determined through a thorough study of diseases and their complexities. The scheme wasn’t thought out well.” Dr Dave  also pointed out  that the procedure prices, last revised in 2014, were outdated and needed urgent revision to reflect current medical realities.

Dr Rakesh Gupta, an ENT specialist, echoed Dr Dave’s concerns, specifically pointing to outdated pricing for ENT-related cancer treatments. Cancers of the larynx, oral cavity, tongue, and cheek were treated under packages priced between 45,000 rupees and 70,000 rupees—rates that had remained unchanged for a decade. In the intervening years, the costs of medicine, electricity, and staff wages had surged, with medical inflation hovering around 10 percent. “It was almost impossible to provide treatment at these rates,” Dr Gupta asserted, urging the government to revise the procedure rates.

Adding to the challenge, generic drugs are not a viable option for critical cases like anaesthesia or ICU care, which require high-quality, and therefore more expensive, medications. Without an overhaul, Dr Gupta warned, it would become increasingly difficult to sustain these life-saving treatments.

When asked about the ideal pricing for ENT cancer treatments, Dr Gupta suggested that the total cost, from admission to discharge, should be closer to 1.5 lakh rupees, significantly higher than the current package rates.

In the general medicine department, the challenges of pricing were even more complex. A doctor, who was a part of the team that created the first healthcare package for Ayushman Bharat and completed his five-year tenure with NITI Aayog, told Object that unlike surgeries, where outcomes and costs could be relatively predictable, treatments for diseases like malaria or dengue varied widely depending on the patient’s condition. This variability made it impossible to establish fixed rates for general medicine treatments. 

For instance, dengue may resolve in ten days for one patient while others might require months of treatment,” he said. “Similarly, malaria can present as a simple case or evolve into kidney failure. As a result, fixing treatment rates is impossible since costs can reach up to 5 lakh rupees, depending on severity.”

In general surgery too, the fixed rates did not reflect the reality of costs incurred. Groin hernia  repair, for example, was priced at 14,200 rupees while a biopsy cost 3,000 rupees. However, Dr Dave pointed out,  these rates did  not reflect the reality of modern medical costs. “How can a laparoscopic hernia surgery, which requires equipment costing 40 lakh rupees, be done for 18,000 rupees?’”" he asked. 

The doctor further explained that medical comorbidities also drove up costs, making it impossible to charge the same amount for every patient. “A patient with diabetes, high blood pressure, and gallbladder disease can’t be treated for the same price as a healthy patient,”  he noted. “An ordinary patient cannot be treated at the same rate in a small 30-bed nursing home as in a large 300-bed multi-specialty hospital where these complex cases are handled. We need price revisions across all surgical fields and a more nuanced pricing structure.”

Dr Prafulla Dawale, director of DKS Hospital, Raipur, believes that the Ayushman card has been a blessing for kidney dialysis patients. According to him, while Ayushman Bharat had successfully provided 30,000 rupees per month for such patients, administrative inefficiencies remain. “Transferring a patient between hospitals could result in a 2-3 day delay in treatment due to issues with Ayushman registration.”

Four years ago, the Chhattisgarh government removed cataract surgery from the Ayushman scheme, which previously covered the procedure at 7,000 rupees. A prominent retina surgeon from Bilaspur said he was confused by this decision since cataracts are common, particularly among the elderly, and including the surgery in Ayushman Bharat would have greatly benefited the economically weaker population of Chhattisgarh.

When asked why the procedure had been removed,  Chandan Kumar, additional chief secretary of the health department, responded, “Cataract surgeries are already being performed by retina surgeons in government hospitals, which is why the procedure was excluded from Ayushman.”

In the field of obstetrics and gynaecology, “90 percent of the treatment packages under Ayushman Bharat were reserved for government hospitals, leaving little room for private facilities,” said Dr Asha Jain, a gynaecologist and the director of SriMaa Sarada Arogyadham, Raipur. She argued that this restriction complicated patient care. “I wasn’t allowed to perform cervical cancer screenings under the Ayushman card scheme,” she said. Patients had to go through multiple channels for diagnosis and treatment, leading to fragmented care. This, she felt, undermined the overall effectiveness of treatment.

“With government hospitals reserving beds for normal deliveries, their patient load is expected to rise significantly. This raises concerns about how cervical cancer screenings will be managed. This is why it is important to allow private facilities to conduct cervical cancer screenings as well,” argued Dr Jain.

The gynaecologist also  pointed out a discrepancy in payment for gynaecological cancer surgeries. “Oncologists receive a fixed package of 70,000 rupees for their operations, while specialists in our field are paid only 20,000 rupees, which includes the cost of medicine,” she said. 

Pricing discrepancies between departments, as pointed out by Dr Jain, as well as those between public and private hospitals, further complicate access to affordable care. For instance, tonsillectomies (the partial or complete removal of the tonsils)—priced at 7,500 rupees—are restricted to government hospitals under the Ayushman Bharat scheme. Private hospitals primarily handle more complex surgeries, such as ear and sinus operations which are excluded from government packages. Additionally, certain procedures such as  intratympanic injections are priced so low (1,000 rupees) that they are rarely performed due to the excessive paperwork involved.

Responding to concerns about the need for price revisions, Chhattisgarh’s health minister Jaiswal said that the government was aware of the issue. “These matters are in our cognisance, and a study is underway,” he said. However, e provided no concrete timeline for the revisions.

DR GUPTA ALSO highlighted significant flaws in the Ayushman Bharat scheme’s monitoring system, particularly in managing fraudulent claims. He estimated that up to 40 percent of claims were fraudulent, facilitated by collusion between hospitals and officials. “The state nodal department, reliant on third-party audits, often employs untrained staff—graduates from Unani or Ayurveda—to substantiate claims,” he said. “They compromise the integrity of claim evaluations. In the absence of a trained doctor in the department, the result of the claim gets affected.”

Following Dr Gupta's assertion, Object analysed the claim rejections for Ayushman. In 2022, claims rejected were as follows: April—315, May—814, June—1,820, July—1,076, August—1,061, September—1,039, October—1,325, November—1,741, and December—2,938. 

In the first half of 2023, the rejections were: January—4,185, February—4,253, March—1,423, April—2,573, May—11,956, and June—401. Over these 15 months, out of 13 lakh claims from 454 registered private hospitals, a total of 36,920 claims were rejected under the scheme.

The high number of claim rejections leads to large losses for hospitals, further increasing their unwillingness to adopt the Ayushman Card scheme. 

Despite the numbers, both the Central government and the Chhattisgarh state government are pushing ahead with plans to expand Ayushman Bharat PM-JAY. 

On September 12, 2024, the Central government announced its plans to expand the Ayushman Bharat scheme to provide an annual health coverage of 5 lakh rupees to all citizens in the country aged 70 and above, regardless of income. 

In August this year, a report stated that the Chhattisgarh government plans to raise the treatment limit under Ayushman Bharat from 5 lakh rupees to 10 lakh rupees for non-APL cardholders, with an announcement expected on November 1. According to the report, APL card holders' limit is also likely to increase from 50,000 rupees to 1 lakh rupees, aiming to benefit around 55 lakh BPL families and 8 lakh APL families. 

But as Object learned through the course of this report, the flaw with the Ayushman Bharat scheme was never in its intent, but in its planning and execution, especially in a sensitive state like Chhattisgarh.

Despite the scheme’s intentions, both BPL individuals like Puriye and APL individuals like Wasim face the harsh realities of inadequate access—losing loved ones and enduring deteriorating health due to a lack of transport, financial resources, and the threat of Naxal-Maoist violence. 

To address this gap, Chandan Kumar points to the Chhattisgarh government’s launch of the ‘Niyad Nellanar’ scheme in February 2024. Calling it a “new beginning” he said, “The scheme aims to extend not only Ayushman cards but also other government schemes to areas affected by left-wing extremism.” He expects that as these sensitive areas increasingly emerge from the influence of the militant Maoist Communist Centre, their residents will gain access to all government benefits, including income support.

Whether this initiative represents genuine progress or proves to be yet another rebranding of existing ineffective policies remains to be seen.