Ayushman Bharat Explained: India’s Health Scheme

Ayushman Bharat is the Government of India’s flagship health programme, launched in 2018 with the stated aim of bringing the country closer to universal health coverage. It is often described as the world’s largest publicly funded health assurance initiative, combining two linked ideas: strengthening primary healthcare close to people’s homes, and protecting poor and vulnerable families from the financial shock of serious hospital treatment.

For decades, health spending in India has been dominated by out-of-pocket payments, and a single hospitalisation has been enough to push a household into debt. Ayushman Bharat was designed to address both the supply side (clinics, staff, medicines and diagnostics) and the demand side (insurance-style cover for secondary and tertiary care). This explainer sets out how the scheme works, who it covers, how an Ayushman card is used, and what its digital and governance layers look like.

Quick Facts

Why India Needed Ayushman Bharat

India’s health system has long been a mix of a modest public network and a large private sector. Public spending on health has traditionally been low as a share of GDP, which means that households have borne much of the cost themselves. Out-of-pocket expenditure, especially on medicines and hospital admissions, has been identified in several national surveys as a major cause of impoverishment.

Earlier attempts at coverage were fragmented. The Rashtriya Swasthya Bima Yojana (RSBY), launched in 2008 for families below the poverty line, offered a limited annual cover and focused on inpatient care. Several states built their own schemes, such as Aarogyasri in Andhra Pradesh and Telangana or the Rajiv Gandhi Jeevandayee Arogya Yojana in Maharashtra. Central schemes for government employees, such as the Central Government Health Scheme (CGHS), covered only a specific workforce.

Gaps the scheme set out to fill

• Primary care was thin in rural and peri-urban areas, so minor illnesses were left unattended until they turned serious.
• Cover under older schemes was low relative to the cost of surgeries, cancer care, cardiac procedures and intensive care.
• Poor and informal-sector families had little protection against catastrophic expenditure.
• Patients moving between states for work or specialist treatment could not carry their entitlement with them.

The National Health Policy of 2017 had already endorsed the goal of universal health coverage and a stronger role for primary care. Ayushman Bharat can be read as a major step to translate that policy direction into an operational programme.

The Two Pillars of Ayushman Bharat

The programme rests on two complementary components, and understanding the split is the key to understanding the scheme.

Pillar one: Health and Wellness Centres

The first pillar upgrades existing sub-centres and primary health centres into comprehensive primary care facilities. These are meant to deliver preventive, promotive, curative, rehabilitative and palliative care, going beyond the traditional focus on maternal and child health and a few communicable diseases. The original target was to create about 1.5 lakh such centres across the country.

Pillar two: Pradhan Mantri Jan Arogya Yojana

The second pillar, PM-JAY, is a publicly funded health assurance scheme that provides cashless hospital cover for secondary and tertiary care. It is the part of the programme most people refer to when they speak of the “Ayushman card”. Cover is offered on a family floater basis, meaning the annual limit is shared by all members rather than assigned individually.

The two pillars are intended to work together. Strong primary care should catch disease early, manage chronic conditions such as hypertension and diabetes, and refer serious cases up the chain, while PM-JAY pays for the hospital stay when referral becomes necessary.

Health and Wellness Centres: Ayushman Arogya Mandirs

The Health and Wellness Centres (HWCs) were launched on 14 April 2018, the birth anniversary of Dr B. R. Ambedkar, at Bijapur in Chhattisgarh. In 2023 the government began rebranding them as Ayushman Arogya Mandirs, so both names appear in official and media usage.

Services offered

The expanded package of services was designed to cover a wide range of needs at the community level.

• Pregnancy care and childbirth services, along with newborn and child health services.
• Management of common communicable diseases and outpatient care for general illnesses.
• Screening and management of non-communicable diseases such as hypertension, diabetes and common cancers (oral, breast and cervical).
• Basic oral, eye and ENT care, mental health services and care for the elderly.
• Emergency and trauma first response and free essential medicines and diagnostics.
• Yoga and wellness sessions, reflecting the “wellness” element in the name.

Staffing and delivery model

A typical sub-centre-level HWC is led by a mid-level healthcare provider, often a trained nurse or Ayurveda practitioner with a bridge course in community health, supported by Accredited Social Health Activists (ASHAs) and Multi-Purpose Workers. Primary health centre-level HWCs are staffed by a medical officer along with the team. Teleconsultation links connect these centres with specialists, which is the main route by which the scheme tries to bring expert advice to remote locations.

PM-JAY: How the Insurance Cover Works

PM-JAY provides financial protection for hospitalisation, and its design has several distinctive features that set it apart from earlier schemes.

Key features

• Cover amount: up to 5 lakh rupees per eligible family per year.
• Cashless and paperless: treatment is free at the point of service at empanelled hospitals, with claims settled between the hospital and the implementing agency.
• No cap on family size or age: unlike many earlier schemes, the number of members and their ages were not restricted.
• Pre-existing conditions: covered from the first day of enrolment.
• Pre- and post-hospitalisation: expenses for a limited period before admission and after discharge, including diagnostics and medicines, are included in the package.
• Portability: a beneficiary can obtain treatment in an empanelled hospital in another state.

What the cover includes

The scheme pays for a defined set of Health Benefit Packages. These include registration charges, bed charges, nursing and boarding, surgeon and anaesthetist fees, medicines and consumables, diagnostics, implants where applicable, and in many cases food during the stay. The cover applies to inpatient treatment and day-care procedures rather than routine outpatient consultations, which is why the primary care pillar matters.

Who Is Eligible for PM-JAY?

PM-JAY is an entitlement-based scheme rather than an enrolment-based one. Families are not required to pay a premium; eligibility is determined by deprivation and occupational criteria drawn from the Socio-Economic Caste Census (SECC) of 2011, which identified households in rural and urban India.

Rural and urban criteria

In rural areas, families qualify through a set of deprivation categories, for example households with only one room with kutcha walls and roof, families with no adult member aged between 16 and 59, female-headed households with no adult male member, households with a disabled member and no able-bodied adult, and landless families deriving a major share of income from manual casual labour. Scheduled Caste and Scheduled Tribe households also qualify.

In urban areas, eligibility is based on occupational categories such as ragpickers, domestic workers, street vendors, construction workers, plumbers, masons, painters, welders, security guards, sanitation workers, drivers, conductors and helpers, among others.

Expansion over time

Initially the scheme was aimed at over 10 crore families, which the government described as about 50 crore people, roughly the bottom 40 per cent of the population. States have been permitted to add their own beneficiary categories at their own cost, and the central government has periodically widened eligibility, including cover for senior citizens of a specified older age group irrespective of income. Anyone checking eligibility should consult the official portal or helpline, since the rules have been revised from time to time.

The Ayushman Card and How to Use It

The Ayushman card, also called the Golden Card or PM-JAY card, is the identity document that lets a beneficiary access cashless treatment. It is issued after the person’s eligibility is verified.

Steps in the beneficiary journey

1. Eligibility check: a person can check their name through the official portal, a helpline or a Common Service Centre, using a mobile number or ration card details.
2. Verification and card generation: identity is verified, commonly through Aadhaar-based e-KYC, and the card is generated.
3. Hospital visit: at an empanelled hospital, the patient meets the Ayushman Mitra, a trained help-desk worker who verifies the card.
4. Pre-authorisation: for most procedures the hospital seeks approval from the insurer or trust before treatment begins; emergencies are handled with some flexibility.
5. Treatment and discharge: the patient receives care without paying, and the hospital submits the claim electronically.

The Ayushman Mitra role is a notable design feature. These workers, posted in hospitals, help patients through the paperwork and are intended to reduce the chances of beneficiaries being turned away or asked to pay.

Empanelled Hospitals and Health Benefit Packages

The scheme works through a network of public and private hospitals that are formally empanelled under it. Government hospitals are empanelled automatically in many states, while private hospitals apply and are assessed against criteria on infrastructure, staffing and services.

Treatment coverage

The Health Benefit Packages cover well over a thousand procedures across many medical and surgical specialties. Typical categories include:

• General medicine and general surgery.
• Cardiology and cardiothoracic surgery, including bypass procedures and angioplasty.
• Orthopaedics, including joint replacements.
• Oncology, covering surgical, medical and radiation treatment.
• Neurosurgery, urology, nephrology (including dialysis) and ophthalmology.
• Obstetrics and gynaecology, paediatric and neonatal care, and intensive care.

Package rates and quality

Each procedure has a fixed package rate. Private hospitals have at times argued that these rates are low for complex treatments, while the government has maintained that standardised rates keep the system financially sustainable. Packages have been revised periodically. Quality assurance involves audits, grievance redress, and action against hospitals found to be misusing the scheme, including de-empanelment in proven cases.

Governance, Funding and Implementation

PM-JAY is a centrally sponsored scheme, so costs are shared between the Union and state governments, with the central share varying by category of state. The cost split has been different for northeastern and hill states compared with the rest, and for Union Territories without legislatures, which receive fuller central support.

Institutional structure

• National Health Authority (NHA): the apex body that designs policy, sets guidelines, builds the IT platform and oversees implementation. It was set up in 2018 and later given the status of an attached office of the Ministry of Health and Family Welfare.
• State Health Agencies (SHAs): the state-level bodies, which may be a trust, a society or a state nodal agency, that carry out implementation on the ground.
• Insurance or trust model: states can run the scheme through insurance companies, through their own trusts, or through a hybrid model.

Some states have chosen to merge their own health schemes with PM-JAY, while a few have, at different points, preferred to run separate programmes. This variation is one reason why national coverage figures differ from state to state.

Ayushman Bharat Digital Mission (ABDM)

The Ayushman Bharat Digital Mission was launched on a pilot basis in 2020 and rolled out nationwide on 27 September 2021. It aims to build an interoperable digital health ecosystem so that records, providers and facilities can be linked through open standards.

Core building blocks

• ABHA number: the Ayushman Bharat Health Account number, a 14-digit voluntary health identifier that individuals can create, often linked to Aadhaar or a mobile number.
• Health Facility Registry: a verified directory of hospitals, clinics and diagnostic labs.
• Healthcare Professionals Registry: a directory of doctors, nurses and other professionals.
• Personal health records: a way for patients to link their prescriptions, reports and discharge summaries and share them with consent.
• Unified Health Interface and health information exchange: protocols for discovery of services and for secure movement of records.

The mission is voluntary and consent-based, and it is meant to reduce repeated testing, ease referrals and, in the long run, provide data for planning. Privacy and data-protection safeguards are an ongoing subject of policy discussion.

Coverage, Achievements and Challenges

Official reports have described several crore hospital admissions authorised under PM-JAY since its launch, and a very large number of Ayushman cards issued, though exact totals keep rising and should be read from current official dashboards. The scheme has particularly been credited with increasing access to dialysis, cancer care, cardiac surgery and joint replacement among poorer households.

Commonly cited strengths

• A large national entitlement with portability across state lines.
• Reduced out-of-pocket expenditure for covered hospitalisations.
• A common IT platform enabling transparency and fraud analytics.
• Encouragement for private hospitals to serve beneficiaries, particularly in smaller cities.

Commonly cited challenges

• Uneven awareness among eligible families, and gaps in card issuance.
• Concentration of empanelled hospitals in better-off districts and states.
• Debate on package rates and delayed claim settlement.
• Risks of overbilling, unnecessary procedures and fraudulent claims, requiring continuous audits.
• Outpatient and medicine costs, which fall largely outside PM-JAY, remain a major source of household spending.

Ayushman Bharat Compared With Other Health Schemes

The table below places the programme alongside other well-known public health schemes in India, to show where it fits.

Conclusion

Ayushman Bharat represents a large and ambitious attempt to combine a stronger primary care base with financial protection for hospital treatment. Its success depends on several moving parts working together: well-staffed Ayushman Arogya Mandirs, adequately paid and honest hospitals, timely claim settlement, and careful targeting of beneficiaries. As the digital health mission matures and eligibility evolves, the scheme will remain central to discussions on how India moves toward universal health coverage.

Frequently Asked Questions

What is Ayushman Bharat?

Ayushman Bharat is a national health programme launched in 2018 with two pillars: Health and Wellness Centres, now called Ayushman Arogya Mandirs, which provide comprehensive primary care, and the Pradhan Mantri Jan Arogya Yojana (PM-JAY), which offers cashless hospital cover for poor and vulnerable families. It is run by the Ministry of Health and Family Welfare through the National Health Authority.

How much health cover does PM-JAY provide?

PM-JAY provides cover of up to 5 lakh rupees per family per year for secondary and tertiary care hospitalisation. The amount is a family floater, so all members share it, and there is no restriction on family size or age. Treatment is cashless at empanelled public and private hospitals.

Who is eligible for the Ayushman card?

Eligibility has been based on deprivation and occupational criteria drawn from the Socio-Economic Caste Census of 2011, covering poor rural households and specified categories of urban workers. Some states and the central government have widened eligibility over time, so applicants should verify their status on the official portal or helpline.

Does Ayushman Bharat cover outpatient treatment and medicines?

PM-JAY is mainly meant for inpatient and day-care treatment, along with limited pre- and post-hospitalisation expenses. Routine outpatient care, screening and essential medicines are intended to be provided through the Ayushman Arogya Mandirs and public health facilities.

Can I use my Ayushman card in another state?

Yes, the scheme is designed to be portable. A beneficiary can generally seek treatment at an empanelled hospital in another state, subject to the scheme’s rules, and the cost is settled between the concerned state agencies through the national platform.

What is the Ayushman Bharat Digital Mission?

The Ayushman Bharat Digital Mission, rolled out nationwide in 2021, builds a voluntary digital health ecosystem. It offers each person an ABHA number, links health records with consent, and maintains registries of hospitals and health professionals to make care more connected and paperless.