How Patients—And Private Hospitals—Are Struggling With Ayushman Bharat

Unny’s father had taken ill at 6 a.m. on July 29. He held private insurance and also had an AB-PMJAY card. She first tried the AB-PMJAY route, calling eight hospitals on a list of establishments empanelled under the integrated MJPJAY and AB-PMJAY scheme.

A couple of hospitals didn’t take her calls. Another couple of hospitals told her that they delivered only certain treatments under the scheme, all of which were irrelevant to her father’s condition. Several told her that they were no longer empanelled under the scheme. One told her that she would have to visit the hospital with her father’s documents, and meet the yojana (scheme) doctor, who would ascertain if he was eligible to be admitted. If he was, she would have to present her father with his ration card.

“It was a long process that we didn’t have time for,” Unny told IndiaSpend. “My father needed urgent attention.” So, Unny took her father to a private hospital and got him admitted under his private health insurance.

In her reel, Unny questions the efficacy of the scheme in medical emergencies. She acknowledges that her family is privileged to hold private health insurance, but questions how those with no other option would manage.

IndiaSpend tried to reach out to those same hospitals.

Platinum Hospital, one of those Unny called, confirmed that it has tied up with AB-PMJAY only for angioplasty and bypass operations. Another, Jupiter Hospital, confirmed that it has tied up only for radiation oncology and paediatric cardiology.

The person who picked up the call to Dr R N Cooper Hospital said he used to look after the AB-PMJAY admission desk but had retired some months ago. He was unable to share the number of the current in-charge.

Sushrut Hospital said it was not empanelled under the scheme.

Vedant Hospital asked for the patient’s details to be able to confirm admission. We shared a slip showing the patient as having febrile encephalopathy, hyponatraemia and acute upper respiratory tract infection (aspiration pneumonia) but they wanted more details, which we sent, and are still waiting to hear back.

How useful would AB-PMJAY be in the eventuality of an emergency? Research shows that many have had poor experiences, and many (see here and here) still incur catastrophic health expenditure that by the government’s own admission pushes 60 million Indians into poverty each year. Further, awareness is low. Issues plague empanelled hospitals too, with the non-payment of dues to hospitals in Haryana for instance, derailing private sector participation in the scheme.

In October 2023, IndiaSpend had reported on the challenges associated with the scheme. The number of empanelled hospitals is small for the eligible population (for instance, Assam’s 354 providers amount to one hospital for every 100,000 people), we had reported. AB-PMJAY also does not cover the cost of out-patient consultations.

Outreach would help increase awareness, utilisation

Soon after Unny posted the reel, the state government assigned a representative of the State Health Assurance Society, the monitoring body for the implementation of the Integrated AB-MPJAY & MJPJAY, to address her grievance.

IndiaSpend reached out to the same representative, who asked not to be named, to ask what he had to say about her poor experience.

“Divya should have taken her father to a hospital, preferably a larger general hospital,” he told IndiaSpend. “If she had been denied treatment, she could have reached out to the help desk.”

Unny’s case was unusual in that she posted a grievance before visiting a hospital, whereas most grievances associated with the scheme are logged by patients who have sought treatment.

“Poor quality of hospital services” is a leading grievance of beneficiaries, according to Patient Struggles: Grievances in Ayushman Bharat, a study by the Association for Socially Applicable Research (ASAR) India and the Centre for Health Equity, Law, and Policy (C-HELP). The study examined over 110,000 grievances filed by beneficiaries between October 2018 and March 2022. Three in four grievances arose from demands for payment to receive treatment. They identified poor governance (to rein in private hospitals) and the lack of awareness of the scheme as reasons for beneficiaries to succumb to such demands.

Arguably, Unny’s poor experience also arose from a lack of awareness of how the scheme works.

Random sampling of the population of Gautam Buddha Nagar, Uttar Pradesh, in 2021 showed very low utilisation of the AB-PMJAY scheme, and low awareness of the scheme benefits.

Barely 9% and 19% of potential beneficiaries in urban and rural areas respectively, were aware of the scheme benefits, while 8% and 15% of potential beneficiaries in urban and rural areas respectively, had actually used the scheme.

Khushboo Juneja, co-author of this study, published in the Indian Journal of Community Medicine in January 2025, proposed intensive outreach campaigns in urban areas on the scheme benefits.

“This would help intended beneficiaries such as slum dwellers, migrants and urban informal workers, especially those who lack documentation or may be excluded due to address mismatches,” she said.

In 2023, the Comptroller & Auditor General of India, the government’s auditor, had recommended that the National Health Authority ensure that State Health Authorities “set up a designated IEC [information, education, communication] cell to promote awareness about the scheme and maximise reach, impact and awareness amongst targeted beneficiaries”.

Juneja, a professor in the Department of Community Medicine at Manipal Tata Medical College, Jharkhand, suggested employing aarogya mitras, local NGOs, ASHA workers, mohalla clinic workers, urban health & wellness centre workers for such outreach activities.

Maximising the reach of the programme would also involve sorting out beneficiary enrolment and registration challenges, and inconsistencies in the distribution of the AB-PMJAY card, including multiple cards issued for one Aadhaar number or mobile number, other concerns mentioned in the CAG report.

The CAG recommended instituting a mechanism to identify genuine beneficiaries and weed out ineligible beneficiaries, and strengthen the registration process to avoid delays. An outreach team could address all these issues.

Payment delays affect private-sector hospitals

In Haryana, 650 private hospitals (of 1,300 hospitals) empanelled with AB-PMJAY--30 in Gurugram city, the rest across the state--suspended services to patients under AB-PMJAY on August 8, 2025, because of the non-payment of dues totalling about Rs 490 crore.

All these private hospitals had also threatened to suspend services in January 2025, with effect from February 3, then, due to the non-payment of Rs 400 crore.

“Private hospitals’ dues are meant to be released within 15 days but many of those hospitals had been waiting for their payments for months,” explained Dilip Bhanushali, president of the Indian Medical Association (IMA).

“If a payment cannot be made within the assured time and a reasonable extension, hospitals should be paid their dues with interest,” said Bhanushali. “How can small and medium hospitals stay afloat if they aren’t paid?”

While last minute payments averted a suspension of services earlier this year, the financial challenges of especially smaller hospitals led to a firm decision to suspend services in August 2025.

“Many smaller private hospitals are running only because they have taken loans,” Mahavir Jain, president of the IMA’s Haryana chapter, told IndiaSpend.

Delayed payment of AB-PMJAY dues is a concern across the country, from Jammu & Kashmir to Nagaland, and from Ranchi to Assam. As of February 2025, Rs 12,161 crore was outstanding, which is 8.7% of the Rs 1.4 lakh crore worth of hospital admissions that have been authorised under the scheme since its inception in 2018, according to data accessed through a right-to-information application filed by activist Ajay Bose.

At the time of writing this, private hospitals in Manipur had just resumed services after threatening to suspend hospitalisation under AB-PMJAY with effect from August 16, 2025, because of the non-payment of dues.

“We have been assured that the dues will be cleared soon,” a representative of the Association of Healthcare Providers India Manipur Chapter told IndiaSpend. “We have been hopeful of our dues being released since the last 18 months, and we continue to be hopeful and not cause patients any inconvenience.”

While Rs 30 crore or so was released to hospitals in Haryana over August 5-6, 2025, according to the IMA’s Jain, such stopgap responses to threats to suspend operations are just “eyewash, deflecting from the main issue”.

Hospitals are equally concerned about claims pre-approved at the time of admission but rejected at the time of settlement.

“If a claim has been approved when the patient was admitted, it should be settled,” the director of a mid-sized hospital in Gurgaon, who asked not to be named, told IndiaSpend. “But certain claims are rejected for no reason causing further financial distress for hospitals.”

“We have indicated to the authorities that the annual AB-PMJAY budget for Haryana should be increased from Rs 750 crore to Rs 2,500 crore,” said Dhirender Soni, secretary, IMA Haryana.

Higher allocations vital to sustain govt-sponsored healthcare

Fund allocations must match the scheme’s ambitions at both the Union and state government levels.

Insofar as a health scheme goes, AB-PMJAY was designed for 40% of India’s population that lives below the poverty line, explained Girdhar Gyani, director general of the Association of Healthcare Providers (India).

But “in recent years, the Centre and several States have extended the free hospitalisation benefit to more people,” continued Gyani.

The Union government has extended AB-PMJAY to about 60 million citizens aged 70 years and above, and about 3.7 million Accredited Social Health Activists (ASHAs), Anganwadi Workers (AWWs), Anganwadi Helpers (AWHs), and their families.

States also add people they see as needy. Maharashtra, for instance, covers below poverty line families as well as certain above poverty line families. Essentially, the beneficiary list includes families holding yellow ration cards, Antyodaya Anna Yojana cards, Annapurna cards and orange ration cards from eight districts.

States like Andhra and Telangana have included more than 80% of their population, said Gyani.

But “as the Centre only supports the cost for the population it covers, the financial burden on states is higher, which calls for higher budgetary allocations to the scheme,” he continued.

If a scheme like AB-PMJAY is to succeed across India, the overall health budget allocation needs to be increased from 1.8% to 5% of the GDP, estimated Bhanushali. “Much of this increased allocation would have to be on the AB-PMJAY.”

The National Health Policy, 2002, had set a target of 2% of GDP by 2010; the United Progressive Alliance government, in 2004, had set a goal to increase public-health spending to 2-3% of GDP over a five-year period; and the Centre’s 12th five-year plan set the target at 1.87% of GDP by March 2017, as IndiaSpend reported in July 2018. None of these goals were met, we had reported. The National Health Policy of 2017 increased this target to 2.5% by 2025.

Further, states were to spend a minimum of 8% of their total expenditure on health by 2022. In 2023-24, of 28 states, only three spent higher than this target: Delhi (12.4%), Puducherry (9%) and Meghalaya (8.3%), as IndiaSpend reported in April 2024.

“Whereas India’s current allocation to the AB-PMJAY scheme is barely 0.075% of the GDP,” according to Siddhesh Zadey, co-founder of ASAR, “Thailand, which has one of best population coverages for government-funded health insurance among middle-income countries, was spending about 3.2% of its GDP on its health insurance policy even before Covid.”

Increasing the allocation to the scheme would enable better payment to hospitals, and address urban private hospital concerns about underpricing, said Zadey.

So far, low service prices that Bhanushali called “unrealistic considering the costs of consumables, overheads and salaries” have kept large private hospitals delivering high-end care away from the scheme. A few have tied up only for select services.

As an example, Jupiter Hospital has associated with AB-PMJAY only for radiation oncology and paediatric cardiology, two high-end services which Ankit Thakker, CEO & executive director, said “are hard to access,” and where he feels “Jupiter Hospital can make a definite contribution”.

Thakker said he sees the hospital’s work under PMJAY “as CSR [corporate social responsibility], not as a commercial activity”.

Now that the National Cancer Grid is associating with AB-PMJAY to streamline the costs of cancer care and ensure evidence-based treatment, Zadey said “possibly, a health association could work with the AB-PMJAY on the same lines for general packages”.

“Allowing co-payments--the government paying part of the cost and the beneficiary part--could also help patients navigate higher priced treatments as well as bring onboard high-end hospitals,” added Gyani.

Zadey also recommended combining all the existing government schemes covering hospitalisation, such as the Central Government Health Scheme for central government employees and their families, the AB-PMJAY and state schemes for efficiency.

“Package rates are substantially higher under CGHS than AB-PMJAY, which helps ensure better outcomes, judging from the fact that CGHS providers and patients are better covered and more satisfied than those under AB-PMJAY, an important fact considering patient care and satisfaction is the end objective,” said Zadey.

IndiaSpend reached out to the Union health ministry for comments on delays in the release of bill payments and allocations and releases to AB-PMJAY. We will update this story when we receive a response.

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