Risky Insurance: The Pradhan Mantri Jan Arogya Yojana in Jharkhand

Basant Sahu, 46 years old, has suffered from kidney stones thrice. The third time, when he had the option to choose between a public and private hospital, he instinctively chose the “better” service. He was admitted with a promise of free treatment. However, it was only after he paid ₹11,000 for his diagnostic tests and admission that his golden card was issued, and the hospital had him pay midway to continue treatment as their package for kidney stones had been exhausted. As a result, he paid three times more than at the public hospital. Now, he works in a garment store saving up money to repay the loans he took from his relatives for treatment. Such is the story of many patients seeking free treatment under the Pradhan Mantri Jan Arogya Yojana (PMJAY).

Set against the background of geographically inaccessible and limited healthcare services administered by poorly trained or unapproachable staff, the scheme has been rolled out prematurely. The poor have lost faith in public hospitals and seek treatment in private hospitals as the last resort. The ethics and goodwill of a hospital largely determine whether the PMJAY beneficiaries receive free treatment; sometimes the poor are spared, mostly they are not. The meek ones are fleeced and often treated badly. They suffer in silence and accept any help from the government as a favour rather than a right. We repeatedly heard them say: “Sarkaari toh sarkaari jaisa hi ilaaj karega, aur kya upaay hai gareeb aadmi ke paas?” (The government will give us government-like [poor quality] treatment, what alternatives do the poor have?).

Ayushman Bharat is a reform of the Indian healthcare system in pursuance of universal healthcare (UHC). The goal is to cover persons who have no health insurance and to reduce their out-of-pocket (OOP) expenditure.

Firstly, it strives to strengthen primary healthcare by establishing health and wellness centres (HWCs) adhering to Indian Public Health Standards’ (IPHS) infrastructure guidelines. All HWCs should have trained healthcare professionals and provide periodic non-communicable disease (NCD) screenings for diabetes, cancer, and blood pressure. They promise digital consultation with doctors working in city hospitals. 

According to a representative of Jhpiego (a non-profit health organisation supporting the programme in Jharkhand), 4,000 sub-centres (SCs), 330 primary health centres (PHCs) and 57 urban primary health centres (UPHCs) were to be converted in Jharkhand. By June 2019, five SCs and one PHC—in Nawatoli, Husir, Sukurhutu, Kokdoro, Ichapidi and Pithoria—were running successfully. However, only the HWC at Pithoria was equipped with all the promised amenities. Those in Husir and Sukurhutu had mostly basic facilities and were shut on the day of our visit. 

Secondly, Ayushman Bharat is to provide secondary and tertiary healthcare assistance (hospitalisation) under the PMJAY by providing coverage of  up to ₹5 lakh per family, every year. However, this does not cover outpatient department (OPD) treatment, forcing patients to pay if they go to a private hospital, despite the scheme’s claim of being cashless, paperless, and covering all pre- and post-hospitalisation charges. In Ranchi, Jharkhand’s capital, the scheme was launched on 23 September 2018. Even if Ayushman Bharat does not deliver as much health coverage as promised, many respondents have received treatment in renowned private hospitals for the first time. Nonetheless, there were many areas of concern.

In a country where public healthcare is viewed as slow and second-rate, the PMJAY gives its beneficiaries an opportunity to access previously unaffordable private healthcare. Any empanelled hospital, public or private, is liable to provide standard healthcare. As reported by the district health office, Ranchi (DHOR), by 4 June 2019, a total of 628 hospitals were empanelled under the PMJAY in Jharkhand—218 public and 410 private. In Ranchi, 105 hospitals were empanelled—86 private and 19 public. To ensure information and mobility support, each empanelled hospital must have an “Arogya Mitra” (literally “medical friend”) coordinating between hospitals and patients, helping to issue the “golden cards,” which must be presented to avail free treatment. 

Methodology

After obtaining a list of 318 patients treated under the PMJAY from the DHOR, we traced and interviewed 57 patients treated between September 2018 and March 2019 from nearby blocks, namely: Angara, Ormanjhi, Nagri, Mandar, Ratu, Kanke, Itki, Bero, and Chanho. Since contact addresses on the list were often missing or inaccurate, we limited ourselves to patients who could be successfully contacted by phone before meeting them in person. In addition, we conducted interviews with six government officials, seven hospital managers, five Arogya Mitras and five health workers (doctors, ANMs [auxiliary nurse midwives] and ASHAs [accredited social health activists]) between February and July 2019.

Observations and Challenges

Issues with golden cards: Over 10 crore households listed in the Socio-Economic Caste Census (SECC), 2011 are entitled to the PMJAY benefits. In Jharkhand, households need to produce their ration card and Aadhaar card, after which they are issued a golden card. By 4 June 2019, a total of 4,02,941 golden cards were issued in Ranchi (the corresponding figure for Jharkhand was 3,500,728), according to the DHOR.

Patients need to produce this golden card at the PMJAY counters in empanelled hospitals. First-time beneficiaries have an option to get the card made on the spot. For many first-time users, the issuance of golden cards was deliberately delayed on the pretext of a “failed network” or protracted communication with the central office. Meanwhile, the patient was being charged for services. We also observed delays in making new cards or activating a new scheme on an existing card (Table 1). 

Table 1: Delays in Preparation of the PMJAY Card

* Card made at Pragya Kendra (CSC) prior to treatment.
Source: Author’s survey.

Additionally, as both an Aadhaar card and a ration card are compulsory for making a golden card, if a poor person’s ration card was unfairly cancelled, they were left with no fallback option and were forced to pay for their treatment. Furthermore, many were issued their golden card after a family member was admitted to a hospital, and not earlier. This caused delays in the card’s activation, resulting in them being charged for most of the initial days of treatment. 

Lack of information and awareness: Ayushman Bharat is a familiar name, but its beneficiaries are unsure of its basic components, that is, the list of empanelled hospitals, the services that are covered, and the procedure for checking enrolled packages. None of the respondents had information on the cost of their treatment or card balance (Table 2). Additionally, they were unsure of where to receive related information. Some of the educated beneficiaries with access to a smartphone and internet connection were able to check the hospital lists. Still, some complained of being told that the empanelment was still in progress or that a certain treatment was not covered by the PMJAY. Patients often found themselves in a weak position to argue for free treatment.

Table 2: Experience of PMJAY Beneficiaries

Source: Author’s survey
* Sample size: 57, with three missing observations for “faced differential treatment” and two missing observations for “got reimbursement for OOP expenditure” (both were cases of C-section deliveries where the patient reported no OOP expenditure).

Lack of patient mobility and poor outreach of immediate healthcare: The HWCs are responsible for providing emergency and basic healthcare services. Health centres have been refurbished and rebranded to match the HWC standards but have limited facilities and are understaffed. For instance, during our visit to the HWC in Kanke, we observed that the HWC only had an ANM and a community health officer (CHO). Although HWCs promise to have a pharmacist, lab technician, staff nurse and a medical officer, available 24/7, we found no one there eligible to deliver medical services in accordance with the IPHS guidelines. For NCD screenings, they could only perform checks for diabetes, blood pressure and malaria, and were unable to carry out an X-ray, let alone an MRI or CT-scan. The centre had only one incubator in the neonatal intensive care unit (NICU). Compared to its neighbours, this was a relatively better equipped HWC. 

Aslam, a resident of Latehar, had to be carried in a bus to Ranchi to get a CT-scan and to receive proper first-aid after a motor accident. Despite going to an empanelled hospital, he had to pay for treatment. Unable to afford the expensive surgery costs, the family hospitalised him hoping he would survive while they gathered the money. 

Ambulance services are sparse, enabling private agents to charge needy patients high prices for Maruti vans. The “108” ambulance service and the sahiyas (ASHAs in Jharkhand) can only take patients to public hospitals, so the PMJAY beneficiaries who choose to go to a private hospital are without transport.

Upon reaching a public hospital, patients often transfer to a private one due to lack of immediate medical attention. The chances of a hospital denying patient services were quite high. Private hospitals sometimes demanded a public hospital’s referral, especially in women’s health cases, which was hard to obtain. A hospital displayed as “empanelled” on the website declined patients, insisting on not having signed the MoU yet. Some said that they were still in the process of empanelment. In two instances, admitted patients were simply informed of the dis-empanelment of the hospital and were asked to pay the remaining fees. Unable to shift hospitals in their critical condition, each of them decided to continue staying in the private hospital, while struggling to afford the exorbitant charges. In other cases, patients were simply told that the treatment they were seeking was not offered under the PMJAY. 

Unfair charges during treatment and follow-up care: Ideally, patients should receive primary healthcare at an HWC; if they need further medical assistance, then their pre- and post-hospitalisation charges should be borne by the government. However, the OPD and diagnostic costs are a grey area, as the golden card can only be activated upon hospitalisation. Hence, patients end up paying for all their diagnostic tests, which are considerably more expensive at a private than at a public hospital. Upon speaking with hospital managers, we found that while some were confident about not being liable to provide free diagnostics, others were unsure. Among the 57 patients we interviewed, 53 said they had paid a diagnostics fee, 52 confirmed a strict demand for a non-exemptible admission fee, and 53 confirmed paying post treatment charges (Table 2). There were two cases of C-section deliveries where the patients reported no OOP expenditures.

Devanti Devi broke down while reporting how she was forced to go to a nearby diagnostic clinic, when a renowned, fully equipped hospital denied having an ultrasound machine. They were unsure who would bear the costs of the tests and were reluctant to perform them as a part of the PMJAY package. For Devi, only the operation and medicine charges were covered. When she returned to remove her catheter, she was asked to pay ₹4,000 or leave. Although the removal should have happened within 15 days, she waited for 35. Follow-up treatments are not a well-accepted part of the health packages. Eventually, Devi did get the follow-up care for free but only because she had political contacts who pressured the hospital administration into following through her treatment.

Some patients reported that they had to pay a considerable part of the estimated fee before admission and before their card was made. In some cases, attendants were asked to bear the costs of medicines and of some of the necessary surgical instruments. Additionally, the PMJAY does not cover the blood banks used during operations. In some cases, the hospitals bear these costs but in others, the patients pay. Hospitals set up independent blood donation camps, but these are mostly unsuccessful. Instead, they purchase blood at an unsubsidised rate of ₹1,100 per unit of blood. 

Travel costs due to distance of private healthcare facilities: Quality healthcare is still restricted to the more developed parts of Jharkhand, meaning people from remote villages must travel long distances for treatment, even in emergencies. Not only is this alarming in terms of the patients’ well-being, it also increases travel costs and makes healthcare less accessible.

Shamshad from Angara block went to Rajendra Institute of Medical Sciences (RIMS) for treatment of severe burns. He stayed for a week with little attention paid to him. When his condition got critical, he moved to a private hospital where he was admitted only after paying an admission fee of ₹30,000. Following a five-day delay, his golden card was issued. His bed charge and doctor’s fee were waived but he still paid for his medicines, bandages, and tests. After being discharged, he had to rent a small room near the hospital for frequent follow-up dressing sessions. Each session cost him ₹1,300 and the medication was expensive. When the sessions became less frequent, he shifted back home. Then, Shamshad and his brother would travel to Ranchi every week, in hope of his full recovery. Eventually, Shamshad’s family spent around ₹4 lakh. His mother went from village to village collecting chanda (donations) and planned to sell all their land to slowly repay their debts.

The PMJAY incentivises patients to select private hospitals in the city but fails to consider the money and time patients and their families invest in travelling between their villages and the city. The lack of compensation for these costs creates a major financial burden for poor families. 

Inclusion and exclusion errors: The list of households eligible for the PMJAY is based on the outdated, unreliable, and incomplete SECC 2011 database. Every hospital manager we spoke to confirmed that, following the rollout of the scheme, a lot of undeserving candidates claimed free treatment under the PMJAY. We observed that most respondents belonged to the relatively educated section of eligible beneficiaries and were technologically adept or had informed kin. The scheme had been unsuccessful in reaching those without digital access.

Almost all patients who got their treatment at least partially covered by the PMJAY had arguments with hospital managers or Arogya Mitras about unfair charges. Some also mentioned needing “connections” to help them negotiate their case. Someone less vocal or powerless would not stand a strong chance of getting treated under the PMJAY without being cheated.

Differential treatment: The respondents generally felt they received enough attention from the doctor and were treated better than at a public hospital. However, each said that they were not sure who to approach with queries as the people-in-charge were quick to snub any questions about their disease, treatment, and the benefits of the golden card.

While some accepted this treatment as normal, others felt like second-class citizens for receiving “free” treatment. As one dejected woman put it, “kutta jaisa vyavhaar karte hain humare saath, aur apna paisa lagao toh aadar-satkaar karte hain” (they treat us like dogs; only when you pay for your own treatment do they treat you with respect). One patient said that after his golden card was activated, he was shifted from a private to a general ward, while another mentioned that his doctor was changed on the day of his golden card activation. Some questions were even shrugged off with a response like “Ayushman Bharat mein ilaaj karwaoge toh waisa hi treatment milega” (If you get treated under the Ayushman Bharat scheme then you should expect such [second-rate] treatment). Some doctors reportedly advised families to pay for the full treatment, instead of availing the PMJAY benefits, for the “safety” of the patient: “PMJAY ke chakkar mein mat padiye. Paisa deke treatment karwaiyega toh sab time se hoga” (Avoid the hassle of PMJAY; if you pay for treatment, it will be timely), one said.

The dynamic of the Arogya Mitra: An Arogya Mitra is appointed as the first functionary that prospective beneficiaries of the scheme meet. They should provide the patients with information regarding issuing the card and enrolment, health packages, treatment costs and any rightful reimbursements. 

However, Arogya Mitras are recruited by the government through a dealer or on the suggestion of the hospital. Many had worked as hospital staff before being trained in Namkum for recruitment as Arogya Mitras. Because they get their salaries from the government, they were often reluctant to discuss the shortcomings of the hospitals or their managers. Upon being asked, all six of them said they saw themselves as employees of the hospital, not the government. Their loyalties put patients at a disadvantage during negotiations with the hospital.

Most empanelled hospitals had only one Arogya Mitra working a single shift, whose offices remained closed on weekends and holidays. During our repeated visits to a children’s hospital in Ranchi, we observed many queuing outside the Arogya Mitra’s closed office. If the Arogya Mitra was away, emergency patients were asked for a “security deposit” with a promise of reimbursement that never happened. 

Lack of transparency and inefficient grievance redressal: The PMJAY does not provide the patients with any bills at the end of the treatment. There is no paper record of services received, amount spent or the remaining golden card balance. Balances can be checked on the PMJAY website under the patient’s “wallet” section. However, this is impossible for beneficiaries without digital access. The Arogya Mitras and the customer service centre (CSC) did not entertain such queries. This left the beneficiaries in the dark: none of the respondents knew their card’s balance and how much free treatment they were still eligible for.

Patients often forgot to demand a bill to verify unfair charges, and when they demanded one, it was often refused. In cases where they suspected wrong charges, most were unsure where to go for grievance redressal. Most approached the Arogya Mitras who turned them down. 

For grievances, patients can either call the toll-free number, or write letters to the chief minister of Jharkhand or the Prime Minister. Many reported that the toll-free number was useful only for eligibility information as the complaint portal never worked. Patients could either send a letter to officials or post the complaint on Twitter. During our conversation with the state consultant of the grievance redressal cell, we found that most complaints were about being charged for denied treatment. When trying to register complaints, the grievance cell demanded a bill-receipt that no patient had. Consequently, their complaints were not registered. 

By 4 June 2019, as reported by the grievance redressal cell of Ayushman Bharat for Jharkhand, there were 14,555 registered complaints, and few resolutions were pending. Despite the many complaints that had been taken up, no appeals for reimbursement had been successful.

Some patients were charged for not producing a golden card when treatment started. Patients also filed complaints about being charged for OPD and diagnostics. Technically, the PMJAY does not cover those, but this lack of clarity persisted because many hospitals promised a reimbursement at the time of admission. 

Rates of reimbursements are low for the hospitals: The deep-rooted corruption of healthcare givers is a major hurdle for patients accessing free healthcare. When asked why patients were charged, hospital managers often mentioned that the rates of reimbursement were too low and health packages insufficient. Leading private hospitals in Ranchi mentioned that they had started with many departments functioning under the PMJAY, however, within three months, they faced heavy losses causing delays in giving salaries to their employees. This meant excluding departments under the PMJAY, especially most of the critical diseases that required extended periods in intensive care.

Hospital managers confirmed the government’s instructions to charge patients for pre- and post-hospitalisation care. Even then, the PMJAY reimbursements were inadequate in many cases, or so they claimed. The bigger hospitals found it difficult to sustain the PMJAY as the reimbursements were lower than their regular costs. The smaller hospitals, on the contrary, found it impossible to survive without adopting the PMJAY: they mainly catered to poor patients who always chose a PMJAY hospital. 

Conclusions

With the government positioning public healthcare as second-rate and private services as the only workable alternative, a shift of patients to the private sector is not surprising. According to the DHOR, out of a total of 1,64,399 patients treated under the PMJAY in Jharkhand between 23 September 2018 and 4 June 2019, only 21,690 (13%) were treated in a public hospital. Government funds are drifting towards the private sector, with only ₹14 crore of PMJAY reimbursements being spent on public hospitals versus ₹150 crore for private hospitals (Figure 1). 

Figure 1: Total Government Expenditure (23 September 2018–4 June 2019)

Source: District Health Office, Ranchi.

The PMJAY hurls the patients into the private sector where it covers only a part of their treatment costs. A startling 53 out of 57 respondents said that their health expenditures were almost the same (if not more) as their expenditure prior to PMJAY. In most cases, the PMJAY covers just the operation and room charges, leaving plenty of scope for exploitation. PMJAY acts as a “trap” by making its beneficiaries believe they can access free healthcare in private hospitals while causing them to incur exorbitant hospital fees and serious debt.