Performance Audit of Ayushman Bharat — Pradhan Mantri Jan Arogya Yojana, Ministry of Health and Family Welfare

Findings

1. By November 2022, 7.87 crore beneficiary households were registered — 73 per cent of the 10.74 crore targeted. Of these, 2.08 crore had been identified from the SECC-2011 database the scheme guidelines envisage.

   “As per NHA records, 7.87 crore beneficiary households were registered, constituting 73 per cent of the targeted households of 10.74 crore (November 2022). Out of this, 2.08 crore households had been identified from SECC-2011 database, as envisaged in the Scheme guidelines.”Executive Summary

2. The match confidence score the registration system generates was rendered ineffective — applications were approved or rejected irrespective of it, and data analysis showed it was not applied at all during approval or rejection.

   “The match confidence score, which the online system of beneficiary registration, generates based on matching the documents of a beneficiary with the SECC list of eligible beneficiaries, has been rendered ineffective as applications for registration were approved or rejected irrespective of the match confidence score.”Executive Summary

3. The beneficiary database carried invalid names, unrealistic dates of birth, duplicate PMJAY IDs and impossible household sizes. In Tamil Nadu 4,761 registrations were made against seven Aadhaar numbers, and up to 7,49,820 beneficiaries were registered against a single mobile number.

   “In the absence of adequate validation controls, errors were noticed in beneficiary database i.e. invalid names, unrealistic date of birth, duplicate PMJAY IDs, unrealistic size of family members in a household etc. In 36 cases, two registrations were made against 18 Aadhaar numbers and in Tamil Nadu, 4761 registrations were made against seven Aadhaar numbers. Registration of multiple beneficiaries against same or invalid mobile number ranging from 11 to 7,49,820 beneficiaries were noted in the Beneficiary Identification System (BIS).”Executive Summary

4. In six states and union territories ineligible households were registered and drew scheme benefits, with expenditure on them ranging from ₹0.12 lakh in Chandigarh to ₹22.44 crore in Tamil Nadu.

   “In six States/UTs, ineligible households were found registered as PMJAY beneficiaries and had availed the benefits of the Scheme. The expenditure on these ineligible beneficiaries ranged from ₹0.12 lakh in Chandigarh, to ₹22.44 crore in Tamil Nadu.”Executive Summary

5. As of November 2022, 3.57 crore claims worth ₹42,433.57 crore had been settled, of which ₹22,619.86 crore — 53.30 per cent — belonged to six states running their own IT platforms, where the audit notes a possibility of overlap with state schemes.

   “As of November 2022, 3.57 crore claims amounting to ₹42,433.57 crore were settled. Out of these, claims amounting to ₹22,619.86 crore (53.30 per cent) pertained to the six brownfield States viz. Andhra Pradesh, Arunachal Pradesh, Rajasthan, Karnataka, Maharashtra and Tamil Nadu… With no segregation of PMJAY beneficiaries in such cases, there is a possibility of overlap of PMJAY with state specific schemes.”Executive Summary

6. Beneficiaries were charged for treatment at empanelled hospitals in Himachal Pradesh, Jammu and Kashmir, Jharkhand and Meghalaya — in Meghalaya 13,418 of them — increasing the out-of-pocket expenditure the scheme exists to reduce.

   “In Himachal Pradesh (50) Jammu and Kashmir, (459), Jharkhand (36) and Meghalaya (13,418) beneficiaries were charged for their treatment in empanelled EHCPs resulting in increase in out-of-pocket expenditure of beneficiaries.”Executive Summary

7. The transaction system allowed pre-authorisation requests for the treatment of beneficiaries already shown as dead, and carried records with surgery dated after discharge and discharge dated before admission.

   “Many discrepancies such as invalid dates of admission/pre-authorization/claim processing, non-availability of certain crucial dates, date of surgery after date of discharge of the patient, invalid/null entries in patient age column were noted. In certain cases, the date of discharge was earlier than admission date. TMS allowed pre-authorisation request of treatment of a beneficiary shown as 'died' in many cases.”Executive Summary

8. 88,760 patients were recorded as having died during treatment under the scheme, and 2,14,923 claims shown as paid in the system related to fresh treatment of those same patients; 3,903 of those claims, worth ₹6.97 crore for 3,446 patients, were actually paid to hospitals.

   “Data analysis of mortality cases in TMS revealed that 88,760 patients died during treatment specified under the Scheme. A total of 2,14,923 claims shown as paid in the system, related to fresh treatment in respect of these patients. Audit further noted that in 3,903 of above claims amounting to ₹ 6.97 crore pertaining to 3,446 patients were paid to hospitals.”Paragraph 5.8.2.8

9. The audit records the scheme's effect as well — an ambitious and well-intentioned programme that has had a strong positive impact on the economically weaker sections who need healthcare.

   “Audit noted that the PMJAY Scheme, an ambitious and well-intentioned programme to provide healthcare access to most vulnerable sections in the country, has had a strong positive impact on the economically weaker sections of the society who need healthcare facilities. However, the implementation of the Scheme needs improvement in the light of the findings made in the report.”Executive Summary

Fact-checks citing this report

• ◐Partly accurateWhile providing annual health cover of Rs. 5 lakh to 10.74 crore poor families under the Pradhan Mantri Jan Arogya Yojana under Ayushman Bharat, we also initiated a programme to set up 1,50,000 Health and Wellness Centres by 2022.
• ?UnverifiableAyushman for Senior Citizens: We will expand the Ayushman Bharat Yojana to cover Senior Citizens and provide them access to free and quality healthcare.