Review: CAG Highlights Multiple Discrepancies in Ayushman Bharat – Pradhan Mantri Jan Arogya, Makes Recommendations
Sai Krishna Muthyanolla
August 18, 2023
Recently, the CAG tabled the performance audit report on the Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (AB-PMJAY). The CAG’s performance audit report of AB-PMJAY covered five different aspects of the scheme that highlighted multiple discrepancies. The report also made important recommendations. Here is a review.
Ayushman Bharat – Pradhan Mantri Jan Arogya Yojana (PMJAY) is a flagship health scheme launched by Government of India in 2018. It aims to provide ‘Universal Health Coverage’ to the poor and vulnerable sections of the society by ensuring access to healthcare services and reduce the out-of-pocket medical expenditure.  PMJAY provides a health cover up to Rs. 5 lakh per family per year, for secondary and tertiary care hospitalization services. It provides cashless and paperless access to services for the beneficiaries at the point of service.
Recently, the Comptroller and Auditor General of India (CAG) tabled the performance audit report on the Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (AB-PMJAY). The CAG’s performance audit report of AB-PMJAY covered five different aspects of the scheme – Beneficiary Identification and Registration, Hospital Empanelment and Management, Claims Management, Financial Management and Monitoring & Grievance Redressal.  The sample size of the Performance audit was 964 hospitals across 161 districts in 28 States. Here is a review of the findings, observations, and recommendations from the CAG report on PMJAY.
Obsolete and erroneous information in the Database used for Beneficiary identification.
One of the key focus areas of the audit was around the process of identification and registration of the beneficiaries. Based on the deprivation and occupational criteria of the Socio-Economic Caste Census, 2011 (SECC-2011), PM-JAY envisages to cover 10.74 core families.
States are also given the flexibility to use their own database for the implementation of PMJAY. This was expanded to 12 crore families in Janaury’2022. The National Health Authority (NHA) laid out process for identification of beneficiaries.
CAG’s report noted some inconsistencies across few states in flagging the beneficiaries eligible for central schemes and those that are part of the state schemes. It has suggested a review of the beneficiary registration system to ensure eligible beneficiaries are covered and a clear identification of beneficiaries under Central and State Schemes is available.
Apart from beneficiary identification, the report highlighted the following observations regarding the Registration process.
On the other hand, nearly 38.6 lakh cases out of 94.9 lakh rejected cases have a match confidence score in the range of 51-100.
CAG report also raised apprehensions about the quality of the data available in the Beneficiary Identification System (BIS) Database. One of the concerns was that the data available was for 2011. By 2018, there could have been changes to the status of the families i.e., few would no more be eligible, and few others are newly eligible, making the data obsolete. It also highlighted the concern with erroneous data.
Registration of multiple beneficiaries against same or invalid mobile numbers
Each verified eligible beneficiary is assigned a PMJAY ID and serves a unique identification key. Data analysis as part of the audit revealed that PMJAY ID is not unique in 1.57 lakh approved cases. Among them, in more than 1.05 lakh cases PMJAY ID is appearing twice.
This presence of duplicate IDs indicates the possible presence of ineligible beneficiaries in the database.  Data analysis highlighted further inconsistencies:
In Tamil Nadu, 4761 PMJAY cards were mapped to multiple Aadhar numbers.
Guidelines indicate that a contact number will be used for any communication related to the scheme. Analysis of the database indicates large numbers of beneficiaries have registered against the same or invalid mobile numbers. Overall, 1119 to 7,49,820 beneficiaries were linked with a single mobile number in the BIS database.
NHA has accepted these discrepancies highlighted by CAG and stated that these issues would be resolved with the deployment of BIS 2.0.
CAG also highlighted discrepancies in Hospital empanelment, claims management etc.
Apart from the inconsistencies in the beneficiaries of PMJAY, the CAG audit also highlighted issues with the implementation of the scheme in various other areas including Hospital empanelment, claims management, Finances, etc. Here is a snapshot of a few of these issues highlighted.
During 2018-19, NHA released grant amounting of Rs. 185.6 crores to eight States without ensuring release of upfront shares by the respective States. NHA has also released grants in three different bank accounts to Chhattisgarh during 2018-21.
In 20 State Health Authorities (SHA), administrative grant of around Rs. 368 crores remain unspent during 2018-21.
District Implementing Units (DIUs) were not formed in five states. There is shortage of manpower in 22 states for various posts in SHAs and DIUs.
Only 9.8% of the complaints received were redressed within the turnaround time.
Strengthening the validation process, investing in infrastructure among the recommendations.
CAG made various recommendations for improving the implementation of the scheme. Here are a few important recommendations.
More than 24.51 crore Ayushman Cards created
As per AB-PMJAY dashboard, more than 24.5 crore Ayushman cards were created so far. In the last 30 days, more than 30 lakh cards were created. The highest number of Ayushman cards are in Madhya Pradesh with around 3.63 crores followed by Uttar Pradesh and Chhattisgarh.
Overall, 27.7 thousand hospitals are empanelled of which 15.6 thousand are public hospitals. The dashboard indicates that since the introduction of the scheme, there were around 5.5 crores authorised hospitalisations. Tamil Nadu has recorded the highest number of hospitalizations followed by Karnataka and Rajasthan.
Around 4.7 thousand empanelled hospitals are inactive since empanelment and a further 3.6 thousand were identified as inactive since the past 6 months. The highest number of hospitals inactive since empanelment are in Andhra Pradesh. In fact, 46% of the hospitals empanelled in Andhra Pradesh are inactive since the beginning.
Data indicates that PMJAY was mostly utilised to cover the procedure of Haemodialysis followed by screening test for COVID-19 infection. General Medicine and Infectious diseases top the list of specialties for which PMJAY was utilised.
Featured Image:AB-PMJAY Dashboard