What ails the biggest health cover

The auditor general has found several holes in Ayushman Bharat’s performance. Misidentification of beneficiaries is one. There may be simple solutions to plug the leaks
Image used for illustrative purposes only. (Express illustration | Soumyadip Sinha)
Image used for illustrative purposes only. (Express illustration | Soumyadip Sinha)

The Comptroller and Auditor General’s (CAG) eleventh performance audit report of 2023 is on the Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (AB-PMJAY). The report covers the period between September 2018 and March 2021. Who can deny the importance of AB-PMJAY?  It is a targeted subsidy for beneficiaries identified by the Socio Economic Caste Census (SECC). PMJAY is one component of AB, the other being health and wellness centres. The number of total expected beneficiaries is just over 107 million and they get health cover of Rs 5 lakh per family every year for secondary and tertiary hospitalisation. (That 107 million is a base figure, so one shouldn’t read too much into it. There has been population growth and those under the National Food Security Act were added.)  

The trouble is, health is on the State List and many states have their own health insurance schemes and databases for identifying beneficiaries. Therefore, they can use their own databases for PMJAY, provided every household identified by SECC is included in whatever database a state uses for PMJAY. There is a beneficiary identification system (BIS). Beneficiaries must register and get e-cards.

To quote from the CAG report, “BIS has a provision for marking/flagging beneficiaries to indicate whether they pertain to PMJAY or the state’s own scheme. The Pradhan Mantri Arogya Mitra which registers beneficiaries on the BIS is required to create/select the appropriate flag code so that any beneficiary registered in BIS is clearly identified by the National Health Authority’s (NHA) IT system as pertaining to PMJAY or the state’s own scheme. This flag is used by the IT system not only in BIS but also while availing scheme benefits subsequently in the transaction management system. Some of the states are using their own IT systems. States/UTs implementing their own health insurance/assurance schemes are allowed to continue with their own datasets for beneficiary identification. States/UTs are required to map their own databases with SECC within a reasonable period of time.”  

This isn’t happening. There are states which aren’t using flags. There are also states that use their own IT systems, not the NHA’s BIS. The upshot is that there is no proper match with the SECC database. As a prospective beneficiary, I apply for registration with all the documents. These are sent to the insurance company or trust, and the online system generates a match confidence score for approval or rejection.

“Data analysis revealed that the match confidence score was not applied as criteria during the approval/rejection process of registration of a person. In the absence of any prescribed threshold levels, approvals and rejections were made irrespective of the confidence score. Out of 11,38,21,032 approved cases, 3,67,10,090 cases (32.25 percent) were approved even though these did not fetch any match confidence score, while in 1,68,91,452 cases (14.84 percent), the match confidence score was zero. Similarly, out of 94,88,583 rejected cases, 38,57,263 cases (40.65 percent) were rejected despite having a match confidence score of 51 to 100.”

CAG reports use polite language. Stated impolitely, approval and rejection are both arbitrary. “Scheme guidelines stipulate that once the eligible beneficiary is verified, a PMJAY ID is assigned to the beneficiary. This PMJAY ID is a nine-digit alphanumeric code and serves as a unique identification key. Data analysis revealed that the PMJAY ID was not unique in 1,57,176 cases (approved cases only)… The presence of duplicate IDs in the system indicates failure of the system to generate a unique ID for each beneficiary. In such circumstances, possibility of presence of ineligible beneficiaries in the BIS database cannot be ruled out.”  

There is more. “As per the scheme guidelines, there is no definition of a family as in other schemes such as the Central Government Health Scheme, Employees’ State Insurance Corporation, etc. Further, guidelines also stipulate that there is no cap on family size for eligible households. Data analysis revealed that in 43,197 households, the size of the family was unrealistic, ranging from 11 to 201 members. … The presence of such unrealistic members in a household in the BIS database indicates not only lack of essential validation controls in the beneficiary registration process, but also the possibility that beneficiaries are taking advantage of the lack of a clear definition of family in the guidelines.” Though 201 family members in a household is logically possible, it does smell fishy.

Shouldn’t life be simpler with Aadhaar? “PMJAY guidelines stipulate ‘Aadhaar’ as one of the identity documents for a family member for registration under AB-PMJAY… If any PMJAY family member does not have an Aadhaar card, they can get treatment only once without an Aadhaar and shall apply and obtain Aadhaar at the earliest for treatment in future. In Tamil Nadu, linking of multiple beneficiaries with same/erroneous Aadhaar numbers were noted during data analysis.”  

Also part of the Jan Dhan-Aadhaar-Mobile trinity is the mobile number. “Guidelines on disabling a BIS e-card provide that the state health agency shall send SMS intimation to the contact number provided at the time of card creation informing the beneficiary to check their eligibility. Data analysis of the BIS database revealed that there were large numbers of beneficiaries registered against the same or invalid mobile number. Overall 1,119 to 7,49,820 beneficiaries were linked with a single mobile number in the BIS database.” I don’t have space to quote every bit from the report, such as violation of the stipulation (across states) that if any household member is a government employee, there should be no beneficiary from that household. “The audit observed that delayed action in weeding out the ineligible beneficiaries resulted in ineligible persons availing benefits of the scheme and excess payment of premium to the insurance companies.”

Who can deny the necessity of PMJAY? Barring the northeastern states, 60 percent of funding comes from the central government. This performance audit report establishes that those who should benefit from the scheme aren’t getting enrolled and those who shouldn’t are beneficiaries.  

A certain amount of leakage and misidentification is inevitable and can also be linked to corruption. How excessive is this and can the system be tightened? There is a beautiful island in Greece called Zakynthos, which became infamous as the island of the blind. Since blind people were given a monthly stipend, many people with sight declared themselves blind. After the scam was unearthed in 2011, the scheme was shut down. At the time, one such ‘blind’ person was found driving a Porsche. If there is misidentification, someone has to pay.

Bibek Debroy

Chairman, Economic Advisory Council to the Prime Minister


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