Indian Journal of Health Social Work
(UGC CARE List Journal)
DOES PRADHAN MANTRI JAN AROGYA YOJANA (PMJAY) PROTECT
ECONOMICALLY VULNERABLE POPULATION FROM FINANCIAL RISK?
: A NARRATIVE REVIEW
Zunatha Banu A1, Mahalakshmy T2 , Kalpana Muthuraj3
1Social Scientist, 2Professor & 3Medical Social Worker, JIPMER, Puducherry
Correspondence: Zunatha Banu A, e-mail: jo0070@jipmer.ac.in
ABSTRACT
Background: More than 50% of health expenditure in India is borne by families through out-of
pocket payments (OOPE) (Nanda & Sharma, 2023). In many cases, such high OOPE becomes
catastrophic, pushing households into financial distress. Both OOPE and catastrophic health
expenditure (CHE) have the potential to impoverish families (Sinha et al., 2016). To address this,
the Government of India has introduced several health insurance schemes aimed at protecting
vulnerable populations from the financial burden associated with healthcare. One such initiative
is Ayushman Bharat – Pradhan Mantri Jan Arogya Yojana (AB-PMJAY), which aims to provide
economically vulnerable groups with access to secondary and tertiary healthcare services without
financial hardship. AIM: To assess the impact of the scheme on Out-of-Pocket Expenditure (OOPE)
and Catastrophic Health Expenditure (CHE), evaluate its effectiveness in providing financial risk
protection and preventing further impoverishment, and identify existing knowledge gaps to guide
future research.Methods: In this narrative review, we conducted a descriptive analysis of the
secondary data available through open access. A systematic search was conducted in PubMed,
Science Direct and Google Scholar for articles published between October 2021 and September
2025. A total of 59 articles from PubMed, 17 from Science Direct and 543 from Google Scholar
were accessed. At the end, 25 articles were reviewed after applying the inclusion and exclusion
criteria.Results: The findings were organized into themes including knowledge, awareness,
coverage, utilization, PMJAY’s impact on OOPE, CHE & financial risk protection and challenges in
implementing the scheme. Conclusion: The findings suggested the need for monitoring and
evaluation mechanisms to strengthen the PMJAY scheme.
Keywords: Narrative, PMJAY, OOPE, CHE, financial risk protection, challenges
Submitted: 05.01.2026 Revised: 28.02.2026 Accepted: 03.06.2026 Published: 30.07.2026
How to cite this article: Banu A.Z., Mahalakshmy T. & M. Kalpana (2026). Does Pradhan
Mantri Jan Arogya Yojana (PMJAY) Protect Economically Vulnerable Population From Financial
Risk? : A Narrative Review. Indian Journal of Health Social Work, 8(1), 17-34.
INTRODUCTION
More than 50% of health expenditure in India
is borne by families through out-of-pocket
payments (OOPE) (Nanda & Sharma, 2023).
In many cases, such high OOPE becomes
catastrophic, pushing households into
financial distress. Both OOPE and catastrophic health expenditure (CHE) have either the
potential to impoverish families (Sinha et al.,
2016) or preventing them from accessing
health care. In this regard, the health
insurance scheme is one of the mechanisms
to ensure health care (Narayanan & Kodali,
2020). In order to shield the economically
disadvantaged population from out-of-pocket
medical expenses (OOPE) that could worsen
their situation, the Indian government has
implemented a number of welfare programs.
Pradhan Mantri and Ayushman Bharath One
program that gives each household Rs.
5,00,000 year is Jan Arogya Yojana AB-PMJAY.
Forty percent of Indians are hospitalized for
secondary and tertiary care. The Socio
Economic Caste Census (SECC) 2011’s
occupational and deprivation criteria for rural
and urban areas were used to determine which
households were included. The goal of this
insurance program is to lower the catastrophic
medical costs that force almost 6 crore Indians
into poverty every year. Up to three days of
pre-hospitalization and fifteen days of post
hospitalization costs, including prescription
drugs and diagnostics, are covered. The
objectives of the PMJAY scheme are to reduce
OOPE, catastrophic health expenditure (CHE)
and improve the access to health care
services. Therefore, this narrative review
synthesizes the findings from diverse studies
to understand the scheme’s impact on
OOPE and CHE and also to understand
comprehensively whether the scheme
prevents from financial risk and further
impoverishment. This review states the
knowledge gaps and suggests future studies.
Abstracts screened
METHODOLOGY
In this literature review, we conducted a
narrative analysis and covered a broad range
of topics by using studies of various
complexity and design (Grant & Booth, 2009).
The search was conducted in the databases
PubMed, Science Direct and Google scholar
using the term ‘PMJAY’. Inclusion criteria were
the English language and articles published
between October 2021 and September 2025.
This strategy results in 59 articles in PubMed,
17 from Science Direct and 543 from Google
Scholar. We conducted a further screening
process and included articles with primary
data, available in full text and accessible
through open access sources. We excluded
articles such as editorials, reviews,
intervention studies conceptual papers and
other publication types. After following
inclusion and exclusion criteria, articles were
stored in Zotero. This strategy resulted in
many doubles, which were deleted. At the
end, we had 27 articles for review process.
RESULTS
Knowledge and Awareness
The table 1 represents the level of knowledge
and awareness regarding the Pradhan Mantri
Jan Arogya Yojana (PMJAY) among both
beneficiaries and healthcare workers (HCWs).
Awareness among beneficiaries showed
considerable variation across geographic
regions and population groups. The patients
who were hospitalized or seeking health care
services also have the limited level of
awareness regarding scheme. Contradict to
this, few studies reported higher levels of
awareness even among the rural population
and BPL families. A study explored the sources
of awareness among beneficiaries through
government-issued letters, village-level
health workers, hospitalization and through
social connections. Knowledge levels among
HCWs were higher than the beneficiaries.
Among HCW’s, Doctors had higher knowledge
followed by community health workers and
nursing officers. Furthermore, HCWs posted
at primary health centers have better
knowledge than those working at community
health centers and tertiary care hospitals.
Coverage and Utilisation
The coverage and utilization of the PMJAY
scheme remains limited across various
settings, despite moderate awareness levels
reported in some populations. PMJAY
enrollment does not relate with the effective
use of health care services due to the
operational challenges. The gap between
awareness and utilization explains that
knowledge alone may not be sufficient to drive
scheme adoption. In contrast, few studies
reported that PMJAY facilitated the urgent care
during COVID 19. It is also contributed in
Ophthalmology surgery but not much in other
surgical care
Table 3: Theme 3- PMJAY Impacts on OOPE, CHE and Financial Risk.
PMJAY’s impact on OOPE , CHE and
Financial Risk
Several studies have evidenced the impact of
the PMJAY scheme on hospital utilization,
OOPE and CHE. It facilitated the access to
secondary and tertiary care. PMJAY enrolled
patients received timely care and most of the
beneficiaries utilized private health facility.
Few studies reported that beneficiaries
experienced zero OOPE and the scheme
reduced financial risk. Contrastingly, an
insurance process evaluation revealed that
delays in claim reimbursement ranged from
two to six times longer than guidelines and
beneficiaries still incurred OOPE during
hospitalization.
Table-4: Theme-4: Challenges in implementation of PMJAY.
Challenges in implementation of PMJAY
The studies elaborate multiple challenges
faced by beneficiaries, healthcare providers,
and the system in the implementation of
PMJAY. Beneficiaries experienced PMJAY
enrollment issues (due to lack of awareness
and exclusion of poor families without BPL
cards), significant out-of-pocket expenses
(due to diagnostics and high-cost drugs) and
operational challenges like approval delays,
technical issues etc., HCW’s and health
system barriers were inadequate
competencies and incentives for ASHAs,
resource shortages (staffing and training),
Other issues included claim portability,
referral difficulties, technological weaknesses,
fraudulent claims, restricted coverage of
essential treatments, exclusion of outpatient
services.
Private sector participation or engagement
remains limited due to insufficient state
budgets, low reimbursement rates, rigid
scheme packages, strict empanelment
criteria, complex and delayed claims
processes, economic non-viability, patient
load concerns, limited administrative capacity
and gaps in monitoring.
DISCUSSION
The art of review: This narrative review
describes the level of knowledge, awareness,
coverage, utilization and its impact on OOPE,
CHE and Financial Risk. It also elaborates the
challenges experienced by beneficiaries,
HCW’s and health system in the
implementation of PMJAY scheme among
different population and geographical areas.
Awareness among urban beneficiaries is not
the optimal level as reported by (Dixit et al.,
2025). Contrasingly, (Prasad et al., 2023) and
(Sankar, Rajendran, Mary, et al., 2025)
revealed that rural awareness was higher and
over 70% of beneficiaries aware of the
scheme. The sources of information regarding
the scheme are vital in spreading awareness.
(Trivedi et al., 2022) identified government
i ssued letters as a primary source for
beneficiary awareness in Gujarat, while social
contacts through friends and relatives were
the source in Madhya Pradesh. It reflects that
multiple communication strategies are
necessary to reach the populations effectively.
Healthcare workers (HCWs), particularly
doctors had higher knowledge score than
beneficiaries, as evidenced by (Sankar,Rajendran, Mary, et al., 2025) and (Nirala et
al., 2022). HCW’s at the primary healthcare
level where knowledge was higher than
community health centers and tertiary care
hospitals. Hence, frontline HCW’s serve as the
first point of contact and can influence
beneficiary awareness and enrollment. The
data from (Sabherwal et al., 2024) revealed
a small fraction were knowledgeable about
all key aspects of the scheme such as
eligibility, covered services and empanelled
hospitals. This finding emphasized awareness
does not relate to comprehensive knowledge
necessary for effective utilization. The low
level of awareness among urban beneficiaries
(Dixit et al., 2025) and the moderate
awareness reported by (Gore et al., 2025)
among cancer treatment patients suggest that
outreach and disease specific awareness
might be required. Socio economic and
informational barriers explain that why eligible
population still unaware or partially aware of
PMJAY.
Low utilization rates reported by (Dixit et al.,
2025), (Prasad et al., 2023) and (Sankar,
Rajendran, & Mary, 2025) across urban and
rural populations highlighted that awareness
alone does not ensure the coverage and
utilisation of the scheme. Barriers such as
enrollment issues (eligible without BPL card),
delay in issuing card (verification process),
procedural complexity, HCW’s attitude and
limited healthcare infrastructure were the
reason for beneficiaries to utilise scheme’s
benefits. (Garg et al., 2024) emphasized that
enrollment under PM-JAY does not ensure into
increased inpatient care utilization. Health
system issues include inadequate HCW’s
knowledge; administrative inefficiency and
lack of beneficiary empowerment to navigate
the healthcare system were the reason for
low utilisation. As evidenced by (Duggal et al.,
2024), who reported improved access to
critical COVID-19 care through empanelled
hospitals. This depicts the scheme’s
importance in facilitating timely healthcare
access during crises. (Marazi & Pandit, 2024)
reported PMJAY’s impact on different medical
and surgical procedures. Ophthalmology
surgeries were increased compared to other
procedures. The gaps in other medical and
surgical procedures to be addressed through
targeted policy measures and provider
engagement.
The evidence reviewed presents a nuanced
picture of PMJAY’s impact on healthcare
utilization and financial protection. Several
studies (Kamath et al., 2024, 2025; Kumar et
al., 2025; Parmar et al., 2023) indicate that
PM-JAY effectively reduces OOPE and CHE
among beneficiaries accessing private
empanelled hospitals and specialized care
such as cardiac surgeries and obstetrics
gynecology. Hence, the scheme supports to
offer financial risk protection to vulnerable
populations.(Garg et al., 2022) presented that
scheme does not reduce in OOPE or CHE.
System challenges exist in implementation,
claim processing and accessing care. (Saxena
et al., 2022) stated that delay in claim
reimbursement was the operational
challenges for still occurring OOPE. Regional
disparities like beneficiaries in Gujarat
satisfied with the scheme and reported lower
OOPE compared to Madhya Pradesh. It can
be due to health system capacities,
governance and HCW’s performance. Scheme
facilitates timely access to critical care
especially cancer care (Halder et al.).
Studies presented administrative and
operational challenges that hinder the
effective implementation and utilization of the
PMJAY. These challenges were from both
beneficiary and provider perspectives.
(Sabherwal et al., 2024) reported that
inefficiencies in beneficiary identification and
card issuing process. (Mohsin & Muzaffar,
2023) captured beneficiary abuse and claim
processing delays. This qualitative insight
reflects not only operational inefficiencies but the emotional and psychological impact on
beneficiaries. (Gore et al., 2025) found that
beneficiaries were dissatisfied due to
incomplete coverage and OOPE. This finding
explains that the current insurance packages
are insufficient for complex conditions like
cancer, with delays in approvals and technical
issues further disturbing treatment access.
Knowledge Gaps and direction for future studies:
Based on this literature review, we identified
few knowledge gaps. First of all, we need an
intervention studies targeted beneficiary’s
awareness through health education or
campaigns, HCW’s training etc., which
address the disparities and support
beneficiary education and scheme utilization.
Second, this review evidenced health system
challenges. It is required to study health
system readiness and quality assessment.
Third, we need critical studies to gain the
insights of policy stakeholder’s perspective.
These studies will helpful to understand the
structural barriers such as card issuance,
framing eligibility criteria, pre authorization
and delay in claim reimbursement and private
sector engagement. Fourth, future research
can focus on why beneficiaries do not utilize
the scheme despite being aware or holding
cards. A qualitative or mixed method studies
to be carried to explore the behavioral, social
and health system. Furthermore, there is a
need to evaluate the long term impact of
PMJAY on health outcomes, CHE, financial risk
protection and current insurance packages for
chronic condition
CONCLUSION
Multiple strategies will helpful to enhance
utilization rates, including strengthening
beneficiary education beyond mere
awareness, simplifying claim processes,
improving HCW’s participation and service
delivery. Without addressing the challenges,
it will not able to realize the full potential of
PMJAY in reducing out-of-pocket expenditures
and providing financial risk protection to the
economically vulnerable populations.
Though PMJAY has demonstrated
effectiveness in reducing financial burdens,
addressing operational inefficiencies,
streamlining claim processes, strengthening
health infrastructure and ctargeting the
underserved regions and people will be
essential. Additionally, improving technology
i nfrastructure and ensuring timely
reimbursements can significantly improve
both provider participation and beneficiary
satisfaction.
Source of Funding:
Indian Council of Social Science Research
(ICSSR), New Delhi
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Conflict of interest: None
Role of funding source: None
ISSN: 2582-1393 (Online)