'Dummy Numbers & Mismanagement': 5 Takeaways From CAG Report on Ayushman Bharat

The Comptroller and Auditor General's report on the Ayushman Bharat - Pradhan Mantri Jan Arogya Yojana, tabled in the Parliament earlier this week, brings to light some startling, big numbers. 7.5 lakh beneficiaries linked to invalid mobile number – 9999999999.4,761 registrations made against seven Aadhar numbers.Missing hospitals enrolled under public health insurance scheme. But how do we make sense of these numbers? What impact will these discrepancies have on the ground when it comes to public health?FIT spoke with Srinivas Kodali, researcher working on data, governance, and the internet, Shweta Mohandas, policy officer at Centre for Internet and Society, and a public health expert to understand it better. Here are five takeaways.CAG Report On PMJAY: 7.5 Lakh Beneficiaries Linked to One Invalid Phone NumberWhen someone goes to a hospital and asks to avail benefits under the Ayushman Bharat scheme, they have to show their Aadhar card, which is used to check the patient's eligibility. “AB-PMJAY identifies the beneficiary through Aadhaar identification wherein the beneficiary undergoes the process of mandatory Aadhaar based e-KYC. The details fetched from the Aadhaar database are matched with the source database and accordingly, the request for Ayushman card is approved or rejected based on the beneficiary details,” an unnamed official told news agency PTI.According to the CAG audit, however, around 4,761 registrations were made against seven Aadhaar numbers in Tamil Nadu.Further, the guidelines also state that State Health Authorities (SHA) send an SMS notification to the registered contact number to check for their eligibility.The question then arises: Were the notifications of 7.5 lakh beneficiaries sent to 9999999999? Who received them? How was the eligibility of the beneficiaries identified when they didn't receive the notification? What about people who did not have phone/phone numbers at all?But there is a possibility that that the pan-India public health insurance scheme points to a 'fraud of some kind' by private hospitals, says Srinivas Kodali. The report has pointed out that Rs 1.1 crore was paid for 403 patients who were reportedly dead in Madhya Pradesh alone. In Kerala, Rs 2.6 crore was paid for the treatment of 966 patients who had been declared dead, and in Chhattisgarh, over Rs 33 lakh were paid for 365 such patients. At the national level, Rs 6.97 crore was shelled out for treatment of 3,446 patient who were reportedly dead according to previous databases.“It’s possible that many of the 7.5 lakh people who registered 9999999999 as their number don’t exist and the hospitals used these dummy numbers to claim money from the government. There are so many missing hospitals enrolled in the Ayushman Bharat scheme.”Srinivas KodaliIt's a fair presumption that money that should have been spent on public health infrastructure is going to private hospitals and companies, Kodali adds.While some people might have concerns about the legitimacy of the CAG report, Kodali says that the report should not be seen in isolation. In August 2022, the Times of India had reported that as many as 26 percent of the claims under PMJAY from Punjab and Haryana were fraudulent. This was not a lone instance though. In 2019, when the Union government first released a report about the scheme, it was found that 341 hospitals across 16 states had been indulging in fraud.The 2019 report had also questioned why no data regarding the "most performed surgeries" was available in the public domain, hinting that it was possible that hospitals could be committing fraud by performing surgeries that are profitable for them.PMJAY: Who’s Eligible, Who’s Not Under Ayushman Bharat YojanaPolicy expert Shweta Mohandas has many concerns about how the data was collected and entered into systems under the Ayushman Bharat scheme. But one major concern that trumps all the others is that if this incorrect data is used to train artificial intelligence bots and systems, the results that come out of it would be inconsistent too.She notes that any deductions made using this data, and any health policies derived from it would be factually wrong."If another pandemic happens, we will need data like this to understand who requires insurance and the scale of how many people require other beneficiary schemes. This incorrect data will then cause more problems because the policy will be flawed and it’ll be difficult to do ground surveillance and assess healthcare needs."Shweta MohandasMohandas also brings to attention the need to train ground staff better when it comes to data collection. Be it ASHA workers, healthcare operators, or nurses, there should be orientation programmes for them on how to collect data, how to enter it into systems, and how to address privacy concerns of patients. Lessons From the AIIMS Cyber Attack: Is India Ready to Digitise Healthcare?“Mobile numbers are significant for searching records related to any beneficiary in the database, who may approach the registration desk without the ID,” the auditors have explicitly said in the CAG report."The mobile number is recorded only for the sake of reaching out to beneficiaries in case of any requirements and for collecting feedback regarding the treatment provided," an unnamed official from the Centre told PTI.A public health expert whom FIT spoke to underlined how the digital divide is resulting in decreased access to healthcare services for people who actually need it the most.She says that schemes like these can end up becoming decreasing healthcare access due to lack of phone number or adequate documentation.(FIT has reached out to the Union Health Ministry with questions over email. This story will be updated if and when a response is received.)CoWIN Breach: What Makes India's Health Data an Easy Target for Bad Actors?