Ghaziabad, Uttar Pradesh: Cradling her infant son as she sat cross-legged on a bed in her musty 10 feet by 12 feet room in Khora Colony in this western Uttar Pradesh town, Muskaan Ansari was a relieved, if exhausted, young mother.
“I was terrified—where would I go for my delivery?” she said, recounting her fears from the final weeks of her pregnancy, the 21-year-old’s second in three years.
As 23-day-old Bilal gurgled, she said her options had been limited—the overcrowded Lal Bahadur Shastri Government Hospital six km away, or a home delivery assisted by a local midwife.
Abandoned by her husband in her first trimester, she had no choice but to depend on her mother and brother. At government hospitals, the long lines consumed her days, her three-year-old daughter Jigna in tow. If the girl cried, the staff would ask her to leave. “But how can I leave her alone?”
Barely 800 m from Ansari’s home is the local government healthcare centre.
For local residents, it’s the ‘dispensary’. Officially, it is one of more than 174,000 comprehensive primary healthcare centres (CPHC), rebranded in recent years as ‘Ayushman Bharat Arogya Mandirs’. Ansari, however, had to travel to the Lal Bahadur Shastri Government Hospital for her delivery.
In 2018, when Prime Minister Narendra Modi launched the first health and wellness centre under the Ayushman Bharat programme in Bijapur district of Chhattisgarh, he promised 150,000 such centres by 2022, envisioning them as a ‘family doctor for the poor’. These health centres are designed to provide services for maternal care, child health, and even non-communicable diseases including hypertension and cancer.
According to the union health ministry, as of 9 April 2024, India had 170,000 Ayushman Bharat Arogya Mandirs, also called ‘health and wellness centres’, a network built by upgrading 23,744 existing primary health centres, 137,000 sub-centres in rural India, and 9,833 urban centres.
A Floundering Promise
On paper, these centres offer free maternity services—including check-ups, tests, vaccinations, and even delivery rooms in some cases—all under the supervision of a community health officer.
Ansari’s experience reveals a different story.
Ayushman Bharat, a flagship scheme of the union government aiming to achieve universal health coverage, works through two main arms—the health and wellness centres and the Pradhan Mantri Jan Arogya Yojana (PMJAY), which sought to provide a health cover of Rs 500,000 per family per year for secondary and tertiary care hospitalisation, to more than 120 million poor and vulnerable families, or about 550 million people—40% of the Indian population.
Presented as India’s flagship healthcare initiative, Ayushman Bharat has fallen far short of promise as old problems persist — there are as few as three or five empanelled clinics for every 100,000 people in some states; vacant posts or untrained community health officers mean patients either travel long distances to district hospitals or opt for private healthcare; data is absent on outcome indicators on how upgraded primary health centres (PHCs) and sub-centres impacted citizens’ health; while previous norm of publishing monitoring reports was suspended.
As a result, out-of-pocket health expenditure, still high at 39.4% of health expenditure despite the decline from 64.2%, has continued to burden the rural poor, rendering the most vulnerable—women and children—at risk of not attending to health concerns.
Health Centres Without Skilled Birth Attendants
Referred there by the Lal Bahadur Shastri Hospital because of its proximity to her home, when she approached the CPHC or Ayushman Arogya Mandir, she was told delivering her baby there would cost her Rs 3,500. “How could I arrange that?”
She said she knew government centres offer free services, and asked why they were charging her, but did not get a clear response.
According to the Ayushman Bharat’s official booklet on its health and wellness centres, community health officers at PHCs who have received birth attendant skill training can handle normal vaginal deliveries. At Khora Colony’s healthcare centre, however, a general physician with no specialised training has the responsibility of delivering babies.
It is not uncommon in India for deliveries to be conducted without doctors or skilled attendants present, a grim reality that continues to claim lives. In a very recent such incident, in September 2024, an unqualified and untrained nurse at a community health centre in Gorakhpur, eastern UP, realised there were complications only after a newborn baby died. She referred the woman to the nearest district hospital, where she was declared dead on arrival.
In April 2023, at Lal Bahadur District Hospital in Durg, Chhattisgarh, a nurse proceeded with a normal delivery in the absence of a doctor or trained birthing assistant, unaware that the umbilical cord was wrapped around the baby’s neck, leading to a stillbirth.
The head nurse at the Khora Colony centre told Article 14 that their daily workload is often overwhelming, and in case of complications they call for an ambulance and refer patients, along with an accredited social health activist (ASHAs, or government-appointed last-mile healthcare workers), to a nearby hospital.
There are not enough ambulances in the densely populated area. “The wait time is often about four or five hours,” said the nurse, who requested not to be identified.
Rising Costs Of Diagnostic Tests For Pregnant Women
Though Ayushman Bharat’s PMJAY was promoted as a transformative healthcare initiative, an August 2023 report of the Comptroller and Auditor General (CAG) pegged Uttar Pradesh as ranking among the lowest in terms of availability of healthcare centres. The state has only five hospitals per 100,000 people, compared to Goa’s 26.6 and Karnataka’s 21.5. (On the lower end of the spectrum, Maharashtra has three empanelled hospitals per 100,000, Assam 3.4, Daman and Diu 3.6, and Rajasthan 3.8.)
The scheme's guidelines stipulate that all participating healthcare centres—including PHCs, community healthcare centres (CHCs), public and private hospitals—must have adequate 24/7 support systems.
The program's goal is to make specialised healthcare accessible and to reduce out-of-pocket expenses for vulnerable populations. Yet, Ansari struggled to find the money for her check-ups.
“I almost didn’t get my last ultrasound because of the costs,” she said.
She had been advised by the Lal Bahadur Shastri Government Hospital to visit the CPHC at Khora Colony for a free ultrasound scan.
According to nurses, the ultrasound scheduling begins on the ninth of every month, with registered pregnant women assigned to ultrasound machines across the district. Once allotted a number, women must travel to these locations on the assigned day, often taking up to 10 days to get their scan.
In Ansari’s case, when she arrived as instructed, she was dismissed by the doctor and nurses. “They asked why I was there if she didn’t have complications.”
Determined to pay close attention to her baby’s health, she paid Rs 1,200 for an ultrasound in a private clinic, and discovered that the umbilical cord was wrapped around the neck of the foetus. “This report was critical for the doctor to know how to proceed with my delivery,” she said.
Ansari’s experience is far from unique.
Numerous reports in Hindi dailies highlight a chronic shortage of functional ultrasound machines in PHCs and CHCs. An August 2024 report from Rohtas district of southwest Bihar said not only did the PHC in the town of Nasriganj not have an ultrasound machine, but the nearest government hospital where pregnant women were referred also didn’t have one. A rash of unregulated private ultrasound centres were doing brisk business, the report said.
Earlier, in 2022, it was reported that hundreds of pregnant women who visited a UPHC in Tiruchirapalli, central Tamil Nadu, for check-ups were forced to turn to private clinics for ultrasounds as the UPHC’s ultrasound machine had been out of order for two years.
In Bihar’s Munger district , some PHCs’ ultrasound services remained dysfunctional for five years, despite repeated complaints.
These instances and Ansari’s experience in Ghaziabad are part of a widespread crisis affecting maternal healthcare in India.
The 2023 CAG report also pointed out serious errors in the beneficiary database of the Ayushman Bharat programme, delays in processing claims, excess payments in some cases and poor information/communication activities.
Missing Progress Reports, Health Services
Under the National Health Mission (NHM), the performance of the PHCs and Community Health Centres (CHCs) is tracked through a health management information system (HMIS), with progress captured in quarterly financial and physical reports.
These reports are key to evaluating progress on health deliverables such as health & family welfare programmes, optimal utilisation of funds, strengthening delivery of primary healthcare aiming to reduce disease burden, progress on improving the infant mortality rate (IMR), neo-natal mortality rate (NMR), under-5 mortality rate (U5MR) and maternal mortality rate (MMR).
Review meetings with state officials and monitoring visits by ministry-level officials ensure oversight of this progress.
Since 2019-2020, however, the HMIS portal has failed to publish any report analysing the key performance indicators at the district level, though the web-based monitoring information system is designed to publish monthly updates. Previous reports, categorised by themes such as child health and maternal health, are now inaccessible on the website, citing "technical errors".
Unlike some Ayushman Arogya Mandirs that were previously PHCs, Gautam Buddha Nagar’s healthcare centre in western Uttar Pradesh was built in 2021 as an Ayushman Arogya Mandir. Painted in the program’s signature yellow colour, it has rooms designated for various services.
Radha Kumari, a shopkeeper who has run her grocery store in front of the centre for years, said the centre had been mostly inactive since it opened. “No doctor has ever been here,” she said, pointing to the padlocked door of the out-patient department.
The only medical practitioner on site in the centre was an Ayush medical practitioner, who attended to patients seeking Ayurvedic treatment. There was no sign of the promised doctor or community health officer, nor were basic diagnostic services such as blood pressure measurement and diabetes screening available. Even childhood immunisations, once a staple at the centre, ceased in recent months.
A Game Of Referrals
Prime minister Modi's vision for these centres was ambitious—they were intended to be a one-stop place to diagnose diabetes, hypertension, heart disease, cancer, as well as other lifestyle and common diseases.
In reality, many centres struggled to offer even basic health check-ups. According to the 2023 CAG report, under the scheme, all diagnostic tests, medicines, and procedures were to be covered by empanelled healthcare providers (EHCPs), the private entities recognised and authorised by the state to impart healthcare services to the public.
Audits revealed, however, that patients often still ended up paying for services. In Meghalaya, the 2023 CAG report said, between February 2019 and March 2021, 13,418 out of 19,459 beneficiaries who received treatment at five EHCPs, or 69%, were charged a cumulative Rs 12.34 crore at discharge.
The CAG report said that in August 2022, the National Health Authority responded to the auditor stating that these out-of-pocket expenses could have been “due to non-availability of health facilities” at certain centres.
Shivani Agnihotri, MBBS, the community health officer at the Ayushman Arogya Mandir in Kaila Khera, Ghaziabad, shed light on this issue. She said a weekly ‘Ayushman Mela’ was organised to screen local patients for hypertension and diabetes, “but any other complications require referral to MMG district hospital”.
Even for a simple eye check-up, patients were sent to the district hospital, 1.5 km away, due to a lack of testing kits at the centre.
In the first week of September, Hindi dailies in Ghaziabad reported that a report compiled by the health department and presented at the Ghaziabad district health committee’s meeting had highlighted a surge in patient load at government hospitals during the 1 April 2024 - 31 August 2024 period, with the MMG district hospital receiving 439,000 more patients than in the same period in 2023.
The increase overwhelmed their diagnostic services, leaving patients waiting days for check-ups and test results. The hospital frequently ran out of essential medicines.
The same report noted that there were an additional 309,732 patients visiting Ayushman Arogya Mandirs in the area in the study period in 2024 as compared to the same period in 2023.
Despite the rising load of patients, the total number of PHCs and CHCs in Uttar Pradesh has actually fallen.
According to the HMIS report titled Health Dynamics of India (Infrastructure and Human Resources 2022-23), Uttar Pradesh had the highest number of PHCs and CHCs in rural areas among all states as of 31 March 2023. However, a comparison of these numbers from 2005 to 2023 reveals a decline, with 52 fewer functional centres in the state than in 2005, according to the same report.
Senior journalist Ashutosh Yadav, who has extensively covered the Ghaziabad area’s health services, told Article 14 that most referrals from PHCs and Ayushman Arogya Mandirs never make it to the district hospital.
“Whether it's the distance or the inability to take time off work to stand in long lines, patients often resort to private clinics for quicker care,” he said. This increases their out-of-pocket expenditure, leaving them vulnerable to small and unregulated private clinics.
Article 14 reached out to director general of the HMIS S R Meena and Rakesh Sharma, a senior consultant to the HMIS who handles state-wise monitoring for Uttar Pradesh, to gather information on the latest district-wise assessment conducted by HMIS on PHCs and the steps taken to address the gaps highlighted in the reports. Despite multiple calls and two emails, neither responded. All three contact numbers listed for these officials on the HMIS portal were invalid.
Centres Manned By ASHA Workers Alone
According to the Health Dynamics of India (Infrastructure and Human Resources 2022-23 report, critical vacancies beset Uttar Pradesh’s healthcare system.
As of 31 March 2023, as many as 1,621 posts for doctors and medical officers were vacant in PHCs in UP, while 2,042 positions for specialists, including surgeons, obstetricians-gynaecologists and paediatricians, were vacant in CHCs.
Across India, medical officers, doctors and specialists play a crucial role in PHCs and CHCs, serving as the first point of contact for rural patients. In 2005, there was a shortfall of 6,110 specialists in rural India’s CHCs, a 45.7% vacancy rate. By 2023, this number surged to 17,551, a 79.9% shortfall, reflecting the growing crisis in rural healthcare access across the country.
This significant rise in shortage of specialists directly impacts the quality of care and the burden placed on an already strained public healthcare system.
“People at the centre are quick to refer patients to the hospitals but the process of referrals from these centres is not easy, as the responsibility falls on us," said ASHA worker Ravitha, who uses only her first name, seated in her house across the main road of Bankhanda village in Hapur district of western UP.
The village’s Ayushman Aarogya Mandir is the only healthcare option for villagers in a 15 km radius. The centre's medical officer left four months ago when she got married, and nobody was hired as a replacement. Four ASHA workers were the only ones managing the facility.
Ravitha shared recent experiences highlighting the challenges faced in rural healthcare due to the shortage of manpower and resources.
“One of my most complicated cases was taking a woman pregnant with twins to the CHC in Hapur, 15 kilometres away.” Upon arrival, the doctor said the pregnancy had complications, the babies’ lives were in danger, and they lacked the resources required to deliver the babies safely.
Ravitha and the woman rushed to the nearest government hospital, in Meerut, 31 km away. “Here we were informed that both babies had died,” she said. “We were stuck there for two days, as the procedure to remove the deceased babies was delayed.”
Ravitha fought for the mother to be referred to a private hospital to save her life. They finally reached Kailash Hospital in Greater Noida. “After days, her condition was stabilised and her life saved.”
Ravitha ended up spending Rs 600-Rs 700 for travel and other incidentals. She said it felt unjust that ASHA workers receive only Rs 600 from the government for every delivery they accompany a woman for. “It hasn’t changed for 19 years.”
ASHA workers have a staggering 65 duties for which they receive performance-based incentives. These include maintaining records of married women and young children in their community, ensuring that pregnant women get antenatal and postnatal care, monitoring children's weight gain, administering oral rehydration salts for diarrhoea, raising awareness about family planning, distributing medication for vector-borne diseases, etc.
Reflecting on her roles at the Ayushman Arogya Mandir, Ravitha said there were posters everywhere promoting cancer screenings and urging people to get checked, “but we don’t have any screening machines here". Local residents would have to travel at least 22 km for a screening.
In dealing with common diseases such as jaundice and tuberculosis, she said ASHA workers were required to act rapidly, and notify the state as soon as potential patients are identified, so that a testing camp may be set up. “This means we always have to be on our toes; sometimes to save time we collect samples in boxes and take them to the diagnostic centres ourselves,” she said.
Despite the critical roles played by ASHA workers, their pay remains meagre—just Rs 2,000 a month from the central government and Rs 1,500 from the Uttar Pradesh state government. Protests by ASHA workers to demand better wages and recognition have not yielded any success.
On 1 February 2024,union finance minister Nirmala Sitharaman announced an extension of Ayushman Bharat's health insurance benefits to ASHA workers, Anganwadi workers, and helpers during her budget speech, acknowledging their contributions as community health volunteers. “Healthcare coverage under the Ayushman Bharat scheme will be extended to all ASHA workers, Anganwadi workers and helpers," Sitharaman declared, a significant recognition of their role in connecting rural communities with the healthcare system.
However, by the time the government presented its first budget of the new term in July 2024, ASHA workers were absent from the finance minister's speech, with no mention of their inclusion or their contribution to India's healthcare system.
According to World Health Organization guidelines, primary healthcare should offer comprehensive, whole-person care throughout a person's life, focusing not only on specific diseases but also on prevention, treatment, rehabilitation, and palliative care.
In July 2024, the Uttar Pradesh government introduced a new system for assessing and ensuring the quality of Ayushman Arogya Mandirs, including a virtual evaluation and a standard certification system. Patients like Muskaan Ansari, however, were sceptical.
"After my experience, do you think I can expect decent, dedicated care at these centres?" she asked.
(Shubhangi Derhgawen is a freelance journalist based in Delhi, specialising in health, welfare and environmental issues.)
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