Government-run medical schemes are designed to expand healthcare access for those who cannot afford costly treatments. In the region of Vidarbha, several such schemes have been implemented with the aim of making hospital care affordable and accessible for families living with economic challenges.

These schemes cover a range of services from catastrophic health events to maternal care and institutional deliveries. The implementation of these programmes involves coordination between state health departments, hospitals, and administrative authorities to ensure the intended benefits reach eligible beneficiaries.

However, gaps between policy intent and implementation realities have produced significant challenges in parts of Vidarbha.

1. Ayushman Bharat–Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) in Nagpur District

The Ayushman Bharat–Pradhan Mantri Jan Arogya Yojana is a federally supported health insurance scheme that provides coverage of up to ₹5 lakhs per family per year for secondary and tertiary hospitalisation to millions of economically vulnerable families. Under this scheme, eligible beneficiaries are entitled to cashless treatment in empanelled hospitals without upfront payments for covered services.

In the Nagpur district of Vidarbha, Right to Information data disclosed that between July 2012 and April 2025, nearly 90 cases of treatment denial under this scheme had been recorded. The information revealed that 24 hospitals in the district were issued notices for allegedly refusing to provide free treatment to eligible patients, prompting disciplinary action from the state health department. These actions included suspending some hospitals and de-enrolling others from the scheme, ending their association with AB-PMJAY. The denial of treatment occurred despite the entitlement of beneficiaries to receive covered care at participating facilities, indicating a gap between scheme entitlements and actual service delivery. Reports also noted that outstanding government reimbursements to hospitals may have discouraged participation in the scheme, potentially contributing to refusals of free care. While thousands of patients did benefit from the scheme in the same period, these recorded instances of denial highlight significant implementation issues in parts of Vidarbha.

In the context of the Nagpur experience, the challenges extended beyond simple administrative paperwork. The failure to ensure that all empanelled hospitals adhered to the scheme terms meant that some families faced sudden out-of-pocket payments or were turned away at critical moments of care. This discord between policy design and on-ground delivery undermined the promise of cashless, accessible treatment for the most vulnerable households in the region. The issue is symptomatic of broader systemic problems where entitlement alone does not guarantee actual access to services. The scheduled coverage under AB-PMJAY is substantial, but without consistent enforcement of compliance among healthcare providers, families seeking urgent or planned care may not obtain the support they are legally due.

The case from Nagpur further illustrates that even well-funded schemes with broad eligibility parameters can suffer failures when front-line delivery mechanisms break down. Patients dependent on these schemes typically lack the financial margin to seek alternative care, making such failures particularly consequential in economically distressed areas. The pattern observed in Nagpur adds to concerns about the practical accessibility of coverage promised under large public health insurance schemes when provider compliance is inconsistent.

The data from the Right to Information application also highlighted the proportion of denials occurring in private facilities compared to government-run hospitals, indicating that the challenge of adherence was not limited to one category of provider. Thus, the failure was not merely a matter of isolated incidents but pointed to a broader issue of regulatory and enforcement gaps.

Despite the scheme’s objective and scale, these recorded setbacks in Nagpur show that structural and administrative obstacles can undercut intended benefits. They also illustrate the importance of active oversight mechanisms to ensure that the stated entitlements of a health insurance programme translate into real care for beneficiaries.

The presence of denied cases over an extensive time period suggests that patient experiences under the scheme varied widely, and that the programme’s success in one dimension, enrolment figures and coverage limits, did not necessarily guarantee universal service delivery. In a region like Vidarbha, where many households are economically disadvantaged, such failures have concrete implications for health outcomes and financial stability.

2. Mahatma Jyotiba Phule Jan Arogya Yojana (MJPJAY) Panel Hospital Failures in Nagpur

The Mahatma Jyotiba Phule Jan Arogya Yojana was a state-level health assurance scheme in Maharashtra intended to offer cashless diagnosis and treatment procedures at empanelled hospitals with government reimbursement. Under this programme, participating hospitals were expected to provide all listed diagnostic and treatment procedures free of cost to beneficiaries, with the government reimbursing the costs to the hospitals afterwards. In August 2018, the state government removed five hospitals in Nagpur from the panel of MJPJAY for allegedly engaging in financial improprieties.

The action was taken on the grounds that these hospitals had collected money from patients for procedures that were supposed to be covered by the scheme, and at the same time claimed reimbursement from the government. Reports from that period show that the de-empanelment was described as part of a wider state exercise to enforce compliance with scheme norms, and that hospitals contested the allegations. The hospitals argued that complaints against them were fabricated or that grievances had not been adequately resolved before action was taken.

The de-empanelment illustrated a significant breach of the terms of the MJPJAY scheme delivery model. In principle, beneficiaries registered under the scheme should receive covered diagnostic and treatment procedures without incurring direct charges at the point of care. However, the fact that certain hospitals allegedly extracted payments directly from patients while also claiming government funds indicated a misuse of scheme provisions. Since cashless service at empanelled facilities is a central pillar of these schemes, any instance where patients are required to pay out of pocket contradicts the core objective of the programme.

This failure was formally recorded with the removal of these hospitals from the scheme network, which effectively signalled a breakdown in trust between the administering authorities and the institutions responsible for service delivery. While the action taken in 2018 cannot be taken as a full assessment of long-term outcomes, it does show concrete evidence that, in practice, the scheme’s protections were circumvented in at least some facilities. The incident underscores how governance and compliance issues at the provider level can undermine the effectiveness of a state-run health insurance programme in areas like Vidarbha.

The episode also demonstrated that regulatory oversight and enforcement play critical roles in whether beneficiaries can fully access entitled services. When hospitals, for whatever reason, do not adhere to financial or procedural norms associated with a scheme, the gap between programme design and beneficiary experience widens. Removing hospitals from the panel under such circumstances is one form of corrective action, but the incident itself marks a failure in protecting the interests of the scheme’s target population.

This case stands as an example of how implementation challenges at the institutional level can erode the operational integrity of a government health scheme. Even with clearly articulated coverage and reimbursement structures, deviations in execution by participating providers can disrupt intended service flows and financial protections for patients. The MJPJAY experience of de-empanelment in Nagpur highlights such a disruption affecting care pathways in the region.

Failures of this nature, captured through documented panel removals, provide concrete instances where the design of a scheme did not align with service realities. As health schemes evolve over time, these documented episodes serve as markers of implementation hurdles that require clear examination separate from policy intent.

In regions like Vidarbha, where public healthcare infrastructure is supplemented by such insurance programmes to broaden access, weaknesses in enforcement can therefore significantly affect beneficiary experience. The removal of hospitals from the panel, and the reasons for that removal, illustrate the tangible consequences of compliance failures.

3. Janani Shishu Suraksha Karyakram (JSSK) Delay in Gadchiroli

The Janani Shishu Suraksha Karyakram is a national health mission scheme intended to eliminate out-of-pocket expenses for pregnant women and infants up to one year of age. Under the programme, participating public health facilities are required to provide free delivery care, diagnostics, drugs, food, transport, and referral services to ensure maternal and neonatal health without financial barriers. In the tribal district of Gadchiroli in Vidarbha, local reports documented cases where mothers did not receive the entitled benefits in a timely manner.

Specifically, some women who underwent procedures as part of maternity and family welfare programmes waited two to two and a half months before availing the financial or service benefits due to administrative delays at primary health centre levels. Such delays in benefit disbursal significantly affect beneficiaries who depend on immediate support for post-delivery care, transport costs, and associated services that JSSK is meant to cover. Reports from the region highlighted that these delays occurred in remote parts of the district where logistical and administrative constraints are more pronounced, and where the immediate availability of benefits is critical to maternal and infant health outcomes. The purpose of JSSK is to reduce maternal and neonatal mortality by providing free and timely care, yet delayed benefit receipt undermines the programme’s operational logic in these circumstances.

The delays in availing benefits, as reported, show a divergence between scheme entitlements and the actual administrative execution at local health facilities. Since these benefits are intended to support mothers and infants at and following delivery without cost barriers, any delay increases the financial stress on families and can deter utilisation of institutional services, contrary to the scheme’s objective.

In contexts such as Gadchiroli, where geography and resource limitations pose additional challenges, the practical delivery of entitlements under JSSK is essential to maternal and neonatal care pathways. Administrative delays, therefore, represent a concrete implementation failure impacting the population that the scheme is designed to serve.

Such documentation of delayed benefits also underscores the importance of robust administrative processes and monitoring at the Primary Health Centre level and above, particularly for schemes that provide time-sensitive support. In these cases, beneficiaries dependent on immediate assistance rather than post-hoc reimbursement face real barriers to accessing the full scope of services for which they are eligible under the scheme.

The reported delays in Gadchiroli point to hurdles that can arise in implementing broad national health programmes in remote and tribal regions. By focusing on specific disadvantages faced by mothers awaiting benefits, the case exemplifies how logistical and administrative inefficiencies weaken scheme effects in parts of Vidarbha.

The experiences of these three medical schemes in Vidarbha reveal consistent themes about the difficulty of translating well-intentioned health policy into reliable on-ground outcomes. Across cashless insurance programmes and maternal care provisions, recorded failures in treatment denial, improper financial practices by participating hospitals, and delayed benefit delivery underscore the recurring gap between entitlement and execution. These documented instances highlight the importance of not only policy design but also robust mechanisms for monitoring, enforcement, and timely administrative action.

They stand as concrete evidence of implementation challenges encountered by vulnerable populations relying on government-run healthcare programmes. Such documented failures in Vidarbha add to the broader understanding of how healthcare delivery mechanisms function in diverse regional contexts and stress the necessity for clear administrative follow-through. By reviewing these cases together, a pattern of operational difficulties emerges, offering a grounded view of where schemes have fallen short in practice. For readers seeking factual insights into the functioning of government medical programmes in the region, these instances provide specific, verifiable illustrations of where policy did not match practice.