Nagrik Dialogue

Healthcare for India’s Poor

In February 2018 the Indian government announced the National Health Protection Scheme or Pradhan Mantri Jan Arogya Yojana (PM-JAY), dubbed by the media as the world’s largest health insurance scheme. Critical to the success of PM-JAY however are the lessons its implementers are willing to learn from the experience of the Rashtriya Swasthya Bima Yojana (RSBY), India’s first nationwide social health insurance scheme. The RSBY was meant to curtail catastrophic out-of-pocket (OOP) expenditure for health care though cashless provision of services and by involving the private sector and increase accessibility to care. While much larger in scale PM-JAY otherwise builds upon the RSBY’s PPP model in several of its aspects, such as scheme design, involvement of the private sector, use of contracts, incentives given and overall administrative structure.

Those in support of the scheme are of the view that RSBY is a success and has expanded the choice available to poor households by allowing them to choose between private and public health-care services. As the scheme is cashless, it has the potential of being relatively corruption free; and more importantly, the poor do not have to make payments upfront. But according to others, the scheme offers limited financial protection, suffers from abuse and cost escalation; and has skewed public resources to curative rather than preventive care. Other criticisms of RSBY relate to inadequate and ineffective awareness campaigns, power inequity among stakeholders, weak governance structure and poor implementation of the scheme. Some studies highlight issues of low enrolment, poor hospitalization, inadequate uptake of the scheme, empanelment and accessibility, as well as increasing out-of-pocket expenditure incurred by beneficiaries.

This book, based on field research, conducted in the states of Punjab and Haryana from 2012-14, aims to evaluate the availability, provision and management of health services under RSBY contracts in order to inform policy makers on how to improve scheme implementation for the BPL beneficiary.
Some of the questions this book attempts to answer include:
• What exactly are the allocated roles and responsibilities of partners, including the incentive structures for different partners since the RSBY’s Public Private Partnership model uses management or service delivery contracts?
• What is the role of external factors in implementation of the program?
• Since insurance companies are among the key stakeholders in RSBY, what are their objectives and the incentives they function under?
• Do the empaneled private sector facilities, engage in ‘cream skimming’, i.e. choose to treat only selected packages, due to cost considerations?
• Does the quality of care differ for RSBY patients from that delivered to non-RSBY patients?

The book is divided in to eight chapters. The first four chapters describe the role of public and private healthcare, healthcare financing and health insurance in India. Chapter five to seven are based on the findings of the field research. Broadly, the themes of the findings are RSBY-context and capacity; contract design; and scheme implementation, utilization and quality of services. The last chapter deals with learnings of RSBY for PM-JAY.
While the design of PM-JAY already indicates those developing it have taken into account some of the strengths and weaknesses of RSBY there are several more significant lessons to be learnt by PM-JAY from the RSBY experience. These include the need to make health apolitical, enforce strong regulations, ensure a proactive role for Government, promote transparency, build trust, strengthen public awareness, and focus on reducing OOP.

It is hoped the detailed research presented in this book will offer important lessons for efficient and effective implementation of the ambitious PM-JAY program and other similar insurance-based models for healthcare services delivery in different parts of the world.

The Author: Sonalini Khatrapal has a bachelors degree in engineering and economics from Cornell University, Masters from Columbia university and PhD from London School of Hygiene and Tropical Medicine.

She has worked with the World Bank in Washington DC and is currently with the Asian Development Bank, Manila. She is an accomplished wildlife photographer and has won several international awards – Sony World Photography award, International Photography award (IPA) and Siena International Photo award.

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Nagrik Dialogue is the face of Nagrik Foundation’s communication skills that comes in the form of a monthly magazine. It will work as a bridge for those working at the grass roots level and those who support them in any form and manner.