Agenda Setting and Policy Adoption of India's National Health Insurance Scheme: Rashtriya Swasthya Bima Yojana

Abstract

Rashtriya Swasthya Bima Yojana (RSBY) is India's largest health insurance scheme. Launched in 2007, it now covers over 37 million, mostly poor, families. This massive scheme represents a major departure from past approaches to government support for health care in India. In this article, we use data from key informant interviews, published and unpublished documents, and newspaper reports, applying Kingdon's framework for agenda setting and policy adoption to explain how RSBY became national policy. India's government-operated health care delivery system had consistently failed to meet its most basic objectives-especially for the poor. A variety of previous reform efforts had been unsuccessful. Then, in 2004, the result of the national election was seen by the victors as representing a mandate to address deprivation among those in India's vast unorganized sector. That election also brought to the fore a new set of policy makers who were willing to introduce subsidized health insurance that made extensive use of the private sector. Technological advancements offered the reformers both new options and new experiences on which to base their innovations. A group of policy entrepreneurs, including Congress Party leaders, technocrats, and senior government officials, collaborated with international agencies to develop the RSBY approach, place it on the agenda, and assure its adoption as national policy. This analysis explores factors that made this significant equityoriented health reform possible in India and provides lessons for health reformers in other countries who seek to learn from India's experiences in moving toward universal health coverage. Finally, we suggest some adjustments in Kingdon's framework to help apply his ideas in different contexts.

Why Performance-Based Financing in Chad Failed to Emerge on the National Policy Agenda

“…These processes, in addition to a well-planned transfer of skills and key roles (such as the purchasing function) to governmental bodies, appear to be critical to ensuring full understanding and appropriation of PBF by national actors, thus increasing its odds of being rolled out at scale, as we see from the study on Cameroon by Sieleunou et al 43 The last and fourth lesson is about the use of Kingdon's multiple streams approach 8 in our study. We agree with Shroff et al 34 that this model allows some flexibility and must not be applied mechanically. We successfully used it to understand why a pilot scheme was not able to come onto the national policy agenda.…”

“…Yet, such a commitment is often decisive to put public policies on the agenda. 33,34 This is particularly crucial in a "competitive" environment where many policy options exist to deal with health issues (in line with the Millennium Development Goals and universal health coverage agenda) and where potential policy entrepreneurs have a key role to play in a given policy being adopted to address the identified problem. Indeed, as Kingdon 8(p142) reminds us, "The availability of a viable alternative is not a sufficient condition for a high position on a decision agenda, since many good proposals kick around the system for a long time before the lightning strikes.…”

Setting performance-based financing in the health sector agenda: a case study in Cameroon

“…In Cameroon, having a new pool of technocrats with good communication, lobbying and networking skills as well as important political connections in the MoPH, as the lead in policy development served as an important factor in opening windows of opportunity towards the introduction of the PBF program onto the national agenda. Strategies and actions of particular policy entrepreneurs, principally leaders who can change the distribution of power to facilitate reform, are at the heart of successful health reform [ 87 ]. In other words, health reform leadership requires political ability and judgment, in addition to political motivation and commitment.…”

“…However, we also concur with Shroff et al . that the Kingdon’s framework does not permit the analysis of the boundaries and the relative importance of each of the three streams [ 87 ]. For example, the engagement to meet MDGs played a role in both the politics and problem streams.…”

Towards universal health coverage in India: a historical examination of the genesis of Rashtriya Swasthya Bima Yojana – The health insurance scheme for low-income groups

“…12 Domestic policy priorities were heavily centred on economic development and RSBY was considered a social investment for improving worker efficiency and the country's economic growth prospects e hence, an economic rather than a human development imperative.…”