Performance of India’s national publicly funded health insurance scheme, Pradhan Mantri Jan Arogaya Yojana (PMJAY), in improving access and financial protection for hospital care: findings from household surveys in Chhattisgarh state

Abstract

Background:A national Publicly Funded Health Insurance (PFHI) scheme called Pradhan Mantri Jan Arogaya Yojana (PMJAY) was launched by government of India in 2018. PMJAY seeks to cover 500 million persons with an annual cover of around 7000 USD per household. PMJAY claims to be the largest government funded health scheme globally and has attracted an international debate as a policy for Universal Health Coverage. India’s decade-long experience of the earlier national and state-specific PFHI schemes had shown poor effectiveness in financial protection. Most states in India have completed a year of implementation of PMJAY but no evaluations are available of this important scheme.Methods:The study was designed to find out the effect of enrolment under PMJAY in improving utilisation of hospital services and financial protection in Chhattisgarh which has been a leading state in implementing PFHI in terms of enrolment and claims. The study analyses three repeated cross-sections. Two of the cross-sections are from National Sample Survey (NSS) health rounds – year 2004 when there was no PFHI and 2014 when the older PFHI scheme was in operation. Primary data was collected in 2019-end to cover the first year of PMJAY implementation and it formed the third cross-section. Multivariate analysis was carried out. In addition, Propensity Score Matching and Instrumental Variable method were applied to address the selection problem in insurance.Results:Enrollment under PMJAY or other PFHI schemes did not increase utilisation of hospital-care in Chhattisgarh. Out of Pocket Expenditure (OOPE) and incidence of Catastrophic Health Expenditure did not decrease with enrollment under PMJAY or other PFHI schemes. The size of OOPE was significantly greater for utilisation in private sector, irrespective of enrollment under PMJAY.Conclusion:PMJAY provided substantially larger vertical cover than earlier PFHI schemes in India but it has not been able to improve access or financial protection so far in the state. Though PMJAY is a relatively new scheme, the persistent failure of PFHI schemes over a decade raises doubts about suitability of publicly funded purchasing from private providers in the Indian context. Further research is recommended on such policies in LMIC contexts.

Using an equity-based framework for evaluating publicly funded health insurance programmes as an instrument of UHC in Chhattisgarh State, India

“…Mechanisms such as the biometric smart card, billing systems, and data reporting and sharing have not delivered on their promises nor led to greater accountability. More recent studies have indicated that these problems continue under the PMJAY [135]. Provider capture remains a central issue in the performance of PFHI-based policies to achieve UHC in the Indian context [136].…”

Analysis of the Effect of Serious Illness Medical Insurance on Relieving the Economic Burden of Rural Residents in China: A Case Study in Jinzhai County

“…The stated objectives of PMJAY are to reduce the nancial burden on poor and vulnerable groups for access to quality health services. However, the out-of-pocket expenditure and incidence of catastrophic health expenditure did not decrease with enrollment under PMJAY or other PFHI Schemes [16]. In the US, the We also found that SIMIS reduced OMISPR at the break point, and the treatment effect value was -0.0016, with self-payment decreasing by about 1.6%.…”

Analysis of the effect of serious illness medical insurance on relieving the economic burden of rural residents in China: a case study in Jinzhai County

“…The stated objectives of PMJAY are to reduce the financial burden on poor and vulnerable groups for access to quality health services. However, the out-of-pocket expenditure and incidence of catastrophic health expenditure did not decrease with enrollment under PMJAY or other PFHI Schemes [16]. In the US, the Affordable Care Act (ACA) sought to protect families from high and rising health care expenditures by expanding health insurance coverage through the Medicaid program and reducing underinsurance through various avenues.…”