Experiences and challenges in accessing hospitalization in a government-funded health insurance scheme: Evidence from early implementation of Pradhan Mantri Jan Aarogya Yojana (PM-JAY) in India

PLoS One. 2022 May 12;17(5):e0266798. doi: 10.1371/journal.pone.0266798. eCollection 2022.

Abstract

Introduction: Government-sponsored health insurance schemes can play an important role in improving the reach of healthcare services. Launched in 2018 in India, Pradhan Mantri Jan Aarogya Yojana (PM-JAY) is one of the world's largest government-sponsored health insurance schemes. The objective of this study is to understand beneficiaries' experience of availing healthcare services at the empaneled hospitals in PM-JAY. This study examines the responsiveness of PM-JAY by measuring the prompt attention in service delivery, and access to information by the beneficiaries; financial burden experienced by the beneficiaries; and beneficiary's satisfaction with the experience of hospitalization under PMJAY and its determinants.

Methods: The study was conducted during March-August 2019. Data were obtained through a survey conducted with 200 PM-JAY beneficiaries (or their caregivers) in the Indian states of Gujarat and Madhya Pradesh. The study population comprised of patients who received healthcare services at 14 study hospitals in April 2019. Prompt attention was measured in the form of a) effectiveness of helpdesk, and b) time taken at different stages of hospitalization and discharge events. Access to information by the beneficiaries was measured using the frequency and purpose of text messages and phone calls from the scheme authorities to the beneficiaries. The financial burden was measured in terms of the incidence and magnitude of out-of-pocket payments made by the beneficiaries separate from the cashless payment provided to hospitals by PMJAY. Beneficiaries' satisfaction was measured on a five-point Likert scale.

Results: Socio-economically weaker sections of the society are availing healthcare services under PM-JAY. In Gujarat, the majority of the beneficiaries were made aware of the scheme by the government official channels. In Madhya Pradesh, the majority of the beneficiaries got to know about the scheme from informal sources. For most of the elements of prompt attention, access to information, and beneficiaries' satisfaction, hospitals in Gujarat performed significantly better than the hospitals in Madhya Pradesh. Similarly, for most of the elements of prompt attention, access to information, and beneficiaries' satisfaction, public hospitals performed significantly better than private hospitals. Incidence and magnitude of out-of-pocket payments were significantly higher in Madhya Pradesh as compared to Gujarat, and in private hospitals as compared to the public hospitals.

Conclusion: There is a need to focus on Information, Education, and Communication (IEC) activities for PM-JAY, especially in Madhya Pradesh. Capacity-building efforts need to be prioritized for private hospitals as compared to public hospitals, and for Madhya Pradesh as compared to Gujarat. There is a need to focus on enhancing the responsiveness of the scheme, and timely exchange of information with beneficiaries. There is also an urgent need for measures aimed at reducing the out-of-pocket payments made by the beneficiaries.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Government
  • Health Services Accessibility*
  • Hospitalization
  • Hospitals, Private
  • Humans
  • India
  • Insurance, Health*

Grant support

The research was made possible through the financial support provided by the World Health Organization. This included support from the Alliance for Health Policy and Systems Research, WHO Geneva as well as from the WHO Country Office, India under grant numbers 68345 (WHO, Geneva) and 67378 (WHO, India). Support was provided under the research program titled- Health Systems Research for PM-JAY: Improving hospital-based processes for effective implementation. The grant was received by Prof. Dileep Mavalankar, Prof. Mayur Trivedi, and Prof. Anurag Saxena of the Indian Institute of Public Health Gandhinagar. The grant period was 4 March to 3 September 2019. The URL of the funder is www.who.int. Dr. Zubin Shroff of WHO provided guidance in strengthening the methodology and finalizing the instruments, and reviewed the manuscript critically.