A step closer towards achieving universal health coverage: the role of gender in enrolment in health insurance in India.

BACKGROUND: There is limited understanding of how universal health coverage (UHC) schemes such as publicly-funded health insurance (PFHI) benefit women as compared to men. Many of these schemes are gender-neutral in design but given the existing gender inequalities in many societies, their benefits may not be similar for women and men. We contribute to the evidence by conducting a gender analysis of the enrolment of individuals and households in India's national PFHI scheme, Rashtriya Swasthya Bima Yojana (RSBY). METHODS: We used data from a cross-sectional household survey on RSBY eligible families across eight Indian states and studied different outcome variables at both the individual and household levels to compare enrolment among women and men. We applied multivariate logistic regressions and controlled for several demographic and socio-economic characteristics. RESULTS: At the individual level, the analysis revealed no substantial differences in enrolment between men and women. Only in one state were women more likely to be enrolled in RSBY than men (AOR: 2.66, 95% CI: 1.32-5.38), and this pattern was linked to their status in the household. At the household level, analyses revealed that female-headed households had a higher likelihood to be enrolled (AOR: 1.36, 95% CI: 1.14-1.62), but not necessarily to have all household members enrolled. CONCLUSION: Findings are surprising in light of India's well-documented gender bias, permeating different aspects of society, and are most likely an indication of success in designing a policy that did not favour participation by men above women, by mandating spouse enrolment and securing enrolment of up to five family members. Higher enrolment rates among female-headed households are also an indication of women's preferences for investments in health, in the context of a conducive policy environment. Further analyses are needed to examine if once enrolled, women also make use of the scheme benefits to the same extent as men do. India is called upon to capitalise on the achievements of RSBY and apply them to newer schemes such as PM-JAY.

Implementation of PM-JAY in India: a qualitative study exploring the role of competency, organizational and leadership drivers shaping early roll-out of publicly funded health insurance in three Indian states.

BACKGROUND: The Pradhan Mantri Jan Arogya Yojana (PM-JAY), a publicly funded health insurance scheme, was launched in India in September 2018 to provide financial access to health services for poor Indians. PM-JAY design enables state-level program adaptations to facilitate implementation in a decentralized health implementation space. This study examines the competency, organizational, and leadership approaches affecting PM-JAY implementation in three contextually different Indian states. METHODS: We used a framework on implementation drivers (competency, organizational, and leadership) to understand factors facilitating or hampering implementation experiences in three PM-JAY models: third-party administrator in Uttar Pradesh, insurance in Chhattisgarh, and hybrid in Tamil Nadu. We adopted a qualitative exploratory approach and conducted 92 interviews with national, state, district, and hospital stakeholders involved in program design and implementation in Delhi, three state capitals, and two anonymized districts in each state, between February and April 2019. We used a deductive approach to content analysis and interpreted coded material to identify linkages between organizational features, drivers, and contextual elements affecting implementation. RESULTS AND CONCLUSION: PM-JAY guideline flexibilities enabled implementation in very different states through state-adapted implementation models. These models utilized contextually relevant adaptations for staff and facility competencies and organizational and facilitative administration, which had considerable scope for improvement in terms of recruitment, competency development, programmatic implementation support, and rationalizing the joint needs of the program and implementers. Adaptations also created structural barriers in staff interactions and challenged implicit power asymmetries and organizational culture, indicating a need for aligning staff hierarchies and incentive structures. At the same time, specific adaptations such as decentralizing staff selection and task shifting (all models); sharing of claims processing between the insurer and state agency (insurance and hybrid model); and using stringent empanelment, accreditation, monitoring, and benchmarking criteria for performance assessment, and reserving secondary care benefit packages for public hospitals (both in the hybrid model) contributed to successful implementation. Contextual elements such as institutional memory of previous schemes and underlying state capacities influenced all aspects of implementation, including leadership styles and autonomy. These variations make comparisons across models difficult, yet highlight constraints and opportunities for cross-learning and optimizing implementation to achieve universal health coverage in decentralized contexts.

Awareness of India's national health insurance scheme (PM-JAY): a cross-sectional study across six states.

The literature suggests that a first barrier towards accessing benefits of health insurance in low- and middle-income countries is lack of awareness of one's benefits. Yet, across settings and emerging schemes, limited scientific evidence is available on levels of awareness and their determinants. To fill this gap, we assessed socio-demographic and economic determinants of beneficiaries' awareness of the Pradhan Mantri Jan Arogya Yojana (PM-JAY), the national health insurance scheme launched in India in 2018, and their awareness of own eligibility. We relied on cross-sectional household (HH) survey data collected in six Indian states between 2019 and 2020. Representative data of HHs eligible for PM-JAY from 11 618 respondents (an adult representative from each surveyed HH) were used. We used descriptive statistics and multivariable logistic regression models to explore the association between awareness of PM-JAY and of one's own eligibility and socio-economic and demographic characteristics. About 62% of respondents were aware of PM-JAY, and among the aware, 78% knew that they were eligible for the scheme. Regression analysis confirmed that older respondents with a higher educational level and salaried jobs were more likely to know about PM-JAY. Awareness was lower among respondents from Meghalaya and Tamil Nadu. Respondents from Other Backward Classes, of wealthier socio-economic status or from Meghalaya or Gujarat were more likely to be aware of their eligibility status. Respondents from Chhattisgarh were less likely to know about their eligibility. Our study confirms that while more than half of the eligible population was aware of PM-JAY, considerable efforts are needed to achieve universal awareness. Socio-economic gradients confirm that the more marginalized are still less aware. We recommend implementing tailored, state-specific information dissemination approaches focusing on knowledge of specific scheme features to empower beneficiaries to demand their entitled services.

Everyday capabilities were a path to resilience during COVID-19: a case study of five countries.

COVID-19 demanded urgent responses by all countries, with wide variations in the scope and sustainability of those responses. Scholarship on resilience has increasingly emphasized relational considerations such as norms and power and how they influence health systems' responses to evolving challenges. In this study, we explored what influenced countries' national pandemic responses over time considering a country's capacity to test for COVID-19. To identify countries for inclusion, we used daily reports of COVID-19 cases and testing from 184 countries between 21st January 2020 and 31st December 2020. Countries reporting test data consistently and for at least 105 days were included, yielding a sample of 52 countries. We then sampled five countries representing different geographies, income levels and governance structures (Belgium, Ethiopia, India, Israel and Peru) and conducted semi-structured key informant interviews with stakeholders working in, or deeply familiar with, national responses. Across these five countries, we found that existing health systems capacities and political leadership determined how responses unfolded, while emergency plans or pandemic preparedness documents were not fit-for-purpose. While all five countries were successful at reducing COVID-19 infections at a specific moment in the pandemic, political economy factors complicated the ability to sustain responses, with all countries experiencing larger waves of the virus in 2021 or 2022. Our findings emphasize the continued importance of foundational public health and health systems capacities, bolstered by clear leadership and multisectoral coordination functions. Even in settings with high-level political leadership and a strong multisectoral response, informants wished that they-and their country's health system-were more prepared to address the pandemic and maintain an effective response over time. Our findings challenge emergency preparedness as the dominant frame in pandemic preparedness and call for a continued emphasis on health systems strengthening to respond to future health shocks and a pandemic moving to endemic status.

Mixed and Multi-Methods Protocol to Evaluate Implementation Processes and Early Effects of the Pradhan Mantri Jan Arogya Yojana Scheme in Seven Indian States.

In September 2018, India launched Pradhan Mantri Jan Arogya Yojana (PM-JAY), a nationally implemented government-funded health insurance scheme to improve access to quality inpatient care, increase financial protection, and reduce unmet need for the most vulnerable population groups. This protocol describes the methodology adopted to evaluate implementation processes and early effects of PM-JAY in seven Indian states. The study adopts a mixed and multi-methods concurrent triangulation design including three components: 1. demand-side household study, including a structured survey and qualitative elements, to quantify and understand PM-JAY reach and its effect on insurance awareness, health service utilization, and financial protection; 2. supply-side hospital-based survey encompassing both quantitative and qualitative elements to assess the effect of PM-JAY on quality of service delivery and to explore healthcare providers' experiences with scheme implementation; and 3. process documentation to examine implementation processes in selected states transitioning from either no or prior health insurance to PM-JAY. Descriptive statistics and quasi-experimental methods will be used to analyze quantitative data, while thematic analysis will be used to analyze qualitative data. The study design presented represents the first effort to jointly evaluate implementation processes and early effects of the largest government-funded health insurance scheme ever launched in India.

Work status and health of women: a comparative study of northern and southern states of rural India.

The paper examines the net effect of work status on women's health and whether the effect persists after controlling for the influence of socio-economic factors. Our hypothesis is that working women face a greater risk of morbidity and mortality, given that most would be expected to shoulder dual responsibilities: market and household. The paper also examines whether the risk varies across regions. In particular, we examine whether the work status-health relationship differs between the southern and northern regions of India, which are known to be distinct in female autonomy. While women in India face many serious health concerns, this analysis focuses on only two issues: nutritional status (as measured by body mass index and prevalence of anemia) and reproductive health (as assessed by the presence of reproductive health problems) of women from villages in the study area. Results show that though both work status and socio-economic factors influence health status, the latter are more important; most of the gross effect of work status is due to socio-economic conditions rather than work participation. This calls for policy intervention in providing better health facilities, female education and supplementary nutrition programs for poor women.