Bridging the healthcare divide: Enabling equity in India's public health insurance schemes
Authors: Jaison Joseph1, Hari Sankar D1
1. The George Institute for Global Health, New Delhi, India
Introduction
Paying for medical expenses from their savings pushes many Indian households into poverty or results in foregone care. The Indian government has launched various publicly funded health insurance schemes (PFHIS) to combat this challenge. Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) is the latest such scheme. It is one of the world's largest health insurance schemes, covering 100 million households with a health cover of up to INR 5 lakh (≈US$-5980) per family per year. This covers secondary and tertiary care cashless and paperless hospitalisation through empanelled health facilities. The south Indian state of Kerala rebranded and launched AB-PMJAY as Karunya Arogya Suraksha Padhathi - PMJAY (KASP-PMJAY), which covers 4.2 million families in the state. Of the states implementing AB-PMJAY, Kerala has received the most free treatments for beneficiaries in the last 3 years. While scheme performance metrics show impressive achievements, and the state is repeatedly applauded at the national level, aggregate averages mask inequalities in access and utilisation. This blog delves into the experiences of accessing care through PFHIS and the systemic challenges that remain for Kerala residents in accessing care. The blog provides an overview of solutions by reimagining policies, people and power. Our reflections are based on evidence from a larger health system study conducted in Kerala.
Experience of accessing care through PFHIS
KASP-PMJAY offers over 1,350 medical services (treatment packages) for secondary and tertiary care through empanelled public and private health facilities. Patients can walk in with their KASP-PMJAY card, which is verified biometrically. Once approved, the patient can avail of treatment without any payment at all. The paperless design and portability feature offered by the scheme is intended to help vulnerable populations access healthcare services across India.
By covering the cost of hospitalization and treatments, KASP-PMJAY provides significant financial protection to families; the quantum of funding for acute hospitalisation costs. An elderly male whom we spoke to in our study recollected his experience as follows:
…It (PFHIS) has benefitted me. When I was bedridden, I got around Rs. 3 lakhs from Karunya Scheme. The scheme provides Rs. 5 (≈US$-5980) lakhs in total but they did the treatment under Rs. 3 lakhs (≈US$-3588). Those who were bedridden with me and did not have the card had to pay Rs. 5 lakhs (≈US$-5980)”.
Barriers to accessing care through PFHIS
While many features of the scheme seek to address challenges for disadvantaged populations in the country, several barriers prevent PFHIS from achieving truly equitable access to healthcare for vulnerable populations in Kerala. Many eligible beneficiaries (the poorest 40% of Indian households) remain unaware of PFHIS or do not understand the benefits and processes involved. A great deal of information has been disseminated virtually, gaining momentum post the COVID-19 pandemic. Even though Kerala has some of the highest digital penetration in the country, some populations remain without access to social media or reside in areas with interrupted internet services.
While PFHIS aims to provide nationwide coverage, inter-district geographical disparities in healthcare infrastructure mean that access to quality healthcare is uneven. Rural and remote areas often lack adequate healthcare facilities and empanelled hospitals, forcing people to travel long distances for treatment. The implementation of PFHIS involves complex administrative processes. Complex enrolment (and annual re-enrolment) procedures prevent eligible individuals from accessing benefits in a timely manner. Procedural errors by some healthcare providers, such as wrong blocking of packages and prescribing of unnecessary tests and diagnostics, can undermine the effectiveness of PFHIS and result in paying out of pocket. Such practices drain resources and erode trust in the system, potentially deterring beneficiaries from seeking care. A female member from the Scheduled Caste community in Thiruvananthapuram shared her challenging experiences using PFHIS. She noted:
“I have used the Karunya card for thyroid (treatment), I had to pay Rs. 3000 (≈US$-35.88) to the doctor for the surgery. We were late for 5 days to submit Karunya cards. In total about Rs. 20,000 (≈US$-239.20) expenses were there. They’ll give it only if you are admitted. Excluding the operation expenses… had to pay an expense of Rs. 20,000 (≈US$-239.20) which included food, transportation, and other expenses. Even though this operation was done from a government hospital. Even the medicine prescribed cost Rs. 1500 (≈US$-17.94)”.
Reimagining policies, people and power
• Addressing geographical disparities within the state: Inter-district disparities persist due to variations in health infrastructure, healthcare workforce, and socio-economic conditions of communities. Addressing these disparities through tailored policies and investment in under-resourced areas is crucial for achieving equitable healthcare access in the state. Local self-governments can play a key role in improving access by encouraging the private sector hospitals in their respective jurisdictions to participate in the pro-poor insurance scheme. They can further improve the infrastructure and services in public hospitals governed by them to reduce disparities in access to healthcare.
• Inclusion of missed households: Ensuring that all eligible households are included and continue to stay covered by the PFHIS is critical to ensuring equity. Efforts must be made—with the support of local self-governments, women’s self-help groups and community health workers—to identify and enrol missed households. This is particularly important in marginalised and remote areas, which are often left out of digitally disseminated services. The healthcare system can provide more comprehensive coverage and support vulnerable populations by closing these gaps.
• Empowering beneficiaries and providers: Empowering both beneficiaries and healthcare providers through awareness campaigns, training and support systems is essential. Educating the population about their entitlements and simplifying the claim processes can reduce barriers to access. Similarly, supporting healthcare providers with the necessary resources and clear guidelines can improve service delivery and ensure that the benefits of PFHIS reach those in need more effectively.
Conclusion
PFHIS such as KASP-PMJAY have the potential to transform healthcare access for Kerala’s vulnerable populations. However, realising this potential requires addressing the persistent barriers and reimagining policies and systems. By enhancing awareness, strengthening infrastructure, simplifying processes, ensuring accountability and fostering inclusivity, Kerala can move closer to achieving equitable healthcare access for all. A strong decentralised health governance structure should be leveraged to improve community engagement and tailored approaches to overcoming these barriers. As PFHIS continue to evolve, a combined effort to address these challenges will be crucial in building a more inclusive and equitable healthcare system.
References
The George Institute for Global Health. (n.d.). Assessing equity of universal health coverage in India: From data to decision-making using mixed methods. The George Institute for Global Health. Retrieved August 19, 2024, from https://www.georgeinstitute.org/projects/assessing-equity-of-universal-health-coverage-in-india-from-data-to-decision-making-using
The Hindu. (2023, September 25). Kerala wins Arogya Manthan award for providing free medical care to maximum number of people. https://www.thehindu.com/news/national/kerala/kerala-wins-arogya-manthan-award-for-providing-free-medical-care-to-maximum-number-of-people/article67341892.ece
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Karan, A., Negandhi, H., Nair, R., & Sharma, A. (2021). Empanelment of health care facilities under Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB PM-JAY) in India. PLOS ONE, 16(5), Article e0251814. https://doi.org/10.1371/journal.pone.0251814
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To link to this article - DOI: https://doi.org/10.70253/DDGR7355
Acknowledgements
This work was supported by Wellcome Trust/DBT India Alliance Fellowship (Grant number IA/CPHI/16/1/502653) awarded to Dr. Devaki Nambiar. We are grateful to Dr. Devaki Nambiar for reviewing this blog.
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