Portrait: Dr Nishant Jain, ‘midwife’ of two of the world’s biggest public health insurance schemes
Days before his shift to the Asian Development Bank’s Manila office, Dr Jain shared highlights from his extraordinary career to date. In over 15 years with German development cooperation, he played a key role in India’s development and deployment of two landmark insurance programmes.
As technical advisor, and later Programme Director of the German-supported health programmes in India, Dr Nishant Jain is considered by many as the motor behind Rashtriya Swasthya Bima Yojana (RSBY – ‘National Health Insurance Programme’). Introduced in 2008, it operated in two thirds of the country and covered at its height some 41 million households of poor and informal workers – an estimated 135 million beneficiaries. But just a few years later, in 2018, Dr Jain and his team were again supporting the Government in conception and implementation of an even more ambitious endeavour – the world’s largest government-funded public health insurance programme: Pradhan Mantri Jan Arogya Yojana (PMJAY – ‘Prime Minister’s Health Programme for People’), which provides coverage for inpatient care to over 500 million poor and vulnerable beneficiaries. These schemes have inspired many countries in design of their national health insurance programmes.
Hired straight from India’s prestigious Institute of Management
While finishing his doctorate on health financing and insurance at the prestigious Indian Institute of Management in Ahmedabad, Jain was considering an attractive job offer in finance from a private sector firm when he was contacted by a head-hunter commissioned by the director of the Indian-German health programme who had read some of Jain’s published articles. Jain checked the website of Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ), which implemented the programme on behalf of the German Federal Ministry for Economic Cooperation and Development (BMZ), and found it interesting enough to apply (at the time, GIZ was still Gesellschaft für Technische Zusammenarbeit, GTZ, but this article uses GIZ throughout, for readibility’s sake). ‘It was a very different kind of organisation, and job, than the ones in the private sector that I was familiar with. I was considering joining them for one year. And when I met Dr. Hans Steinmann, the Programme Director, I liked him right away.’
‘One funny thing: The GIZ car that collected me at the hotel on my first day of work was painted all over with bright yellow HIV/AIDS slogans. The driver told me that it had to do with some competition – the kids who won the competition got to paint the car. Here I was, fresh from my management institute, riding through Delhi in a brightly painted car – and I asked myself: “Have I made the right decision?”’ Fortunately, Jain was not discouraged: He and Amit Paliwal (who will now succeed him as programme director) both joined the team days apart in November 2006.
Taking on Germany’s contribution to RSBY as a voluntary extra task – and ‘the rest is history’
‘At the Indian-German programme I immediately liked the people and realised that the work was quite fulfilling.’ Within one year of joining, Jain discovered a promising health insurance concept being piloted under the Ministry of Labour and Employment: RSBY. The problem was that the Indian-German health project’s agreement was with the Ministry of Health and Family Welfare. ‘We had no formal mandate to support the labour ministry. I asked Hans, my boss: “I think this is something very interesting – it could become THE big thing in the country. Could we support it, just at my level?” Hans recognised the opportunity and let me go for it. The rest is history.’
A fortuitous encounter propels Jain to the heart of RSBY
The crucial connection between Jain and the Ministry of Labour came about when the state of Gujarat reached out to GIZ, with questions on the RSBY implementation guideline they had received from the labour ministry. ‘When I saw the guideline I liked the ideas, but also saw that many aspects could be improved. So I re-wrote it and sent it back to the Gujarat government who forwarded the suggested changes to the labour ministry. But they didn’t accept a single change. That was tough. But I didn’t give up.’
After Gujarat, several other states called upon GIZ and Jain to present the scheme on their behalf and support its implementation. At the end of one of these initial workshops, he shared a long car ride to the station with Mr Anil Swarup, Joint Secretary, and head of the RSBY programme at the national Ministry of Labour and Employment. Their train back to Delhi was delayed by three to four hours, Jain recalls: ‘We were in a very small station with nothing to do, so we were just walking and talking about everything – books, health insurance, anything. Mr Swarup said, “You are supporting State Governments so much, why don’t you support at the national level? The impact can be much larger.” I told him that I’d have to check with my boss. And once again Hans said, “Fine.” I discussed with Mr Swarup many things in the guideline which could be further improved. He said, “Why don’t you work with us to revise it?” So I was able to help the Government in making various changes – and the implementation design improved further. RSBY was new and we were learning and improving with experience.’
Shuttling from state to state to keep the momentum
In close collaboration with Anil Swarup, Jain threw himself wholeheartedly into the development and expansion of RSBY.Swarup later wrote about Jain’s role in this formative period of RSBY: ‘He was the one who kept the momentum going, shuttling from one state capital to the other, trying to find solutions to problems (…). Much of the success of the scheme after its launch can be attributed to the small team of GIZ that became an intrinsic part of [the] RSBY movement.’ (Swarup A (2019). Not just a civil servant. New Delhi: Unicorn Books). In one memorable incident, Jain called off his engagement ceremony in his home town to make a crucial presentation at the Ministry in Delhi: ‘My wedding was 30th November, and two days before was the engagement ceremony. But that same day was the first national RSBY workshop in Delhi! I was home on leave for my wedding, but I asked my future wife, “Is it OK if we don’t have an engagement? We’ll still get married in two days.” She understood – credit to her that she agreed! I flew to Delhi, gave my presentation, took part in the discussions and then flew back home and got married!’
Jain kept working with Swarup in a continual process of adjusting and perfecting the scheme. According to Jain, ‘the initial RSBY document had all the elements but was not structured very well, especially in clearly defining the roles of Government and private sector. I wanted to improve it and through a gradual process it happened.’
Reaching across India – and beyond, through the Joint Learning Network
In 2011, what had previously been ‘voluntary’ support by GIZ to the Ministry of Labour by the health sector support programme finally became a dedicated programme supporting RSBY: the Indo-German Social Security Programme. Jain recalls how at the time RSBY was extended to 27 out of 36 states and territories. ‘From 2011 to 2014 was a time of big growth for RSBY – it started very fast. It reached almost the whole country; it was appreciated a lot across the world. I was approached by different countries: “Can you help?” So I’ve worked closely with a few countries in this region and outside.’
‘There were many meetings where I would present on behalf of RSBY, both inside India and outside. There was one such meeting in Geneva in 2009 where they asked me to go. There were three countries invited: Ghana, Thailand and India. We presented and that evening there was a dinner at which we were discussing about why people who spent a few days in a country become ‘experts’ on that country and tell national staff what to do. Why can’t countries learn from each other directly? Others at the dinner were interested including Stefan Nachuk from Rockefeller Foundation. And this later gave rise to the Joint Learning Network for Universal Health Coverage initially supported by Rockefeller Foundation. It’s now a large network with 34 countries. I was a steering group member since inception as GIZ representative.’
A challenging shift to a new ministry – on the road to PM-JAY
By the end of 2013, Anil Swarup had been promoted and moved to another ministry and in 2015, a few months after coming into office the new Indian government decided to transfer RSBY to the Ministry of Health – a massive undertaking. Fortunately, Jain and his team had the crucial institutional memory to support the key staff in the health ministry as they took over all aspects of RSBY administration and implementation.
In 2017, Jain became programme director of the Indo-German Social Security Programme, and shortly thereafter took on a new challenge: the proposed, far larger, PM-JAY scheme. Jain reminisces: ‘Designing the new scheme was like RSBY all over again but at a much bigger scale. With RSBY we had to go sell it to the states – this time the Central Government was completely behind it, and most of the States just agreed: We got all the support that was required. RSBY played a crucial role because it created a foundation structure on which PM-JAY could build. This made PM-JAY much easier to develop. There were lots of learnings from RSBY that we could introduce. And many things in RSBY which couldn’t be done for policy reasons, this time the team could do in PM-JAY. For instance, we had always wanted a separate national level agency to manage RSBY, but the government never agreed. But for PM-JAY, they agreed to create the National Health Authority (NHA) to manage it. There were many small things we learned in RSBY and various State health insurance schemes that we could now build into the new scheme. It’s not always that you get an opportunity to do things twice!.’
Dr Jain’s secrets of success: common sense, patience and opportunity
When asked to reflect on what enabled him to accomplish what would take others several lifetimes, Dr Jain responds with a laugh, ‘It’s basic common sense. One needs to be realistic about what can work. The biggest enemy of good is best. It’s good to aspire for best, but sometimes good is enough and you can get best later.’
‘With the government I learned patience: You need to not be in a hurry to do things, but you do need to think big. If you start small, still think big. So much energy goes into pilots, of course it will work. But think about scaling up right from the start! Sometimes people miss this or learn it too late. I learned it slowly, and built on it.’
‘I was also lucky enough to be in the right time in the right place. If there had been another bureaucrat in the place of Mr Swarup, I don’t know what would have happened with RSBY – the same with the excellent team of PM-JAY colleagues including Dr. Indu Bhushan, Dr. Dinesh Arora, Dr. R.S. Sharma, Dr. Praveen Gedam and Dr. Vipul Agarwal. If you have a great partner and a great team you can accelerate change, even if overall government tends to move slowly. I was fortunate to happen on counterparts who were eager to run as fast or faster than I.’
‘I didn’t want to do the same thing thrice!’
Dr Jain admits that his decision to leave German development cooperation for the Asian Development Bank has surprised many: ‘People say: “Why are you going now when things are going so great? Why now?” And I say: “Why not now?” As an organisation I like GIZ a lot. I could do what I felt was good for the country and the priorities of the partner. There are good opportunities for national personnel to become programme directors or to work outside the country. Now in India there are many national programme directors. At GIZ I had wonderful colleagues, not only in India but across the world and at headquarters. People are open and support each other.’
‘However, from RSBY to PM-JAY I have been redoing the same thing in one way or another. Now government has been talking about expanding PM-JAY further and moving towards Universal Health Coverage – and I have already started thinking and discussing ways and means for that! There were many threes in my life: three Masters degrees, three jobs before Ph.D…. I knew if I stayed I’d be designing the scheme for the third time!’
When Jain came across the opportunity at Asian Development Bank, he felt ready for a change. ‘I’ll be at ADB in Manila working in the South Asia region – in health only. I thought, “It will be a different kind of work – let me try and see if I like it. I shouldn’t feel later on that I didn’t try.” ‘
Dr Jain’s GIZ colleagues wish him well in this new adventure, yet hope his departure is not a farewell, but an ‘Auf Wiedersehen’!
Dr Mary White-Kaba