Research into the implementation of India’s PM-JAY generates wealth of learning
Researchers and development practitioners reflect on learnings from comprehensive research, commissioned by the Indo-German Social Security Programme, examining the implementation and impact of the world’s largest health insurance scheme.
When the opportunity came up to tender for accompanying research into PM-JAY, India’s national health insurance scheme, Germany-based academic Prof. Dr. Manuela De Allegri from the Heidelberg Institute of Global Health immediately jumped at the chance.
She and three fellow academics – Dr. Christoph Strupat, Senior Researcher at the German Institute of Development and Sustainability (IDOS); Dr. Divya Parmar, Senior Lecturer at King’s Centre for Global Health and Health Partnerships, King’s College London; and Dr. Swati Srivastava, Research Scientist at the Heidelberg Institute of Global Health – had long dreamed of jointly researching social protection in India. They knew such research would yield rich learnings, both for other countries wanting to give their citizens Universal Health Coverage and for development practitioners wanting to understand where best to focus their efforts.
Prof. De Allegri says:
This was a dream in a drawer. We were four people just looking for an opportunity to work together on social health protection in India.Prof. Manuela De Allegri, Heidelberg Institute of Global Health
Together, they put together a winning consortium including Indian partners IQVIA and Nielsen, with each party bringing different expertise to the table including in supply chain, population studies, sampling, field work and economic expertise. In the autumn of 2018, after an international tendering process, the team signed a contract with the Indo-German Social Security Programme, implemented by Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) on behalf of the German Federal Ministry for Economic Development and Cooperation (BMZ). This contract included permission from the Indian government and GIZ for Prof. De Allegri and her colleagues to use the wealth of data collected under the study for both the project deliverables (reports, policy and technical briefs) and for their own independent academic research.
In January 2019, the team began work, starting with a five-day introductory workshop in New Delhi to refine the study objectives in consultation with local policy stakeholders.
The birth of PM-JAY
Pradhan Mantri Jan Arogya Yojana (PM-JAY) or ‘ModiCare’ as it’s known colloquially was launched in September 2018 as part of the Ayushman Bharat (‘Long Live India’) initiative. It replaced the previous Rashtriya Swasthya Bima Yojana (RSBY) health insurance scheme which was introduced in 2008. The aim of PM-JAY was to improve publicly-funded health protection, giving 500 million poor and vulnerable beneficiaries coverage for secondary and tertiary health care. Under the scheme, eligible households enjoy cashless access to inpatient healthcare services provided by private or public hospitals up to a limit of 500,000 rupees per family per year (the equivalent of €6,000). To date, the scheme has been adopted by 29 states and seven union territories in India.
Health financing experts of the current Indo-German cooperation projects and its predecessor projects helped design and implement both RSBY and PM-JAY, translating international expertise into the local context and providing a wide range of flexible technical assistance.
How the research project came about and why it was commissioned
Before PM-JAY was introduced, the Indian government, with German support, commissioned local agencies to carry out a baseline research study looking at, in particular, out-of-pocket expenditure by beneficiaries and the quality of service delivery in selected secondary and tertiary hospitals.
The Indian government was hopeful that just one year after launching PM-JAY, further research would be able to show that the scheme had already led to considerable improvements in health coverage, so helping it to make a strong case for deepening reform. Dr Nishant Jain, the then programme director of the Indo-German Social Security Programme, was keen to help the government realise this ambition. Known as the midwife of both RSBY and PM-JAY, Dr Jain is a strong believer in the value of academic research to generate continuous learning in health policy development. He therefore proposed to BMZ to use approx. €1.5 million of existing programme funds for this research, which BMZ approved.
Dr Jain says: ‘At the time, there was uncertainty about the future of the Indo-German development cooperation programme. But the feeling was that if good analysis and research was carried out then, whatever happened, the knowledge generated would remain, and would show the impact and change caused by PM-JAY.’
We worked in partnership with the Indian government right from the start. This was important because it meant they supported the research and owned the results.Dr Nishant Jain, former programme director of the Indo-German Social Security Programme
What the research activities covered
The planned research activities used a mixed-method approach integrating qualitative and quantitative methods of data collection and analysis.
There were four distinct but highly interrelated components to the study:
- a systematic review of social health insurance systems in South Asia with a particular focus on India
- a process documentation describing the sequence of events that led to the implementation of PM-JAY
- a household survey based on a sample of 16,000 households to determine the impact of the scheme on people’s use of healthcare and their health expenditure
- a hospital survey based on a sample of 168 hospitals in eight states to assess the impact of insurance on the delivery of healthcare services.
Implementation – everything went smoothly until Covid struck
Everything went smoothly with the implementation of the research until the COVID-19 pandemic struck in early 2020. The timeline for the study was extended multiple times due to pandemic related issues but when the research team realised they would not be able to complete the small amount of outstanding field work, they called it a day and prepared their project deliverables, submitting these by the end of 2020.
Once they had completed the commissioned study reports and policy briefs, the research team was keen to communicate their findings to the new managers of PM-JAY before publishing any academic papers. However, the significant impact of the pandemic in India meant that, understandably, the priorities and focus of the government had shifted. As a result, it took longer for the reports to be approved than would otherwise have been the case.
Key learnings from the project set-up and implementation
Looking back, the research team attributes much of the successful set-up and smooth implementation of the project to the contacts and local knowledge of the long-standing Indo-German development cooperation team led by Dr Jain. From the start, considerable effort was made to ensure buy-in not just from the Government but also from the eight selected states and the National Health Agency (later renamed as the National Health Authority). For example, official letters were sent by the Government of India to the states informing them that a research study into PM-JAY was being conducted jointly by the Indian Government and GIZ. This was followed up by specific letters, discussions and visits to the states.
Dr Jain says:
To get better buy-in from the states, we prepared individual reports for them so that the research would be useful for them. This was an incentive for them to cooperate as they knew they’d be getting something concrete and useful out of it.Dr Nishant Jain, former programme director of the Indo-German Social Security Programme
Local development cooperation advisors also set up the policy interviews in the states, drawing on existing trusted relationships to open doors and facilitate the interviews.
Prof. De Allegri says: ‘Each state in India runs its own insurance agency and within each state each district does its own thing within the broader scheme guidelines. So in many ways it was like working in eight different countries, for example interviewing people in Italy one day, the UK the next and Sweden the day after.
Single people make the difference and make things possible in the very complex world of India. We had two people – Dr Nishant Jain and his team member Sharmishtha Basu– who really understood research. This helped a lot.Prof. Manuela De Allegri, Heidelberg Institute of Global Health
Dr Jain agrees that the mix of international and local skills was critical to the success of the project. He says: ‘I feel sure that if Manuela and her team had had to do this on their own without an Indian partner, it would have been more challenging for them.
‘At the same time, she and her team brought international expertise, best practice and real academic rigour to the project.’
Reflecting on what he would have done differently if he were starting again, Dr Jain comments that in hindsight the household questionnaire used in the data collection should have been pre-tested in several locations. He says: ‘We did pre-test it but only in one location. When the questionnaire was implemented, there were varying interpretations of some questions because of different cultural contexts.’
Dr Jain also highlights the importance of building a large buffer into data sets so the desired sample size is achieved and the value of a mixed-method approach.
He says: ‘Many issues don’t come out very clearly from quantitative research. A lot of nuances came from the qualitative research so my advice would be “Don’t only do quantitative research.” Mixed method research is very important and becoming more so.’
The research findings
To date, in addition to the policy briefs prepared for India’s National Health Authority, five academic papers have been published by the research team in specialist publications. These are:
- The research protocol: Mixed and Multi-Methods Protocol to Evaluate Implementation Processes and Early Effects of the Pradhan Mantri Jan Arogya Yojana Scheme in Seven Indian States
- Study on awareness: Awareness of India’s national health insurance scheme (PM-JAY): a cross-sectional study across six states
- Study on hospitalizations, direct payments: Effects of the Indian National Health Insurance Scheme (PM-JAY) on Hospitalizations, Out-of-pocket Expenditures and Catastrophic Expenditures
- The genesis of the PM-JAY health insurance scheme in India: technical and political elements influencing a national reform towards universal health coverage
- 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
Commenting on the key findings, Dr. Strupat says the research showed that PM-JAY had led to a significant reduction of 13% in Out-of-Pocket Expenditure (OOPE) and of 21% in Catastrophic Health Expenditure (CHE). However, this improvement was driven by hospitalisations in private healthcare facilities rather than public hospitals, which implied that PM-JAY had shifted use from public to private hospitalisations. Dr. Strupat adds that the research also revealed a lack of awareness of the scheme. Only 62% of the eligible respondents were aware of the scheme, a situation attributed to the scheme’s relative newness at the time.
Lack of awareness is one of the biggest barriers to utilisation of health insurance schemes. If people aren’t aware of their rights, then they can’t take up the benefits.Dr. Christoph Strupat, Senior Researcher, IDOS
How the research findings are translating into policy and practice on the ground
These and other findings are already being translated into policy on the ground. Amit Paliwal, who took over from Dr Jain as the GIZ project manager in January 2022, says more than half of ‘empanelled’ hospitals (certified facilities that can be reimbursed under the PM-JAY scheme) are now public hospitals. At the same time, the latest statistics show that approximately half of healthcare claims (in terms of volume) are now being directed towards public hospitals.
Amit Paliwal says: ‘For PM-JAY to be financially sustainable, it is important that participation by public hospitals increases and that the quality of services improves. These were some of the major findings by the research study and when we look at the data today, we can see that there have been significant improvements in both areas.’
This research created a narrative – and policy and the health eco-system have since responded to that narrative.Amit Paliwal, current manager of the Indo-German Social Security Programme
Other improvements that have been made since the research was carried out include work to raise awareness of PM-JAY; better targeting of vulnerable groups such as women; action by individual states to refine their processes; and capacity building for future health systems research.
Amit Paliwal says that perhaps the biggest vindication of the value delivered by the research is the fact that in 2024 a new follow-up study commissioned by the Indian Government started. This continued cooperation between German and Indian Governments is a great example of how research is being used to generate evidence for policy making and improved implementation.
The wider impact
Meanwhile, Prof. De Allegri and her fellow researchers are hopeful that the rich data yielded by their research will benefit health policy development in other countries as well as India – and also lead to further opportunities to inform development cooperation in the area of social health protection.
‘We have many other dreams in a drawer,’ says Prof. De Allegri.