When India rolled out the Pradhan Mantri Jan Arogya Yojana (PM-JAY) in September 2018 to provide cashless annual hospitalisation cover of up to ₹5 lakh to at least 107.4 million families, it was building on the experience of the country’s first nationwide social health insurance scheme, the Rashtriya Swasthya Bima Yojana (RSBY), which used public-private partnerships (PPP) to fill the gaps in public health delivery and increase access.

While much larger in scale, PM-JAY expanded on several aspects of RSBY’s PPP model, such as scheme design, involvement of the private sector, use of contracts, incentives given and overall administrative structure to offer provider plurality without having to pay money upfront.

The PMJAY design indicates that the strengths and weaknesses of RSBY were kept in mind during its development, but gaps remain, points out Sonalini Khetrapal in her insightful new book, Healthcare for India’s Poor: The Health Insurance Way (Academic Foundation; ₹1,195).

“There are several lessons that RSBY offers that would be useful to take on board to make PM-JAY more effective. These relate to scheme design, its implementation primarily enrolment of beneficiaries, empanelment of health facilities, role of insurance companies, contracting and regulation,” writes Khetrapal.

Drawing on her experience as a social sector specialist at the Asian Development Bank in Manila, and her training as a health economist at the London School of Hygiene and Tropical Medicine, Khetrapal identifies the lacunae that need to be filled to ensure that PMJAY, which will become the world’s largest fully government-financed health protection scheme when fully implemented, reaches each one of the 500 million beneficiaries who need it.

There is considerable scale up under PM-JAY, with beneficiaries increasing from 150 million to 107.4 million families (around 500 million individuals), hospitalisation cover rising from ₹30,000 to ₹5 lakh per family per year, removal of the cap on family from five per family under RSBY, expansion of treatment packages from 1,090 to 1,345, with no restriction on pre-existing conditions.

The PPP model has helped to rapidly scale up services and bring in private-sector efficiencies and management tools to the public sector, but regulation is essential to ensure fair market competition, check frauds, and end inequities that prevent the most marginalised, particularly women and children, from accessing services, writes Khetrapal. The banning of 30 private nursing homes in East Champaran district conducting illegal hysterectomies under RSBY is an example of profiteering by exploitative players in the private sector in the absence of regulation.

“For the regulation of private sector hospitals, stricter enforcements are required and clearer guidelines are needed to register and monitor the quality of services being provided… regular medical and social audits of the providers (must be) be conducted, and sanctions be imposed on the providers who do not follow the norms,” writes Khetrapal.

“For the success of PM-JAY, it is critical to provide a robust regulatory network. Though there is a considerably large presence of private providers in the country, information about their numbers, role, nature, structure, functioning, type and quality of care remains grossly inadequate…. Only a few states have requirements for registration of private facilities, such as hospitals and nursing homes,” says the book, which is based on extensive field research over 2012-14.

She also highlights the need for more proactive government engagement. Khetrapal suggests state governments could identify and engage with hospitals proactively rather than waiting for them to apply for empanelment, and motivate the good ones to participate in the scheme.

Greater transparency can be ensured by engagement with the community through elected village and local body representatives, NGOs, and rogi kalyan samitis (patient welfare boards) to prevent “cream skimming”, where private sector chooses to treat only selected profitable packages, and ensure continuity of all services, writes Khetrapal, who is a wildlife photography enthusiast who has won several international awards, including the Sony World Photography and Siena International Photo awards.

The need for a health protection scheme like PM-Jay cannot be overstated. Around 85.9% of rural households and 82% of urban households in India had no access to healthcare insurance/assurance in 2015, according to 17th National Sample Survey Organization 2015, with more than 17% of population spending at least 10% of household budgets for health services.

India’s new health vision also provides free out-patient services and over-the-counter medicines to everyone for ailments like fevers that don’t need hospitalisation at the newly set-up Health and Wellness Centres staffed by community health officers (CMOs). The CMOs are trained to do simple diagnostics tests like malaria tests, and measure blood pressure and blood glucose to refer cases that need clinical review to hospitals.

Khetrapal’s book is a timely reminder that by building on the learnings from RSBY and enforcing strong regulations, transparency, efficiency, trust and public awareness to reduce out-of-pocket health spending, PM-JAY may well be the proverbial giant leap towards Universal Health Coverage in the country.