Are Publicly Funded Health Insurance Schemes Leading Towards Better Healthcare Utilization and Quality of Life? A Case Study from India
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Shashi Kant Sharma
Abstract
India introduced a new healthcare scheme, the Pradhan Mantri Jan Arogya Yojana (PMJAY), in 2018, which has been in effect since 2019. This scheme aims to achieve universal health coverage and supports the catastrophic Out-of-Pocket Expenditure (OOPE) of below poverty line population in Indian states. This study assesses the impact of PMJAY in two selected districts of the Indian state of Bihar considering a sample of 324 respondents. Propensity score matching (PSM) and entropy balancing (EB) are two widely used methods to ensure the robustness of impact assessment exercises. The EB method is considered relatively robust and therefore, we use and compare both. The average effect of PMJAY on the beneficiaries using EB shows a significant rise in healthcare utilization; the values are 2.51, 0.79 and 0.36 for OPD visits, hospitalizations, and surgeries, respectively. Our sample consists of 22 percent PMJAY-beneficiaries. The findings highlight the scheme’s potential to improve healthcare access and outcomes for the vulnerable population. Beneficiaries have reported better post-hospitalization quality of life and are more likely to return to work regularly after treatment. These insights may assist policymakers in further improving their effectiveness by raising awareness among the eligible households, as there are still barriers to enrollment and information asymmetries with regard to utilization.
Acknowledgments
The authors thank participants at the 28th Asia Pacific Risk and Insurance Association 2024 Annual Meeting in National University of Laos, Vientiane, Laos (2024) and Global Conclave 2024 organized by Institute of Human Development, New Delhi, India (2024) for their constructive comments on an earlier version of this paper. The authors are responsible for any remaining errors in this manuscript and endorse that the research did not receive any research funding. The participation and presentation of the earlier version of the paper by the first author at the APRIA 2024 Annual Conference was possible because of the partial financial support from the Indian Council for Social Science Research (ICSSR).
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Research ethics: Not applicable.
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Informed consent: Not applicable.
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Author contributions: All authors have accepted responsibility for the entire content of this manuscript and approved its submission.
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Use of Large Language Models, AI and Machine Learning Tools: None declared.
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Conflict of interest: The authors state no conflict of interest.
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Research funding: None declared.
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Data availability: Data can be shared upon reasonable request.
1. Household information
| S. no. | Questions | Responses |
|---|---|---|
| 1.1 | District | |
| 1.2 | Block | |
| 1.3 | Village | |
| 1.4 | Name of the household head | |
| 1.5 | Name of the respondent | |
| 1.6 | Is he/she the household head? | Yes – 01 |
| No – 02 | ||
| 1.7 | Gender | Male – 01 |
| Female – 02 | ||
| 1.8 | Education of household head | 1. Primary |
| 2. Secondary | ||
| 3. Higher secondary | ||
| 4. Graduate | ||
| 5. Postgraduate | ||
| 6. Not literate | ||
| 1.9 | Religion | 1. Hindu |
| 2. Muslim | ||
| 3. Christian | ||
| 4. Buddhist | ||
| 5. Sikh | ||
| 1.10 | Caste | 1. Upper caste |
| 2. OBC 1 | ||
| 3. OBC 2 | ||
| 4. SC | ||
| 5. ST | ||
| 6. Others…… |
| S. no. | Questions | Responses |
|---|---|---|
| 1.11 | Do you have ration card? | Yes – 01 |
| No – 02 | ||
| 1.12 | In which category do you belong? | 1. APL |
| 2. BPL | ||
| 1.13 | Latrine system | Yes – 01 |
| No – 02 | ||
| 1.14 | Drainage system | Yes – 01 |
| No – 02 | ||
| 1.15 | Drinking water facility | Yes – 01 |
| No – 02 | ||
| 1.16 | Distance of village from nearest hospital | Specify……… |
| 1.17 | Locality | 1. Urban |
| 2. Rural | ||
| 3. Peri-urban | ||
| 1.18 | Land holding (in Kattha) | Specify……… |
| 1.19 | Source of income | 1. Agriculture |
| 2. Casual labour | ||
| 3. Self-employment | ||
| 4. Formal sector job | ||
| 5. Others…… | ||
| 1.20 | Monthly consumption expenditure | 1. Up to Rs. 2,000 |
| 2. Rs. 2,000–5,000 | ||
| 3. Rs. 5,000–10,000 | ||
| 4. Above Rs. 10,000 | ||
| 1.21 | Total borrowings | |
| 1.22 | Source of borrowings | 1. Bank loan |
| 2. Co-operatives | ||
| 3. SHGs | ||
| 4. Money lenders | ||
| 5. Others | ||
| 1.23 | Assets purchased in the past 4 years | |
| 1.24 | Growth of income during past 4 years | |
| 1.25 | Assets sold in the past 4 years | |
| 1.26 | Do you have mobile phone with internet connectivity? | Yes – 01 |
| No – 02 | ||
| 1.27 | Any member of your family hospitalized during Covid-19? | Yes – 01 |
| No – 02 | ||
| 1.29 | Do you know about PM-JAY? | Yes – 01 |
| No – 02 | ||
| 1.30 | Do you know the eligibility of this scheme? | Yes – 01 |
| No – 02 | ||
| 1.31 | Is your family eligible? | Yes – 01 |
| No – 02 | ||
| 1.32 | Is your family enrolled? | Yes – 01 |
| No – 02 |
2. Demographic profile of household
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 |
| Sl. no | Name | Relationship to head (code) | Age (code) |
Sex (code) |
Marital status (code) | Educational level (code) | Employment status (code) | Health status(code) |
1. Health status of households
| Questions | Responses | |
|---|---|---|
| 3.1 | How will you rate your health risk? | Extremely high – 01 |
| High – 02 | ||
| Average – 03 Low – 04 | ||
| Extremely low – 05 | ||
| 3.2 | From which diseases are you suffering? | 1. Heart problem |
| (Circle more than one if applicable) | 2. High BP | |
| 3. Diabetes | ||
| 4. Arthritis | ||
| 5. Disability diseases | ||
| 6. Respiratory | ||
| 7. Injury due to accident | ||
| 8. Thyroid | ||
| 9. Others……. | ||
| 3.3 | What is household average monthly medical | 1. Up to Rs 1,000 |
| expenses? | 2. Rs 1,000–5,000 | |
| 3. Rs 5,000–10,000 | ||
| 4. Above Rs 10,000 | ||
| 3.4 | What preventive health care measures are you | 1. Disease screening |
| undertaking? (Circle more than one if applicable) | 2. Identify risk factors for disease | |
| 3. Discuss tips for a healthy and balanced lifestyle | ||
| 4. Stay up to date with immunizations and boosters | ||
| 5. Regular exercise/yoga/walking |
| Questions | Responses | |
|---|---|---|
| 6. Washing hands with soap frequently | ||
| 7. Wearing helmet/car seat belt while driving | ||
| 8. Avoid smoking/alcohol | ||
| 9. Maintain weight | ||
| 10. Eating healthy food (fresh fruits and vegetables) | ||
| 3.5 | What is the source of financing your inpatient medical expenses? | 1. Free medical service by government |
| 2. Out of pocket expenditures | ||
| 3. Paid by employer/company | ||
| 4. Health insurance schemes | ||
| 5. Others (Specify) ………………. |
2. Awarenress about health insurance
| Questions | 5 | 4 | 3 | 2 | 1 | |
|---|---|---|---|---|---|---|
| 4.1 | I am aware of the benefits of health insurance | |||||
| 4.2 | I am aware of the general cost of health insurance premium | |||||
| 4.3 | I am aware of the health insurance claim procedure | |||||
| 4.4 | It is better to take a health insurance policy at a younger age | |||||
| 4.5 | Health insurance policies offered by non-life insurance companies usually last for a period of one year. | |||||
| 4.6 | I am aware that the Insurance Regulatory & Development Authority of India (IRDAI) is the insurance regulator for Health Insurance in India? | |||||
| 4.7 | I am aware that IRDA allows online issuance of HI policies | |||||
| 4.8 | Social health insurance schemes like Rashtriya Swasthya Bima Yojana (RSBY) and Ayushman Bharat help to create awareness regarding purchase of HI policy | |||||
| 4.9 | Rising social awareness about health care has positive influence on purchase decision of health insurance | |||||
| 4.10 | I am aware of the difference between life insurance and health insurance |
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Note: Please give responses to the following questions on a scale of 5 to 1, where 5 = strongly agree, 4 = agree, 3 = neither agree nor disagree, 2 = disagree and 1 = strongly disagree.
3. Healthcare utilization
| 5.1 | Is any member of your household covered by a health insurance scheme? | Yes – 01 |
| No – 02 |
If Yes, then answer the following questions.
| 5.2 | What type of health insurance plan do you have? | 1. Government sponsored health insurance scheme (Ayushman Bharat scheme) |
| 2. Employees state insurance Scheme | ||
| 3. Central government health insurance Scheme | ||
| 4. Medical Reimbursement from employer | ||
| 5. Health insurance from employer | ||
| Private Voluntary Health Insurance | ||
| 6. Public company | ||
| 7. Private company | ||
| 8. Any other……………………………. | ||
| 5.3 | Which factor motivated you to buy health | 1. Advertisement |
| insurance policy? | 2. Insurance agent | |
| 3. Internet | ||
| 4. Friends and relatives | ||
| 5. Others………………………(specify) | ||
| 5.4 | Name of the provider company | Specify……. |
| 5.5 | Total sum assured | Specify……. |
| 5.6 | Premium payable per annum | Specify……. |
| 5.7 | Frequency of OPD visits in a year | |
| 5.8 | Frequency of hospitalization visits in the last 4 years | Specify……. |
| 5.9 | Frequency of surgery in the past 4 years | Specify……. |
| 5.10 | Where did you get treatment? | 1. Public hospital |
| 2. Private hospital | ||
| 5.11 | What was the total cost of hospitalization? | Specify- - - - |
| 5.12 | What was the other cost (transportation, food etc.) | Specify- - - - |
| 5.13 | Did you claim your health insurance amount? | Yes – 01 |
| No – 02 |
If No , then answer the following questions.
| 5.14 | Why you have not opted any health | 1. Low availability of funds |
| insurance policy? | 2. Don’t feel the need for it | |
| 3. Lack of awareness | ||
| 4. Lack of reliability and flexibility | ||
| 5. Difficulty in availing services in hospital | ||
| 6. Cumbersome claim procedure |
6. Financial protection and satisfaction level
| 6.1 | Total inpatient expenses | |
| 6.2 | Borrowing in inpatient expenses (or surgery) | |
| 6.3 | Share of borrowing in expenses | |
| 6.4 | Post-surgery expenses | |
| 6.5 | Income lost as ratio of income | |
| 6.6 | Whether require post-surgery intervention? | Yes – 01 |
| No – 02 | ||
| 6.7 | Whether life improved post-surgery? | Yes – 01 |
| No – 02 | ||
| 6.8 | Whether work regularly post-surgery? | Yes – 01 |
| No – 02 | ||
| 6.9 | Whether money saved? | Yes – 01 |
| No – 02 | ||
| 6.10 | Satisfaction level from financial protection using health insurance? | 1. Excellent |
| 2. Good | ||
| 3. Average | ||
| 4. Poor |
Remarks (If any)
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