Abstract
A single hospital admission can deplete household resources so considerably as to induce impoverishment, especially in the Indian context of low government healthcare expenditure. Rashtriya Swasthya Bima Yojana (RSBY) was a national health insurance scheme for below-poverty-line Indian families, to provide improved access to hospitalization and greater financial protection via a public-private-partnership employing private sector implementation capacity. Study objectives were to understand governance (including regulatory) environment and contract arrangements; evaluate expansion of services to beneficiaries; and assess compliance of providers and user satisfaction. A case study approach in two districts met the need for in-depth information on scheme functioning, and RSBY implementation was examined between 2011 and 13 in Patiala (Punjab) and Yamunanagar (Haryana). Methods included 20 key stakeholder interviews, analysis of secondary datasets on beneficiaries and claims, primary data collection in 31 public and private hospitals and in greater depth in 12 hospitals, and an exit survey of 751 patients. Enrolled and non-enrolled hospitals were mapped in each district and service availability of enrolled hospitals assessed; enrollee characteristics were analysed; for the 12 hospitals, information was obtained on structural quality and process of care, and patient satisfaction and out-of-pocket payments.The Indian states and the government of India did not specify formal regulatory and implementation procedures in detail and states largely contracted out their functions to private insurance firms. Findings show regulatory weaknesses, and contractual breaches. Enrolment rates were low in both districts and more so for Patiala and there was limited access to services. There was little difference in process of care between public and private hospitals, though the structural capacity of private hospitals was better than public hospitals. RSBY helped improve accessibility and gave some degree of financial protection to patients. It also actively engaged with existing resources in the Indian health care and insurance markets.
Highlights
New Public Management (NPM) has been a dominant paradigm in the discipline of public administration (Arora, 2003), encouraging policies which have included market orientation of public services, contracting out, and privatization (Kalimullah et al, 2012)
Given that Rashtriya Swasthya Bima Yojana (RSBY) was initiated by the federal Ministry of Labour and Employment, an important contrasting feature was that governance responsibility was assigned in Punjab to the state Ministry of Health and Family Welfare (MoHFW), and in Haryana to the Ministry of Labour and Employment (MoLE)
The governance framework driving the PPP arrangement was expected to affect the enrolment of eligible beneficiaries, the availability and accessibility of the providers who were contracted to treat them, and the services received by users
Summary
New Public Management (NPM) has been a dominant paradigm in the discipline of public administration (Arora, 2003), encouraging policies which have included market orientation of public services, contracting out, and privatization (Kalimullah et al, 2012). Public-PrivatePartnerships (PPPs) have been an area of particular interest, as a new tool for supporting public service provision. The Government of India (GoI), since the economic liberalization reforms of 1980s, envisions significant untapped potential for the use of a PPP model in the health sector and has developed enabling tools and activities to encourage private sector investment and engagement (Government of India, 2011). Out-of-pocket expenditure amounts to nearly 65%, one of the highest rates globally (World Health Organization, 2018; World Bank, 2018). One-time high expenditure can deplete household resources so considerably as to induce impoverishment (NSS, 2015)
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