How does Context Influence Implementation Mechanism of Publicly Funded Health Insurance Schemes in Indian States

Abstract

Introduction: The success of any insurance scheme is contingent upon well-defined processes related to payment, referral, grievances and quality control mechanisms. Any deviation observed may result in unsatisfactory performance. This study attempts to examine various processes related to the implementation of Pradhan Mantri Jan Arogya Yojana (PMJAY) and a state-specific insurance scheme across three states of India. Objective: To describe the policies and process adapted by selected states in implementing a government-sponsored health insurance scheme. To examine the strategies that work effectively, how they operate and what contextual factors enable or disable the desired implementation mechanisms. Methodology: The three states of Karnataka, Chhattisgarh, and Odisha were selected to understand various processes related to the implementation of Publicly Funded Health Insurance Schemes (PFHIS) schemes in diverse settings. A realist evaluation framework was used to study the contexts and mechanisms and how this influences outcomes. Results: The three schemes differ in implementation modes and follow different strategies owing to the local contexts. Some mechanisms worked well in specific contexts, whereas similar things have hindered the process in other contexts. Conclusion: The evidence generated is helpful to strengthen implementation processes under PMJAY and allows learning from each other to increase uptake of the scheme.