Understanding the extent of economic evidence usage for informing policy decisions in the context of India's national health insurance scheme: Ayushman Bharat Pradhan Mantri Jan Aarogya Yojana (PM-JAY)

Abstract

Introduction: Ayushman Bharat Pradhan Mantri Jan Aarogya Yojana (PM-JAY) is one of the world's largest tax-funded insurance schemes. The present study was conducted to understand the decision-making process around the evolution (and revision) of health benefit packages (HBPs) and reimbursement rates within PM-JAY, with a specific focus on assessing the extent of use of economic evidence and role of various stakeholders in shaping these policy decisions.

Methods: A mixed-methods study was adopted involving in-depth interviews with seven key stakeholders involved in HBP design and reimbursement rates decisions, and a survey of 80 government staff and other relevant stakeholders engaged in the implementation of PM-JAY. The data gathered were thematically analysed, and a coding framework was developed to explore specific themes. Additionally, publicly available documents were reviewed to ensure a comprehensive understanding of the decision-making processes.

Results: Findings reveal a progressive transition towards evidence-based practices for policy decisions within PM-JAY. The initial version of HBP relied heavily on key criteria like disease burden, utilisation rates, and out-of-pocket expenditures, along with clinical opinion in shaping decisions around the inclusion of services in the HBP and setting reimbursement rates. Revised HBPs were informed based on evidence from a national-level costing study and broader stakeholder consultations. The use of health economic evidence increased with each additional revision with consideration of health technology assessment (HTA) evidence for some packages and reimbursement rates based on empirical cost evidence in the most recent update. The establishment of the Health Financing and Technology Assessment unit further signifies the use of evidence-based policymaking within PM-JAY. However, challenges persist, notably with regard to staff capacity and understanding of HTA principles, necessitating ongoing education and training initiatives.

Conclusion: While substantial progress has been made in transitioning towards evidence-based practices within PM-JAY, sustained efforts and political commitment are required for the ongoing systematisation of processes.

Keywords: Health economics; Health insurance; Health policies and all other topics; Health services research; India.

Figure 1

Evolution of Health Benefit Packages (HBPs) under Ayushman Bharat Pradhan Mantri Jan Aarogya Yojana.

Figure 2

Process flow for designing and updating health benefit packages (HBPs): (A) HBP1.0, (B) HBP 2.0 and (C) HBP 2022. CHSI, Costing of health services in India; CII, Confederation of Indian Industry; FICCI, Federation of Indian Chambers of Commerce and Industry; HTA, health technology assessment; ICMR, Indian Council of Medical Research; NHA, National Health Authority; NITI, National Institution for Transforming India; SHA, State Health Agency.

Figure 3

Health economic evidence used in different phases of HBPs. CGHS, Central Government Health Scheme; ESIS, Employees’ State Insurance Scheme; HBPs, health benefit packages; HTA, health technology assessment; RSBY, Rashtriya Swasthya Bima Yojana.

Figure 4

Survey findings based on actual practice: (1) stakeholders involved, (2) factors considered and (3) sources of information used for updating HBPs and their reimbursement rates. HBPs, health benefit packages; HTA, health technology assessment; OOP, out-of-pocket.

Figure 5

Survey respondents’ perspective on the importance of different stakeholders, factors influencing HBP selection and different sources of evidence in updating of HBPs and their reimbursement rates. HBPs, health benefit packages; HTA, health technology assessment; OOP, out-of-pocket.

Figure 6

Survey respondents’ perspectives on areas needing capacity building. HTA, health technology assessment.