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. 2021 May 27;16(5):e0251814. doi: 10.1371/journal.pone.0251814

Empanelment of health care facilities under Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB PM-JAY) in India

Jaison Joseph 1,*, Hari Sankar D 1, Devaki Nambiar 1,2,3
Editor: Srinivas Goli4
PMCID: PMC8158976  PMID: 34043664

Abstract

Introduction

India’s Pradhan Mantri Jan Arogya Yojana (PM-JAY) is the world’s largest health assurance scheme providing health cover of 500,000 INR (about USD 6,800) per family per year. It provides financial support for secondary and tertiary care hospitalization expenses to about 500 million of India’s poorest households through various insurance models with care delivered by public and private empanelled providers. This study undertook to describe the provider empanelment of PM-JAY, a key element of its functioning and determinant of its impact.

Methods

We carried out secondary analysis of cross-sectional administrative program data publicly available in PM-JAY portal for 30 Indian states and 06 UTs. We analysed the state wise distribution, type and sector of empanelled hospitals and services offered through PM-JAY scheme across all the states and UTs.

Results

We found that out of the total facilities empanelled (N = 20,257) under the scheme in 2020, more than half (N = 11,367, 56%) were in the public sector, while 8,157 (40%) facilities were private for profit, and 733 (4%) were private not for profit entities. State wise distribution of hospitals showed that five states (Karnataka (N = 2,996, 14.9%), Gujarat (N = 2,672, 13.3%), Uttar Pradesh (N = 2,627, 13%), Tamil Nadu (N = 2315, 11.5%) and Rajasthan (N = 2,093 facilities, 10.4%) contributed to more than 60% of empanelled PMJAY facilities: We also observed that 40% of facilities were offering between two and five specialties while 14% of empanelled hospitals provided 21–24 specialties.

Conclusion

A majority of the hospital empanelled under the scheme are in states with previous experience of implementing publicly funded health insurance schemes, with the exception of Uttar Pradesh. Reasons underlying these patterns of empanelment as well as the impact of empanelment on service access, utilisation, population health and financial risk protection warrant further study. While the inclusion and regulation of the private sector is a goal that may be served by empanelment, the role of public sector remains critical, particularly in underserved areas of India.

Introduction

Sustainable Development Goal (SDG) 3.8 seeks to ensure the health and wellbeing of all by achieving Universal Health Coverage (UHC) [1]. UHC emphasises on the importance of equity in access to quality health care for everybody without risking financial hardship [2]. India faces enormous challenges in moving towards UHC, which include suboptimal access, insufficient availability of services, poor quality health service delivery, and high out of pocket expenditure [3]. In 2015, global spending on health was USD 10 trillion and total health spending is projected to double to USD 20 trillion (18 trillion to 22 trillion) in 2040 [4]. India and China have increased the pooled per capita health spending by more than 265% between 1995–2015, a positive step in the direction of UHC [4]. However, India’s financial allocation to health sector remains inadequate. The country’s 2019 National Health Accounts reported Total Health Expenditure (THE) of Rs. 581,023 ten million (USD 767.7 trillion) which is 3.8% of GDP and Rs.4,381 (USD 58) per capita for the year 2016–17. Out of pocket expenditure is a major contributor to THE (at 58.7%) [5]. Analysis of catastrophic health expenditure trends in India show an increasing trend in last two decade with households with older people suffering the most [6]. There is evidence to suggest this will only increase in the context of the coronavirus pandemic [7]. High level of fragmentation in the sources of revenues and low risk pooling mechanisms in the country resulted in high out of pocket expenditure (about 62% of expenditure coming directly from households) especially among the poor and near poor [8].

However, the national health policy reflects the commitment towards achieving UHC through developing institutional mechanisms to improve the coverage and access to health services. The National Health Policy of 2017 expressed a commitment to increase the government health expenditure from 1.15% to 2.5% of the GDP by 2025 [9]. A flagship effort in this direction was the Ayushman Bharat Program [10], launched in 2018 to holistically address the primary, secondary and tertiary level health needs of the population by ensuring continuum of care [11]. The two interrelated components of Ayushman Bharat are: 1) Health and Wellness Centres (HWCs) to provide comprehensive primary care services and 2) the Pradhan Mantri Jan Arogya Yojana (PM-JAY) to provide secondary and tertiary care services which will enable the realization of the aspiration for UHC [12]. HWCs are upgraded primary care facilities intended to progressively expand access to comprehensive primary health care, free essentials drugs as well as diagnostics services; whereas the PM-JAY aims to provide financial protection for secondary and tertiary care to bottom 40% of India’s population [12]. PM-JAY aims to ensure improved access to good quality healthcare services through a combination of public and private empanelled providers for everyone without financial hardship [13].

PM-JAY has evolved with learnings from longstanding Indian Publicly Funded Health Insurance Schemes (PFHIS) for formal sector like Employee State Insurance (ESI,1952) and Central Government Health Scheme (CGHS,1954) in the formal sector, and the Rashtriya Swasthya Bima Yojana (RSBY, 2008) for the informal sector. However, the benefits and coverage offered under PM-JAY are much larger than these schemes [13]. AB PM-JAY is designed to meet the hospitalisation expense in cashless mode with a coverage of Rs.5,00,000/- (approx. $ 6,800) per family per annum to entitled beneficiaries on a floater basis i.e. the total insured amount can be used by one or all the members of the family (see characteristics of the scheme in Table 1).

Table 1. Key features of the Pradhan Mantri Jan Arogya Yojana (PMJAY).

Purchasers National Health Authority (NHA) through State Health Agencies (SHA) with flexibility for states to implement the scheme and purchase care through one of three modes: a public trust, a third-party Insurance, or a combination (i.e. trust and Insurance)
What services are purchased? a) Health insurance coverage of Rs. 5,00,000 (roughly $ 6,800) per family annually for secondary and tertiary care hospitalization.
b) Covering 3 days of pre-hospitalization and post hospitalization charges up to 15 days
c) As of 2019, services comprise of nearly 1,393 procedures (1,083 are surgical, 309 medical and 1 unspecified package) covering all the costs incurring for treatment, drugs and consumables diagnostics, and various user fees [14]. However, states are given power to restrict certain treatment packages for public sector only
d) There is no restriction on family size, age or gender and beneficiaries can avail cashless treatment from an empanelled healthcare provider
Who uses the services? Enrolled Population falling under the category
• Below the Poverty Line (BPL) in the Socio-Economic Caste Census (SECC)
• Existing Rashtriya Swasthya Bima Yojana (RSBY) beneficiaries
• State notified categories
Who provides services? Public- All public hospitals (including ESIC [15]) equipped with inpatient facilities (Community Health Centre level and above) are empanelled by default [16].
Private and not for profit hospitals–Hospitals meeting the minimum criteria established by National Health Authority (NHA) which include qualified doctor and nurse presence, in-patient beds with staff, medical and surgical service availability (including human resources around the clock, support systems, ambulance facilities 24x 7 with technically qualified staff) [16].
How are providers paid? Based on the treatment package, public and private hospitals have the same package rate, which may be specified, like a surgical package for which there is case based bundled payment or unspecified, for which a claimant will negotiate with pre-approval by intermediary/ SHA.
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Source: Categories based on Etiba & colleagues [17]; data from PM-JAY public websites/portal [11, 18], compiled by authors

It is important to note that since health is a state subject in India, the implementation model of PM-JAY varies across the country, and employs the concept of cooperative federalism, where components of program design, implementation and funding across federal and state levels are shaped in part by flexibilities offered by the scheme but also state context and prior experience with implementing public insurance (see Table 1). There is a strong possibility that these design variations may have a differential impact while operationalizing, which is the starting point for our analysis apart from addressing concerns that the core design of PM-JAY itself may be inadequate to fulfil the requirements of financial risk protection envisioned through UHC [19–22].

We place emphasis in this analysis on scheme empanelment at the state level, which is one of the four core functions of insurance (alongside enrolment, claims processing and grievance redressal). Under PM-JAY, empanelment of hospitals is processed through an online IT platform called the Hospital Empanelment Module (HEM). Based on defined criteria (see “who provides services” in Table 1) [23], the decision on empanelment of hospitals is subject to approvals from the empanelment committees at the district and state/union territory levels. Selection of providers is critical in strategic purchase of care from a mix of public and private sector and is often advocated to ensure competition and increase quality of delivery [24]. This option may not always be available as India’s private sector health providers are mostly urban-centric and the empanelment of private facilities under PM-JAY scheme varies from state to state [24]. For example, in Bihar half of all private providers in the state are situated in the capital city Patna and out of the 38 districts in the state 14 districts do not have a single private provider registered in the scheme [24]. Similar studies on RSBY have also reported that empanelled private hospitals tend to be greater in urban areas, providing a narrow and selective range of packages/conditions which were profitable, and only a fixed number of beds were earmarked for RSBY patients [25]. A study in Chhattisgarh on examining the availability of empanelled hospitals reported poor availability of private hospital services in geographically challenged areas [26]. Studies show that availability of hospital care had increased for RSBY enrolees [27], but access has remained skewed due to absence of empanelled hospitals in many geographically challenged areas, leading to non-utilization of services [28].

One of the key objectives of the PM-JAY is to increase the availability and choice of healthcare facilities such that beneficiaries can avail free treatment, through public or private healthcare providers [29]. PM-JAY offers portability of care to its beneficiaries which is essential for India’s vast geography and high interstate migration of workforce. The approach to empanelment of private providers by different states is governed by their existing public health infrastructure as well as state capacity to provide treatment for different specialties [29]. Certain states have adopted a policy to empanel only a limited number of hospitals that meet their requirement (e.g. Maharashtra), while certain States have reserved packages for public hospitals (e.g. Bihar, Madhya Pradesh) and states such as Uttarakhand have adopted a policy of referral from a public hospital for every procedure to be carried out at a private hospital [29]. Some abuse prone packages like hysterectomy have been reserved exclusively for public hospitals. Some states like Kerala, Jharkhand, Madhya Pradesh etc have adopted the list as is, while others like Karnataka, Tamil Nadu, Gujrat etc have added more packages depending on capacity of public hospitals and other local factors [29]. In most of the tertiary care schemes, the minimum criteria for empanelment is 50 beds, however in order to secure a more geographical accessible network, hospitals with 10 beds or more are also empanelled under PM-JAY [30]. It is estimated that on an average only a single bed is available for 1,844 persons in public hospitals and nine beds per 10,000 population in India against the global average of 30, in which private sector accounts for nearly half (49%) of the beds available [31].

While there are a fair number of state specific analyses, very few studies have explored the availability and distribution of EHCFs across India under public health insurance. With the UHC goal of equitable access in mind, we looked at the building blocks of insurance, specifically the first component of empanelment and sought to fill some gaps in knowledge. Specifically, we were interested in a) where people could access care under PM-JAY, and b) what services were being provided in these hospitals. Given the evidence, we sought to understand the public/private mix of hospital empanelment while also exploring patterns related to models of implementation, which vary across states.

Methodology

Study design

Secondary analysis of cross-sectional data using descriptive statistical methods was conducted to determine the geographical distribution, type and sector of empanelled hospitals and services offered through PM-JAY scheme. Data from all the states and UTs were taken into consideration for this study based on their mode of implementation. The study did not use any personal identifiable information and the data used for the study is available in the public domain (our extracted dataset is included as S1 File). Thus, this study was exempt from review by an ethics committee.

Data sources

This is a descriptive analysis of data sourced for the reference period February to March 2020. The analysis was carried out using data accessed from the Government of India’s PM-JAY website on the public and private hospitals empanelled under the scheme across Indian 30 states and 06 Union Territories (UTs) [32]. Information available included: a) hospital name b) hospital type (public, private for profit, private not for profit) c) hospital address d) hospital email e) hospital contact f) specialties empanelled and g) specialties upgraded. We prepared a database of all hospitals enlisted under the scheme with above mentioned variables in Microsoft Excel [33], for analysis. Further we obtained information on the state wise number of eligible household’s from “state at a glance” [34], on the PM-JAY website and estimated the number of eligible beneficiaries manually using the average family size from Indian Socio Economic Caste Census Report 2011 [35]. The analysis was done by classifying states based on the mode implementation as hybrid mode, insurance mode, trust mode, or the National Health Claims Platform (NHCP), based on information obtained from PM-JAY website. Information on specialties offered in 15,177 hospitals for which information were provides as indicated in the PMJAY website was recoded and linked for analysis in Microsoft Excel and the state wise count of facilities providing specialties under each sector was obtained.

Public sector facilities were classified based on the Indian Public Health Standards (IPHS) as Sub-centres, Primary Health Centres (PHCs), Community Health Centres (CHCs), Sub-District and District Hospitals [36]. Other type of facilities like medical colleges were categorized as given, while facilities like Public Sector Undertaking (PSU) hospitals, Railway and Military hospitals were grouped as “other” facilities. For understanding the availability of beds in public health facilities, sanctioned beds were collated from reports available on state health department and National Health Mission (NHM) websites wherever available else the maximum bed strength as per IPHS standard was allocated and bed strength was estimated.

As the data are dynamic, there were variations in total number of empanelled hospitals under the scheme ranging from 18,699 on February 2020 to 20,257 on March 2020. This study focuses on the 20,257 hospitals empanelled as on March 2020 to analyse the spread and access to network hospitals under the scheme. We conceptualized the empanelment data of facilities through an access framework by looking at the data through state wise distribution of facilities, sector wise (public/private), by mode of implementation, and availability of specialties offered through EHCFs.

Results

We analysed the overall distribution of EHCF by public and private sector and by the mode of implementation adopted by the states viz. trust mode, hybrid mode and insurance mode. Out of the total facilities empanelled (N = 20,257) under the scheme, more than half 11,367 (56%) were in the public sector, 8,157 (40%) facilities were private for profit, and 733 (4%) were private not for profit entities. Even though there was not much difference in distribution of empanelled healthcare facilities by sector across the different modes of implementation, the trust model dominates (60.4% of empanelled facilities) followed by hybrid model 30.9% and with insurance mode accounting for 7.7% of empanelled hospitals (see Table 2).

Table 2. Overall distribution of PMJAY empanelment by mode of implementation and sector.

Mode of Implementation Public (row percentages) Private for Profit (row percentages) Private Not for Profit (row percentages) Total EHCFs (column percentages)
Trust Mode 6988 (57%) 4796 (39%) 454 (4%) 12238 (60.4%)
Hybrid Mode 3419 (55%) 2695 (43%) 158 (3%) 6272 (30.9%)
Insurance Mode 811 (52%) 644 (41%) 115 (7%) 1570 (7.7%)
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Note

a Four states are not implementing PMJAY scheme, however public sector facilities are empanelled in these states for ensuring portability accounting for 153 facilities (Delhi 53, Odisha 29, Telangana 12 and West Bengal 59)

b24 Hospitals are empanelled under National Health Claims Platform (NHCP) which include hospitals empanelled by National Health Authority (NHA) at National level.

Source: Data from PM-JAY portal [16], compiled by authors

It was noted that 8% of the EHCFs in the public sector were empanelled based on bed occupancy parameter and belonged to Ministry of Home Affairs (562), Ministry of Railways (91), Ministry of Power (52), Ministry of Coal (42), Institute of National Excellence (14), Ministry of Heavy Industries and Public Enterprises (14), Ministry of Labour and Employment (ESIC) (14), Ministry of Steel (13), Ministry of Shipping (7), Ministry of Défense (7), Ministry of Mines (3), Ministry of Petroleum and Natural Gas (2) and New Delhi Municipal Council (1).

State wise distribution of hospitals (see Table 3) showed that five states contributed to more than 60% of empanelled facilities under PMJAY: Karnataka with 2,996 (14.9%), Gujarat with 2,672 (13.3%), Uttar Pradesh with 2,627 (13%), Tamil Nadu with 2315 (11.5%) and Rajasthan with 2,093 facilities (10.4%). Among these states, Rajasthan, Uttar Pradesh and Karnataka implement the scheme through a trust model and the remaining through hybrid models. Karnataka and Gujarat had relatively high proportions of public facility empanelment as a share of total empanelment, while Rajasthan had a large share of private (for profit) empanelment, and Tamil Nadu and Uttar Pradesh had empanelment shares close to being split across public and private sectors.

Table 3. State wise distribution of PMJAY empanelment by mode of implementation and sector.

State Name Mode of Implementation Public Private
(For Profit)		 Private (Not for Profit) Total
Gujarat Hybrid 1817 (68.0%) 765 (28.6%) 90 (3.4%) 2672
Jharkhand Hybrid 274 (36.1%) 425 (56.1%) 59 (7.8%) 758
Maharashtra Hybrid 123 (23.3%) 404 (76.7%) 0 527
Tamil Nadu## Hybrid 1205 (52.1%) 1101 (47.6%) 9 (0.4%) 2315
Dadra & Nagar Haveli Insurance 4 (100.0%) 0 0 4
Daman & Diu Insurance 3 (100.0%) 0 0 3
Jammu & Kashmir Insurance 126 (79.2%) 26 (16.4%) 7 (4.4%) 159
Kerala Insurance 187 (46.6%) 182 (45.4%) 32 (8.0%) 401
Meghalaya Insurance 163 (92.1%) 9 (5.1%) 5 (2.8%) 177
Nagaland Insurance 75 (92.6%) 6 (7.4%) 0 81
Puducherry Insurance 12 (60.0%) 6 (30.0%) 2 (10.0%) 20
Punjab Insurance 241 (33.2%) 415 (57.2%) 69 (9.5%) 725
Andhra Pradesh Trust 225 (32.1%) 477 (67.9%) 0 702
Andaman & Nicobar Trust 3 (100.0%) 0 0 3
Arunachal Pradesh Trust 5 (100.0%) 0 0 5
Assam Trust 160 (53.9%) 117 (39.4%) 20 (6.7%) 297
Bihar Trust 571 (71.3%) 196 (24.5%) 34 (4.2%) 801
Chandigarh Trust 5 (27.8%) 11 (61.1%) 2 (11.1%) 18
Chhattisgarh Trust 714 (75.9%) 227 (24.1%) 0 941
Goa Trust 11 (45.8%) 13 (54.2%) 0 24
Haryana Trust 166 (30.9%) 323 (60.1%) 48 (8.9%) 537
Himachal Pradesh Trust 143 (70.1%) 52 (25.5%) 9 (4.4%) 204
Karnataka Trust 2517 (84.0%) 475 (15.9%) 4 (0.1%) 2996
Lakshadweep Trust 1 (100.0%) (0.0%) 0 1
Madhya Pradesh Trust 411 (77.8%) 92 (17.4%) 25 (4.7%) 528
Manipur Trust 50 (87.7%) 7 (12.3%) 0 57
Mizoram Trust 86 (89.6%) 10 (10.4%) 0 96
Rajasthan Trust 595 (28.4%) 1498 (71.6%) 0 2093
Sikkim Trust 9 (90.0%) 0 1 (10.0%) 10
Tripura Trust 100 (98.0%) 2 (2.0%) 0 102
Uttarakhand Trust 123 (62.8%) 51 (26.0%) 22 (11.2%) 196
Uttar Pradesh Trust 1093 (41.6%) 1245 (47.4%) 289 (11.0%) 2627
Total 11218 (56%) 8135 (41%) 727 (4%) 20080
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Note: 177 EHCFs accounting for states not implementing the scheme and empanelled by NHCP not included for analysis.

## Tamil Nadu employs its own information system for empanelment which considers individual departments in individual facilities. Therefore, the total number of ‘empanelled’ facilities is likely lower than what is reported above.

Source: Data from PM-JAY portal [16], compiled by authors

We also found that nine states and one union territory (Andhra Pradesh, Goa, Haryana, Jharkhand, Kerala, Maharashtra, Rajasthan, Punjab and Uttar Pradesh, and Chandigarh) had a higher proportion of private facilities (for profit and not for profit combined) empanelled when compared with the public sector facilities. Otherwise, the public sector dominated empanelment across states.

Given the dominance of the public sector at the national level, we sought to understand empanelment in this category further (see S1 Table). Results show that out of the total public hospitals empanelled under the scheme, 40.4% were primary health care facilities and 29.1% were secondary care facilities (comprising Community Health Centres (CHC)/Urban Community Health Centres (UCHC) and Sub District Hospitals (SDH)). District hospitals accounted for 8.4% and medical colleges offering tertiary care accounted for 7.3% of facilities. The number of tertiary care facilities was fewer than the other primary and secondary facilities in the sector.

State wise distribution of hospitals (see S2 and S3 Tables) showed that out of the total public EHCFs, 39% of facilities fell under the category of Primary Health Centres and in five states (Gujarat 79%, Meghalaya 68%, Bihar 55%, Karnataka 82%, Mizoram 66%) more than 50% of empanelled facilities were PHCs. Further, 30% of facilities were Community Health Centres which deliver some specialty services and in nine states CHCs contribute to more 50% of empanelled facilities. This pattern of higher proportion of PHC empanelment is visible in trust (43%) and hybrid modes (42%).

State wise distribution of estimated number of beds in the public sector empanelled hospitals (see S4 and S5 Tables) showed that 75% of the bed availability was in secondary and tertiary care facilities. It is to be noted states like Delhi, Odisha, Telangana and West Bengal, which do not implement the scheme, also offer significant number of tertiary care beds under the scheme, ensuring portability. Uttar Pradesh had the highest absolute number of beds in public sector (12%) but the availability of bed per hundred thousand eligible population was only 87 (see S6 Table). Sikkim and Goa had the highest beds available per 100,000 population.

At the national level, AB-PMJAY has empanelled 3 hospitals per 100,000 eligible population, 2 in public and 1 in private sector, respectively (see Table 4). In Chandigarh, the rate of private hospitals empanelled per 100,000 population was double that in the public sector, in Rajasthan it was 3 times greater in private than in public, whereas in Nagaland it was 6 times higher in public than in private. In Tamil Nadu, Kerala and Assam we saw roughly matched public and private sector empanelment ratio to population.

Table 4. Empanelment of hospitals across the states relative to population, by model of implementation.

State/UT Name Hospitals / 100,000 eligible beneficiaries Public Hospitals / 100,000 eligible beneficiaries Private Hospital / 100,000 eligible beneficiaries
Hybrid
Gujarat 7 5 2
Jharkhand 2 1 2
Maharashtra 1 0 1
Tamil Nadu 4 2 2
Insurance
DNH and DD 1 1 0
Jammu & Kashmir 5 4 1
Kerala 2 1 1
Meghalaya 4 4 0
Nagaland 7 6 1
Puducherry 5 3 2
Punjab 3 1 2
Trust
Andaman & Nicobar 3 3 0
Andhra Pradesh 1 0 1
Arunachal Pradesh 0 0 0
Assam 2 1 1
Bihar 1 1 0
Chandigarh 6 2 4
Chhattisgarh 4 3 1
Goa 15 7 8
Haryana 6 2 4
Himachal Pradesh 9 6 3
Karnataka 5 5 1
Lakshadweep 12 12 0
Madhya Pradesh 1 1 0
Manipur 4 3 0
Mizoram 10 9 1
Rajasthan 4 1 3
Sikkim 5 5 1
Tripura 5 5 0
Uttar Pradesh 3 1 2
Uttarakhand 3 2 1
Total 3 2 1
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The distribution of specialty care packages available in public and private empanelled hospitals are depicted in Fig 1. It is observed that 40% of facilities were offering 2–5 specialty care and 14% of empanelled hospitals provided 21–24 specialties.

Fig 1. Number of empanelled hospitals providing specialty care as per PMJAY Package.

Fig 1

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Note: The data of 15177 EHCFs with available specialty information from PMJAY website was used for this analysis Source: Data from PM-JAY portal [16], compiled by authors.

Across facilities, the key specialties (Fig 2) available in the empanelled hospitals were general medicine (74.4%), emergency room packages (71.8%), general surgery (62.1%), obstetrics and gynaecology (58.9%), and orthopaedics (50%).

Fig 2. Top 15 specialties available across the states as per PMJAY package.

Fig 2

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The data of 15177 EHCFs with available specialty information from PMJAY website was used for this analysis Source: Data from PM-JAY portal [16], compiled by authors.

Tertiary care packages were offered mostly in public sector hospitals (see Table 5) Super-specialty packages like cardiothoracic surgery (79.6%), medical oncology (73.9%), cardiology (65%), were available in most of the empanelled tertiary care public hospitals, while their share in private sector were reported lower. The private sector had greater relative provision of orthopaedics (56.3%) general surgery (55.2%), urology services (51.5%) and obstetrics & gynaecology (49.5%).

Table 5. Services available through empanelled facilities.

Specialties Total Available Empanelled Hospitals (N = 15177) Availability in Private Empanelled Hospitals Availability in Public Empanelled Hospitals
General Medicine 11295 (74.4%) 4950 (43.8%) 6345 (56.2%)
Emergency Room Packages 10894 (71.8%) 4634 (42.5%) 6260 (57.5%)
General Surgery 9425 (62.1%) 5201 (55.2%) 4224 (44.8%)
Obstetrics & Gynaecology 8938 (58.9%) 4421 (49.5%) 4517 (50.5%)
Orthopaedics 7582 (50.0%) 4267 (56.3%) 3315 (43.7%)
Paediatric medical management 6731 (44.4%) 2963 (44.0%) 3768 (56.0%)
Otorhinolaryngology 5648 (37.2%) 2417 (42.8%) 3231 (57.2%)
Ophthalmology 5525 (36.4%) 2329 (42.2%) 3196 (57.8%)
Urology 5035 (33.2%) 2595 (51.5%) 2440 (48.5%)
Neurosurgery 4203 (27.7%) 1864 (44.3%) 2339 (55.7%)
Oral and Maxillofacial Surgery 4135 (27.2%) 1028 (24.9%) 3107 (75.1%)
Burns management 4022 (26.5%) 1561 (38.8%) 2461 (61.2%)
Plastic & reconstructive 4022 (26.5%) 1561 (38.8%) 2461 (61.2%)
Interventional Neuroradiology 3876 (25.5%) 1621 (41.8%) 2255 (58.2%)
Polytrauma 3841 (25.3%) 1391 (36.2%) 2450 (63.8%)
Cardiology 3637 (24.0%) 1272 (35.0%) 2365 (65.0%)
Paediatric surgery 3522 (23.2%) 1152 (32.7%) 2370 (67.3%)
Neo-natal 3368 (22.2%) 904 (26.8%) 2464 (73.2%)
Surgical Oncology 3122 (20.6%) 873 (28.0%) 2249 (72.0%)
Medical Oncology 3065 (20.2%) 800 (26.1%) 2265 (73.9%)
Cardio-thoracic & Vascular surgery 2728 (18.0%) 556 (20.4%) 2172 (79.6%)
Mental Disorders Packages 2635 (17.4%) 204 (7.7%) 2431 (92.3%)
Paediatric cancer 2626 (17.3%) 265 (10.1%) 2361 (89.9%)
Radiation Oncology 2514 (16.6%) 278 (11.1%) 2236 (88.9%)
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Source: Data from PM-JAY portal [16], compiled by authors

Discussion

The availability of timely, robust data in the public domain is the cornerstone of any monitoring process and is key to the transparency, accountability of any health system. The AB—PMJAY website offers detailed facility-related information which can provide useful insights regarding the nuances of scheme functioning and progress. The present study looked at data on PMJAY empanelment of facilities to understand the nature of distribution of services to its target population.

EHCFs are an essential element for any health insurance programme: identifying and empanelling providers working towards both quality and access [37]. Our study found that more than half of the EHCFs were government facilities. This was consistent with an earlier study on public health insurance which reported that majority of the hospitals empanelled under PFHIs are from public sector and in low income states of the country, empanelled private hospitals were concentrated in a few pockets, had low willingness to participate, which authors argued would limit access to healthcare for intended beneficiaries [38]. Results from a recent study in India’s Aspirational Districts [39], showed that 9 states had no private hospitals empanelled in any aspirational districts and the share of hospitals available to provide key tertiary care services in aspirational districts were less when compared with other districts [40]. This is also discussed in the PMJAY policy brief which reiterates the low participation of private sector in aspirational districts of the country [41]. The skewed distribution of private hospitals in states with low per capita income is an area of concern as a significant proportion of the eligible population under AB-PMJAY is concentrated in these states [41, 42]. A report on a government funded health insurance scheme in Maharashtra reported that the unwillingness of the multi-specialty private hospitals to participate in the scheme negatively affected the availability of services; infrastructural lacunae in the rural government hospitals continued unaddressed [43]. PMJAY was intended to increase access to services for the poor; yet the distribution of empanelled hospitals suggests poor service availability in many states. Participation of the private sector in public health insurance depends on profitability; thus, low premia and/or price-controlled package rates may discourage participation [44, 45]. This is clearly an area for further research.

PMJAY allows beneficiaries to access healthcare services free of cost through empanelled facilities anywhere in the country. Our analysis showed that states where the scheme was not implemented (like Delhi, Telangana, Odisha and West Bengal), accounted for 28% of bed share of public empanelled facilities. The national interoperability is a unique feature which is showcased as an asset of the scheme. India has huge interstate migration of labourers–this feature is therefore vital in principle. A survey done among the patients who have utilized the portability feature under PM-JAY from other state/districts revealed that lack of required services in their home state is by far the most common reason for seeking cross-border care [46]. Particularly in a COVID19 context, portability will be increasingly important and must continue to be assessed using deeper analytic approaches.

Access to health services in India is highly inequitable, with major disparities in health outcomes across income, gender, tribe, caste, and geographically defined population subgroups [47]. Our study found that Rajasthan, Uttar Pradesh, Gujarat, Karnataka and Tamil Nadu together accounted for more than 50% of total hospitals empanelled under the scheme. The ratio of empanelled hospitals to population was 4 hospitals per hundred thousand population in these five states as compared to 2 hospitals per hundred thousand population for all remaining 25 states/UTs combined, even as the latter account for an estimated share of 55% of eligible beneficiaries under the scheme. This is consistent with previous study which reported inequitable distribution of empanelled hospitals, especially of private hospitals, within six Indian states [48]. All the states with high empanelment are implementing the scheme under trust mode wherein the autonomy of empanelment relies with the State Health Agency (SHA). All the above-mentioned states except for Uttar Pradesh have over a decade of experience in successfully implementing Publicly Funded Health Insurance Schemes and have governance and institutional structures that likely facilitated implementation of PMJAY. Features of the health system and the broader political economy of empanelment warrants further study, however, as it is likely that system actors also have played a role in this pattern. Health systems research methods that explore governance may offer insights in this regard [49, 50].

The distribution of empanelment (private versus public) does not seem to vary substantially by mode of implementation (trust, insurance agency, or hybrid model) as of now. Among the public hospitals empanelled under the scheme by various modes, the insurance mode had more secondary and tertiary care facilities than other two. The model as it stands right now is similar to Indonesia’s Jamkesmas provider network, even as in this case, the network has not significantly increased benefit package availability in remote, rural locations [51]. Evidence from India suggests that neither trust nor insurance company purchasing models are associated with increased utilisation of hospital care in southern Indian states (where these programmes have some maturity), nor is there an association with out of pocket expenditure associated with enrolment [52]. Another study has noted that hospital insurance reforms in LMICs like Kenya require particular attention to design, where threats like “purchaser capture” may prove unsustainable [53].

Results showed that primary care facilities accounted for 25% of the total bed share under PM-JAY. These facilities are officially available to the entire population technically free or for nominal charges [54]. The National Sample Survey 2018 defines PHCs as institutions that provide curative OPD services, ante natal check-ups and deliveries (4–6 beds to conduct delivery) with limited facilities for in-patient treatment [55]. Given the large evidence base suggesting that public facilities have poor infrastructure, under-staffing and lack of equipment and medicines [56–58], it is unclear how PMJAY empanelment relates to the service design at the public primary care level. On the one hand, empanelment under PMJAY is based on a set of criteria for all facilities and may have contributed towards upgradation of primary care facilities, although it is unlikely that this upgradation may have occurred uniformly at the scale and pace of empanelment. On the other, pressure to maximise empanelment numbers may have resulted in relaxation of empanelment criteria in the public sector. There is lack of evidence on these processes and a strong need for further research.

More fundamentally moreover, the precise implication of empanelment in public facilities is unclear; it is suggested that while empanelment may change payment mechanisms on the provider side, there is likely little difference for patients, who remain entitled to free or subsidized care at the government hospitals in any case [59]. It remains to be seen whether empanelment is a pathway to improvements in facility quality across public and private sectors and whether over time, this mechanism helps expand access where it is needed most. As of now, this may not be the case: a 2019 report found slightly lower public and private sector facility empanelment in states with higher poverty head count [60].

While analysing the access to specialties across the states, the share of public sector was high in providing care for tertiary care packages. Recent global burden of disease estimates for India reported cardiovascular diseases contribute to 28·1% (95% UI 26·5–29·1) of the total deaths and 14·1% (12·9–15·3) of the total DALYs in 2016 [61]. However, cardiology specialty is offered by only 24% total facilities through the scheme in the country. Emergency care services were available in 71.8% of facilities which are vital in managing road traffic injuries which are among the top 15 causes of mortality in the country [62]. Another leading cause for mortality is chronic kidney disease and despite dialysis being reported as the most sought after procedure under PMJAY, however nephrology as specialty package was not reported under the scheme [63]. This service and burden mismatch should be addressed through empanelment as the program advances.

Prior research has shown that eligible households do not access care due to the supply side constraints in the form of fewer hospitals in their vicinity, and that there is a strong negative correlation between state poverty levels and specialty hospital empanelment [60]. As aforementioned gaps in service availability, while associated with portability of care, are paradoxically associated with restricted beneficiary access to local specialty care. Also, it was found that not all private facilities were providing specialties like General Surgery, Obstetrics & Gynaecology, Orthopaedics and Urology, meaning that the comprehensiveness of coverage was inconsistent.

Limitations

While analysing the data we observed the following data quality issues which may affect the validity of findings. The presence of large number of SHCs and PHCs, some of them reported to be offering even tertiary care services like paediatric cancer management raises serious concerns over quality of data in the central registry. Public facilities often get upgraded to higher level facilities, but their old names may not be upgraded in the website which might be a reason for large number of SHCs and PHCs. The specialty department in medical colleges of Tamil Nadu were counted as separate institutions in the database which amplifies the count empanelled facilities under the scheme. Moreover, population adjusted figures use Census 2011 estimates, population sizes have obviously grown in the years since the last Census and it would be most appropriate to use updated figures to compute more precise coverage estimates. Given the scope of this analysis, we were unable to explore reasons for patterns of empanelment across and within states, address the impact of empanelment on population, service and system outcomes, or reflect on aspects like budgetary allocations and claims utilisation across settings. These are clearly critical areas of further inquiry.

Conclusion

This study undertook to characterise patterns of empanelment under PMJAY nationally. We found that a majority of the hospital empanelled under the scheme are in states with previous experience of implementing publicly funded health insurance schemes, with the exception of Uttar Pradesh. Reasons underlying these patterns of empanelment as well as the impact of empanelment on service access, utilisation, population health and financial risk protection warrant further study. While the inclusion and regulation of the private sector is a goal that may be served by empanelment, the role of public sector remains critical, particularly in underserved areas of India.

Supporting information

S1 Table. Distribution of public sector PMJAY empanelment across levels of care and by mode of implementation.

(DOCX)

Click here for additional data file. (16.1KB, docx)
S2 Table. State wise distribution of public health care facility empanelment under PMJAY.

(DOCX)

Click here for additional data file. (20.1KB, docx)
S3 Table. State wise distribution of public health care facility empanelment under PMJAY by geography.

(DOCX)

Click here for additional data file. (20KB, docx)
S4 Table. State wise estimates of number of beds in public empanelled health care facilities under PMJAY.

(DOCX)

Click here for additional data file. (21.8KB, docx)
S5 Table. State wise estimates of number of beds in public empanelled health care facilities under PMJAY by geography.

(DOCX)

Click here for additional data file. (22.1KB, docx)
S6 Table. State wise availability of public empanelled hospitals per hundred thousand eligible population by mode of implementation.

(DOCX)

Click here for additional data file. (15KB, docx)
S1 File

(XLSX)

Click here for additional data file. (700.5KB, xlsx)

Acknowledgments

We are grateful to Dr. Shalini Singh, Associate Faculty, Health Systems, Department of International Health, John Hopkins Bloomberg School of Public Health for her key reflections and critical inputs. We also acknowledge our collaboration with ITAD Ltd.

List of abbreviations

AB PM-JAY

Ayushman Bharat Pradhan Mantri Jan Arogya Yojana

BPL

Below the Poverty Line

CGHS

Central Government Health Scheme

CHC

Community Health Centres

COVID19

Novel Coronavirus SARS-CoV-2

DALYs

Disability Adjusted Life Years

EHCF

Empanelled Health Care Facilities

ESI

Employee State Insurance

GDP

Gross Domestic Product

HEM

Hospital Empanelment Module

IPHS

Indian Public Health Standards

NHA

National Health Authority

NHM

National Health Mission

OPD

Outpatient Department

PFHIS

Publicly Funded Health Insurance Schemes

PHC

Primary Health Centres

PSU

Public Sector Undertaking

RSBY

Rashtriya Swasthya Bima Yojana

SDG

Sustainable Development Goal

SDH

Sub District Hospital

SECC

Socio-Economic Caste Census

SHA

State Health Agencies

THE

Total Health Expenditure

UHC

Universal Health Coverage

USD

United States Dollars

UTs

Union Territories

Data Availability

All relevant data are within the manuscript and supporting information files.

Funding Statement

We wish to indicate that this work was supported by the Wellcome Trust/DBT India Alliance Fellowship (https://www.indiaalliance.org) Grant number IA/CPHI/16/1/502653) awarded to Dr. Devaki Nambiar. The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. The funder provided support in the form of salaries and research materials and field work support for authors DN, HS and JJ but did not have any additional role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. The specific roles of these authors are articulated in the ‘author contributions’ section.

References

Decision Letter 0

Srinivas Goli

11 Jan 2021

PONE-D-20-33726

Empanelment of Health Care Facilities under Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB PM-JAY) in India

PLOS ONE

Dear Dr. Joseph,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

All four reviewers are favourable for recommending this paper with a minor revision. However, my observation on this paper is it needs a major revision. So, I go with a decision of major revision.  I have enclosed my comments for authors as below.

  1. The paper currently looks more of a descriptive in nature. Lacks analytical rigour and critical/logical interpretations. Some of the interpretations of the findings look indolent and show a sloppiness.

  2. The conclusion doesn’t support with data. Authors need a little more intriguing interpretations and conclusions. For instance, the authors write: “the current distribution of empanelled AB-PMJAY hospitals favours better performing states”. In what terms authors saying better performing states. If I look at the five states that authors listing on socio-economic and health status grounds, only two states are better performing states. Rajasthan, Uttar Pradesh and Gujarat are poor and moderately performing in terms of health care and outcome indicators. The possible reason for the larger contribution from these states needs to be explained. Maybe one reason could be all of them are BJP ruling states or its alliance ruling states at the time of programme conceptualisation and initiation. So, the state role needs to be clearly drawn in this case.

  3. Also, the authors must explain the reasons why Private Sectors hospitals not actively taking part in the programme from several angles, especially from the side of state subsidies vis-a-vis the regular out-pocket expenses of hospitals in this sector.  Thus, how to reach a consensus on these grounds?

  4. Some states following a much better health care schemes than AB-PMJAY for instance, Telangana and Andhra Pradesh. Thus, the states private hospitals have mostly partnered with states programmes than central programmes. Some of these intricacies missing from the paper.

  5. Also, authors critically need to evaluate how far private insurance-based health care schemes work in a highly privatised, compartmentalised and hierarchical health care service delivery system like India.  

  6. The paper completely silent on budgetary allocations to meet the stated goals.

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We look forward to receiving your revised manuscript.

Kind regards,

Srinivas Goli, Ph.D.

Academic Editor

PLOS ONE

Additional Editor Comments:

All four reviewers are favourable for recommending this paper with a minor revision. However, my observation on this paper is it needs a major revision. So, I go with a decision of major revision. I have enclosed my comments for authors as below.

1. The paper currently looks more of a descriptive in nature. Lacks analytical rigour and critical/logical interpretations. Some of the interpretations of the findings look indolent and show a sloppiness.

2. The conclusion doesn’t support with data. Authors need a little more intriguing interpretations and conclusions. For instance, the authors write: “the current distribution of empanelled AB-PMJAY hospitals favours better performing states”. In what terms authors saying better performing states. If I look at the five states that authors listing on socio-economic and health status grounds, only two states are better performing states. Rajasthan, Uttar Pradesh and Gujarat are poor and moderately performing in terms of health care and outcome indicators. The possible reason for the larger contribution from these states needs to be explained. Maybe one reason could be all of them are BJP ruling states or its alliance ruling states at the time of programme conceptualisation and initiation. So, the state role needs to be clearly drawn in this case.

3. Also, the authors must explain the reasons why Private Sectors hospitals not actively taking part in the programme from several angles, especially from the side of state subsidies vis-a-vis the regular out-pocket expenses of hospitals in this sector. Thus, how to reach a consensus on these grounds?

4. Some states following a much better health care schemes than AB-PMJAY for instance, Telangana and Andhra Pradesh. Thus, the states private hospitals have mostly partnered with states programmes than central programmes. Some of these intricacies missing from the paper.

5. Also, authors critically need to evaluate how far private insurance-based health care schemes work in a highly privatised, compartmentalised and hierarchical health care service delivery system like India.

6. The paper completely silent on budgetary allocations to meet the stated goals.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

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The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: No

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: No

Reviewer #2: Yes

Reviewer #3: I Don't Know

Reviewer #4: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: No

Reviewer #4: No

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

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Reviewer #1: No

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: 1.The objective of study is not stated and data presented its analysis in the study does not support the conclusion.

2.A large section of introduction and discussion appear to copy and pasted.

3.The entire introduction section needs to rewritten which focus on what the author intent to achieve though the study.

4.The result do not support the conclusion

5.The discussion section of the study is vague and does not support the conclusion.

Reviewer #2: Indeed a good attempt to do the secondary data analysis and given a good insight to the PMJAY scheme in India.

Narration was good. Very well explained with necessary tables and figures.

Please be uniform while converting INR to USD all through the manuscript (Line no. 91)

Considering India having large geographical area, result could have discussed in terms of regions (South, North, Central, Eastern) rather than individual states.

Reviewer #3: I believe the article is much relevant to scientific literature concerning the access to healthcare services under PM-JAY. It is interesting to find that public sector dominates empanelment across states in India. I enjoyed reading the article and how it concludes saying that although there is a need to regulate and include more private hospitals, it is also critical to ensure and maintain the role of public sector in underserved areas.

Additional comments:

• Abstract - conclusion section: In Line 46 the authors mention “better performing states”. I would like to see it written specifically with regard to what aspects they are better performing.

Line 49- the authors mention that finding the appropriate balance of in purchase of care is critical to the success of any publicly financed insurance scheme in India. How do we measure success? I think the authors could provide the specific detail of success of PM-JAY in terms of coverage, or effectiveness of the health insurance scheme.

• In the Methods section, the authors need to mention about why the ethics statement was not needed for this study.

• The authors have used the term cross sectional in line 32 and line 168. This is not a cross sectional study design in my understanding since it doesn’t involve primary research. The study methodology could be written as “secondary analysis of cross-sectional data using descriptive statistical methods”.

• Table 1. Key Features of the Pradhan Mantri Jan Arogya Yojana (PMJAY),

Under Who uses the services? Section, Point “a” mentions “Enrolled Population falling under the category” is not clear to me.

Does the word “category” in point “a” refer to the ones mentioned in b, c and d? I would like to see if that part can be clarified.

• Line 177: citation 34 – the link directs to a page with the message “forbidden access”.

• Line 180: The Database that has been developed as mentioned and link given on reference number 35 is not accessible. I would recommend the authors to check the submission guidelines so as to meet the publication criteria with regard to fulfilling the criteria for validation, utilization and availability of database. “The Database should ideally discuss plans for long term database growth, maintenance and stability. Authors should provide a direct link to the database hosting site from within the paper.” The link is provided in the manuscript in reference number 35 but I have not been able to access the same.

• Line 234: In my understanding, when the term “only” is used, the authors seem to be inclined towards the empanelment of more private facilities which may or may not guarantee effectiveness of PM JAY coverage as per the studies that I have come across. Or if the authors prefer to stick to that statement then they may choose to highlight more studies that show why empanelment of private facilities has shown to be effective or also provide evidence as to why creating a balance between private and public is crucial. Although they have addressed the same, I think it is not enough. It would be good to ponder over the following questions. 1)Do we solely take the patient choice of providers/facility into consideration 2) Do we consider how effective the coverage can be regardless of the type of facility (public/private) especially in terms of reduction in the out-of-pocket expenditure and catastrophic expenditure for the enrolled patients. 3) Would empanelment of private/public facilities improve access or financial protection for the enrolled patients? The same goes for the statement in line 412 where the authors mention about the over representation of public facilities. I hope the authors understand what I am trying to say. If they would like additional insights, they may refer to literature on the suitability of publicly funded purchasing from private providers in the Indian Context.

• Line 336 and 340: I am unable to read the articles as the link directs to a website that mentions error/ page not found. (Citation number 39 and 40)

• I am in total agreement with Line 352 where the authors mention that Participation of the private sector in public health insurance is a critical area for further research and policy attention.

Reviewer #4: This paper presents an analysis of public data from the PH-JAY program, which is the world’s largest health assurance scheme providing health cover to about 500 million of the poorest Indians. The issue addressed by the paper is undoubtedly both an important and pertinent one, and has far-reaching implications for the many millions of vulnerable people served by the program.

Regarding rigour and reporting: the underlying logic and philosophy of the work is made clear, the objectives outlined well, and the approach and methods used to address them are presented well. The findings of this study offer very important lessons for improving the AB PM-JAY, and these could be communicated more clearly accessible to the reader to improve the impact of this paper. To this end, I offer the following recommendations:

Abstract

- The states named in the Results should be placed in order of the percentage of empanelled PMJAY facilities.

- The statements made in the conclusion are somewhat ambiguous. The authors could clarify what they mean by the “distribution of empanelled AB-PMJAY hospitals favours better performing states”. Firstly, does ‘better performing” allude to the state’s population health status, or the state’s health system, or something else? It is unclear what is meant by ‘favours’. It might be easier to simply state, for example, that most of the empanelled hospitals are located within states that already have well-functioning health system performance.

- The implications of this finding for policymakers could easily be outlined in the final sentence; i.e. highlight the need for greater empanelment of hospitals in states where it is most needed. In its current form, the final sentence is somewhat ambivalent in its tone and could do with some rewriting.

- Page 3 line 48-49: “appropriate balance of in purchase of care”. This sentence should be edited to use either ‘of’ or ‘in’.

Introduction

- The authors do well to introduce the key concepts and ground them within the international development agenda of the United Nations. The ongoing operationalization of PM-JAY is discussed in the context of cooperative federalism in the Indian union, and the contrasts in healthcare equity (e.g. RSBY) between urban and rural India.

- Page 5, Line 90 - 91: what is ‘cashless mode’ and a ‘floater basis’?

- Page 6, line 113: add a hyphen ‘urban-centric’

- Spelling and grammar:

o Page 5, line 81:“…financial protection for secondary and tertiary care to about bottom 40% of…” Please remove ‘about’.

Methods:

- These have been well described in sufficient detail to facilitate replication.

- The public data that was used in the analysis should be made available in a suitably formatted file (and a link provided in the manuscript), in accordance with the PLOS Data policy.

Results

- A lot of data has been presented here, including 7 tables. While the well-illustrated figures certainly make the findings more accessible, the sheer number of large tables do appear to compromise the readability of the manuscript, and thus risk obscuring the important messages buried therein.

- I would recommend that the authors consider placing large unwieldy tables in the supplementary material while making reference to them and their findings in the main body of the manuscript. Additionally, it is recommended that the authors avoid presenting the same data in both the table and figures. Wherever data has been presented in a figure with data values labelled, it is no longer necessary to also present this in a table.

Discussion

- The discussion identifies several issues of high importance, for example, the primary care coverage, lack of cardiology and nephrology services, etc. I request that the authors compile and present a discrete, bulleted list of policy recommendations based on the critical analysis outlined in the discussion. Not only would this improve the accessibility of the study’s findings and highlight the importance of this analysis, but this would go some way towards fulfilling the social responsibility of research such as this: to actually improve human health. The recommendations could be presented in a box or figure for better readability and could also be outlined in the final part of the abstract. Such presentation would provide ideal messages for effective media communication in the post-publication period.

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Reviewer #1: Yes: Dr Nishant Kumar

Reviewer #2: Yes: Dr. Ramesh Holla

Reviewer #3: No

Reviewer #4: No

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PLoS One. 2021 May 27;16(5):e0251814. doi: 10.1371/journal.pone.0251814.r002

Author response to Decision Letter 0

26 Mar 2021

Empanelment of Health Care Facilities under Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB PM-JAY) in India; PONE-D-20-33726

Response for Additional Editor Comments

1. The paper currently looks more of a descriptive in nature. Lacks analytical rigour and critical/logical interpretations. Some of the interpretations of the findings look indolent and show a sloppiness.

Thank you for the critical feedback. This analysis is based on a data of empanelled health facilities, therefore only basic descriptive inferences were made. We don’t intend for the results to look sloppy – while additional analyses would be desirable, we feel there are already novel contributions based on this work, worthy of publishing. We are encouraged that other reviewers have not rejected our argument, but rather offered critical revisions to improve it.

2. The conclusion doesn’t support with data. Authors need a little more intriguing interpretations and conclusions. For instance, the authors write: “the current distribution of empanelled AB-PMJAY hospitals favours better performing states”. In what terms authors saying better performing states. If I look at the five states that authors listing on socio-economic and health status grounds, only two states are better performing states. Rajasthan, Uttar Pradesh and Gujarat are poor and moderately performing in terms of health care and outcome indicators. The possible reason for the larger contribution from these states needs to be explained. Maybe one reason could be all of them are BJP ruling states or its alliance ruling states at the time of programme conceptualisation and initiation. So, the state role needs to be clearly drawn in this case.

We agree that our findings are not dramatic and indeed that empanelment is not greater only in better performing states. However, there are an important foundation on which to advance other areas of inquiry. The “why” of these findings is out of scope of the current analysis and would make use of methods – political economy analysis etc. We make mention of this in our discussion on page 23.

The editor may appreciate that we as authors are not looking at the “why” question using a purely academic, political economy lens as that would affect our ability to work in and partner with states, precisely for the reasons of political economy that can be studied or explored at a distance, but come at a cost in terms of applied health systems research.

3. Also, the authors must explain the reasons why Private Sectors hospitals not actively taking part in the programme from several angles, especially from the side of state subsidies vis-a-vis the regular out-pocket expenses of hospitals in this sector. Thus, how to reach a consensus on these grounds?

The data we accessed for the study will not provide answers to the question of why private hospitals are actively taking part, as we are looking only at the empanelment and facility distribution provided by NHA. We tried to examine the literature on this but were not able to find any published evidence. However, we did find evidence on private sector participation in publicly funded health insurance in relation to poverty status of the state and have referenced this in the discussion, on page 18. Further research is required to answer the above questions which we have also mentioned on our limitation section on page 28.

4. Some states following a much better health care schemes than AB-PMJAY for instance, Telangana and Andhra Pradesh. Thus, the state’s private hospitals have mostly partnered with states programmes than central programmes. Some of these intricacies missing from the paper.

In the current study, our aim is to describe the pattern and distribution of hospitals under AB-PMJAY. We looked for published literature that describes the partnership models of certain states in the insurance space and were not able to find such resources. We’d be grateful if the editor could point us to towards such resources so we may add them in our discussion.

5. Also, authors critically need to evaluate how far private insurance-based health care schemes work in a highly privatised, compartmentalised and hierarchical health care service delivery system like India.

We agree that the landscape in India is highly privatised; yet the relationship of this to empanelment is vexed, as we point out on page 8 (i.e. empanelment of the private sector is low in states like Bihar and Chhattisgarh). Beyond this, a critical evaluation of how private schemes work is not in the scope of our study as we were only focussing on the distribution of public/private facilities under PMJAY scheme using the empanelment data.

6. The paper completely silent on budgetary allocations to meet the stated goals.

This is an absolutely critical analysis that we have recommended in our limitations of study on page 28. However, our focus is on the empanelment issue beyond which we are not clear on what budgetary allocations the editor is referring to. Do you mean overall funding for PMJAY? Or is this in reference to claims processing? This data is often not easily available and while important – we have tried to explore issues we feel are relevant on page 29.

Response to Reviewers Comments to the Author

Reviewer #1:

1. The objective of study is not stated, and data presented its analysis in the study does not support the conclusion.

Thank you for the comment, objectives of our study are stated at the end of the introduction section, on page 10-11. We have, moreover rephrased and re-written sections for clearer readability and linkage across results and conclusions (see pages 13-23).

2. A large section of introduction and discussion appear to copy and pasted.

We were surprised to see this comment! We did a plagiarism check and, the percentage of repeated text is less than 10%. However, based on this comment, we have revised the introduction (5-11) and discussion sections (23-28).

3.The entire introduction section needs to re-written which focus on what the author intent to achieve though the study.

Thank you for the comment; our introduction (5-11) has been revised focusing on the aims and objectives of the study.

4.The result do not support the conclusion. The discussion section of the study is vague and does not support the conclusion.

This point is well taken. We have revised the conclusion (page 29) substantially to reflect the results (12-33) and also made appropriate changes to the discussion section (23-22) accordingly.

Reviewer #2:

1. Please be uniform while converting INR to USD all through the manuscript (Line no. 91)

Suggestion well taken and changes made where relevant.

2. Considering India having large geographical area, result could have discussed in terms of regions (South, North, Central, Eastern) rather than individual states.

Considering the suggestions, we have added the major tables of the study geographically and the same is added as Supplementary File (S1 File).

Reviewer #3:

1. Abstract - conclusion section: In Line 46 the authors mention “better performing states”. I would like to see it written specifically with regard to what aspects they are better performing.

Thank you for the comment, we have removed the statement better performing state, changes have been made in page 4 of abstract conclusion section

2. Line 49- the authors mention that finding the appropriate balance of in purchase of care is critical to the success of any publicly financed insurance scheme in India. How do we measure success? I think the authors could provide the specific detail of success of PM-JAY in terms of coverage, or effectiveness of the health insurance scheme.

It is true that measuring success has many dimensions in the case of insurance schemes. PMJAY has shown limitations and strengths in coverage and the evidence on effectiveness is limited as of now. We point this out in our discussion on pages 23-28.

3. In the Methods section, the authors need to mention about why the ethics statement was not needed for this study.

This was an inadvertent omission. An ethics statement is now included in the methods on page 11.

4. The authors have used the term cross sectional in line 32 and line 168. This is not a cross sectional study design in my understanding since it doesn’t involve primary research. The study methodology could be written as “secondary analysis of cross-sectional data using descriptive statistical methods”.

The suggestion is well taken, the changes have been made in the abstract page 3 as well as the methods page 11

5. Table 1. Key Features of the Pradhan Mantri Jan Arogya Yojana (PMJAY),

Under Who uses the services? Section, Point “a” mentions “Enrolled Population falling under the category” is not clear to me. Does the word “category” in point “a” refer to the ones mentioned in b, c and d? I would like to see if that part can be clarified.

The suggestion is well taken, the changes have been made in Table 1 under “Who uses the services?”

6. Line 177: citation 34 – the link directs to a page with the message “forbidden access”.

Thank you for pointing out the error. This issue happened due to site upgradation by PMJAY post data collection. The chance of recurrence of this issue cannot be avoided as there may be changes in the data URL with every website upgradation.

7. Line 180: The Database that has been developed as mentioned and link given on reference number 35 is not accessible. I would recommend the authors to check the submission guidelines so as to meet the publication criteria with regard to fulfilling the criteria for validation, utilization and availability of database. “The Database should ideally discuss plans for long term database growth, maintenance and stability. Authors should provide a direct link to the database hosting site from within the paper.” The link is provided in the manuscript in reference number 35 but I have not been able to access the same.

The dataset used for this study is now submitted as Supplemental File (S 2 File).

8. Line 234: In my understanding, when the term “only” is used, the authors seem to be inclined towards the empanelment of more private facilities which may or may not guarantee effectiveness of PM JAY coverage as per the studies that I have come across. Or if the authors prefer to stick to that statement then they may choose to highlight more studies that show why empanelment of private facilities has shown to be effective or also provide evidence as to why creating a balance between private and public is crucial. Although they have addressed the same, I think it is not enough. It would be good to ponder over the following questions. 1)Do we solely take the patient choice of providers/facility into consideration 2) Do we consider how effective the coverage can be regardless of the type of facility (public/private) especially in terms of reduction in the out-of-pocket expenditure and catastrophic expenditure for the enrolled patients. 3) Would empanelment of private/public facilities improve access or financial protection for the enrolled patients? The same goes for the statement in line 412 where the authors mention about the over representation of public facilities. I hope the authors understand what I am trying to say. If they would like additional insights, they may refer to literature on the suitability of publicly funded purchasing from private providers in the Indian Context.

The reviewer brings up critical points. We had referenced the literature on publicly funded health insurance as part of our discussion on page 24. Some of these questions cannot be answered from our analysis, which we indicate in our limitations on page 28 and recommendations for further analysis across the discussion.

9. Line 336 and 340: I am unable to read the articles as the link directs to a website that mentions error/ page not found. (Citation number 39 and 40)

Thank you for pointing this out, the citation has been updated

10. I am in total agreement with Line 352 where the authors mention that Participation of the private sector in public health insurance is a critical area for further research and policy attention.

Thank you for your comment

Reviewer #4:

This paper presents an analysis of public data from the PH-JAY program, which is the world’s largest health assurance scheme providing health cover to about 500 million of the poorest Indians. The issue addressed by the paper is undoubtedly both an important and pertinent one, and has far-reaching implications for the many millions of vulnerable people served by the program.

Regarding rigour and reporting: the underlying logic and philosophy of the work is made clear, the objectives outlined well, and the approach and methods used to address them are presented well. The findings of this study offer very important lessons for improving the AB PM-JAY, and these could be communicated more clearly accessible to the reader to improve the impact of this paper. To this end, I offer the following recommendations:

1. Abstract - The states named in the Results should be placed in order of the percentage of empanelled PMJAY facilities.

We thank the reviewer for the suggestion, changes are made on page 3

2. The statements made in the conclusion are somewhat ambiguous. The authors could clarify what they mean by the “distribution of empanelled AB-PMJAY hospitals favours better performing states”. Firstly, does ‘better performing” allude to the state’s population health status, or the state’s health system, or something else? It is unclear what is meant by ‘favours’. It might be easier to simply state, for example, that most of the empanelled hospitals are located within states that already have well-functioning health system performance.

Suggestion is well taken, although as other reviewers have pointed out, not all the states with high empanelment have well-functioning health system. We have revised the text to reflect this on page 3-4

3. The implications of this finding for policymakers could easily be outlined in the final sentence; i.e. highlight the need for greater empanelment of hospitals in states where it is most needed. In its current form, the final sentence is somewhat ambivalent in its tone and could do with some rewriting.

Thank you for the comment, the section has been re-written in both the abstract and conclusion page 3-4

4. Page 3 line 48-49: “appropriate balance of in purchase of care”. This sentence should be edited to use either ‘of’ or ‘in’.

Suggestion is well taken, and changes on pages 3-4

Introduction - The authors do well to introduce the key concepts and ground them within the international development agenda of the United Nations. The ongoing operationalization of PM-JAY is discussed in the context of cooperative federalism in the Indian union, and the contrasts in healthcare equity (e.g. RSBY) between urban and rural India.

5. Page 5, Line 90 - 91: what is ‘cashless mode’ and a ‘floater basis’?

Suggestion well taken, explanation provided for cashless mode and floater basis in page 7

6. Page 6, line 113: add a hyphen ‘urban-centric’

Suggestion well taken; changes made in page 9

7. Spelling and grammar: Page 5, line 81: “…financial protection for secondary and tertiary care to about bottom 40% of…” Please remove ‘about’.

Suggestion well taken; changes made in page 6

8. Methods:

- These have been well described in sufficient detail to facilitate replication.

- The public data that was used in the analysis should be made available in a suitably formatted file (and a link provided in the manuscript), in accordance with the PLOS Data policy.

Thank you for the suggestion, all the data that were for the analysis shall be made available publicly in compliance with PLOS data policy as Supplementary File S 2 File

9. Results

- A lot of data has been presented here, including 7 tables. While the well-illustrated figures certainly make the findings more accessible, the sheer number of large tables do appear to compromise the readability of the manuscript, and thus risk obscuring the important messages buried therein.

Thank you for the suggestion, Many of the tables are now incorporated in Supplementary file S1 File

- I would recommend that the authors consider placing large unwieldy tables in the supplementary material while making reference to them and their findings in the main body of the manuscript. Additionally, it is recommended that the authors avoid presenting the same data in both the table and figures. Wherever data has been presented in a figure with data values labelled, it is no longer necessary to also present this in a table.

Thank you for the suggestion, we have moved the large table to Supplementary file S1File

9. Discussion

- The discussion identifies several issues of high importance, for example, the primary care coverage, lack of cardiology and nephrology services, etc. I request that the authors compile and present a discrete, bulleted list of policy recommendations based on the critical analysis outlined in the discussion. Not only would this improve the accessibility of the study’s findings and highlight the importance of this analysis, but this would go some way towards fulfilling the social responsibility of research such as this: to actually improve human health. The recommendations could be presented in a box or figure for better readability and could also be outlined in the final part of the abstract. Such presentation would provide ideal messages for effective media communication in the post-publication period.

A number of suggestions have emerged from this research, particularly for more research(!). We have indicated these in the abstract as well as the discussion section (pages 3-4 & 23). Listing them in a box makes them somewhat disconnected from context, so we haven’t done this, but if the reviewer is strongly keen on this, we could try.

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Attachment

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Decision Letter 1

Srinivas Goli

4 May 2021

Empanelment of Health Care Facilities under Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB PM-JAY) in India

PONE-D-20-33726R1

Dear Dr. Joseph,

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Acceptance letter

Srinivas Goli

17 May 2021

PONE-D-20-33726R1

Empanelment of Health Care Facilities under Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB PM-JAY) in India

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Associated Data

    This section collects any data citations, data availability statements, or supplementary materials included in this article.

    Supplementary Materials

    S1 Table. Distribution of public sector PMJAY empanelment across levels of care and by mode of implementation.

    (DOCX)

    Click here for additional data file. (16.1KB, docx)
    S2 Table. State wise distribution of public health care facility empanelment under PMJAY.

    (DOCX)

    Click here for additional data file. (20.1KB, docx)
    S3 Table. State wise distribution of public health care facility empanelment under PMJAY by geography.

    (DOCX)

    Click here for additional data file. (20KB, docx)
    S4 Table. State wise estimates of number of beds in public empanelled health care facilities under PMJAY.

    (DOCX)

    Click here for additional data file. (21.8KB, docx)
    S5 Table. State wise estimates of number of beds in public empanelled health care facilities under PMJAY by geography.

    (DOCX)

    Click here for additional data file. (22.1KB, docx)
    S6 Table. State wise availability of public empanelled hospitals per hundred thousand eligible population by mode of implementation.

    (DOCX)

    Click here for additional data file. (15KB, docx)
    S1 File

    (XLSX)

    Click here for additional data file. (700.5KB, xlsx)
    Attachment

    Submitted filename: Response to Reviewers.docx

    Click here for additional data file. (34.7KB, docx)

    Data Availability Statement

    All relevant data are within the manuscript and supporting information files.

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