Heidelberg Institute of Global Health, Medical Faculty and University Hospital, Heidelberg University, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany.
Institute for Global Health and Development, Queen Margaret University, Edinburgh, EH21 6UU, United Kingdom.
Health Res Policy Syst. 2023 Jun 27;21(1):65. doi: 10.1186/s12961-023-01012-7.
The Pradhan Mantri Jan Arogya Yojana (PM-JAY), a publicly funded health insurance scheme, was launched in India in September 2018 to provide financial access to health services for poor Indians. PM-JAY design enables state-level program adaptations to facilitate implementation in a decentralized health implementation space. This study examines the competency, organizational, and leadership approaches affecting PM-JAY implementation in three contextually different Indian states.
We used a framework on implementation drivers (competency, organizational, and leadership) to understand factors facilitating or hampering implementation experiences in three PM-JAY models: third-party administrator in Uttar Pradesh, insurance in Chhattisgarh, and hybrid in Tamil Nadu. We adopted a qualitative exploratory approach and conducted 92 interviews with national, state, district, and hospital stakeholders involved in program design and implementation in Delhi, three state capitals, and two anonymized districts in each state, between February and April 2019. We used a deductive approach to content analysis and interpreted coded material to identify linkages between organizational features, drivers, and contextual elements affecting implementation.
PM-JAY guideline flexibilities enabled implementation in very different states through state-adapted implementation models. These models utilized contextually relevant adaptations for staff and facility competencies and organizational and facilitative administration, which had considerable scope for improvement in terms of recruitment, competency development, programmatic implementation support, and rationalizing the joint needs of the program and implementers. Adaptations also created structural barriers in staff interactions and challenged implicit power asymmetries and organizational culture, indicating a need for aligning staff hierarchies and incentive structures. At the same time, specific adaptations such as decentralizing staff selection and task shifting (all models); sharing of claims processing between the insurer and state agency (insurance and hybrid model); and using stringent empanelment, accreditation, monitoring, and benchmarking criteria for performance assessment, and reserving secondary care benefit packages for public hospitals (both in the hybrid model) contributed to successful implementation. Contextual elements such as institutional memory of previous schemes and underlying state capacities influenced all aspects of implementation, including leadership styles and autonomy. These variations make comparisons across models difficult, yet highlight constraints and opportunities for cross-learning and optimizing implementation to achieve universal health coverage in decentralized contexts.
印度政府于 2018 年 9 月推出了全民健康保险计划（PM-JAY），旨在为贫困印度人提供获得医疗服务的经济支持。PM-JAY 设计允许各州根据自身情况对项目进行调整，以促进分散的医疗实施空间中的实施。本研究考察了影响 PM-JAY 在印度三个具有不同背景的邦实施的能力、组织和领导方法。
我们使用实施驱动因素（能力、组织和领导）框架来理解在 PM-JAY 的三种模式下促进或阻碍实施经验的因素：北方邦的第三方管理机构、恰蒂斯加尔邦的保险、泰米尔纳德邦的混合模式。我们采用了定性探索性方法，于 2019 年 2 月至 4 月期间，在德里、三个邦首府以及每个邦的两个匿名区，对参与项目设计和实施的国家、州、地区和医院利益相关者进行了 92 次访谈。我们采用了演绎法进行内容分析，并对编码材料进行解释，以确定影响实施的组织特征、驱动因素和背景因素之间的联系。
PM-JAY 指导方针的灵活性使该计划能够在非常不同的邦实施，这是通过各州适应的实施模式实现的。这些模式利用了与员工和医疗机构能力以及组织和促进管理相关的、具有现实意义的调整，这些调整在招聘、能力发展、项目实施支持以及协调项目和执行者的共同需求方面有很大的改进空间。调整还在员工互动方面造成了结构性障碍，对隐含的权力不平衡和组织文化提出了挑战，表明需要调整员工的等级制度和激励结构。同时，特定的调整，如员工选拔和任务转移的去中心化（所有模式）；保险公司和邦机构之间的理赔处理共享（保险和混合模式）；以及使用严格的列名、认证、监控和基准测试标准进行绩效评估，并为公立医院保留二级保健福利套餐（混合模式），都有助于成功实施。体制记忆和州能力等背景因素影响了实施的各个方面，包括领导风格和自主权。这些变化使得对不同模式进行比较变得困难，但突出了交叉学习和优化实施的限制和机会，以在分散的背景下实现全民健康覆盖。
