International Journal of Community Medicine and Public Health

Rout SK et al. Int J Community Med Public Health. 2021 May;8(5):2338-2345

http://www.ijcmph.com pISSN 2394-6032 | eISSN 2394-6040

DOI: https://dx.doi.org/10.18203/2394-6040.ijcmph20211755
Original Research Article

State led innovations for achieving universal health coverage in a low

resource setting Odisha, India: opportunities and challenges
Sarit K. Rout1*, Upasona Ghosh1, Amrita Parhi1,
Sudhashree Chandrashekhar2, Shridhar M. Kadam1

1
Indian Institute of Public Health, Bhubaneswar, Odisha, India
2
Senior consultant, World Bank Health system transformation platform- HSTP and New Delhi, India

Received: 23 February 2021

Revised: 05 April 2021
Accepted: 06 April 2021

*Correspondence:
Dr. Sarit K. Rout,
E-mail: sarit.kumar@phfi@org

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background: Odisha, a developing state of India, has introduced an innovative scheme known as Biju Swasthya Kalyan
Yojana (BSKY), which aims at providing free health care to all the people. This paper examines the scope, key features,
challenges and potentiality of BSKY to achieve universal health coverage (UHC) in Odisha.
Methods: We reviewed policy documents and conducted qualitative interviews with key state government officials and
other stakeholders to understand implement processes and constraints.
Results: The scheme intends to provide free health care to all people in public health care institutions and additionally,
71 lakh poor households can avail health care services from the empanelled private hospitals with financial coverage
up to 5 lakhs per family and women members up to 10 lakhs annually. This is implemented in assurance mode by
merging state-run schemes- Rashtriya Swasthya Bima Yojana (RSBY), Biju Krushak Kalyan Yojana (BKKY) and
Odisha State treatment fund (OSTF). The implementing agency is introducing several measures to control unnecessary
health care utilisation and cost. Gate keeping mechanism and reserved packages by public hospital are major initiatives
in this direction. Further, efforts to settle claims on time and IT related challenges are teething problems of the scheme.
The findings further suggest that public expenditure on health stands at 1.3% of GSDP and inadequate human resources
and health infrastructure are affecting service delivery.
Conclusions: Achieving UHC with such a low public spending on health and different service delivery constraints
looks ambitious. Odisha may learn from other countries to implement UHC phase wise.

Keywords: Biju swasthya kalyan yojana, Publicly funded health insurance, Financial protection, Universal health
coverage

INTRODUCTION budget. Further, percentage of population impoverished

due to OOP increased from 1.8 to 2.5% in 2015. This
Globally, the health systems are facing several constraints suggests financial protection is deteriorating across the
for achieving Universal Health Coverage (UHC). One of globe. The progress towards UHC differs across countries
the major barriers in achieving UHC has been low financial with different service coverage and financial protection
protection to people and the proportion of population with measures.1 Since there is no standard approach towards
out-of-pocket expenditure exceeding 10% of household achieving UHC, countries have adopted different

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 Rout SK et al. Int J Community Med Public Health. 2021 May;8(5):2338-2345

pathways. In a recent review, the World Bank suggested public health system in order to achieve UHC for its 43
how countries have designed bottom-up approach million people.13
especially focusing on the poor and vulnerable population
to achieve UHC. This review suggested that balance In this paper, we critically examined the scope, key
between financing and provisioning gaps is required to features, challenges and potentiality of BSKY to achieve
provide financial protection to achieve UHC.2 Successful UHC in Odisha. The scheme is new and many processes
examples of bottom-up approaches with emphasis on are undergoing rapid changes during the implementation
financing and provisioning strategies towards achieving phase. Hence, evidence generated and recommendation
UHC can be cited from several middle-income and low made at the initial stage (within one and half years of
middle-income countries. For instance, Philippines’ tax implementation) by the study might help the State and the
based social health insurance for both public private sector other regions alike globally, with similar financial and
workers; Thailand’s Universal Coverage Scheme (UCS); service provision challenges to learn from this experiment.
Brazil’s Unified Health System run by publicly- funded
services at the municipal level though federal government METHODS
revenues and a decentralized health care system; Cuban
system of community- based polyclinics embedded within The study used a mix of qualitative techniques, review of
traditional medical care services and building trained secondary literature and exiting related data to investigate
health human resources from the local neighbourhood- the objectives. We analysed available scientific literature
based family medicine clinics are some of the innovations and government published documents to understand
which strengthen the paths towards UHC.3-6 service coverage and health financing situation of Odisha.
Programme guidelines, government orders and
India is also not an exception and has introduced several notifications of BSKY were reviewed to understand
measures to achieve UHC. Low public spending on health implementation processes.
is one of the major obstacles to achieve UHC in India.
Despite high economic growth witnessed in last decade, Qualitative techniques - key informant interviews,
India’s public spending stands at 1.18% of GDP and out of participant observations, and group discussions were used
pocket expenditure (OOPE) is quite high at 64.7% of total to explore how the scheme has evolved and implemented.
health expenditure.7 Scholarly evidence showed impacts of Stakeholders related to BSKY formulation and
OOPE on household poverty and vulnerability, estimated implementation both in state and district level were our
that around 32.5 to 37 million people have fallen below the study respondents. An open ended questionnaire was
poverty line due to OOPE on health.8,9 administered to understand perspectives of the
stakeholders after piloting the same with a few significant
Another recent study shows medicine constitutes a major state level officials. Key Informant Interviews were
share in total OOPE and alone pushed 38 million people in conducted with personnel associated with the process of
to poverty.10 World Health Organization (2019) report on designing the scheme at the state level – state health
financial protection in health estimated that only 56% of assurance society (SHAS) and in one district of Odisha in
the population of India has access to essential services.1 an inductive way. We interviewed six key respondents
Therefore, financing health remains a major challenge in involved in formulation, operation, claims settlement and
the country for achieving UHC. IT operations of BSKY, four district level health officials
and four Third Party Administrators (TPAs) associated
In order to address ‘financing gap’, the country has with BSKY implementation between August 2019 and
introduced several publicly financed insurance/assurance December 2019.These respondents were identified based
schemes and many states launched their own schemes to upon their level of association with the implementation
provide financial risk protection against hospitalization process. We asked the questions related to: 1) genesis of
cost.11 Most recently, in 2018, the union government BSKY 2) state-central polity dynamics 3) processes of
introduced Ayushman Bharath Pradhan Mantri Jan Arogya BSKY 4) implementation challenges 5) ground level
Yojana (AB PM-JAY) that intends to provide financial experiences and 6) future plans. We participated as
coverage up to five lakhs against secondary and tertiary observant in BSKY monthly review meetings conducted
care hospitalization to 40% of vulnerable households.12 by SHAS and we analysed our observations along with the
Although, PM-JAY is a national scheme, there are certain Key informant interviews through framework analysis
states which have not joined the scheme but have approach.
introduced their own scheme.
RESULTS
Odisha an eastern Indian, launched - Biju Swasthya Kalyan
Yojana (BSKY) in August, 2018 without joining the Health status and service coverage indicators
national scheme. Within the resource-scarce setting of
Odisha state, BSKY promises free health care for all the Odisha accounts for 3.5% of India’s population and ranks
people of the state irrespective of their socio-economic 16th in per capita GDP among 26 states of India.14 The
conditions. The scheme has inherent features to strengthen disease and morbidity pattern are rapidly changing in
Odisha with increase of non-communicable diseases along

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with the existing burden of communicable diseases. State’s workforce at 10 (Physician, surgeon and Nurse) doctors
Infant Mortality Rate (IMR) is 41 per thousand live births per 10,000 populations is woefully lower than the national
against the national average of (33) during 2019. Further, average of 21 and WHO recommendations of 2320.19
the maternal mortality ratio though was high, has reduced Further, there is also acute shortage of specialist doctors in
to 150 in 2016- 18 from 180 in 2014-16 as compared to the rural areas affecting service delivery adequately.
113 at all India during 2016-18.15 Moreover, the Crude
Death Rate (CDR) is higher (7.9) in Odisha than the As observed from the table 1, state’s performance in
national average (6.7).16 It is also noticed that even if the service coverage indicators is better than the national
state average has improved, a large rural and urban divide average barring gaps in a few indicators. Around 62% of
is found in some of the indicators. pregnant women received at least 4 ANC check-up in
Odisha which was above the national average of 51.2% as
Firms and Ngos V per NFHS-4. Similarly, the proportion of 12-23-month-old
HI Social children immunized in Odisha was 78.6% while in India it
Central health
government was only 62%. Further, Odisha recorded 85.3% of
institutional births and out of these, 75.9% were at public
State institutions.
government
More than three-fourth delivery (86.6%) took place under
13%
Househ supervision of trained medical professionals in Odisha
olds against the national average of 81.4%. (Table1).

Health financing situation of Odisha

According to the state health accounts report, total health

Figure 1: Distribution of health expenditure in 2013- expenditure constituted 4.58% of GSDP of which the share
14. of public expenditure was 1.12% and rest 3.46% was
Source: Odisha State Health Accounts 2013-14. private in 2013-14.20 Further, the distribution of health
expenditure showed that the risk pooling mechanism was
weak as the share of out of pocket expenditure (OOPE) in
Government Health
total health expenditure was 76%. A further breakdown of
6 Expenditure (%)
household expenditure indicated that a majority around
5. 5.
61 14 5. 58% was spent on medicine, followed by diagnostic and
5 4. 4. 24 patient transport. There has been a minor drop in the share
95 77
4
of OOPE to 71.5% of total health expenditure in 2015-16
as indicated in the recent National health accounts report.7
This suggests that the OOPE is too high in the state.

1. 1. 1. Recently the state government has taken measures to

3 1. 29 21 3
1.
14 increase public expenditure on health and as mentioned in
1 03 Figure 2, the share of public expenditure on health has
stepped up and it has reached around 1.3% of GSDP and
2014 2015 2016 2017 2018
5.24% of total government expenditure in 2018-19. As
-15 -16 -17 -18 -19 major portion of OOPE purchase of medicine by the
PHE (% of PHE (% people, the state government has introduced NIRAMAYA-
GSDP) of TE)
(free drug distribution scheme) in public hospitals to
Figure 2: Share of public health expenditure in total contain the share of OOP for drugs and Nidhan (free
government expenditure and GSDP. diagnostic services) at district hospitals partnership with
Source: Authors calculation from State Government Budget private laboratories.
Documents
Considering Odisha’s high OOP, the state government had
Odisha’s health system shows a higher utilization from introduced Rashtriya Swasthya Bima Yojana (RSBY),
public sector with a limited role of private sector. As Biju Krushak Kalyan Yojana (BKKY), and Odisha State
observed, 56.8% of outpatient and 72.2% inpatient visits Treatment Fund (OSTF) to provide financial protection to
take place in public facilities.17 Public health system faces people. RSBY was introduced by the Central government
several constraints due to inadequate man power, limited and was launched in Odisha in 2009. This scheme aimed
public spending on health leading to high OOPE at the at covering hospital expenses up to 30,000 per family for
point of care, inaccessible health services resulting from below poverty line population with sharing of premium by
several supply side and demand side constraints and poor both state and union government.
quality of care.18 A recent study showed that the health

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Table 1: Service indicators.

Service Indicators Odisha India

Maternal health
% Mothers who had at least 4 or more ANC check-ups (to total ANC regd.) (NFHS-
62 51.2
4 2015-16)
% Mothers who had full antenatal care (NFHS-4 2015-16) 23.1 21
% Institutional deliveries (NFHS-4 2015-16) 85.3 78.9
% Institutional delivery in public facility (NFHS 4 2015-16) 75.9 52.1
% Births attended by (Doctor/Nurse/ANM/LHV)- (NFHS 4 2015-16) 86.6 81.4
Family planning
% Contraceptive prevalence rate (any method) (NFHS 2015-16) 57.3 53.5
Immunization
Children age 12-23 months fully immunized (BCG, measles, and 3 doses each of
78.6 62
polio and DPT) (%) (NFHS 4 2018-19)
Infectious diseases
Total case notification rate of TB per 1,00,000 population (NHP 2018-19) 159 204
347860 84455
No. of Malaria cases & deaths in 2017 (NHP 2018-19) and 8 and
24 194
Annual Parasite Incidence (API) per 1,000 population (2019) >5 <2

The state launched another scheme- BKKY, for the farmer announced AB PMJ-AY in February 2018, one of the
community to protect them from the financial hardships largest health insurance schemes in the world, which aims
resulting from hospitalization. As per the scheme, the at providing health cover of Rs. 5 lakhs per family per year
farming households are eligible for coverage of 100,000 for secondary and tertiary care hospitalization to over
INR per year. There are two streams: BKKY stream I and 10.74 crores poor households constituting 40 percent of
stream II. In stream I, all eligible farming households get Indian Population . Both centre and participating states
coverage up to 100,000 INR per family per year.21 Under share the resources in 60: 40 ratios while North-east states
stream II, all eligible farming households who are RSBY the sharing pattern of centre and state is 90:10 and Union
beneficiary get 70,000 on the top of 30,000 available under territories 100% support is provided by the centre.
RSBY. In addition to the health insurance schemes, the
state also provides financial assistance to people suffering As per our discussions with respondents, Odisha, in spite
from life threatening disorders and diseases, through the of several rounds of negotiations opted out of the scheme
Odisha State Treatment Fund (OSTF). because of differences on population coverage with the
union government. As per the criteria of union
Nearly about 71 lakh households constituting nearly 71% government, 61 Lakhs families were eligible under
population of the state are covered by different schemes. PMJAY, who fulfilled the deprivation/inclusion criteria as
Though a limited number of studies have been conducted per the Socio-Economic Caste Census (SECC). However,
on the impact of these schemes on OOPE, most of them Government of Odisha considered including 71 Lakhs
showed that, despite implementation of these schemes, economically vulnerable families who were already
people incurred a huge OOPE at the point of care. One enrolled within the existing state health schemes. Since the
study suggested that most of the people despite being centre and state could not reach consensus regarding the
covered by the RSBY had to incur OOP and 60.01% of the number of beneficiaries, the state government preferred to
total OOP was on medicines. While only 5.7% of announce its own innovative scheme by merging all the
beneficiaries could benefit through the scheme, about existing state schemes.
47.5% beneficiaries spent out of their pocket to avail
treatment.22 RSBY beneficiaries incurred OOPE post Analysis of the processes of BSKY revealed that the
exhausting the coverage of Rs. 30,000/- so as to continue scheme is innovative in terms of covering all the citizens
treatment at the private hospitals.23 of Odisha assuring free health care services irrespective of
income, caste and social status at public health institutions.
Biju Swasthya Kalyan Yojana- Genesis and innovation Additionally, 71 lakh economically vulnerable households
can avail health care services from the empanelled private
BSKY is the latest endeavour by the state government to hospitals with financial coverage up to 5 lakhs per family
provide financial protection against hospitalization for its and 10 lakhs to women members.14 The families under
socio-economic vulnerable population. This was lunched these categories can receive cashless treatments at all
by the state government after the National government public health facilities as well as 179 empaneled private

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hospitals. Presently, there are 1589 packages under BSKY the TPA respondents explained the challenge with the
after merging all the packages from other schemes. This following case: “there are varying rates for a single
includes lump sum cost of inpatient treatment /day care/ procedure. The private hospitals are charging the higher
diagnostic procedure for which a beneficiary avails the package rate, as it is beneficial for them. While verifying
scheme. the documents, SHAS doctors raise objections to the
claims. This leads to rejection of claims or reducing the
A nodal agency known as State Health Assurance Society claim amount”. However, recently the state government
(SHAS) under the supervision of a senior bureaucrat has has modified the health benefit packages similar to AB-
been formed to implement the scheme. For managing the PMJAY.
hospitalization and settling claims by the private hospitals,
the SHAS hired two Third Party Administrators (TPAs) According to the state level respondents, transition from
who worked with private hospitals in different regions of insurance-based IT system to an assurance-based IT
the state till February 2020 and from March 1st, 2020 the system was itself a challenge. They further pointed out that
SHAS moved to a completely assurance mode. The IT cell the IT platform is facing basic challenges due to database
of BSKY has been developed to effectively implement, issues of earlier schemes of incorrect information of the
monitor and maintain transparency with the private sector. beneficiaries loaded in the RSBY/BKKY or OSTF
The software is also an integral part of the TPA managed identification cards. This creates confusion during the
private sector claim. Upon initial approval from both TPA claim settlement process. Respondents also stated that lack
and SHAS, patient details and medical transcripts are of trained and limited human resources increased the work
uploaded to the IT system for pre-authorization (for load; hence settling claim process after fraud checks,
packages only above Rs. 10000) and claims. TPAs review became a time-consuming process.
the documents and recommend for payment. Doctors from
the SHAS team verify the records and provide decision on At district level, the respondents stated that in most of the
a particular claim. district hospitals, there are inadequate infrastructure and
specialist doctors. Henceforth, district head quarter
Implementation challenges hospitals are forced to refer patients to private hospitals.
However, the referral system has its own formal and
During the interactions with various officials- SHAS team, informal limitations. As per BSKY guideline, a patient has
District Program Managers (DPM) and Medical Officers, to be referred to the medical college hospital after
the study found out a series of challenges related to consulting the referral committee comprising of health
governance, package rates, and generating awareness personnel in the treating facility.
among people. According to the majority of the
respondents, implementation challenges arise due to However, in the case of emergency, the district health
availability less than desired infrastructure and human officials have the authority to refer the patient without
resources at the ground. consulting the committee. According to a respondent at
district level:
Respondents at the state level stated that, implementing an
assurance (fully supported by the government) scheme like “In a formal referral procedure, a patient from our district
BSKY is different from implementing the previous hospital should be referred to the nearest medical college
insurance schemes- RSBY and BKKY. While hospital which is around 110 KM away. The newly opened
implementing insurance schemes, most of the activities medical college is still developing its infrastructure and
were managed by the insurance company. However, in the facilities. More so, being a hard-to-reach district,
assurance scheme-BSKY, the state authority- SHAS is availability of specialized doctors is a challenge there.
responsible for implementation of various activities- Hence, in most of the cases, the patients again have to be
fixations of package rate, empanelment process, IT referred back to us only”.
management, fraud detection and settlement of claims. As
per the state level respondents, seamless functioning of Respondents also stated that political influence and
such nuance processes requires more skilled human preferences of the patients are playing crucial role
resources which, at present, need to be developed at SHAS. informally in the referral system at district level. The state
According to most of the respondents, it may be the reason has also empanelled few hospitals in the neighbouring
for not able to achieve the turnaround time of the claims, states to improve access. One district level health official
leading fund flow issues to private hospitals. pointed out: “People of our district have a personal
preference to go to the city of neighbouring state which is
It was also observed that another implementing challenge approximately five hours journey by road. They prefer it
was related to the packages. During the launch of the because of the availability of specialized facilities for
scheme, number of packages was more, and efforts have treatment. Often, patients prefer to go there to avoid the
been made to minimize the number by converging similar long waiting time in the government health facility here.
packages. However, according to TPA and private sector Patients even use political pressure to refer the patient to
respondents there are overlaps, creating confusion among the neighbouring state”.
the private hospitals, TPAs and the SHAS doctors. One of

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Further, as a crucial stakeholder of the scheme -the private especially, in the districts covered by tribal population. As
health sector also have some concerns with the SHAS. the state has a higher proportion of people reliant on public
According to the private sector respondents, the long health facility (56.8% of OP and 72.2% IP visit occurs in
turnaround time for transfer of payments is one of the public hospitals)18, these gaps affect the service delivery
major reasons for which the private sector is losing interest largely.
in the scheme. The respondents unanimously agreed that
their previous experience of working with the government As revealed from this study, the scheme has some
in RSBY scheme influenced their concerns. Head of one implementation level constraints related to IT system,
of the prominent private hospitals in a district of Odisha experienced staff, multiple and overlapping packages,
stated- “I had lots of administrative as well as financial slow claims settlement process which is the main concern
issues while dealing with the government in RSBY. raised by private sector. The processing of claims is
Henceforth, I do not want to enter in any legal formalities delayed due to lack of compliance to documentation issues.
with the government again, we have good and functional It is further observed that the processes followed for
relations with the public facility in my block. We help each referral mechanism from public to private sector delay the
other in need”. service delivery which could be made seamless by
integrating with the IT system and updating the capabilities
According to the respondents, unavailability of specialist of the facilities on a regular basis to ensure appropriate
doctors is hampering the referral process and compelling referral. It is also observed that since the state is learning
the patients to seek care from neighbouring states by to implement such a large scheme, it may take some more
spending from their pocket. Further, concentration of time to overcome the process related challenges.
private hospitals only in urban areas is limiting the
utilization of the scheme. Further, the socio-economic indicators of the state need to
be discussed in order to draw inferences regarding the
DISCUSSION sustainability of BSKY. Odisha is one of the backward
regions of the country largely an agrarian economy, limited
This study based upon review of policy documents and industrial growth, prone to natural disasters and a higher
qualitative interview generated evidence on how an concentration of tribal people with multiple socio-
economically developing state of India made a modest economic deprivations. However, in the recent years, the
attempt to introduce an innovative scheme –BSKY, which state has witnessed higher gross state domestic product
aims at achieving UHC. We present here the findings from (GSDP) growth compared to the national average. In the
this study along with the socio-economic and fiscal fiscal front, the state has managed its fiscal situation well
position to explain the scope and feasibility of BSKY to in the recent past. It is noticed that the share of
provide universal health coverage to all its citizens. developmental expenditure to GSDP has remained around
16.44%, fourth highest among the comparable states of
The philosophy of declaring such a scheme though is well India.25 Similarly, state’s commitment to social sector
placed, the financing and provisioning gaps needs to be development is also comparable to many states of India
explained in proper perspective. The financing dimension and the current spending is around 41% of its total
as revealed from this study suggests that the share of public government expenditure.26 Given these developments, the
expenditure on health is low and lower level of public announcement of BSKY is commendable as it draws from
spending has led to higher OOPE.7 A large part of OOPE the people centered policies designed in the recent past.
occurs due to expenditure on medicine and diagnostic
services. Though this scheme has mandated to provide free Finally, learning from international and other state
medicine and diagnostic services in public hospitals, experiences also provide an opportunity for Odisha to draw
however, the success lies in adequate financial resources lessons and shorten the learning curve for implementation
and man power at the periphery health care institutions to of UHC schemes in Odisha. It is noticed that the share of
balance between ‘financing’ and ‘provisioning’ gaps. public expenditure has remained substantially higher in
countries that have achieved UHC or have made
The service coverage indicator, another dimension of considerable progress in UHC. For instance, the share of
UHC, as revealed from this study shows that the state’s government health expenditure in total government
performance is better than the national average in most of expenditure was 6.5% in Ghana, 10.4% in Mexico and
the indicators- percentage of institutional delivery, mothers 15.3% in Thailand in 2016, whereas this was around 5% in
who had full antenatal check-ups and births attended by Odisha.26 It might be difficult to provide all population of
skilled personal except the burden of malaria and the state free health care services in public hospitals with
tuberculosis. Though this appears to be a positive such a low level of public expenditure. Moreover, some of
development, however, the service delivery is severely these countries have designed the scheme differently
affected due to shortage of health infrastructure and human unlike Odisha which aimed at providing free care to all
resources at the peripheral health care institutions. There is citizens in spite of several constraints in public health
huge shortage of specialists at the district hospitals and system. The experiences of Thailand, Ghana or Mexico are
below.19 For instance, there are only 1.44 government worth mentioning here. Thailand started its UHC journey
doctors per 10,000 populations. This is worse in rural areas long back in 1975. It gradually started with initially

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 Rout SK et al. Int J Community Med Public Health. 2021 May;8(5):2338-2345

covering 30 percent of its population, extending to near Transformation in Odisha" and technical support provided
poor in 1985, and inclusion of formal sector employees by HSTP team for this study.
through contributory social security scheme and finally in
2000 it declared UCS for everyone.3,4 Similarly, Mexico Funding: Sir Ratan Tata Trust
introduced publicly funded insurance for informal sector Conflict of interest: None declared
and poor where there was strongly social security for Ethical approval: The study was approved by the
formal sector workers. It moved toward UHC by Institutional Ethics Committee
increasing public spending on health 5 % annually from
2000 to 2006.27 Therefore, in the current form, the REFERENCES
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