Towards universal health coverage in India: a historical examination of the genesis of Rashtriya Swasthya Bima Yojana – The health insurance scheme for low-income groups

•The authors explore the RSBY's genesis and early development.•The authors aim was to understand its conceptualisation and design principles and thereby establish a baseline for assessing RSBY's performance in the future.•Efficiency and productivity rather than human needs were overriding concerns for RSBY designers.•RSBY hence only funded the ‘poorest’ of the poor and offered only inpatient services.•Expanding access requires evidence-based policies guided by local morbidity and health spending patterns.

ObjectivesMany low- and middle-income countries have introduced State-funded health programmes for vulnerable groups as part of global efforts to universalise health coverage. Similarly, India introduced the Rashtriya Swasthya Bima Yojana (RSBY) in 2008, a publicly-funded national health insurance scheme for people below the poverty line. The authors explore the RSBY's genesis and early development in order to understand its conceptualisation and design principles and thereby establish a baseline for assessing RSBY's performance in the future.Study designQualitative case study of the RSBY in Delhi.MethodsThis paper presents results from documentary analysis and semi-structured interviews with senior-level policymakers including the former Labour Minister, central government officials and affiliates, and technical specialists from the World Bank and GIZ.ResultsWith national priorities focused on broader economic development goals, the RSBY was conceptualised as a social investment in worker productivity and future economic growth in India. Hence, efficiency, competition, and individual choice rather than human needs or egalitarian access were overriding concerns for RSBY designers. This measured approach was strongly reflected in RSBY's financing and benefit structure. Hence, the programme's focus on only the ‘poorest’ (BPL) among the poor. Similarly, only costlier forms of care, secondary treatments in hospitals, which policymakers felt were more likely to have catastrophic financial consequences for users were covered.ConclusionsThis paper highlights the risks of a narrow approach driven by developmental considerations alone. Expanding access and improving financial protection in India and elsewhere requires a more balanced approach and evidence-informed health policies that are guided by local morbidity and health spending patterns.