Study Protocol: A mixed method and multimethod study of implementation and impact of Ayushman Bharat- Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) scheme in Assam State

Study Protocol: A mixed method and multimethod study of implementation and impact of Ayushman Bharat- Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) scheme in Assam State | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Study protocol Study Protocol: A mixed method and multimethod study of implementation and impact of Ayushman Bharat- Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) scheme in Assam State Vivek Verma, Dilip Chandra Nath, Robina Chetri, Pallavika Sarma, and 8 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4794755/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction: Ayushman Bharat- Pradhan Mantri Jan Arogya Yojana (AB-PMJAY), is an Indian Government initiated health insurance scheme, with the purpose to improve access and availability of secondary and tertiary inpatient care and reduce additional financial burden of out-of-pocket expenditure (OOPE) due to medical expenses from economical weaker sections of Indian population. AB-PMJAY was launched in the year 2018 and in the same year was implemented in Assam state. To obtain the evidence of impact and implementation of of AB-PMJAY in terms of healthcare services availability, accessibility, and affordability after the first 5 years of the scheme’s operations in Assam state. Methods and analysis : The study will follow a mixed methods approach using triangulation mixed methods design along with a multimethod approach. Primary data (qualitative and quantitative surveys) and secondary data (National Sample Survey (NSS) previous rounds – 60 th (2004), 71 st (2014) and 75 th (2017) will be considered. 75 th round of NSS of Assam will be considered as the baseline for the present study. The present protocol describes the methodological aspects adopted for evaluation of effectiveness and implementation strategies of AB-PMJAY in five districts viz. Kamrup Metropolitan, Sonitpur, Cachar, Sivasagar, and Kokrajhar of Assam. Quantitative data will be evaluated through descriptive statistical measures under quasi-experimental design and quantitative aspect will be explored through thematic analysis. The study protocol presented is the first attempt to collectively assess the early impacts and implementation procedures of the biggest government funded health insurance programme in Assam State. Figures Figure 1 Figure 2 Introduction India spends over 3.27% of its GDP on healthcare, with out-of-pocket expenditure (OOPE) contributions at about 1.54%. 1 OOPE as a percentage of total health expenditure (THE) has declined from 64.2% in 2013-14 to 47.1% in 2019-20, but still contributes to 52% of current health expenditure. 1 OOPE continues to contribute to catastrophic health expenditure (CHE) with the proportion of households with more than 10% of household expenditure on health rising from 4.5% in 2017-18 to 6.7% in 2022-23. 2 Through improving the delivery of high-quality healthcare services and making them more widely available and accessible, recent health sector reforms in India have aimed to increase social health protection for most of the socioeconomically vulnerable segments of society. This approach has mostly been carried out through the establishment of Publicly Funded Health Insurance (PFHI) programmes, which are administered at the federal or state levels and are designed to increase end users' access to high-quality healthcare by providing them with financial protection. The National Health Accounts-Estimations for India: 2019-20 report states that the nation's public health spending as a percentage of overall health spending increased from 29% in 2014–2015 to 41.4% in 2019–20. 1 Public Funded Health Insurance (PFHI) schemes have been seen as important means to achieve Universal Health Coverage (UHC) in low-and middle-income countries (LMICs) such as India. The primary goals of PFHI programmes are to lessen the cost burden of access to high-quality healthcare for the impoverished and vulnerable populations. These programmes cover the majority of secondary and tertiary healthcare provided in hospitals 3 and health insurance coverage has been increased from 5% to 29% in a decade (2005-2015). 4 Studies on AB-PMJAY scheme have reported reduction of OOPE, health security through insurance in achieving UHC and enhancing population health and significantly reducing medical-related poverty. 6,7,8,9 However, studies exploring factors relating to scheme ideation have highlighted implementation challenges in terms of low awareness, knowledge, and utilization related implication of AB-PMJAY at designing and conceptualization levels. 4,10,11,12,13 The Ayushman Bharat -Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) was launched by the Government of India in 2018 as a national PFHI scheme. The National Health Authority (NHA) at the central level oversees the program's administration, and the state health agency in each state oversees its implementation through either already-existing insurance companies, nodal agencies, or a combination of these two, with the possibility of state-specific modifications. 4 AB-PMJAY provides cashless cover of up to INR5,00,000 to each eligible family per annum as a health insurance coverage at empanelled secondary and tertiary care medical institution. Currently, AB-PMJAY has been considered the basis of economic status as a proxy for inclusion, which is based on the report of socio-economic and caste census. The scheme also encompasses households that were previously enrolled under other health initiatives such as Rashtriya Swasthya Bima Yojana (RSBY). Assam was the first state in the Eastern India to sign Memorandum of Understanding (MOU) for implementation of AB-PMJAY scheme with the launch date of September 23, 2018, and as of March 2021, 185 public hospitals and 150 private hospitals have been empanelled. 5 The objective of the present study is to obtain the evidence of effectiveness in implication and impact of AB-PMJAY, a public health and policy intervention aimed at economically weaker section of India in terms of healthcare services availability, accessibility and affordability, after the first 5 years of operations in Assam state. The results from the study would be useful to guide both policy makers and beneficiaries about implementation strategy, scope for modification to improve coverage and benefits of the scheme in Assam state, and the same can be formulated or generalized in other states in India. Methods Conceptual framework A conceptual framework (Figure 1) that formulates the interrelationship between supply (healthcare facilities) and demand (quality of life improvement and reduction in OOPE) of due to effective implication has been developed to evaluate the impact of AB-PMJAY on health and healthcare outcomes in terms of accessibility, and availability of facilities. The study objectives are: To evaluate how AB-PMJAY affects financial security in terms of OOPE and catastrophic health expenditure; To evaluate and comprehend how AB-PMJAY affects people's knowledge of its characteristics, coverage, utilisation of health services, and standard of care; To explore healthcare providers’ experiences with AB-PMJAY; and To document implementation process of AB-PMJAY at state and district level. Study Design The triangulation mixed methods design in this work is supported using a multimethod approach (see Figure 2). 14 “Mixed methods” relate to the utilisation of both quantitative and qualitative methodologies in data collection, analysis, and knowledge generation. 15 “Multi methods” refers to the utilisation of diverse techniques or procedures, such as quantitative and qualitative approaches, in parallel or sequential fashion without combing them until conclusions are reached. 15 The population coverage and scheme outcomes of interest (financial protection, OOPE, and health service utilisation) are being measured using a quasi-experiment study design. We will use qualitative methodologies to examine the factors driving change by analysing the implementation procedures of AB-PMJAY. When we refer to data collection as "concurrent," we are indicating that it occurs simultaneously for both quantitative and qualitative purposes, without any delay in starting another study strand’s results until the completion of one. 16 Study setting To capture the geographical diversity of Assam state, the study will be carried out in five distinct geographical divisions (districts) – Lower (Kamrup Metropolitan), North (Sonitpur), Barak valley (Cachar), Upper Assam (Sivasagar), and Kokrajhar (Tribal population) (Figure 2). The present study will be conducted over a period of 12 months i.e., from September 2023 to August 2024. Study Component Every study objective is matched to a part of the study design (Table 1). Study component 1 examines the scheme's impact evaluation; study component 2 examines how the implementation of AB-PMJAY affects service quality as well as beneficiaries' awareness of features, coverage, and use of health services; and study component 3 records the planning and execution of AB-PMJAY. Table 1: Study components, objectives, and methods Study component Study objective Study design Data collection Methods Study component 1 To assess the impact of AB-PMJAY on financial protection on OOPE and catastrophic health expenditure Quasi-experimental study design Propensity Score Matching Instrument variable Repeated Cross-sectional surveys Survey1-NSO year 2004 (60 th round) Survey 2- NSO year 2014(71 st round) Survey 3- NSO year 2017(75 th round) Survey 4-Primary data collection Study component 2 To explore the influence of AB-PMJAY implementation on the quality of services and to explore awareness of features, coverage, and health service use Qualitative Individuals Interview (Community) FGD (focus group discussion) (beneficiaries of Ayushman Bharat-PMJAY and other insurance beneficiaries) Study component 3 To document implementation process of AB-PMJAY at state and district level of Assam Qualitative Key Informant interviews (community health workers, and implementing officials associated with the scheme), and/or policy makers in the state A. Study Component 1: Impact of Ayushman Bharat-PMJAY on financial protection related to OOPE and catastrophic health expenditure The literature suggests using many observations with a single measurement made prior to the start of the insurance programme for PFHI schemes. 17 The national representative cross-sectional survey household data from the various NSS rounds have used by several previous studies for measuring impact of PFHI schemes at national and state levels. 3,21,22,23 Data on hospital care and OOPE for the year 2004, before to the introduction of PFHI programmes in Assam, is available in the 60th round of the NSS. 18 Data from the 71st NSS round in 2014 is available regarding the implementation of the RSBY scheme, which offered an annual cover of INR 30,000 per family. 19 The 75 th round of NSS in 2018 provides data when Atal Amrit Abhiyan (AAA) was in operation and AB-PMJAY was introduced in the state. 20 Our study utilises a primary survey to be conducted between December 2023-January 2024, i.e. five years after scheme implementation, to measure the implementation and impact of AB-JAY in the state. Table 2 provides a summary of PFHI schemes at the four cross-sections. Table 2: PFHI schemes and annual cover in Assam State: four cross-sections Year GFHI scheme Annual cover per family Eligible group 2004 None None None 2014 RSBY INR 30000 a) Poor Households (supported by central government funding) b) Non-Poor Households (fully funded by state government) 2016 AAA (Atal Amrit Abhiyan) INR 200,000 1) All the BPL families in the state with income of less than Rs. 1.2 lakhs per annum will get free health care under the scheme. 2) Moreover, those who belong to the APL category with income between Rs. 1.2 lakhs and 5 lakhs per annum have to pay a nominal premium of Rs. 100/- per year per member to avail of the scheme 2018 AB-PMJAY INR 500,000 Poor households supported by Central Government Funding 2023 AAMM-JAY INR 500,000 Not enrolled in AB-JAY and possess Aadhaar card The health schedule of 2004, 2014 and 2018 are comparable to each other and have been observed by researchers to provide comprehensive information on morbidity patterns, healthcare, type of providers (public or private), and out-of-pocket expenditure. 3,24 Assam state's actual hospitalisation episodes for the years 2004, 2014, and 2018 were 700, 145, and 1304, respectively, covered by the NSS sample. Sampling The primary data collection for this study will be based on a stratified multi-stage design that was adopted and followed by NSO in their latest 75th round survey of 2017-2018 in Assam. Likewise, NSO sampling design, here also a subset of the population within each geographical study area may be the subject of the study. The smallest area units used as first-stage sampling units (FSU) in rural and urban regions, respectively, are villages and urban blocks which will be obtained from Census. Household or household-based inquiries will be considered as the second or ultimate stage sampling units (SSU or USU). Within each selected district of Assam, here also two basic strata will be formed: (i) a rural stratum and (ii) an urban stratum. From each stratum sample (villages and blocks) will be selected with Probability Proportional to Size with Replacement (PPSWR) based on their size as per Census 2011. We will select two distinct random points say, A and B in the village and list, say, 15% households starting from A and 15% households starting from B. The study conducted in the NSS 75 th round (2018) provided information about 18603 individuals from 27 districts of Assam, out of which only 4.6% individuals were insured under any health insurance. An appropriate number of hospitalisation episodes must occur in the sample to quantify the change in protection for hospital treatment, which is the primary goal of the study. For a detectable difference at least 3%(d), a sample size of 2191 achieves 90% power using a two-sided exact test with a target significance level of 5%(α). Assuming 20% non-responses resulted to 2739. As the study considered five study sites (districts), therefore, a sample of 3000 individuals (AB-PMJAY scheme recipient and other scheme recipient), will be recruited for capturing geographical diversity. Selection of participants will be based on an inclusion criterion, namely, adult aged 18 years or above, residing in the selected geographical area, enrolled, and hospitalised under AB-PMJAY or any other health insurance scheme in a public or private hospital, and those consenting to participate. Those with any physical/medical condition that precludes the possibility of interview will be excluded from the study. Data collection tools and strategies Data will be collected using a questionnaire (Annexure I) by trained interviewers through the Research Electronic Data Capture (RED Cap) on digital devices (RED Cap powered by Vanderbilt). RED Cap is a safe, browser-based web application that will assist with data management, storage, and monitoring while maintaining data confidentiality through logic and range checks, a decrease in data entry errors, and the identification of incomplete or missing data. Data will be transferred from the questionnaire to an Excel document and recoded for data analysis using R software. Analytical approach As suggested by Wagstaff and Doorslaer 25 , financial protection will be quantified in terms of Catastrophic Health Expenditure (CHE). Every episode's OOPE will be determined by deducting any cash reimbursements the patient has received from the total amount of medical and transportation costs. According to current studies, the OOPE amounts for 2004, 2014, 2018, and 2024 will be updated at 2024 prices for a realistic comparison. 26,27 The survey will gather information on typical monthly consumption expenses, which will then be multiplied by twelve to determine typical annual consumption expenditures. The similar method has been employed in recent research analysing the NSS datasets to determine Annual Household Consumption Expenditure. 26,27 For CHE, thresholds of 10, 25, and 40% of the annual consumption expenditure of the household in question will be used. Changes in the use of hospital care will be used to evaluate improvements in access to care. For the continuous outcome variables, Ordinary Least Squares (OLS) will be employed to analyse the continuous outcome variables namely OOPE and the logarithm of OOPE. The Probit model will be employed for binary outcome variables, such as catastrophic health expenditure (CHE). The robustness of the Average Treatment Effect on the Treated (ATET) will be evaluated by comparing it with the results obtained from Propensity Score Matching (PSM) modelling. PFHI in India and other countries has been evaluated using Propensity Score Matching (PSM) and other similar "matching" methods. 3,21 A multivariate analysis will be done to assess the impact of AB-PMJAY on usage, out-of-pocket expenditure (OOPE), and catastrophic health expenditure (CHE) in comparison to persons enrolled in AB-PMJAY without any additional benefits. In addition, the Instrumental Variable (IV) technique will be employed to replicate the multivariate analysis for out-of-pocket expenditure (OOPE) and catastrophic health expenditure (CHE). This further investigation will be carried out to tackle the issue of endogeneity, or the potential selection bias, which is commonly acknowledged as a usual obstacle when establishing the impact of insurance on economic outcomes such as out-of-pocket expenditures (OOPE). 3,21 The Instrumental Variable (IV) technique, has been suggested as a reliable solution to address the potential issue of endogeneity. 17 B. Study Component 2: Influence of Ayushman Bharat-PMJAY implementation on the quality of services and to explore awareness of features, coverage, and health service use Data Collection Tools and Strategies The primary data on qualitative aspect will be obtained at all five selected districts specifically in a subset composed of village or block through a focus group discussion (FGDs) and key informant interviews (KIIs) among eligible participants at selected community levels as mentioned in Table 1 (Annexure 2). We expect to hold at least two focus groups (AB-PMJAY availing and other schemes availing) in each district, with 8-10 participants in each FGD. Here, the qualitative aspect will be covered through purposive sampling. Following written informed consent, these sessions will be recorded, verbatim transcribed, and translated into English for analysis. Trained qualitative research assistants will be responsible for collecting data using the guidelines that are briefly explained. Analysis The beneficiaries will be traced those willing to participate, an in-person interview will be conducted and recorded. The collected data will be transcribed, analysed using thematic analysis. The interviews will be conducted in Hindi, Assamese, Bengali, Manipuri and Bodo languages based on the study site. The transcriptions will be cross validated by the team members for its validity. The transcriptions will be exported to the qualitative analysis software. Data will be coded, and analysis will be carried out using thematic analysis. The results will be discussed among the team members to arrive at the explanation of the phenomena of interest. C. Study Component 3: Document implementation process of AB-PMJAY at state and district level of Assam To meet the third research component, which focuses on creating and documenting the processes involved in the conception, creation, and implementation of AB-PMJAY in the state of Assam, this study component takes a qualitative approach. We will examine AB-PMJAY implementation through the perspectives of those directly involved in the scheme design and deployment, using a constructivist viewpoint method as our foundation. 28 Sampling We will include community health workers, hospital manager, AB-PMJAY in charge at hospital, and state level officials with AB-PMJAY. Data collection tools and strategies Data collection will rely on KIIs conducted using the interview guides developed for the present study (Annexure 2). State level official interviews will be conducted by the Principal Investigator. Analytical Approach We will use thematic analysis to explain the AB-PMJAY implementation procedures, including their successes and setbacks, considering the larger socio-political environment in which the scheme is being implemented. Ethics and Dissemination The study investigators will ensure that this study is conducted in accordance with the principles set forth in the National Ethical Guidelines for Biomedical and Health Research involving Human Participants of the Indian Council of Medical Research (ICMR). 29 The study has been approved by the Institutional Ethics Committee of Assam University, Silchar (ref no: IEC/AUS/2023/VV/01 dated 5thOct, 2023). Written informed consent will be obtained from all study participants. We aim to present the initial study results in a workshop attended by state officials, hospital providers and researchers in Assam state. The final study results will be submitted to the funding organisation in the form of a technical report and to a peer-review journal. We also plan to integrate our study findings within a systematic review focusing on impact, utilisation, and implementation of AB-PMJAY in India. Authorship will be determined according to the statement from the International Committee of Medical Journal Editors. Open access to individual participant data is not planned, but all requests for the study data will be considered on an individual basis by the PI (VV) and Co-PI (DJ). All investigators will be given access to the cleaned data sets. Patient and public involvement statement Six of the author members include employees with central government-funded university or institutions who are beneficiaries of AB-PMJAY scheme and are involved in the design and conduct of the study. Discussion The study design described in this paper is the first attempt to assess the procedures and outcomes of the largest PHFI programme ever introduced in India, AB-PMJAY in the state of Assam. In order to emphasise the endeavours focused on producing reliable scientific data, it is essential to clearly define our study design in consideration of the practical assessment requirements that are influenced by policy concerns and implementation circumstances. Due to the statewide coverage of AB-PMJAY, it was impractical for our team to have control over treatment assignment criteria and rely on a standard experimental design for state-specific evaluation. Despite the challenges, this study aimed to create a scientifically rigorous study design. It utilised a combination of different methods for data collection and analysis and had the ability to incorporate quasi-experimental design elements into the quantitative analysis. The design of our study is enhanced by incorporating both the AB-PMJAY impact and implementation assessment components into a single protocol. This protocol effectively considers the practical aspects of implementation and the resulting effects on both the supply and demand sides. Although the data collection methods are established and the analytical frameworks for progress are presented in a dynamic manner, the process components are utilised to elucidate the outcomes of the effects, and the findings of the effects are employed to stimulate further research into the aspects of the process. We recognise the intricacy of our study design and the difficulties in successfully carrying out our combined method and evaluation, even though our proposed technique for impact evaluation has the capacity to produce highly insightful results through a more comprehensive analytical approach. At the beginning, implementing our research plan requires relying on a diverse set of investigators, each with unique expertise in both subject matter and research methods. To ensure comprehensive comprehension of the intricacies of plan implementation and its effects across the academic and policy communities, the team must devise strategies to efficiently and succinctly convey the findings, employing a range of analytical methodologies. Moreover, it is important to recognise that the generalizability of the findings and methods used in this study is restricted. 30 While we have confidence in the internal validity of our sample and data gathering technique, we cannot ensure that the results will precisely represent the processes and impacts of AB-PMJAY implementation for the entire state. Moreover, it is crucial to acknowledge the inherent bias that arises from the sampling methodologies employed to select hospitals for the supply-side component and residences for the demand-side component. Prior to commencing our study, we examined various alternatives. However, after careful consideration, we concluded that due to the unavailability of a more up-to-date and comprehensive population listing, as well as a complete health facility listing (or the insufficient resources to conduct such listings), our only viable course of action was to utilise the techniques previously discussed in this manuscript. It is important to acknowledge that our findings will not accurately reflect urban conditions, especially in regard to the demand-side aspect. Further research is needed to explore the practicalities and effects of implementation in metropolitan areas, using various primary sampling methods. The study design aims to collectively evaluate the impacts and implementation protocols of the largest government-funded insurance policy ever established in Assam. Through providing a comprehensive analysis of our study design, we aim to motivate other researchers who are examining novel social health protection programmes in India and similar settings elsewhere. Confidentiality Study participants will be identified solely by a study number that represents the study site and the order in which they were enrolled at that site. All study records will have their identifiers removed. The study data will be securely maintained in a closed room, and access to the online data management platform will be protected by a password. The confidentiality of study participants' information will be maintained and handled in accordance with the regulations outlined in the National Ethical Guidelines for Biomedical and Health Research Involving Human Participants 31 and Institutional Ethics Board. The guidelines mandates that every participant must provide consent for the collection, utilisation, and retrieval of personal health information, unless the Institutional Ethics Board waives the need for consent. When consent is necessary, it is imperative that every participant is provided with the following information: The ability of a research participant to withdraw their consent for the use of their Protected Health Information (PHI). If a participant withdraws their consent to collect or utilise PHI, the investigator is allowed to utilise all the information that was obtained before the withdrawal of consent. For participants who have withdrawn consent to collect or utilise PHI, efforts should be made to gain consent to collect at least vital status (i.e., confirmation that the participant is alive) at the conclusion of their designated study period. Data Sharing Only the study procedure is being highlighted in this study protocol, and participant-level data collected for it will not be publicly accessible. However, the corresponding author can be reached with any questions. Declarations Ethics statements Patient consent for publication Not required. Competing interests* None of the authors have any competing interests to declare. Acknowledgements Authors would like to express their deepest gratitude and sincere thanks to Mr. Ajay Verma, Mrs. Swapnalee Bhattacharya, Dr. Kanchan Kanti for their support and insightful suggestions. Contribution statement : Funding : Authors would like to acknowledge Indian Council of Social Science Research, New Delhi for providing the grant for this study (F.No. 30/CRP-2023-696/AB/SCD, dated 20 September 2023). Competing interests : The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Data sharing statement : Only the study procedure is being highlighted in this study protocol, and participant-level data collected for it will not be publicly accessible. However, the corresponding author can be reached with any questions. Underlying data - No data is associated with this article. Ethical statement : The study has been approved by the Institutional Ethics Committee of Assam University, Silchar (ref no: IEC/AUS/2023/VV/01 dated 5thOct, 2023). Author contributions : Writing of original protocol, VV and DJ; writing of original manuscript, VV, BB, MK and DJ; review and editing of manuscript draft, RC, PS, PP, JY, SS, MNT, and RY; quantitative component, VV, DJ, JY; qualitative component, SS, DJ, VV; supervision, VV; funding procurement, VV and DJ; all authors have read and agreed to the published version of this manuscript. References National Health Systems Resource Centre (2023). National Health Accounts Estimates for India (2019-20). New Delhi: Ministry of Health and Family Welfare, Government of India Ministry of Statistics and Programme Implementation (2023). Sustainable Development Goals: National Indicator Framework, Progress Report 2023. New Delhi: National Statistical Office, Ministry of Statistics and Programme Implementation, Government of India Garg, S., Bebarta, K. K., & Tripathi, N. (2020). Performance of India’s national publicly funded health insurance scheme, Pradhan Mantri Jan Arogaya Yojana (PMJAY), in improving access and financial protection for hospital care: findings from household surveys in Chhattisgarh state. BMC Public Health, 20(1), 1-10. De Allegri M, Srivastava S, Strupat C, Brenner S, Parmar D, Parisi D, Walsh C, Mahajan S, Neogi R, Ziegler S, Basu S, Jain N. Mixed and Multi-Methods Protocol to Evaluate Implementation Processes and Early Effects of the Pradhan Mantri Jan Arogya Yojana Scheme in Seven Indian States. Int J Environ Res Public Health. 2020 Oct 26;17(21):7812 Government of Assam. http://atalamritabhiyan.assam.gov.in/schemes/ayushman-bharat-pradhan-mantri-jan-arogya-yojana. Accessed on 09 February 2024 Bala, R., Kumar, M., Krishna, K. K., & Devi, C. S. (2021). Has Ayushman Bharat dwindled the out-of-pocket expenditure. Journal of Evolution of Medical and Dental Sciences, 10(25), 1895-1898. Ambade, M., Sarwal, R., Mor, N., Kim, R., & Subramanian, S. V. (2012). Components of out-of-pocket expenditure and their relative contribution to economic burden of diseases in India. JAMA Network Open, 5(5), e2210040-e2210040. Joseph, J., Sankar D, H., & Nambiar, D. (2021). Empanelment of health care facilities under Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB PM-JAY) in India. PloS one, 16(5), e0251814. Angell, B. J., Prinja, S., Gupt, A., Jha, V., & Jan, S. (2019). The Ayushman Bharat Pradhan Mantri Jan Arogya Yojana and the path to universal health coverage in India: Overcoming the challenges of stewardship and governance. PLoS medicine, 16(3), e1002759. Parisi, D., Srivastava, S., Parmar, D., Strupat, C., Brenner, S., Walsh, C., ... & De Allegri, M. (2023). Awareness of India's national health insurance scheme (PM-JAY): a cross-sectional study across six states. Health Policy and Planning, 38(3), 289-300. Gowda, N. R., Hakim, A., Singh, G., Gupta, A., & Sharma, D. K. (2022). The Experience of Patient and Implementation of the Landmark Scheme Ayushman Bharat (AB-PMJAY) of Government of India in a Tertiary Care Hospital. Journal of Health Management, 24(4), 566-571. Dubey, S., Deshpande, S., Krishna, L., & Zadey, S. (2023). Evolution of Government-funded health insurance for universal health coverage in India. The Lancet Regional Health-Southeast Asia, 13. Saxena, A., Trivedi, M., Shroff, Z. C., & Sharma, M. (2022). Improving hospital-based processes for effective implementation of Government funded health insurance schemes: evidence from early implementation of PM-JAY in India. BMC Health Services Research, 22, 1-13. Knappertsbusch, Felix, Langfeldt, Bettina and Kelle, Udo. "Mixed-Methods and Multimethod Research". Soziologie - Sociology in the German-Speaking World: Special Issue Soziologische Revue 2020, edited by Betina Hollstein, Rainer Greshoff, Uwe Schimank and Anja Weiß, Berlin, Boston: De Gruyter Oldenbourg, 2021, pp. 261-272. https://doi.org/10.1515/9783110627275-018 Hesse-Biber, Sharlene Nagy, and R. Burke Johnson (eds), The Oxford Handbook of Multimethod and Mixed Methods Research Inquiry, Oxford Library of Psychology (2015; online edn, Oxford Academic, 19 Jan. 2016), https://doi.org/10.1093/oxfordhb/9780199933624.001.0001, accessed 22 Feb. 2024 Schoonenboom J, Johnson RB. How to Construct a Mixed Methods Research Design. Kolner Z Soz Sozpsychol. 2017;69(Suppl 2):107-131 Acharya A, Vellakkal S, Taylor F, Masset E, Satija A, Burke M, et al. Impact of national health insurance for the poor and the informal sector in low-and middle-income countries: a systematic review. London: EPPI-Centre, Social Science Research Unit, Institute of Education, University of London; 2012 Government of India. NSS 60th Round: Jan - June 2004. Ministry of Statistics and Programme Implementation. National Sample Survey Organization. Dataset. Available at: http://microdata.gov.in/nada43/index.php/catalog/105. Government of India. Health in India-NSS 71st Round (January to June 2014). (Ministry of Statistics and Programme Implementation. National Sample Survey Organisation NSSO). 2016. Government of India. Health in India-NSS 75st Round (2017-2018). (Ministry of Statistics and Programme Implementation. National Sample Survey Organisation NSSO) Karan A, Yip W, Mahal A. Extending health insurance to the poor in India: An impact evaluation of Rashtriya Swasthya Bima Yojana on out of pocket spending for healthcare. Soc Sci Med. 2017 May;181:83-92 Johnson, Douglas; Krishnaswamy,Karunakaran. The impact of RSBY on hospital utilization and out-of-pocket health expenditure (English). Washington, D.C. : World Bank Group Prinja S, Singh MP, Aggarwal V, Rajsekar K, Gedam P, Goyal A, Bahuguna P. Impact of India's publicly financed health insurance scheme on public sector district hospitals: a health financing perspective. Lancet Reg Health Southeast Asia. 2022 Dec 17;9:100123 Mohanty, S., Padhi, B., Singh, R., & Sahoo, U. (2022). comparable estimates of out-of-pocket payment on hospitalisation and outpatient services in india, 2004-18. Clinical Epidemiology and Global Health, 17, 101139 Wagstaff A, Doorslaer E. Catastrophe and impoverishment in paying for healthcare: with applications to Vietnam 1993–98. Health Econ. 2003;12:921–34 Yadav, J., Allarakha, S., Menon, G., John, D., & Nair, S. (2021). socioeconomic impact of hospitalization expenditure for treatment of noncommunicable diseases in india: a repeated cross-sectional analysis of national sample survey data, 2004 to 2018. Value in Health Regional Issues, 24, 199-213 Yadav, J., John, D., Allarakha, S., & Menon, G. (2021). rising healthcare expenditure on tuberculosis: can india achieve the end tb goal?. Tropical Medicine & International Health, 26(10), 1256-1275 Poletti, B., Carelli, L., Lafronza, A., Solca, F., Faini, A., Ciammola, A., … & Silani, V. (2017). Cognitive-constructivist approach in medical settings: the use of personal meaning questionnaire for neurological patients’ personality investigation. Frontiers in Psychology, 08 Indian Council of Medical Research. National ethical guidelines for biomedical and health research involving human participants. New Delhi: Indian Council of Medical Research; 2017. Available from: https://ethics.ncdirindia.org/asset/pdf/ICMR_National_Ethical_Guidelines.pdf Lavrakas P. Encyclopedia of Survey Research Methods. Sage Publications, Inc.; New York, NY, USA: 2013. External Validity National Ethical Guidelines for Biomedical and Health Research Involving Human Participants. 2017. [Last accessed on 2018 Jun 26]. Available from: https://www.icmr.nic.in/guidelines/ICMR_Ethical_Guidelines_2017.pdf . Additional Declarations No competing interests reported. Supplementary Files Appendix.pdf Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4794755","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Study protocol","associatedPublications":[],"authors":[{"id":336710987,"identity":"4ff32368-b497-4256-81bd-50bfb3bb6ac1","order_by":0,"name":"Vivek Verma","email":"","orcid":"","institution":"Assam University","correspondingAuthor":false,"prefix":"","firstName":"Vivek","middleName":"","lastName":"Verma","suffix":""},{"id":336710988,"identity":"d47a871d-1f03-4def-9fcb-eda7c3a6fde5","order_by":1,"name":"Dilip Chandra Nath","email":"","orcid":"","institution":"Royal Global 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10:52:02","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4794755/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4794755/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":63009344,"identity":"fbf89661-01ea-43d8-8063-23b3dda18bd7","added_by":"auto","created_at":"2024-08-22 05:24:02","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":180162,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eConceptual framework of AB-PMJAY in Assam state\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Figure1ConceptualframeworkofABPMJAYinAssamstate.png","url":"https://assets-eu.researchsquare.com/files/rs-4794755/v1/cd02214e3fcb85af8cbf0a95.png"},{"id":63009343,"identity":"d5c36a22-ef68-4252-beec-d1c485246aea","added_by":"auto","created_at":"2024-08-22 05:24:02","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":164653,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eStudy Design\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Figure2.StudyDesign.png","url":"https://assets-eu.researchsquare.com/files/rs-4794755/v1/c08585f624559496bcda0cfb.png"},{"id":71236558,"identity":"e11cd920-527e-4858-99fc-a71c2a39a6e9","added_by":"auto","created_at":"2024-12-12 12:01:43","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1050968,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4794755/v1/caf10bce-0e6c-4129-b7f8-d950fcdde854.pdf"},{"id":63009345,"identity":"641c91de-6e26-4c32-a78b-4826ff8cf042","added_by":"auto","created_at":"2024-08-22 05:24:02","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":291443,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4794755/v1/5cec15075601e1bb2476d196.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Study Protocol: A mixed method and multimethod study of implementation and impact of Ayushman Bharat- Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) scheme in Assam State","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIndia spends over 3.27% of its GDP on healthcare, with out-of-pocket expenditure (OOPE) contributions at about 1.54%.\u003csup\u003e1\u003c/sup\u003e OOPE as a percentage of total health expenditure (THE) has declined from 64.2% in 2013-14 to 47.1% in 2019-20, but still contributes to 52% of current health expenditure.\u003csup\u003e1\u003c/sup\u003e OOPE continues to contribute to catastrophic health expenditure (CHE) with the proportion of households with more than 10% of household expenditure on health rising from 4.5% in 2017-18 to 6.7% in 2022-23.\u003csup\u003e2\u003c/sup\u003e\u0026nbsp; \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThrough improving the delivery of high-quality healthcare services and making them more widely available and accessible, recent health sector reforms in India have aimed to increase social health protection for most of the socioeconomically vulnerable segments of society. This approach has mostly been carried out through the establishment of Publicly Funded Health Insurance (PFHI) programmes, which are administered at the federal or state levels and are designed to increase end users\u0026apos; access to high-quality healthcare by providing them with financial protection. The National Health Accounts-Estimations for India: 2019-20 report states that the nation\u0026apos;s public health spending as a percentage of overall health spending increased from 29% in 2014\u0026ndash;2015 to 41.4% in 2019\u0026ndash;20.\u003csup\u003e1\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePublic Funded Health Insurance (PFHI) schemes have been seen as important means to achieve Universal Health Coverage (UHC) in low-and middle-income countries (LMICs) such as India.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe primary goals of PFHI programmes are to lessen the cost burden of access to high-quality healthcare for the impoverished and vulnerable populations. These programmes cover the majority of secondary and tertiary healthcare provided in hospitals\u003csup\u003e3\u003c/sup\u003e and \u0026nbsp;health insurance coverage has been increased from 5% to 29% in a decade (2005-2015).\u003csup\u003e4\u003c/sup\u003e Studies on AB-PMJAY scheme have reported reduction of OOPE, health security through insurance in achieving UHC and enhancing population health and significantly reducing medical-related poverty.\u003csup\u003e6,7,8,9\u003c/sup\u003e However, studies exploring factors relating to scheme ideation have highlighted implementation challenges in terms of low awareness, knowledge, and utilization related implication of AB-PMJAY at designing and conceptualization levels.\u003csup\u003e4,10,11,12,13\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eThe Ayushman Bharat -Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) was launched by the Government of India in 2018 as a national PFHI scheme.\u0026nbsp;The National Health Authority (NHA) at the central level oversees the program\u0026apos;s administration, and the state health agency in each state oversees its implementation through either already-existing insurance companies, nodal agencies, or a combination of these two, with the possibility of state-specific modifications.\u003csup\u003e4\u003c/sup\u003e AB-PMJAY provides cashless cover of up to INR5,00,000 to each eligible family per annum as a health insurance coverage at empanelled secondary and tertiary care medical institution. Currently, AB-PMJAY has been considered the basis of economic status as a proxy for inclusion, which is based on the report of socio-economic and caste census. The scheme also encompasses households that were previously enrolled under other health initiatives such as Rashtriya Swasthya Bima Yojana (RSBY).\u003c/p\u003e\n\u003cp\u003eAssam was the first state in the Eastern India to sign Memorandum of Understanding (MOU) for implementation of AB-PMJAY scheme with the launch date of September 23, 2018, and \u0026nbsp; as of March 2021, 185 public hospitals and 150 private hospitals have been empanelled.\u003csup\u003e5\u003c/sup\u003e The objective of the present study is to obtain the evidence of effectiveness in implication and impact of AB-PMJAY, a public health and policy intervention aimed at economically weaker section of India in terms of healthcare services availability, accessibility and affordability, after the first 5 years of operations in Assam state. The results from the study would be useful to guide both policy makers and beneficiaries about implementation strategy, scope for modification to improve coverage and benefits of the scheme in Assam state, and the same can be formulated or generalized in other states in India.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConceptual framework\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA conceptual framework (Figure 1) that formulates the interrelationship between supply (healthcare facilities) and demand (quality of life improvement and reduction in OOPE) of due to effective implication has been developed to evaluate the impact of AB-PMJAY on health and healthcare outcomes in terms of accessibility, and availability of facilities.\u003c/p\u003e\n\u003cp\u003eThe study objectives are:\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eTo evaluate how AB-PMJAY affects financial security in terms of OOPE and catastrophic health expenditure;\u003c/li\u003e\n \u003cli\u003eTo evaluate and comprehend how AB-PMJAY affects people\u0026apos;s knowledge of its characteristics, coverage, utilisation of health services, and standard of care;\u003c/li\u003e\n \u003cli\u003eTo explore healthcare providers\u0026rsquo; experiences with AB-PMJAY; and\u003c/li\u003e\n \u003cli\u003eTo document implementation process of AB-PMJAY at state and district level.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eStudy Design\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe triangulation mixed methods design in this work is supported using a multimethod approach (see Figure 2).\u003csup\u003e14\u003c/sup\u003e \u0026ldquo;Mixed methods\u0026rdquo; relate to the utilisation of both quantitative and qualitative methodologies in data collection, analysis, and knowledge generation.\u003csup\u003e15\u003c/sup\u003e \u0026ldquo;Multi methods\u0026rdquo; refers to the utilisation of diverse techniques or procedures, such as quantitative and qualitative approaches, in parallel or sequential fashion without combing them until conclusions are reached.\u003csup\u003e15\u003c/sup\u003e The population coverage and scheme outcomes of interest (financial protection, OOPE, and health service utilisation) are being measured using a quasi-experiment study design. We will use qualitative methodologies to examine the factors driving change by analysing the implementation procedures of AB-PMJAY. When we refer to data collection as \u0026quot;concurrent,\u0026quot; we are indicating that it occurs simultaneously for both quantitative and qualitative purposes, without any delay in starting another study strand\u0026rsquo;s results until the completion of one.\u003csup\u003e16\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eStudy setting\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo capture the geographical diversity of Assam state, the study will be carried out in five distinct geographical divisions (districts) \u0026ndash; Lower (Kamrup Metropolitan), North (Sonitpur), Barak valley (Cachar), Upper Assam (Sivasagar), and Kokrajhar (Tribal population) (Figure 2). The present study will be conducted over a period of 12 months i.e., from September 2023 to August 2024.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eStudy Component\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEvery study objective is matched to a part of the study design (Table 1). Study component 1 examines the scheme\u0026apos;s impact evaluation; study component 2 examines how the implementation of AB-PMJAY affects service quality as well as beneficiaries\u0026apos; awareness of features, coverage, and use of health services; and study component 3 records the planning and execution of AB-PMJAY.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1: Study components, objectives, and methods\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"632\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.455696202531644%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eStudy component\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.90506329113924%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eStudy objective\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.88607594936709%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eStudy design\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.75316455696203%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eData collection Methods\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.455696202531644%\" valign=\"top\"\u003e\n \u003cp\u003eStudy component 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.90506329113924%\" valign=\"top\"\u003e\n \u003cp\u003eTo assess the impact of AB-PMJAY on financial protection on OOPE and catastrophic health expenditure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.88607594936709%\" valign=\"top\"\u003e\n \u003cp\u003eQuasi-experimental study design\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003ePropensity Score Matching\u003c/li\u003e\n \u003cli\u003eInstrument variable\u0026nbsp;\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.75316455696203%\" valign=\"top\"\u003e\n \u003cp\u003eRepeated Cross-sectional surveys\u003c/p\u003e\n \u003cp\u003eSurvey1-NSO year 2004 (60\u003csup\u003eth\u003c/sup\u003e round)\u003c/p\u003e\n \u003cp\u003eSurvey 2- NSO year 2014(71\u003csup\u003est\u003c/sup\u003e round)\u003c/p\u003e\n \u003cp\u003eSurvey 3- NSO year 2017(75\u003csup\u003eth\u003c/sup\u003e round)\u003c/p\u003e\n \u003cp\u003eSurvey 4-Primary data collection\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.455696202531644%\" valign=\"top\"\u003e\n \u003cp\u003eStudy component 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.90506329113924%\" valign=\"top\"\u003e\n \u003cp\u003eTo explore the influence of AB-PMJAY implementation \u0026nbsp; on the quality of services and to explore awareness of features, coverage, and health service use\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.88607594936709%\" valign=\"top\"\u003e\n \u003cp\u003eQualitative\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.75316455696203%\" valign=\"top\"\u003e\n \u003cp\u003eIndividuals Interview (Community)\u003c/p\u003e\n \u003cp\u003eFGD (focus group discussion)\u003c/p\u003e\n \u003cp\u003e(beneficiaries of Ayushman Bharat-PMJAY and other insurance beneficiaries)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.455696202531644%\" valign=\"top\"\u003e\n \u003cp\u003eStudy component 3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.90506329113924%\" valign=\"top\"\u003e\n \u003cp\u003eTo document\u003c/p\u003e\n \u003cp\u003eimplementation process of AB-PMJAY at state and district level of Assam\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.88607594936709%\" valign=\"top\"\u003e\n \u003cp\u003eQualitative\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.75316455696203%\" valign=\"top\"\u003e\n \u003cp\u003eKey Informant interviews\u003c/p\u003e\n \u003cp\u003e(community health workers, and implementing officials associated with the scheme), and/or policy makers in the state\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eA.\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eStudy Component 1: Impact of Ayushman Bharat-PMJAY on financial protection related to OOPE and catastrophic health expenditure\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe literature suggests using many observations with a single measurement made prior to the start of the insurance programme for PFHI schemes.\u003csup\u003e17\u003c/sup\u003e The national representative cross-sectional survey household data from the various NSS rounds have used by several previous studies for measuring impact of PFHI schemes at national and state levels.\u003csup\u003e3,21,22,23\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eData on hospital care and OOPE for the year 2004, before to the introduction of PFHI programmes in Assam, is available in the 60th round of the NSS.\u003csup\u003e18\u003c/sup\u003e Data from the 71st NSS round in 2014 is available regarding the implementation of the RSBY scheme, which offered an annual cover of INR 30,000 per family.\u003csup\u003e19\u003c/sup\u003e The 75\u003csup\u003eth\u003c/sup\u003e round of NSS in 2018 provides data when Atal Amrit \u0026nbsp;Abhiyan (AAA) was in operation and AB-PMJAY was introduced in the state.\u003csup\u003e20\u003c/sup\u003e Our study utilises a primary survey to be conducted between December 2023-January 2024, i.e. five years after scheme implementation, to measure the implementation and impact of AB-JAY in the state. Table 2 provides a summary of PFHI schemes at the four cross-sections.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2: PFHI schemes and annual cover in Assam State: four cross-sections \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"6.722689075630252%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eYear\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.630252100840336%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eGFHI scheme\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.672268907563026%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAnnual cover per family\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"56.97478991596638%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eEligible group\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"6.722689075630252%\" valign=\"top\"\u003e\n \u003cp\u003e2004\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.630252100840336%\" valign=\"top\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.672268907563026%\" valign=\"top\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"56.97478991596638%\" valign=\"top\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"6.722689075630252%\" valign=\"top\"\u003e\n \u003cp\u003e2014\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.630252100840336%\" valign=\"top\"\u003e\n \u003cp\u003eRSBY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.672268907563026%\" valign=\"top\"\u003e\n \u003cp\u003eINR 30000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"56.97478991596638%\" valign=\"top\"\u003e\n \u003cp\u003ea) Poor Households (supported by central government funding)\u003c/p\u003e\n \u003cp\u003eb) Non-Poor Households (fully funded by state government)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"6.722689075630252%\" valign=\"top\"\u003e\n \u003cp\u003e2016\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.630252100840336%\" valign=\"top\"\u003e\n \u003cp\u003eAAA\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(Atal Amrit Abhiyan)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.672268907563026%\" valign=\"top\"\u003e\n \u003cp\u003eINR 200,000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"56.97478991596638%\" valign=\"top\"\u003e\n \u003cp\u003e1) All the BPL families in the state with income of less than Rs. 1.2 lakhs per annum will get free health care under the scheme.\u003c/p\u003e\n \u003cp\u003e2) Moreover, those who belong to the APL category with income between Rs. 1.2 lakhs and 5 lakhs per annum have to pay a nominal premium of Rs. 100/- per year per member to avail of the scheme\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"6.722689075630252%\" valign=\"top\"\u003e\n \u003cp\u003e2018\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.630252100840336%\" valign=\"top\"\u003e\n \u003cp\u003eAB-PMJAY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.672268907563026%\" valign=\"top\"\u003e\n \u003cp\u003eINR 500,000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"56.97478991596638%\" valign=\"top\"\u003e\n \u003cp\u003ePoor households supported by Central Government Funding\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"6.722689075630252%\" valign=\"top\"\u003e\n \u003cp\u003e2023\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.630252100840336%\" valign=\"top\"\u003e\n \u003cp\u003eAAMM-JAY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.672268907563026%\" valign=\"top\"\u003e\n \u003cp\u003eINR 500,000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"56.97478991596638%\" valign=\"top\"\u003e\n \u003cp\u003eNot enrolled in AB-JAY and possess Aadhaar card\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eThe health schedule of 2004, 2014 and 2018 are comparable to each other and have been observed by researchers to provide comprehensive information on morbidity patterns, healthcare, type of providers (public or private), and out-of-pocket expenditure.\u003csup\u003e3,24\u003c/sup\u003e Assam state\u0026apos;s actual hospitalisation episodes for the years 2004, 2014, and 2018 were 700, 145, and 1304, respectively, covered by the NSS sample.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eSampling\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe primary data collection for this study will be based on a stratified multi-stage design that was adopted and followed by NSO in their latest 75th round survey of 2017-2018 in Assam. Likewise, NSO sampling design, here also a subset of the population within each geographical study area may be the subject of the study. The smallest area units used as first-stage sampling units (FSU) in rural and urban regions, respectively, are villages and urban blocks which will be obtained from Census. Household or household-based inquiries will be considered as the second or ultimate stage sampling units (SSU or USU). Within each selected district of Assam, here also two basic strata will be formed: (i) a rural stratum and (ii) an urban stratum. From each stratum sample (villages and blocks) will be selected with Probability Proportional to Size with Replacement (PPSWR) based on their size as per Census 2011. We will select two distinct random points say, A and B in the village and list, say, 15% households starting from A and 15% households starting from B.\u003c/p\u003e\n\u003cp\u003eThe study conducted in the NSS 75\u003csup\u003eth\u003c/sup\u003e round (2018) provided information about 18603 individuals from 27 districts of Assam, out of which only 4.6% individuals were insured under any health insurance. An appropriate number of hospitalisation episodes must occur in the sample to quantify the change in protection for hospital treatment, which is the primary goal of the study. For a detectable difference at least 3%(d), a sample size\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cimg 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FPD2a8jfQFzChzNmzvM88co/+ec/5fQq/3x4OvdcP56gS+/k+oV/bd8upyd57P6xjAn1PG7ovA5DzkZ2f7GSFXmBFIaN55bbpzGxpyteemFRlFbS0KrHKI6023ToK8qoLEznyIHv2Lb6Az7/ci3/3V1Bwf9iic8dkbe2gj1sPdxCkd90pk8dy41R8o4WzGXZNJoDUIfEYm+pJUjUjJPWKbt4U2YjrS4qrL5eOIsW/ey6g8STS3WUH3PFYkziksGJDOz5w5UkDNoSKopr0QcFoQ7yJVplQy2VU11RSGlNPPG9hjCot/v/RiU3l1F+JJ1MazOVQR64mSydD/HuBEUUuoiLu5qgkBiMkitlNVrxQs3te05GJc2Za1n9ySa+KYgm5JJ53HDFYC4JFbv0xeR+tYldq4Vb0WpyVHA54MdSuolN723i/eV23Ics5PF/v8Lzd81menMTRiEuq79ayuNLPuaDzaWUiDNObKXqi2ooL2wgMToW/0Q5VE0+ooa6nEpKysIIv+Yx7nz9n7z+ygu8Oq8PowPLyTpYSuYx42k6zFxRubvg7uaCysUdN01ntqkBGvaQtn4dK3YYqI+9ganXXMuNyfIcRa1oDxxg89Kv2ZNzTJYrrIZyKrYIoVopBzLVCusgHw/XOqzCdz/t14CuYDLSVCPuqRbXjQwl1NsNL+Eq2bN2ceDddWxNNVHVbyj9+4TRR4j/SSuHvhVrQx3H/NypjQzET7Tiwto/C+Q8EiLfIIwj53D8QryOm3agCG1FCUV5vniE9aFv/1jhZor3aK1G5eRLgzoej8BAwgJ/EC6r+E0V5Oceo9ImGgFfDyJczz7MUhGFLqLSuBIaFIGp2UJjow6t7EucFD263F2kr97H7pYUPC6bzx8XXsUNvV2EuddKs/BdD+Q3kGUNRvLQOMxpW20tJd9/RKFZQ7pmNIkjp3L5oPFMTIkitukgxZtXk3esAZ/Bw3AN9mgzG39Ervy11DVYqaz1JaVfBPGxstcuv2J/DL49SbjqasbPmsbNl07g0knXMGlSDPGhOnIr6tGL5+nU2rQbserNGIQI2s0GjPpTRTRK2JqzyFq+kt0ZGkoSb+X2OXNYMDmAIPnnVB2htPAYu2uEqxGZ2Da/gMoDTUg4IdHxBIf6E+xuRmOqw0M0nKqzNIFPht2gQautwCXCk7gkXyJrtpO5+n3eWH6Y9c2RuIwex5U3jWFkoh8+4r4nvbWuheb6KppDfdELSyHCxeXs+kbMrRgKciguq6HA7o7dz49Ixw7R0KS9y7Y9aexVj2fMtKlMHyBafvk9OqnwFn6E2tRCa4tZDhsRWLBm7ufI9v3s1dbjFhNNYmwoYW5nX7UVUegq7t74xMQQbDQReKyKylbzT1tYmwFDzWbyvl3JO+/tId0ejVeEF6HaNNLS0khdvZyVH6/h/ZJWvm1ywsMkidbGSmtROenbj6KPT2LIvdcwol/b/E0mew021yOkFtVRYupBytT+XHt5rOPb/48FUtKJgpZBleTOIWMUKqmZno4mTC7aMUSPv4IrF8/kkiQNjsgAXR6l+RJm/wH0GRRLoq+6Y3/AyRCms5urC04ublhO4TZZWzKpPPAZX30o3JN0K6aoOCKd8qlJTSV11wY2v/8h7+7M5Cu7H+U1TY7W0UUTRcTE6Vx+/UyuH5/E2KhQPCzid8txA22XbceEpbWaiswjHDl0iEOnTGkcOlxEeZ1BSPMP2DHpy6ksqRSZ5kVcj1CcK/ez9fMPeG/NUfa7JBN9yVhmTYzB36+TGIzWemqEq+Pm401gkA/Brp0c2xkGA9rcdMoajpKtLyQzbT8HcnLIOfg1332znd21HnhOv45Rw6OEWyafIN60czTOfiriQsppzN/Lvp2FpBYeJefoUbZty6C8yZWecT0Z0CsYyzmEvSii0FVc/aBXEn1crfQvyqJVtMxF7bt+wNZaS/mWj9kv/ONvy0rJ2vcp6197mN8/9CBz587lnkef46Wv97FPL8TA15dwRydSLU11xRSmx6KyRJI82BPfdhfTZq4RFfEY/kMvJ3b0DUwZGInsfnZoyczNUJCBVhPIfu+ehLp64ChLJ6WEpsI9rD0SSq19OAtnJjM07kw/UXRuz7dkbiJ722o2lZRw4Og2Dn76J/72h/ksWLCAe+9fzEOvL+fz/FrxOzUEatrXQZADooRv7iTMAo27K27O6lNYLXU0523gyycW86iwPuacMj3AvLnvsHxXJcXirDZhEa1rUwZFGQaaytyEVZJI+OhZTP7dHdw8NozAw/kU7yxxuGSndght6BurhHtWg7daQ1KfSLzcz64K2YzC1asuweRbQZ3qEKtfe5YnHniAxc98wL/Soom56n7m3DWWCXHHrxURiV9iMjEjnDEWLeO/TzzJM+9tZ6eHFx4JyYTXJxInxDZEvHj1OdRsRRS6ipPwpb0H0S9GYkBgDlvSctknf0Q+DidRYNz8RuE3YBazF8zlrtkTmD4iibCwMOLi4hgw8hIum341d08dxK3DgghwFi6ItdxRsUvqwzBZvAgWRoLj5VgKaSzMYk+VKAgJ40kUrXof4Tec2Lllb7VSl7qVZmMD7vH9CPPyOnkHWON+8mTXpTYK12E30W/IIGYnBRN42rHfalTRY4juO5bbRglrpUdH5+UHVJoEnEInMeb2edx11zXcNimFpMQEYoR11btfMmNm3MB1U8bywOR4hgf+9J4mkwWzzX4K6RGmusafwB7xxCUmknjKJFylxDCCfVz5XyhEAxphjVXX9sHJuQeJvX0Iie1Pr8uu55ZZPRjSsI36nbvZkm2i+lSdK4Z0GrTNrK/sTUjcQC7v64HqpJl8eixC6FubWtGExjL4skmMSEqgX+/exMX3J27EbCZNnMzVvfxE2Wg/wYE73rGjGHXTHKZNGcNlg4IJdXcjKFgiLCiQJl28sCZ8CPL6afnoEvLQ6dOhK10rbfj9SGmUODyi9+3Sgs8LpAO29p0XK6nvSjvfuU+asnip9MiHR6V6U/v2dmw2m2QxmyVzezIajZJOp3Mkg8EgmUwmySxscLtdPtoiScYtUtYHT0m3975RWvjCLmmzI3/Nkj7vP9LK318pDYqfIV37wjZpbZNdatYZJKtJXF8c4ThdskothQek7UvGSSs+/o/0/B67VNDq2PE/7OIH6oul8v1vSR9+sFR66t0MaWulJBksVsne0iBZ7VbJIB/WdvTJsYvfa7NKFqtNsp3iQLvVKlmPe275OfV6veO55b8dz20W1zjVBVr2SWkvTpV+f+NMacbr6dLmqvbtDsT9reK64jr69rw8eZLvZ5RMIn/lbGzL4t1SzqdPS/MHPSw99NRuaZe8zUGTpE3/u/TKhAHSbVMelR75Vi9lyRlxIuYKqXHvy9JHf39KuuzhFdIb++qlE7P4zDFL9RkfS1/MGSk9+ejz0v/ts0nZjW03bcs38ZyO/50cu93yY9nSGxskc/bb0pdP3CsNTH5GWvxZoVTQftxP0GZIBf+5VnrgEg8pZODl0vTXjkibatr3HYdiKZwtiZfSb+QYJusyMGfu48u8ekdP+g/IcyU4u7g45g6Qk5ubm2MuATm5u7vj6uqKi7M8lsBxtEPh3b19HLM3SQYTrqKptDflkZZ+iLX7a7DW+RHtacODcooO51FTqRdt3w/GvJYmQzV52rGobElc3s+J0BO9geZMWo58w9YsX0qtA7l5Sj9GhYkWpSyPo6tWUdrYKK9z9NMY++Nxkk18Nc7CNj1VB6CTWo36uOeWn1MjXAX5ueW/Hc/tIq5xqgsI10Hep5L3i/t1HG8m7q8W1xXX0bTn5cmTfD83XEX+ygXccaeKYkqzjpDXYqTB5oXbjz7CMY4VF7K/1ZUyz2B8vJ0cHZwdqcVc+h3rtpRwUBfNmJkjGN/X/xxmLi/DqaWe7OIQmq09ieuhoodvm03Tlm/iOR3/OzlykNIPZUvj5oNLYzUN5hYM0aH4hvif8+TJZzRHo6U5j9J9O9i2p5ymoGT6Xj6BwSJTIjr75b91XPxwdtYQZqohsU8Ah0uryC8yIrn74+Wrxr1LeSMOVjljqqqi7vBhKkz1HNOZRA21YfEPwGKxElhzDINbK7qwWDy9EnD1UOHj22YeOxkzQFfPhsJ+SCG9mZTiieeP95dlo5aGQ2vIXr2V9/cZ2ZuRS6i6hHRxr8/eW0uxPoC+M8Y7jvYX6RdvKUSBrjuymsM7vmbtpl3s2X2YA0XN5FY2UJubSn1jK7XOEfj4uOB5Vl39YMzcyL5dq9lQZaFJb8AghDz90C52bPyand83UhR0CWEjRzNrXCwJ3qq2Tld5ive6dPIL93O03EKRbTBuUb2YNTmRJPGCz7r461NpPPwdy9YXk1GvptXqS3C8qMwnBn+dCaZGavZ+RHpWFntrVHjHD8bP24sIH3X7GhTHYRDlIHsb+9LyyTBGEzlkCqP6n+McjQodcQ6IJ372TAb08yBO/rKwN5v0Y5ZO4uY7Q7RSkb2JH+GNuWIjn7zyMq9/kUaD7yCmzhzFkBStsBC28c23eRwQguEa6uGwKuQXKJUX0lJUgL5XEKZY3xNaMLmbrZ7mOgMrVx0ma89KatNX8NJLLznSir1H+aJWw5Ecg+OT2FnWuXPCbm6lIWs9B9cv5c13VrPsYCM5VbUYj3zJrpXvsOKbnXxXaETbeSBFJ0i0NjfTYq5HFWuhsmIbaeK6y5YuZemyPWw+6kfEiHFcd00Ko4LV//vUK0TBrM2gIKeQVWmiksUN5soJA+krhyC3H3JWGNU0terQ+zZTVrCD/C1plGhN8oDzs0CFQe2NqbkWz/o9ZBzcT2qZGVOnJl/nKNOxdQdSNeVHy8hrFIofF0dsmDPCCu0ykr4FbUk6ecW1VAtDQR2cSHJKbyJdtNQcOUB6iQVj2ABiEnuQEKD+MWim7puXKS4pYdeARUQm9GB2yPE3l19vA83FZRxJLZIDqBF+vWN6NBlXt2A8eyQzqF8ksb6dm60/F5JFR1PBLopKaoXV4iHM47ZfIRdNnU6HZ2g8oYlD6B3pTuBZ9aA1Uf3Vn1n2yed8FXg7PeOHMLuHjUZ5MSO1K57eCaLV7EvPKM+2z7U/IJkxN+RzTGuk1BBMVEw0MUKJz6kTT8ZYTXNFAYeKtDS22ISR2JNeoxKJCWwPWe4KdtEIlaVxrES4lU3C6ApMIjImjgERwmU9sX6e4XRsP4MoNFOTmUpW+jEq5f+qIogZMpD+if74yoEWpamkHswnT45vFSrnF55CYu8EYkJEAT0fzdSvGuEYm2vY8+4nZJWZiJ33MLGRHiQqYn0coqC1HqRizde89sFR6mb9mStmDeC6i2rVonZ+8TkaJRt2Ywmm+nT2f/c1q//9V/6yeBGPPvISSzcdJc1spaUpj4r9G9jy2T954enHePThx3nhuU/4eEMZhY3SKT5DnQKrAVNLHdraaiorK886Vdc1oG0V5tavcVYtuxZb6UbyW1zZqx+EVWchRhGEE5BFoYbULB1V5niiAj1IuBgFoQt0n6Vg0NJ8+H1sEYlsrvRDU7SHtC8+4qtdTkQ/9DzTpg+mjzAR/TR+GAJcyMvcxPf/WcXOnAg0Ux/g7ocmMXOA5szjyMu2c3DzZyzfXU16aZfnvvkRv95jiBp9HTdO6MPQU0f7XJg0ZlCz7e/sdbqWpUfjefyWXoyOPl28wcWG8MNaSynK1FKsdSckuTfRkZpfzQrQ3covbynIxoIz2YXNWAMSGHbNZVw9sT/Rqgoqvv2C9G0HSauVKHWPE+7EBG68bRozB4XiWpPJ7vSDlNYbuubPSnZxPwsWi2jlhY98tslssTpCdrt14M0vhV8E/jFjiOkdy+yrkxiuCMJJcAOvROJGjOTSaYPod7EKQhfoPktBHtFmbMYkqbG6ueNl2U3asnd56snV5NGPyU88yiUzRzImNJAwdxVOlm/57rF/8Oz7lewZPZfnHruZRWP8z1ylLDqMuibHarpGS8cI+a6gdvPA2cMXX083PE5Tp+SVtuV0wSBE0WpsweLsIdpDVwI0zo74CKv1tzfD8Nki54f8Pf+HzksZOX9+y3nkiF/QaBzP3oHz19EoY0E6+h++/OBd/vhhPpa+93LrI/O5fkoP4sVeJxqxla9m9XP/5uVvJMqv+D1L5k/nzuRzGMXxC7Bs2TI+//zz9v+df+Slxb29vR2TvdhsNlpaWhRBUCAlJYX77ruPwMATlpM+r6JgMqLd8AjvL/2I19LiGf7k+9x8dX+uChMFWd4vHcOaupw3/rqC9zLDibjtURbdOoIrun9usm7lrbfe4sMPP2z/34XB8S3gGbxKhYuAUaNGOSaiDQ4+obafT1GQdNUUfraAd975jk+qZzHrpSe5Z0YUSe3HS4ajtG5ZyrOvHWatcQRTH7mPOVNi6NsVl1he09JqaesPOIcOATlsV+Xs4gjd7WxiZpna2lrq6o4PZlZQuPDw8vIiPDzcYUl24HyKgr0lh+z3f8/LK0pY6zmfJU/dwm1j2tbml7FUfEfmssd54T0LuQn3Mve1O5gZ59LJUN+TULGH9O9W89X+WrKOnV0smIxPz+FEDLuKa0YnkHxC5igo/Kb4xb8+/IgZc3M+2hoz1YThnhRDuJ97h2nMbU21FBUXo3XyQBMcRoirvetTWplb0WtLKS8tJC8v76xTUVkl5Q1G9IorrqDg4GewFCppOvgxn/ztI97NjcXt+sd5+pZhTIr+wTY3Y0j7kE9ffIHXay8lcNL9vHHvABL92i/W7iOfxpIHYwPN9dVUNZpoNZ59oLezpx/uvqGEBXjic/bT2il0M/KKTXLRlPtMftKLrnB2nDdLwSovKlpKVnU11Sp3QvxD8P7fkD1BPRpfFyqL1ZTqvNFE+hBpPkbz2jV8//l2Dtc2OYYEnxZ3f3wi+tArKZkhQ4acdRrYO55eYYognH9MoMuncO1bfPr4Yzz10EPMmzePhx76I8+9s4M1uVrqzmGQj8KZ0+2iYNNWUpGVTnWLGy4RvYmO8yOgw0pANmqKqpFEGdDUlVKXsZPN3x8kN6+OkpIG6k0WuXgoXFTIxqpW/Mkle9U69m7ZwcatW9m7bw/b1qzg23Ub+GhLNkfqrJ3P96DQLXS7KBhrK8jLyaG6JpiQoP4k9xHWQocJPwLRBCaT0D+Cfs6pHP3kNf64fD/7YoYTMXEUA4N8Oo5UU7gIkKt6I9rsMvLzfAmY8iC3v/kmb7zxCm8uGsLlERUUppeTVWZ0rBOh8PPS7aKg9ksi5rL7uXnBAubPHs64CNcThhG74xE9hJG/m899C+9k0e+u5KqUgfRIjqfvoDBC5Ik7249UuFiQP535Y/HvRe9rZ3PZddO5ccwYxo+byOgJMfSKMJBfVY+u0Xxe5nu42Oh2UXCPGkTKjU8w59HbuW1aDAnOqp+8SLV/MLGX3sCM+U+1LYv20I1cmeAhbAiF3zZW0FehLc8lIyODzMwCyqt1jklp7IQTNuxSrlh0NWP7e+Lo+zKWUJZjodmjH0kpPekToD5uIlaFn4vu72hUUDgVkh7KN7N/1Yvcc88C7r77Rd5alU2mVZLl4gTK0RXv5pvMIMqNI5g/I5kxvbp7fW6Fk6GIgsIvh5MPRCXSM0RNoksVx2p0VDsFYXc5Yb7DpgPkHdnJrrJAXIffTP+RKcwaEEqgl+I8/BIooqDw8yIZ0NUWU5Sf7wgWyy71x+aVwMRRIfQYkYhRbSXYLLVNcSaZwVBKVVE636c2saMklOjB0VwzPgD3pnpsNou8AuMJq0YpdDeKKCj8jBgwFexgx0d/Ysn8exyrYy1e/BeeeHU1O2tbcU2IIy42jCjndjuh5SgtqavZkelJjq4/103sz6gIUJcVcHTVSsrqGxwrPp31/K0KZ4QiCgo/E63ojmzk4Ger2JxVh77XQAaOGktCjBcWbSnpGc2o3YOIDPdE4yiFtTTl7CR79SbWrNnHys9XsPXL13n/zTd57KlX+Wh/K6aAEMeVlUL786Lkr0L3Yzdh1e3k4Nrl/Ou9A+T6T2HY3Y/z4OMP8H9LxnPziEj8tV74Sl74/fjJqYnWJhNr1mWTue8rDIVrefvtt3n99df5Yl8Wa5u8OJytI1oc2ZXBtApdRxEFhW7H1nCMgrXvsyWrksyYaYydeg03DQmnh1cQXuE+hAfH4anqQYi/N4H+bfGM8roXfklTufovL/P8m2/wyit/55lnnmHJkiX85flHeGHhFEZFaRxrWnTolFTodhRRUOhmzBjrM8let5esan9Cp9/K6OQIejj2WaBSuAmuEehjU+g9oAex7j9Ucl88I/qSMnUqU6ZMYcaMGdx4443cdNNNzJ49hakjo8/buhQXG4ooKHQz8mpURynM88TDZwjDh/Yi6odx8bZarCVFFBngWGxvvP1c6aHU8gsORRQUuplaXEw2Kk2xqAPjiItxwre9E8DeWkr+gcOkFlTS4u9PmJfm3FdbUuh2FFFQ6Gbamn7JakGnM+HsQdsEO42l1O7ew96dhyhqsRISGoCvrgxDay25LXaaleGPFwyKKCh0M0FYNS5E+lVjrT7C0TQtmdoqjqWnkrUjl2NNrTh7SfhZGynOSSOvsorMJjsNiihcMCiioNDNBOAdNZi40T4Eue/mm9ef4rW31rGxRbgTI69m4MQxRJgOUbn7M7bX+LJfG0iitwpfJYL5gkERBYVuxtUxX0b/q28gZVQ8kVI5tUdyKDZr8B81nqTLZjGiT18SvHTorc74+UXQ31eFnyIKFwyKKCh0Oyr3IHoMuYMb5r3kCEB6+x8Pcd/EOHqHeNBjwCxuW/w2//zH33jx1hSukFcHUrigUERB4WdB7eKDj38EERFyCiPE20XYEGK7sye+Qe3bAzR4KXNjXnB0SRTkyDOVyhU3Tx+EG6igoPBrwtcbb40Lbu0D0E41jfsZVW1nZzVqlZPjYLvNiKG5nlp922KrRqO8crMN26nuoKCgcH6wW8UfeVX29rpaXUdtow6DpW3qfHkN0pNV2zNa9wHdHr5/8TGe+vsOdrslkTBmJCG+ZkIdghNC/4mzGDppBMMinJVlvhUULghs2As2cnDvDj7bU01VkxnJqEVfsp/iykZqwiYz7oF3uGNyOFNOWJrtjCwFY6sKp9Ak+o0dTXJfPzzrs2nKyyUzM1OkXErETRrMkjLOXUHhgkFC0mtpriogL+eoo65mF9VQ5ZyIJmY4Q/snkuhjIvgksySfkaVgt7RiqK9D26intT3IxGKxYDabxb/c8AmJxD/EnwCNShnWqqBwQSBEobWaxgYt5VrhOljsjpW23NzcHH+7uHvi4R+Gn7cbnidU2jNzHxQUFC4alG8ICgoKHVBEQUFBoQOKKCgoKHRAEQUFBYUOKKKgoKDQAUUUFBQUOqCIgoKCQgcUUVBQUOiAIgoKCgodUERBQUGhA4ooKCgodEARBQUFheOA/wegDKv+6sewqgAAAABJRU5ErkJggg==\" height=\"92\" width=\"261\"\u003e\u003c/p\u003e\n\u003cp\u003eof 2191 achieves 90% power using a two-sided exact test with a target significance level of 5%(\u0026alpha;). Assuming 20% non-responses resulted to 2739. As the study considered five study sites (districts), therefore, a sample of 3000 individuals (AB-PMJAY scheme recipient and other scheme recipient), will be recruited for capturing geographical diversity.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSelection of participants will be based on an inclusion criterion, namely, adult aged 18 years or above, residing in the selected geographical area, enrolled, and hospitalised under AB-PMJAY or any other health insurance scheme in a public or private hospital, and those consenting to participate. Those with any physical/medical condition that precludes the possibility of interview will be excluded from the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData collection tools and strategies\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData will be collected using a questionnaire (Annexure I) by trained interviewers through the Research Electronic Data Capture (RED Cap) on digital devices (RED Cap powered by Vanderbilt). RED Cap is a safe, browser-based web application that will assist with data management, storage, and monitoring while maintaining data confidentiality through logic and range checks, a decrease in data entry errors, and the identification of incomplete or missing data. Data will be transferred from the questionnaire to an Excel document and recoded for data analysis using R software.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAnalytical approach\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAs suggested by Wagstaff and Doorslaer\u003csup\u003e25\u003c/sup\u003e, financial protection will be quantified in terms of Catastrophic Health Expenditure (CHE). Every episode\u0026apos;s OOPE will be determined by deducting any cash reimbursements the patient has received from the total amount of medical and transportation costs. According to current studies, the OOPE amounts for 2004, 2014, 2018, and 2024 will be updated at 2024 prices for a realistic comparison.\u003csup\u003e26,27\u003c/sup\u003e The survey will gather information on typical monthly consumption expenses, which will then be multiplied by twelve to determine typical annual consumption expenditures. The similar method has been employed in recent research analysing the NSS datasets to determine Annual Household Consumption Expenditure.\u003csup\u003e26,27\u003c/sup\u003e For CHE, thresholds of 10, 25, and 40% of the annual consumption expenditure of the household in question will be used. Changes in the use of hospital care will be used to evaluate improvements in access to care.\u003c/p\u003e\n\u003cp\u003eFor the continuous outcome variables, Ordinary Least Squares (OLS) will be employed to analyse the continuous outcome variables namely OOPE and the logarithm of OOPE. The Probit model will be employed for binary outcome variables, such as catastrophic health expenditure (CHE). The robustness of the Average Treatment Effect on the Treated (ATET) will be evaluated by comparing it with the results obtained from Propensity Score Matching (PSM) modelling. PFHI in India and other countries has been evaluated using Propensity Score Matching (PSM) and other similar \u0026quot;matching\u0026quot; methods.\u003csup\u003e3,21\u003c/sup\u003e A multivariate analysis will be done to assess the impact of AB-PMJAY on usage, out-of-pocket expenditure (OOPE), and catastrophic health expenditure (CHE) in comparison to persons enrolled in AB-PMJAY without any additional benefits. In addition, the Instrumental Variable (IV) technique will be employed to replicate the multivariate analysis for out-of-pocket expenditure (OOPE) and catastrophic health expenditure (CHE). This further investigation will be carried out to tackle the issue of endogeneity, or the potential selection bias, which is commonly acknowledged as a usual obstacle when establishing the impact of insurance on economic outcomes such as out-of-pocket expenditures (OOPE).\u003csup\u003e3,21\u003c/sup\u003e The Instrumental Variable (IV) technique, has been suggested as a reliable solution to address the potential issue of endogeneity.\u003csup\u003e17\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eB. Study Component 2: Influence of Ayushman Bharat-PMJAY implementation on the quality of services and to explore awareness of features, coverage, and health service use\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Collection Tools and Strategies\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe primary data on qualitative aspect will be obtained at all five selected districts specifically in a subset composed of village or block through a focus group discussion (FGDs) and key informant interviews (KIIs) among eligible participants at selected community levels as mentioned in Table 1 (Annexure 2). We expect to hold at least two focus groups (AB-PMJAY availing and other schemes availing) in each district, with 8-10 participants in each FGD. Here, the qualitative aspect will be covered through purposive sampling. Following written informed consent, these sessions will be recorded, verbatim transcribed, and translated into English for analysis. Trained qualitative research assistants will be responsible for collecting data using the guidelines that are briefly explained.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAnalysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe beneficiaries will be traced those willing to participate, an in-person interview will be conducted and recorded. The collected data will be transcribed, analysed using thematic analysis. The interviews will be conducted in Hindi, Assamese, Bengali, Manipuri and Bodo languages based on the study site. The transcriptions will be cross validated by the team members for its validity. The transcriptions will be exported to the qualitative analysis software. Data will be coded, and analysis will be carried out using thematic analysis. The results will be discussed among the team members to arrive at the explanation of the phenomena of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eC.\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eStudy Component 3: Document implementation process of AB-PMJAY at state and district level of Assam\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo meet the third research component, which focuses on creating and documenting the processes involved in the conception, creation, and implementation of AB-PMJAY in the state of Assam, this study component takes a qualitative approach. We will examine AB-PMJAY implementation through the perspectives of those directly involved in the scheme design and deployment, using a constructivist viewpoint method as our foundation.\u003csup\u003e28\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSampling\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe will include community health workers, hospital manager, AB-PMJAY in charge at hospital, and state level officials with AB-PMJAY.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData collection tools and strategies\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData collection will rely on KIIs conducted using the interview guides developed for the present study (Annexure 2). State level official interviews will be conducted by the Principal Investigator.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAnalytical Approach\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe will use thematic analysis to explain the AB-PMJAY implementation procedures, including their successes and setbacks, considering the larger socio-political environment in which the scheme is being implemented.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics and Dissemination\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study investigators will ensure that this study is conducted in accordance with the principles set forth in the National Ethical Guidelines for Biomedical and Health Research involving Human Participants of the Indian Council of Medical Research (ICMR).\u003csup\u003e29\u003c/sup\u003e The study has been approved by the Institutional Ethics Committee of Assam University, Silchar (ref no: IEC/AUS/2023/VV/01 dated 5thOct, 2023). Written informed consent will be obtained from all study participants. We aim to present the initial study results in a workshop attended by state officials, hospital providers and researchers in Assam state. The final study results will be submitted to the funding organisation in the form of a technical report and to a peer-review journal. We also plan to integrate our study findings within a systematic review focusing on impact, utilisation, and implementation of AB-PMJAY in India. Authorship will be determined according to the statement from the International Committee of Medical Journal Editors. Open access to individual participant data is not planned, but all requests for the study data will be considered on an individual basis by the PI (VV) and Co-PI (DJ). All investigators will be given access to the cleaned data sets.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatient and public involvement statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSix of the author members include employees with central government-funded university or institutions who are beneficiaries of AB-PMJAY scheme and are involved in the design and conduct of the study.\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe study design described in this paper is the first attempt to assess the procedures and outcomes of the largest PHFI programme ever introduced in India, AB-PMJAY in the state of Assam. In order to emphasise the endeavours focused on producing reliable scientific data, it is essential to clearly define our study design in consideration of the practical assessment requirements that are influenced by policy concerns and implementation circumstances. Due to the statewide coverage of AB-PMJAY, it was impractical for our team to have control over treatment assignment criteria and rely on a standard experimental design for state-specific evaluation. Despite the challenges, this study aimed to create a scientifically rigorous study design. It utilised a combination of different methods for data collection and analysis and had the ability to incorporate quasi-experimental design elements into the quantitative analysis.\u003c/p\u003e\n\u003cp\u003eThe design of our study is enhanced by incorporating both the AB-PMJAY impact and implementation assessment components into a single protocol. This protocol effectively considers the practical aspects of implementation and the resulting effects on both the supply and demand sides. Although the data collection methods are established and the analytical frameworks for progress are presented in a dynamic manner, the process components are utilised to elucidate the outcomes of the effects, and the findings of the effects are employed to stimulate further research into the aspects of the process.\u003c/p\u003e\n\u003cp\u003eWe recognise the intricacy of our study design and the difficulties in successfully carrying out our combined method and evaluation, even though our proposed technique for impact evaluation has the capacity to produce highly insightful results through a more comprehensive analytical approach. At the beginning, implementing our research plan requires relying on a diverse set of investigators, each with unique expertise in both subject matter and research methods. To ensure comprehensive comprehension of the intricacies of plan implementation and its effects across the academic and policy communities, the team must devise strategies to efficiently and succinctly convey the findings, employing a range of analytical methodologies.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMoreover, it is important to recognise that the generalizability of the findings and methods used in this study is restricted.\u003csup\u003e30\u003c/sup\u003e While we have confidence in the internal validity of our sample and data gathering technique, we cannot ensure that the results will precisely represent the processes and impacts of AB-PMJAY implementation for the entire state. Moreover, it is crucial to acknowledge the inherent bias that arises from the sampling methodologies employed to select hospitals for the supply-side component and residences for the demand-side component.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePrior to commencing our study, we examined various alternatives. However, after careful consideration, we concluded that due to the unavailability of a more up-to-date and comprehensive population listing, as well as a complete health facility listing (or the insufficient resources to conduct such listings), our only viable course of action was to utilise the techniques previously discussed in this manuscript. It is important to acknowledge that our findings will not accurately reflect urban conditions, especially in regard to the demand-side aspect. Further research is needed to explore the practicalities and effects of implementation in metropolitan areas, using various primary sampling methods.\u003c/p\u003e\n\u003cp\u003eThe study design aims to collectively evaluate the impacts and implementation protocols of the largest government-funded insurance policy ever established in Assam. Through providing a comprehensive analysis of our study design, we aim to motivate other researchers who are examining novel social health protection programmes in India and similar settings elsewhere.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConfidentiality\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStudy participants will be identified solely by a study number that represents the study site and the order in which they were enrolled at that site. All study records will have their identifiers removed. The study data will be securely maintained in a closed room, and access to the online data management platform will be protected by a password. The confidentiality of study participants\u0026apos; information will be maintained and handled in accordance with the regulations outlined in the National Ethical Guidelines for Biomedical and Health Research Involving Human Participants\u003csup\u003e31\u003c/sup\u003e and Institutional Ethics Board. The guidelines mandates that every participant must provide consent for the collection, utilisation, and retrieval of personal health information, unless the Institutional Ethics Board waives the need for consent. When consent is necessary, it is imperative that every participant is provided with the following information:\u003c/p\u003e\n\u003cp\u003eThe ability of a research participant to withdraw their consent for the use of their Protected Health Information (PHI). If a participant withdraws their consent to collect or utilise PHI, the investigator is allowed to utilise all the information that was obtained before the withdrawal of consent. For participants who have withdrawn consent to collect or utilise PHI, efforts should be made to gain consent to collect at least vital status (i.e., confirmation that the participant is alive) at the conclusion of their designated study period.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Sharing\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOnly the study procedure is being highlighted in this study protocol, and participant-level data collected for it will not be publicly accessible. However, the corresponding author can be reached with any questions.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics statements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatient consent for publication\u003c/p\u003e\n\u003cp\u003eNot required.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests*\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNone of the authors have any competing interests to declare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAuthors would like to express their deepest gratitude and sincere thanks to Mr. Ajay Verma, Mrs. \u0026nbsp;Swapnalee Bhattacharya, Dr. Kanchan Kanti for their support and insightful suggestions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eContribution statement\u003c/strong\u003e:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e:\u0026nbsp;Authors would like to acknowledge Indian Council of Social Science Research, New Delhi for providing the grant for this study\u0026nbsp;(F.No. 30/CRP-2023-696/AB/SCD, dated 20 September 2023).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e:\u0026nbsp;The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData sharing statement\u003c/strong\u003e:\u0026nbsp;Only the study procedure is being highlighted in this study protocol, and participant-level data collected for it will not be publicly accessible. However, the corresponding author can be reached with any questions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eUnderlying data\u003c/strong\u003e- No data is associated with this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical statement\u003c/strong\u003e: The study has been approved by the Institutional Ethics Committee of Assam University, Silchar (ref no: IEC/AUS/2023/VV/01 dated 5thOct, 2023).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e: Writing of original protocol, VV and DJ; writing of original manuscript, VV, BB, MK and DJ; review and editing of manuscript draft, RC, PS, PP, JY, SS, MNT, and RY; quantitative component, VV, DJ, JY; qualitative component, SS, DJ, VV; supervision, VV; funding procurement, VV and DJ; all authors have read and agreed to the published version of this manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eNational Health Systems Resource Centre (2023). National Health Accounts Estimates for India (2019-20). New Delhi: Ministry of Health and Family Welfare, Government of India\u003c/li\u003e\n \u003cli\u003eMinistry of Statistics and Programme Implementation (2023). Sustainable Development Goals: National Indicator Framework, Progress Report 2023. New Delhi: National Statistical Office, Ministry of Statistics and Programme Implementation, Government of India\u003c/li\u003e\n \u003cli\u003eGarg, S., Bebarta, K. K., \u0026amp; Tripathi, N. (2020). Performance of India\u0026rsquo;s national publicly funded health insurance scheme, Pradhan Mantri Jan Arogaya Yojana (PMJAY), in improving access and financial protection for hospital care: findings from household surveys in Chhattisgarh state.\u0026nbsp;BMC Public Health,\u0026nbsp;20(1), 1-10.\u003c/li\u003e\n \u003cli\u003eDe Allegri M, Srivastava S, Strupat C, Brenner S, Parmar D, Parisi D, Walsh C, Mahajan S, Neogi R, Ziegler S, Basu S, Jain N. Mixed and Multi-Methods Protocol to Evaluate Implementation Processes and Early Effects of the Pradhan Mantri Jan Arogya Yojana Scheme in Seven Indian States. Int J Environ Res Public Health. 2020 Oct 26;17(21):7812\u003c/li\u003e\n \u003cli\u003eGovernment of Assam. http://atalamritabhiyan.assam.gov.in/schemes/ayushman-bharat-pradhan-mantri-jan-arogya-yojana. Accessed on 09 February 2024\u003c/li\u003e\n \u003cli\u003eBala, R., Kumar, M., Krishna, K. K., \u0026amp; Devi, C. S. (2021). Has Ayushman Bharat dwindled the out-of-pocket expenditure. Journal of Evolution of Medical and Dental Sciences, 10(25), 1895-1898.\u003c/li\u003e\n \u003cli\u003eAmbade, M., Sarwal, R., Mor, N., Kim, R., \u0026amp; Subramanian, S. V. (2012). Components of out-of-pocket expenditure and their relative contribution to economic burden of diseases in India. JAMA Network Open, 5(5), e2210040-e2210040.\u003c/li\u003e\n \u003cli\u003eJoseph, J., Sankar D, H., \u0026amp; Nambiar, D. (2021). Empanelment of health care facilities under Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB PM-JAY) in India. PloS one, 16(5), e0251814.\u003c/li\u003e\n \u003cli\u003eAngell, B. J., Prinja, S., Gupt, A., Jha, V., \u0026amp; Jan, S. (2019). The Ayushman Bharat Pradhan Mantri Jan Arogya Yojana and the path to universal health coverage in India: Overcoming the challenges of stewardship and governance. PLoS medicine, 16(3), e1002759. \u0026nbsp;\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eParisi, D., Srivastava, S., Parmar, D., Strupat, C., Brenner, S., Walsh, C., ... \u0026amp; De Allegri, M. (2023). Awareness of India\u0026apos;s national health insurance scheme (PM-JAY): a cross-sectional study across six states. Health Policy and Planning, 38(3), 289-300.\u003c/li\u003e\n \u003cli\u003eGowda, N. R., Hakim, A., Singh, G., Gupta, A., \u0026amp; Sharma, D. K. (2022). The Experience of Patient and Implementation of the Landmark Scheme Ayushman Bharat (AB-PMJAY) of Government of India in a Tertiary Care Hospital. Journal of Health Management, 24(4), 566-571.\u003c/li\u003e\n \u003cli\u003eDubey, S., Deshpande, S., Krishna, L., \u0026amp; Zadey, S. (2023). Evolution of Government-funded health insurance for universal health coverage in India.\u0026nbsp;The Lancet Regional Health-Southeast Asia,\u0026nbsp;13.\u003c/li\u003e\n \u003cli\u003eSaxena, A., Trivedi, M., Shroff, Z. C., \u0026amp; Sharma, M. (2022). Improving hospital-based processes for effective implementation of Government funded health insurance schemes: evidence from early implementation of PM-JAY in India.\u0026nbsp;BMC Health Services Research,\u0026nbsp;22, 1-13.\u003c/li\u003e\n \u003cli\u003eKnappertsbusch, Felix, Langfeldt, Bettina and Kelle, Udo. \u0026quot;Mixed-Methods and Multimethod Research\u0026quot;. Soziologie - Sociology in the German-Speaking World: Special Issue Soziologische Revue 2020, edited by Betina Hollstein, Rainer Greshoff, Uwe Schimank and Anja Wei\u0026szlig;, Berlin, Boston: De Gruyter Oldenbourg, 2021, pp. 261-272. https://doi.org/10.1515/9783110627275-018\u003c/li\u003e\n \u003cli\u003eHesse-Biber, Sharlene Nagy, and R. Burke Johnson (eds), The Oxford Handbook of Multimethod and Mixed Methods Research Inquiry, Oxford Library of Psychology (2015; online edn, Oxford Academic, 19 Jan. 2016), https://doi.org/10.1093/oxfordhb/9780199933624.001.0001, accessed 22 Feb. 2024\u003c/li\u003e\n \u003cli\u003eSchoonenboom J, Johnson RB. How to Construct a\u0026nbsp;Mixed Methods Research Design. Kolner Z Soz Sozpsychol. 2017;69(Suppl 2):107-131\u003c/li\u003e\n \u003cli\u003eAcharya A, Vellakkal S, Taylor F, Masset E, Satija A, Burke M, et al. Impact of national health insurance for the poor and the informal sector in low-and middle-income countries: a systematic review. London: EPPI-Centre, Social Science Research Unit, Institute of Education, University of London; 2012\u003c/li\u003e\n \u003cli\u003eGovernment of India. NSS 60th Round: Jan - June 2004. Ministry of Statistics and Programme Implementation. National Sample Survey Organization. Dataset. Available at: http://microdata.gov.in/nada43/index.php/catalog/105.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eGovernment of India. Health in India-NSS 71st Round (January to June 2014). (Ministry of Statistics and Programme Implementation. National Sample Survey Organisation NSSO). 2016.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eGovernment of India. Health in India-NSS 75st Round (2017-2018). (Ministry of Statistics and Programme Implementation. National Sample Survey Organisation NSSO)\u003c/li\u003e\n \u003cli\u003eKaran A, Yip W, Mahal A. Extending health insurance to the poor in India: An impact evaluation of Rashtriya Swasthya Bima Yojana on out of pocket spending for healthcare. Soc Sci Med. 2017 May;181:83-92\u003c/li\u003e\n \u003cli\u003e\u0026nbsp;Johnson, Douglas; Krishnaswamy,Karunakaran. The impact of RSBY on hospital utilization and out-of-pocket health expenditure (English). Washington, D.C. : World Bank Group\u003c/li\u003e\n \u003cli\u003ePrinja S, Singh MP, Aggarwal V, Rajsekar K, Gedam P, Goyal A, Bahuguna P. Impact of India\u0026apos;s publicly financed health insurance scheme on public sector district hospitals: a health financing perspective. Lancet Reg Health Southeast Asia. 2022 Dec 17;9:100123\u003c/li\u003e\n \u003cli\u003eMohanty, S., Padhi, B., Singh, R., \u0026amp; Sahoo, U. (2022). comparable estimates of out-of-pocket payment on hospitalisation and outpatient services in india, 2004-18. Clinical Epidemiology and Global Health, 17, 101139\u003c/li\u003e\n \u003cli\u003eWagstaff A, Doorslaer E. Catastrophe and impoverishment in paying for healthcare: with applications to Vietnam 1993\u0026ndash;98. Health Econ. 2003;12:921\u0026ndash;34\u003c/li\u003e\n \u003cli\u003eYadav, J., Allarakha, S., Menon, G., John, D., \u0026amp; Nair, S. (2021). socioeconomic impact of hospitalization expenditure for treatment of noncommunicable diseases in india: a repeated cross-sectional analysis of national sample survey data, 2004 to 2018. Value in Health Regional Issues, 24, 199-213\u003c/li\u003e\n \u003cli\u003eYadav, J., John, D., Allarakha, S., \u0026amp; Menon, G. (2021). rising healthcare expenditure on tuberculosis: can india achieve the end tb goal?. Tropical Medicine \u0026amp; International Health, 26(10), 1256-1275\u003c/li\u003e\n \u003cli\u003ePoletti, B., Carelli, L., Lafronza, A., Solca, F., Faini, A., Ciammola, A., \u0026hellip; \u0026amp; Silani, V. (2017). Cognitive-constructivist approach in medical settings: the use of personal meaning questionnaire for neurological patients\u0026rsquo; personality investigation. Frontiers in Psychology, 08\u003c/li\u003e\n \u003cli\u003eIndian Council of Medical Research. National ethical guidelines for biomedical and health research involving human participants. New Delhi: Indian Council of Medical Research; 2017. Available from: https://ethics.ncdirindia.org/asset/pdf/ICMR_National_Ethical_Guidelines.pdf\u003c/li\u003e\n \u003cli\u003eLavrakas P. \u0026nbsp;Encyclopedia of Survey Research Methods. Sage Publications, Inc.; New York, NY, USA: 2013. External Validity\u003c/li\u003e\n \u003cli\u003eNational Ethical Guidelines for Biomedical and Health Research Involving Human Participants. 2017. [Last accessed on 2018 Jun 26]. Available from: https://www.icmr.nic.in/guidelines/ICMR_Ethical_Guidelines_2017.pdf .\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-4794755/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4794755/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction:\u003c/strong\u003e Ayushman Bharat- Pradhan Mantri Jan Arogya Yojana (AB-PMJAY), is an Indian Government initiated health insurance scheme, with the purpose to improve access and availability of secondary and tertiary inpatient care and reduce additional financial burden of out-of-pocket expenditure (OOPE) due to medical expenses from economical weaker sections of Indian population. AB-PMJAY was launched in the year 2018 and in the same year was implemented in Assam state. To obtain the evidence of impact and implementation of of AB-PMJAY in terms of healthcare services availability, accessibility, and affordability after the first 5 years of the scheme’s operations in Assam state.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods and analysis\u003c/strong\u003e: The study will follow a mixed methods approach using triangulation mixed methods design along with a multimethod approach. Primary data (qualitative and quantitative surveys) and secondary data (National Sample Survey (NSS) previous rounds – 60\u003csup\u003eth\u003c/sup\u003e (2004), 71\u003csup\u003est\u003c/sup\u003e (2014) and 75\u003csup\u003eth\u003c/sup\u003e (2017) will be considered. 75\u003csup\u003eth\u003c/sup\u003e round of NSS of Assam will be considered as the baseline for the present study. The present protocol describes the methodological aspects adopted for evaluation of effectiveness and implementation strategies of AB-PMJAY in five districts viz. Kamrup Metropolitan, Sonitpur, Cachar, Sivasagar, and Kokrajhar of Assam. Quantitative data will be evaluated through descriptive statistical measures under quasi-experimental design and quantitative aspect will be explored through thematic analysis. The study protocol presented is the first attempt to collectively assess the early impacts and implementation procedures of the biggest government funded health insurance programme in Assam State.\u003c/p\u003e","manuscriptTitle":"Study Protocol: A mixed method and multimethod study of implementation and impact of Ayushman Bharat- Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) scheme in Assam State","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-08-22 05:23:58","doi":"10.21203/rs.3.rs-4794755/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0b1de772-efe1-4961-85c6-2964521aa279","owner":[],"postedDate":"August 22nd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-12-12T11:53:36+00:00","versionOfRecord":[],"versionCreatedAt":"2024-08-22 05:23:58","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4794755","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4794755","identity":"rs-4794755","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}