PONE-D-20-33726

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

PLOS ONE

Dear Dr. Joseph,

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

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

1. The paper currently looks more of a descriptive in nature. Lacks analytical rigour and critical/logical interpretations. Some of the interpretations of the findings look indolent and show a sloppiness.
2. The conclusion doesn’t support with data. Authors need a little more intriguing interpretations and conclusions. For instance, the authors write: “the current distribution of empanelled AB-PMJAY hospitals favours better performing states”. In what terms authors saying better performing states. If I look at the five states that authors listing on socio-economic and health status grounds, only two states are better performing states. Rajasthan, Uttar Pradesh and Gujarat are poor and moderately performing in terms of health care and outcome indicators. The possible reason for the larger contribution from these states needs to be explained. Maybe one reason could be all of them are BJP ruling states or its alliance ruling states at the time of programme conceptualisation and initiation. So, the state role needs to be clearly drawn in this case.
3. Also, the authors must explain the reasons why Private Sectors hospitals not actively taking part in the programme from several angles, especially from the side of state subsidies vis-a-vis the regular out-pocket expenses of hospitals in this sector.  Thus, how to reach a consensus on these grounds?
4. Some states following a much better health care schemes than AB-PMJAY for instance, Telangana and Andhra Pradesh. Thus, the states private hospitals have mostly partnered with states programmes than central programmes. Some of these intricacies missing from the paper.
5. Also, authors critically need to evaluate how far private insurance-based health care schemes work in a highly privatised, compartmentalised and hierarchical health care service delivery system like India.  
6. The paper completely silent on budgetary allocations to meet the stated goals.

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Kind regards,

Srinivas Goli, Ph.D.

Academic Editor

PLOS ONE

Additional Editor Comments:

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

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

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

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

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

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

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

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

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

Reviewer #1: No

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

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

Reviewer #1: No

Reviewer #2: Yes

Reviewer #3: I Don't Know

Reviewer #4: Yes

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

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: No

Reviewer #4: No

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

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: No

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

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5. Review Comments to the Author

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

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

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

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

4.The result do not support the conclusion

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

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

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

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

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

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

Additional comments:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Abstract

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

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

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

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

Introduction

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

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

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

- Spelling and grammar:

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

Methods:

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

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

Results

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

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

Discussion

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

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Reviewer #1: Yes: Dr Nishant Kumar

Reviewer #2: Yes: Dr. Ramesh Holla

Reviewer #3: No

Reviewer #4: No

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

PONE-D-20-33726R1

Dear Dr. Joseph,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Srinivas Goli, Ph.D.

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Considering reviewers opinion and my own reading of this paper, I am recommending it for publication.

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: All comments have been addressed

Reviewer #4: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

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

Reviewer #2: Yes

Reviewer #4: Yes

**********

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

Reviewer #2: Yes

Reviewer #4: I Don't Know

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

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

Reviewer #2: Yes

Reviewer #4: Yes

**********

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

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #2: Yes

Reviewer #4: Yes

**********

6. Review Comments to the Author

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

Reviewer #2: The authors have addressed all the comments raised by the reviewer in the satisfactory manner and all the supporting data was shared along with the manuscript itself.

Reviewer #4: (No Response)

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #2: Yes: Dr. RAMESH HOLLA

Reviewer #4: Yes: Dr. Myron Anthony Godinho