Women’s empowerment and publicly-funded health insurance in India: associations with PM-JAY verification, outpatient service use, and out-of-pocket spending across six states
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Objectives
Women’s empowerment is a key determinant of health and well-being and may shape how women access and benefit from publicly-funded health insurance (PFHI). We aimed to examine whether different levels of women’s empowerment were associated with 1) verification in India’s PFHI Pradhan Mantri Jan Arogya Yojana (PM-JAY), 2) outpatient care utilization, and 3) resultant out-of-pocket expenditure.
Design
We conducted a cross-sectional observational study. We analyzed data from a household survey, created a composite empowerment index using structural equation models, and used multivariate regression models to test associations between women’s empowerment and the outcome variables.
Setting
The study was conducted between December 2019 and February 2020 among PM-JAY eligible households in six Indian states (Bihar, Chhattisgarh, Gujarat, Meghalaya, Tamil Nadu, and Uttar Pradesh).
Participants
14,378 women across the six states.
Results
Three main findings emerged: First, high levels of women’s empowerment were associated with higher odds of completing PM-JAY verification (AOR: 1.22, 95% CI: 1.09-1.36). Second, women’s empowerment was not associated with outpatient service utilization. And third, either medium levels of empowerment (coef = -0.49, p = 0.020) or PM-JAY verification (coef = -0.37, p = 0.034) was associated with lower OOPE for outpatient services. Women who had both, PM-JAY verification and medium levels of empowerment, experienced higher OOPE (coef = 0.45, p = 0.058).
Conclusions
Women’s empowerment is an important factor related with PM-JAY verification, but not with outpatient service use. OOPE varied depending on whether women were both empowered and PM-JAY verified or not. Our results suggest that institutional and structural barriers may play a greater role in healthcare access than individual factors pertaining to empowerment alone. Achieving equitable access therefore requires gender-responsive systems that reduce administrative barriers and support women in navigating the healthcare pathway. Our findings highlight the importance of integrating outpatient care into PM-JAY to increase financial protection, streamlining verification processes to improve women’s engagement with PM-JAY and the broader health system, and advancing health financing reforms that better support women.
STRENGTHS AND LIMITATIONS OF THIS STUDY
- We used a large cross-sectional household survey representative of PM-JAY eligible households from districts across six Indian states.
- We constructed a composite empowerment index based on established theoretical domains of empowerment and estimated it using structural equation modelling.
- Although outpatient care is not covered under PM-JAY, we focused specifically on outpatient services as little is known about the income and substitution effects of PM-JAY coverage on outpatient service utilization.
- Sampling lists used for the study derived from the official PM-JAY targeting database from 2011; many households have since changed social status and were untraceable in urban areas due to incorrect identifiers. This restricted data collection to primarily rural and semi-urban (as opposed to urban) areas.
- A reliance on self-reported data may have introduced selection and recall biases.
