The Rashtriya Swasthya Bima Yojana (RSBY) is the Government of India health insurance scheme for families below the poverty line (BPL), with over 37 million families currently enrolled. RSBY covers a range of inpatient services and surgical procedures, provided by a network of private and public hospitals and reimbursed on a fee-for-service basis with defined benefits packages (bundle of services) for each procedure or intervention. However, these packages are not determined through a scientific process Healthcare providers and insurers currently lack clear guidance on the most appropriate treatment options for the clinical management of the conditions covered by the scheme. This lack of direction often leads to disagreement about payment and sub-optimal care for patients.

With technical assistance from NICE International (iDSI), RSBY has established a quality programme to provide authoritative and evidence-based clinical guidance for its network hospitals. This is the first time such guidance has been introduced at a national (Central) level in India. The new guidance will serve as a benchmark for regulating the quality of healthcare services received by patients and informing claims reimbursement with potential impact on the millions of citizens covered by RSBY.

Initially seven procedures under the RSBY scheme were selected on the basis of their high volume, high cost, or potential for fraud. For example, hysterectomy was identified as the second most frequent claim, contributing to 3.7% of all RSBY procedures and 10% of its budget. The other six selected procedures related to:

• chronic kidney disease and end-stage renal disease
• uncomplicated gallstone disease
• hernia
• hydrocele
• appendicitis
• pterygium

RSBY established a committee, chaired by the Director General Labor Welfare, to oversee four Expert Groups in gynaecology, nephrology, surgery, and ophthalmology. Each group consists of:

• public and private providers
• specialist and district level clinicians
• public health personnel
• representation from professional bodies
• insurance companies, the World Bank
• RSBY
• NICE International’s India technical adviser.

Each Expert Group is tasked with developing evidence-informed clinical pathways and related tools (including quality standards and audit tools, insurance pre-authorisation checklists, and patient information sheets) for the relevant procedures. NICE International (iDSI) has provided advice on the governance and process of the RSBY quality programme, as well technical assistance throughout the development of the guidance documents. In addition, NICE International facilitated an independent external review of the guidance by UK experts.

This work is expected to set a precedent for the development of authoritative clinical pathways on other healthcare topics, showcasing how the Indian government as a major purchaser and provider of service can leverage improvement in quality of healthcare.