The Health Assurance Agenda For Viksit Odisha

Manorama Bakshi
Arjun Kumar

Odisha’s Health Assurance Question

Odisha has spent the past decade steadily widening the boundaries of public health protection. From the launch of the Biju Swasthya Kalyan Yojana (BSKY) in 2018 to the more recent Gopabandhu Jan Arogya Yojana (GJAY) and its integration with AB-PMJAY, the state has moved towards a system in which the government assumes a much larger share of the financial risk of illness. That shift is especially significant at a time when Odisha is setting out its ambitions for Viksit Odisha @ 2036. A healthier population is integral to that vision, but so is protecting families from medical expenses that can erode savings, increase debt and reverse hard-won economic gains.

The scale of what Odisha has already built should not be understated. Treatment in state government health facilities is free for all citizens, while eligible families can access cashless treatment through an expanding network of empanelled hospitals. The scheme also gives women an additional ₹5 lakh cushion beyond the ₹5 lakh family cover—an unusual attempt to recognise that access to healthcare resources within households is not always equal.

But wider coverage has brought the remaining gaps into sharper view. Some urban households still fall outside private-hospital protection; specialised private care is concentrated around Bhubaneswar and Cuttack; and referral and billing requirements can make a nominally cashless system more difficult to use in practice.

For Odisha, then, the challenge ahead is less about building a health assurance system from scratch than about finishing what it has begun. The real test of the model will be whether its financial protection can reach those still outside it, work without unnecessary friction for those already covered, and remain affordable for the state as it expands.

From BSKY to an Integrated Health Assurance Model

Odisha’s present health assurance system is the result of several rounds of expansion rather than a single policy intervention. For much of the previous decade, the state followed its own path through the Biju Swasthya Kalyan Yojana (BSKY), introduced in 2018. BSKY combined free treatment in government health facilities with financial protection for eligible families seeking care in empanelled private hospitals. Operating independently of the central Ayushman Bharat framework, however, meant that access outside Odisha remained relatively limited—an important constraint for a state with a sizeable migrant population.

The transition to the Gopabandhu Jan Arogya Yojana (GJAY) marked a significant change in this arrangement. Under the Mohan Charan Majhi government, the state brought GJAY together with Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY), giving eligible beneficiaries access to a much larger national network of empanelled hospitals. The state has backed this shift with a five-year commitment of ₹27,019.25 crore for 2025-30. The integrated framework also brings senior citizens aged 70 and above under the Ayushman Vayo Vandana Yojana, with ₹5 lakh in annual cashless treatment irrespective of socio-economic status. For patients formally referred to specialised institutions outside Odisha, GJAY also provides conveyance assistance for the patient and an attendant.

At the centre of the model is a combination of universal public provision and targeted access to private care. All citizens can receive free treatment in Odisha’s government health facilities, including medicines, diagnostics, surgery and intensive care, irrespective of income. In empanelled private hospitals, eligible families receive ₹5 lakh in annual cashless cover. Women have an additional ₹5 lakh reserved for their treatment once the family limit is exhausted, taking the potential protection available to a household to ₹10 lakh when a female member requires further care. The design is particularly important because it does not assume that healthcare resources within a household are necessarily shared equally.

The protection also extends beyond the hospital stay itself. Covered packages include consultations, diagnostics and medicines for three days before admission and 15 days after discharge, alongside follow-up treatment and readmission for surgical complications. Thousands of procedures across areas such as cardiology, oncology, neurosurgery, neonatal care and joint replacement fall within the package system.

GJAY, moreover, sits within a wider network of state health programmes rather than operating on its own. NIRAMAYA provides free essential medicines and NIDAN supports free diagnostic services in public facilities, while the Ama Hospital Scheme focuses on infrastructure, sanitation and patient amenities in Community Health Centres and District Headquarters Hospitals. The Surendra Sai Divya Drushti Yojana extends this approach to eye care through free screening, cataract surgery, glaucoma management and spectacles. Together, these programmes matter because financial protection for hospitalisation can only go so far if medicines, diagnostics and basic public facilities remain difficult or expensive to access.

How Far Has Odisha’s Health Protection Reached?

The reach of Odisha’s health protection system has widened considerably over the past decade. NFHS-4 recorded health insurance or financing coverage among 47.7% of households in 2015–16. By NFHS-5, the figure had risen to 52.2%, alongside the expansion of BSKY. The article estimates that under the more recent GJAY and AB-PMJAY arrangement, health protection now extends to more than 85–90% of households, connecting nearly one crore families, or around 3.5 crore people, to public and empanelled hospitals across a much larger network.

The expansion is also visible in the state’s spending priorities. Of Odisha’s ₹23,635 crore health-sector allocation, ₹6,249 crore is earmarked for GJAY. Alongside it are ₹3,881 crore for the Mukhyamantri Swasthya Seva Mission, ₹939 crore for NIRAMAYA and ₹229 crore for NIDAN. These allocations show that health assurance is being supported by investment in the public system as well—in infrastructure, medicines and diagnostics—rather than being treated only as a mechanism for financing hospital claims.

Most families, however, use only a fraction of the financial protection available to them. The median package cost is around ₹14,500, and more than 95% of participating families use less than ₹1.2 lakh in a year. General surgery, obstetrics and general medicine account for a large share of admissions. At the more expensive end, cardiology, oncology and nephrology together account for more than 48% of claims expenditure. This is also where the higher protection available to women becomes particularly relevant. A ₹10 lakh potential ceiling may be far above what most families use in an ordinary year, but prolonged cancer treatment or complex cardiac care can produce very different bills.

The system is becoming more digitally connected too. Odisha has been expanding registrations under Ayushman Bharat Health Accounts (ABHA), through which health records, prescriptions and laboratory reports can be linked across participating facilities. At hospital helpdesks, Swasthya Mitras assist beneficiaries with verification and pre-authorisation. For patients, the practical value is fairly straightforward: less paperwork and, when the system functions as intended, a smoother route into cashless treatment.

Where Health Assurance Still Falls Short

For all the expansion in coverage, the experience of using health assurance can still depend heavily on where a patient lives, which hospital they approach and how easily they can navigate the rules. Some of these difficulties have surfaced in the state’s own enforcement efforts. Field inspections found empanelled private hospitals charging beneficiaries for diagnostics before admission and medicines or follow-up care after discharge, even though these expenses were covered under the scheme. The State Health Assurance Society responded with surprise inspections and warnings of de-empanelment for hospitals continuing such practices.

Referral requirements create another difficulty. For around 10% of clinical packages, patients need a formal referral from a government facility before receiving treatment at an empanelled private hospital. The rule is intended to prevent an unnecessary diversion of publicly financed care towards private providers, but it can become cumbersome when treatment is urgent. A patient may first have to pass through an already busy government facility simply to obtain the referral needed for private care.

Where that care is available is equally important. More than 45% of empanelled private specialty beds are reported to be concentrated in the Bhubaneswar–Cuttack corridor. For people in western and southern Odisha, accessing advanced treatment can therefore involve considerable travel. Free or cashless treatment offers less protection if reaching an appropriate hospital itself becomes difficult or expensive.

There is also a group for whom private-hospital protection remains much thinner. The article estimates that around 8–12% of the population—roughly 35–50 lakh people—falls into an urban “missing middle.” This includes non-NFSA urban informal workers such as gig workers, shop assistants and auto drivers who may earn too much to qualify through food-security-based eligibility but do not necessarily have employer-provided or private insurance. They can use Odisha’s free public health facilities, but do not have the same financial protection when private hospital care is required.

Access, however, is only one part of health assurance. As the network grows, the quality of treatment provided under it becomes just as important. One option proposed in the article is to link hospital empanelment more closely to NABH accreditation, with stricter requirements for institutions undertaking complex tertiary procedures and a phased route for smaller facilities to improve their standards. Independent medical audits could then look beyond the number of claims processed to outcomes such as hospital-acquired infections, 30-day readmissions and mortality following surgery.

Patient dignity also needs to form part of that quality framework. Verification should be rigorous without requiring intrusive practices such as photographs of surgical wounds or intimate body parts when authenticated clinical records and diagnostic evidence can serve the purpose. A dedicated digital grievance mechanism could similarly allow patients to report problems with cleanliness, nursing responsiveness and quality of care. The original proposal goes a step further by suggesting that patient satisfaction should have consequences for how hospitals are monitored and reimbursed.

None of this takes away from the expansion Odisha has achieved. But it does change how that achievement should be judged. The size of an entitlement matters less if a patient cannot reach the right hospital, faces unexpected charges or encounters unnecessary barriers to treatment.

Closing the Gaps: What Odisha Can Do

Odisha does not need to redesign its health assurance system from the ground up. The more immediate task is to deal with the people and places that the present arrangement does not serve as well, while making it easier to use the protection that already exists.

The urban “missing middle” is one such gap. Rajasthan allows families outside the usual eligibility categories to enter its health assurance system through a subsidised annual contribution of ₹850. Odisha could consider a similar arrangement for urban informal workers and middle-income households outside the NFSA and SFSS framework. It would provide a route into private-hospital protection without requiring a wholesale change in the existing system.

There are useful lessons elsewhere too. In Tamil Nadu, insurance reimbursements generated when patients are treated in government hospitals can be channelled back into those institutions. Applied in Odisha, this could give medical colleges and larger public hospitals another source of funds for equipment and service improvements. Goa addresses a different problem through an outpatient allowance of up to ₹15,000 a year for medicines required for specified chronic conditions. A similar provision for illnesses such as diabetes, hypertension and epilepsy could help with recurring costs that a largely hospitalisation-based scheme does not cover well.

Extending protection to those who remain outside the system would, of course, have a cost. The estimates presented in the article identify around 14 lakh urban households, representing roughly 45–50 lakh individuals, currently outside the NFSA/SFSS net. At an assumed average premium of ₹1,600 per family, covering this group would require around ₹224 crore a year. The additional claims generated by new beneficiaries are estimated at another ₹580-650 crore, while easing public-to-private referral restrictions is expected to require a further claims reserve of about ₹150 crore. This puts the estimated additional annual requirement at approximately ₹954-1,024 crore.

Odisha’s annual budget expenditure exceeds ₹2.65 lakh crore, making the estimated cost of this expansion roughly 0.36-0.38% of the state budget. This does not make the additional spending insignificant, and the estimate depends on the assumptions used to calculate enrolment and future claims. But it suggests that bringing the remaining population within the health assurance net is not beyond the state’s fiscal reach.

Some changes are less about additional spending than about how the scheme works. In cardiac, neurological, trauma and other time-sensitive emergencies, requiring a patient to obtain a public-sector referral before approaching an empanelled private hospital can cost valuable time. An emergency clinical override, as proposed in the article, would allow this requirement to be waived when immediate treatment is necessary. Linking GJAY records with the voter register, Aadhaar and NFSA databases could also make enrolment and renewal easier for eligible residents and reduce avoidable paperwork.

Private-hospital access cannot, however, become a substitute for strengthening government facilities. District Headquarters Hospitals and Sub-Divisional Hospitals outside the Bhubaneswar–Cuttack corridor need greater specialist capacity so that patients in western and southern Odisha do not routinely have to travel long distances for advanced care. At the same time, an automated claims platform with a 15-day settlement timeline could reduce delays for empanelled private hospitals and make their participation in the scheme more predictable.

The direction of reform is therefore fairly clear. Odisha already has a wide health assurance system and relatively generous financial protection. What remains is to reach the households still outside it, make emergency access less cumbersome, strengthen care beyond the major urban centres and ensure that hospitals—public and private—can deliver the protection the scheme promises.

Making Health Assurance Count for Viksit Odisha

Odisha has already done much of the difficult work of bringing health protection within the reach of a large share of its population. The question now is what happens at the edges of that system—where eligibility ends, where specialised care is difficult to reach, or where the rules surrounding cashless treatment get in the way of care.

The unfinished part of the story lies beyond the size of the insurance cover. A family is protected only if it can find appropriate care within reasonable reach, enter a hospital without unnecessary delays and receive the treatment promised without being asked to pay for services that should already be covered. The same protection has to work for a woman facing prolonged cancer treatment, a worker in an Odisha town who falls outside the existing eligibility net, and a patient in a western or southern district who cannot easily travel to Bhubaneswar or Cuttack.

This is what makes the next phase important for Viksit Odisha @ 2036. The state has already committed considerable public resources to health and created much of the institutional framework needed to protect families from large medical bills. Extending that protection further will require additional spending, but also better access, stronger public facilities and fewer obstacles between a patient and treatment.

For households, health assurance ultimately has a very practical meaning: an illness should not become the reason a family loses its savings, takes on debt or postpones necessary care. If Odisha can make that protection dependable across income groups and districts, healthcare will become more than another welfare commitment within the Viksit Odisha agenda. It will be part of the economic security on which that larger ambition depends.

About the Authors

Dr. Manorama Bakshi is Director & Head of Healthcare & Advocacy at Consocia Advisory, Founder & Director of the Triloki Raj Foundation, and a Senior Visiting Fellow at IMPRI.

Dr. Arjun Kumar is the Director of the IMPRI Impact and Policy Research Institute, New Delhi. He holds a Ph.D. in Economics from the Centre for the Study of Regional Development, School of Social Sciences, Jawaharlal Nehru University (JNU), New Delhi.

Disclaimer: All views expressed in the article belong solely to the author and not necessarily to the organisation.