Can beneficiary information improve hospital accountability? Experimental evidence from a public health insurance scheme in India

We study the role of hospital compliance in the effectiveness of government health insurance in India. Using patient surveys, we document that participating hospitals charge unauthorized fees to poor patients eligible to receive free care. Average out-of-pocket payments (OOPP) for chronic kidney care patients are $43 per month, or 25% annual GDP per capita, and are high at both public and private hospitals. Awareness of program benefits is low despite patients having used insurance for several months. We conduct a randomized experiment to test whether phone-based information about program benefits can enable insurance beneficiaries to hold hospitals accountable and lower OOPP. The intervention effectively increases program awareness by 0.17 standard deviations but has no effect on OOPP overall. However, effects differ dramatically by hospital sector: patients at private hospital see no change in OOPP despite increased bargaining and search; monthly OOPP among patients visiting public hospitals, who are poorer and lower caste, drop by $12 (35%), because they are able to negotiate to get more of their benefits at the hospital instead of paying for them off-site. The findings suggest that patient-driven accountability can meaningfully improve public service delivery, even in the context of specialized tertiary care, but may not substitute for top-down monitoring of private agents.