Author: Amanpreet Singh , Navneet Seth

ABSTRACT
Background: Health insurance is an important mechanism for improving access to healthcare and protecting households from financial hardship caused by illness. India has expanded publicly funded health insurance while private health insurance markets have also grown. However, insurance coverage does not necessarily provide effective financial protection because households may continue to pay for medicines, diagnostics, outpatient care, non-covered services, and other residual costs.
Objective: This review synthesises evidence published between 2010 and 2025 on determinants of health insurance adoption and the relationship between public and private health insurance and financial protection in India, with particular attention to Punjab.
Methods: A systematic narrative review was structured around PRISMA 2020 reporting principles. Evidence was identified from peer-reviewed literature and authoritative institutional sources addressing health insurance adoption, awareness, public schemes, private insurance, healthcare utilisation, out-of-pocket expenditure, catastrophic health expenditure, and financial protection in India. The synthesis was narrative because the included evidence is heterogeneous in study design, population, insurance programme, outcome definition, and analytical approach. No numerical study-count or PRISMA-flow values are reported here unless supported by a documented reproducible search record.
Results: The evidence indicates that health insurance adoption is influenced by income, education, employment, awareness, accessibility, affordability, trust, perceived benefits, and previous healthcare experience. Publicly funded schemes have improved access to covered services, but evidence of consistent reductions in out-of-pocket and catastrophic expenditure remains mixed. PM-JAY evidence shows continuing gaps in knowledge of eligibility, benefits, empanelled hospitals, and covered services, alongside residual spending on medicines, diagnostics, and other costs. Private insurance offers additional protection but is more dependent on household purchasing power, perceived value, affordability, and trust. Punjab-specific evidence indicates substantial financial burden associated with healthcare, especially for non-communicable diseases and private-sector care.
Conclusion: Health insurance coverage should not be treated as equivalent to financial protection. Effective policy requires wider awareness, affordable and comprehensive benefit packages, transparent claims processes, stronger regulation, and better coordination between public schemes and private insurance. Punjab requires further state-specific research examining how economic conditions and public–private insurance arrangements jointly influence adoption and actual financial protection.

Keywords: health insurance adoption; financial protection; public health insurance;
private health insurance; PM-JAY; out-of-pocket expenditure; catastrophic health expenditure; India; Punjab; systematic review.