The stakes of this question are enormous. Out-of-pocket expenditure remains one of the most stubborn barriers to healthcare access across India, and it falls hardest on households in low-income districts like Murshidabad, where a single hospitalization can erase years of savings. Publicly funded health insurance has been promoted as a central instrument of universal health coverage in low- and middle-income countries, and West Bengal’s Swasthya Sathi Scheme is among the largest state-level experiments in this approach. Yet the gap between a scheme on paper and a scheme in practice is where most such programmes succeed or fail. Understanding that gap requires talking to the people who queue at enrolment camps, carry smart cards to hospital counters, and process claims behind the scenes, which is precisely what this study set out to do.

Between December 2024 and March 2025, the research team conducted 28 in-depth interviews in Murshidabad district: 16 with beneficiaries who had actually used the scheme and 12 with individuals involved in its implementation at the hospital, block and sub-divisional levels. Participants were recruited through purposive sampling, a technique that deliberately selects informants with direct experience of the phenomenon under study rather than relying on random selection. The interviews were conducted in Bengali, audio-recorded, transcribed verbatim and translated into English before being analysed thematically using ATLAS.ti version 8, a software platform widely used to code and organize qualitative data. The study was approved by the Institutional Review Committee and the Institutional Ethics Committee of Kasturba Medical College, Manipal Academy of Higher Education, and reported in line with the COREQ standards for qualitative research, lending the work a methodological transparency that strengthens confidence in its findings.

From this body of testimony, five major themes crystallized: awareness, accessibility and scheme coverage; delivery of scheme services and healthcare utilization; coordination and support systems; health-seeking behaviour and scheme enablers; and challenges in scheme access and implementation. The architecture of these themes matters because it maps the full journey of a patient through the system, from first hearing about the insurance card to navigating a hospital admission and, in some cases, hitting a wall of bureaucratic or social resistance. Rather than treating utilization as a single yes-or-no outcome, the thematic structure reveals how each stage of the patient pathway carries its own vulnerabilities, and how a failure at any one of them can prevent a family from converting an entitlement on paper into care at the bedside.

The most consistent finding was the scheme’s perceived value as a financial shield. Beneficiaries described Swasthya Sathi as an important source of support that measurably improved their access to healthcare, particularly for costly treatments and surgical procedures that would otherwise have been catastrophic expenses. This is the core promise of cashless insurance: the patient presents the card, the hospital bills the insurer directly, and the family walks out without a debt. For households in a district where income is often precarious and seasonal, that mechanism transforms the calculus of whether to seek care at all. The researchers found that this financial protection was not an abstract benefit but a lived experience, recounted by families who had faced exactly the kind of high-cost medical events that the scheme was built to absorb.

Three facilitators of utilization stood out in the testimony. Community-level enrolment camps brought registration directly into villages, sparing families the cost and complexity of travelling to government offices. The involvement of local stakeholders, including frontline workers and block-level officials, created trusted human channels through which information about the scheme could flow. And the cashless design of the programme itself was repeatedly identified as a decisive enabler, because it removed the need for families to find money upfront at the moment of illness, when liquidity is scarcest. Together, these findings suggest that the last-mile infrastructure of a health insurance scheme, the camps, the local intermediaries and the payment architecture, can matter as much as the headline coverage figure printed on the card.

Yet the study is equally candid about the obstacles. Participants reported limited awareness of what the scheme actually entitles them to, a gap that leaves many beneficiaries unsure which services are covered, where they can be accessed and what documentation is required. Card-related issues emerged as a recurring irritant, ranging from problems obtaining or updating cards to difficulties at the point of use. Operational constraints within the implementation machinery, including staffing and coordination challenges across hospital, block and sub-divisional levels, added further friction. The researchers also documented socio-cultural barriers that shaped who could reach care and how, underscoring that health insurance utilization is never purely an administrative problem but is embedded in family dynamics, gender norms and community expectations.

These implementation challenges carry a technical lesson for health systems researchers. A cashless insurance scheme is, in essence, a chain of dependent processes: enrolment, card issuance, verification at the facility, claim processing and grievance redress. Each link depends on information flowing correctly, and the Murshidabad findings show that breakdowns cluster precisely where information asymmetries are greatest, at the boundary between beneficiaries and the bureaucracy. One-time-password-based verification, unique registration numbers and card infrastructure all assume a level of digital literacy and administrative support that is unevenly distributed in rural populations. When a beneficiary does not know an entitlement exists, or cannot resolve a card error, the coverage ceiling of 500,000 rupees is irrelevant; the effective coverage is zero.

The study’s conclusions are measured but pointed. The Swasthya Sathi Scheme was perceived as an important mechanism for improving access to healthcare and reducing financial burden in Murshidabad district, and beneficiaries reported broadly positive experiences. At the same time, the researchers emphasize that several implementation challenges continue to affect utilization, and they highlight the importance of awareness, community engagement and effective administrative processes in supporting publicly funded health insurance programmes. In other words, the scheme works where its human and procedural infrastructure works, and falters where that infrastructure thins out. This framing shifts the policy conversation away from whether large-scale cashless insurance can protect poor households, toward the more actionable question of how to harden the enrolment, information and support systems that determine whether protection reaches everyone.

For the wider field of universal health coverage, the Murshidabad evidence arrives at a moment when governments across low- and middle-income countries are scaling up similar programmes and searching for implementation evidence rather than headline statistics. The study’s method, pairing beneficiary voices with stakeholder perspectives across multiple administrative tiers, offers a replicable template for diagnosing where a scheme leaks value. Its message is deceptively simple: a health insurance card is only as strong as the awareness, trust and administrative machinery behind it. In Murshidabad, that machinery has demonstrably lifted families over the financial cliff of major illness, and, with targeted investment in awareness and card support, could carry the scheme’s promise to the many beneficiaries for whom it remains, for now, a card they hold but cannot fully use.

Subject of Research: Utilization and implementation of the Swasthya Sathi cashless health insurance scheme in Murshidabad district, West Bengal, India

Article Title: Beneficiary and stakeholder perspectives on the utilization and implementation of the Swasthya Sathi Scheme in Murshidabad District, West Bengal, India: a qualitative study

Article References: Sultana, N., Prabhu, V., Jahangir, S., & Sumit, K. (2026). Beneficiary and stakeholder perspectives on the utilization and implementation of the Swasthya Sathi Scheme in Murshidabad District, West Bengal, India: a qualitative study. BMC Health Services Research. https://doi.org/10.1186/s12913-026-15731-4

Image Credits: AI Generated

DOI: 10.1186/s12913-026-15731-4

Keywords: Swasthya Sathi Scheme, health insurance, out-of-pocket expenditure, universal health coverage, West Bengal, India, qualitative research, health services research, financial protection, healthcare access, implementation challenges, Murshidabad