Table 4 Selected quotes from respondents

Competency drivers

Selection of human resources: “So, we had to employ Ayushman Mitras according to the hospitals, we had to deploy 2 Ayushman Mitras in hospitals with more than 50 beds. So, we conducted the interviews of all the Ayushman Mitras before 16th September and we didn’t take previous employees as all of them were corrupted. That is why we took fresh employees whom we would be able to understand better because the process of PM-JAY and RSBY is totally different. So, it is very difficult for the previous employees to forget about the previous process and implementing the new process, but it was easier to implement the same thing with the help of newer employees. That is why we hired new employees who could work and who had the will to work.”—State Health Agency respondent, male, age 44 years, 20 years’ work experience, Chhattisgarh

Selection of human resources: “Under the CMCHIS we have appointed some special position in some department which leads to overall improvement but they have paid very minimal money. I think they are paid very less money.”—State Health Agency respondent, female, age 40 years, 13 years’ work experience, Tamil Nadu

On-job coaching: “No, training was given, in fact it was just a formality…There are only two people in all government hospitals in XXX, one is XXX and one is District level and no other block is involved. In winters everyone sits around the fire. In the training they had just shown a presentation.”—Hospital respondent, male, age 40 years, 12 years’ work experience, Uttar Pradesh

Organizational drivers

On attitude of support team: “Working team has not been here to support us. They have been here to find out our mistakes and how to reject cases.”—Hospital respondent, male, age 53 years, 23 years’ work experience, Chhattisgarh

On medical paternalism and relationships between different doctor cadres: “We had a meeting in IMA [Indian Medical Association] and there we complained about the support team. They can’t raise their finger on a surgeon or radiologist or gynecologist when they themselves are BAMS or BHMS because they have no idea about surgeries. At-least the doctor from X [insurance company] should be MBBS and the District Manager should have some technical knowledge and they should cooperate with us because we are treating patients.”—Hospital respondent, male, age 47 years, 16 years’ work experience, Chhattisgarh

On relationship between hospitals and TPAs: “…that is the main issue because there is the problem. Definitely there is a problem. The third party wants to be more autonomic. The third party wants to be not synchronizing with the medical team and maybe they think that they may not know that the medical persons and they may not be knowing on this, so they can decide their own. So those attitudes should be completely [gone], it is very important.”—Hospital respondent, male, age 58 years, 28 years’ work experience, Tamil Nadu

Inadequacy of reimbursement rates: “I do not see much benefit, and actually financially, we have the support from various other sources because the amount provided by the government is not enough, especially in complicated cases it is very, very difficult to manage.”—Hospital respondent, male, age 60 years, 30 years’ work experience, Tamil Nadu

On organizational culture: “This organization is a public organization. So, the way of working here is like public organizations in UP.”—State Health Agency respondent, female, 5 years’ work experience, Uttar Pradesh

Leadership drivers

On state wanting greater leadership: “Many things are handled by NHA which need to be given to the state level authority that can be easily handled. For every small thing we need to generate a ticket, we keep on requesting via email to NHA or X [information technology company], for doing any small changes also.”—State Health Agency respondent, male, 1.5 years’ work experience, Chhattisgarh

On state leadership based on prior expertise and legal authority: “And the certain things were, see legally speaking we emphasis state subject here… So, naturally we will have a better hold over the scheme implementation and second thing is, our is a little bigger scheme and older scheme. So naturally we will also try to maintain whatever the technical and political gain, which comes along with the scheme.”—State Health Agency respondent, male, 30+ years’ work experience, Tamil Nadu

On coordinated leadership: “Mr. XX has been involved since the beginning and he has been one IAS [Indian Administrative Service] officer who has every update and every health scheme and PM-JAY being the flagship program, he has facts and figures on his fingertips. I think he calls and talks to Mrs. XX at least once a day, there is a conference call with all the CMs [Chief Medical Officers] and DMs [District Magistrates] once a week, there is a video conferencing and meeting with the chief secretary once a week, so there is a lot of updates, there is a meeting with CM every month, so that is a lot of monitoring, that is a lot of handholding, lots of cautions from seniors which is a good thing. But if you come to the mid-level which is comprised of people like directorate, then have been equally involved.”—State Health Agency respondent, female, 15 years’ work experience, Uttar Pradesh