How effective health insurance schemes are in tackling economic burden of healthcare in India

An Examination of Inter-State Variation in Utilization of Healthcare Services, Associated Financial Burden and Inequality: Evidence from Nationally Representative Survey in India

This study examines the health care utilization pattern, associated financial catastrophes, and inequality across Indian states to understand the subnational variations and aid the policy makers in this regard. Data from recent National Sample Survey (2017-2018), titled, "Household Social Consumption: Health," covering 113,823 households, was employed in the study. Descriptive statistics, Erreygers concentration index (CI), and recentered influence function decomposition were applied in the study. We found that, in India, 7 percent of households experienced catastrophic health expenditure (CHE) and 1.9 percent of households were pushed below poverty line due to out-of-pocket expenditure on hospitalization. Notably, outpatient care was more burdensome (CHE: 12.1%; impoverishment: 4%). Substantial interstate variations were observed, with high financial burden in poorer states. Utilization of health care services from private health care providers was pro-rich (hospitalization CI 0.31; outpatient CI 0.10), while the occurrence of CHE incidence was pro-poor (hospitalization CI -0.10; outpatient CI -0.14). Education level, economic status, health insurance, and area of residence contributed significantly to inequalities in utilization of health care services from private providers and financial burden. The high financial burden of seeking health care necessitates the need to increase public health spending and strengthen public health infrastructure. Also, concerted efforts directed towards increasing awareness about health insurance and introducing comprehensive health insurance products (covering both inpatient and outpatient services) are imperative to augment financial risk protection in India.

Social and demographic determinants of health insurance status in India: Evidence from a nationally representative cross-sectional survey

BACKGROUND

Out-of-pocket medical expenses are a crucial metric for assessing how well the healthcare system is working toward obtaining universal health coverage in any country. In India, out-of-pocket expenses for health are relatively high compared to other developed countries due to a lack of alternative finance arrangements. The disparity in out-of-pocket medical expenses largely depends upon the public health expenditure, government policies, and level of health insurance coverage.

MATERIALS AND METHODS

The study used a logit regression model to examine the association of the status of health insurance with socio and demographic variables using National Sample Survey 2018 data. The objective of the study is to analyze the impact of demographic variables on the status of health insurance in India.

RESULTS

This research found that education and occupation have a significant impact on the status of health insurance, among other demographic factors.

CONCLUSION

These findings underscore the importance of targeted policies and interventions aimed at improving access to health insurance among specific demographic groups. Addressing disparities in health insurance coverage based on educational and occupational factors is essential for achieving equitable healthcare access and improved health outcomes in the country. Increasing awareness of health insurance reduces out-of-pocket medical expenses and subsequently brings down economic poverty.

Is health insurance really benefitting Indian population? Evidence from a nationally representative sample survey

BACKGROUND

Universal health coverage (UHC) is the centrepiece of the sustainable development goals and aims to ensure access to essential and quality healthcare services to all without facing financial hardships. Several health insurance programmes have been launched in India to progress towards UHC.

OBJECTIVE

This study aims to assess the impact of health insurance (overall health insurance, government sponsored health insurance (GSHI), and private voluntary health insurance) on accessibility and utilization of inpatient care, out-of-pocket health expenditure (OOPE), catastrophic health expenditure (CHE), and impoverishment in India.

DATA AND METHODOLOGY

The 75th round of National Sample Survey Office was used in the study, which covered 555,115 individuals, 113,823 households, and 91,445 hospitalization incidence all over India. Descriptive statistics, multivariable logistic regression, and propensity score matching (PSM) methods were employed.

RESULTS

Enrolment under health insurance has impacted the accessibility and utilization pattern of hospitalization to some extent for the insured. PSM showed that enrolment under GSHI schemes reduced OOPE by INR 3314 (USD 49) and CHE incidence by 1%-4% at various thresholds. Among poor persons, there was a marginal but statistically significant reduction of OOPE among those enrolled under GSHI schemes (p < 0.05). However, GSHI schemes did not statistically significantly reduce the CHE burden for poor persons enrolled (p > 0.05). Furthermore, enrolment under private voluntary health insurance reduced OOPE by INR 13,511 (USD 198) and CHE by 13.47% at 10% threshold, 4.61% at 25% threshold, and 2.65% at 40% threshold. However, its uptake was primarily confined to richer economic quintiles and urban areas that exacerbates equity concerns. All the results were confirmed through robustness measures employed.

CONCLUSIONS

There is a necessity to increase awareness and uptake of health insurance, along with introducing comprehensive insurance packages covering both inpatient and outpatient care. Also, increasing public health spending, strengthening public healthcare facilities, and improving regulatory implementation of private healthcare providers are imperative to augment financial protection.

Public Health Insurance Status and Utilization of Healthcare Services Across India: A Narrative Review

Health insurance literacy gauges how knowledgeable people are regarding the comparison of health insurance plans to find out the optimal health plan that suits their needs and preferences. Enrolling in a comprehensive plan and proactively addressing health and financial aspects can fortify the stability of families. The plan needs to be used effectively by adapting to evolving circumstances and prioritizing the well-being and prosperity of the household. Having public health insurance can significantly impact an individual's utilization of healthcare services. Having health insurance encourages individuals to promptly seek medical attention without hesitating or avoiding treatment due to financial worries. This results in higher utilization of healthcare services, encompassing routine check-ups, preventive care, and timely intervention for illnesses and injuries. Public health insurance can also improve access to specialized care and expensive treatments that may otherwise be unaffordable for individuals without insurance. By having health insurance, individuals and families can experience a decrease in the economic strain associated with healthcare expenses, thereby enhancing the accessibility and affordability of healthcare services.

How social norms and values shape household healthcare expenditures and resource allocation: Insights from India

We present a novel perspective on thinking about and studying healthcare spending in contexts where few health-related financial risk protection mechanisms exist and where out-of-pocket spending by households is the norm. Drawing on interviews conducted across 20 villages in two states of India, we illustrate and problematize how a complex interplay of social norms and cultural factors underpin spending decisions within households in such contexts. While our analysis draws on the fieldwork at large, we present our findings through selected narratives - stories of patients suffering from chronic breathlessness. We engage with and reveal the various ways in which social norms dynamically drive this household economy, and shape resource allocation-related decisions. We conclude that in health system contexts where out-of-pocket spending by households is the norm, it is essential to recognise the pragmatic and calculative nature of intra-household allocation of resources, and how it involves bargaining and negotiations at the intersection of social norms, economic class, caste, gender, age, and productive status. And at the same time, how all of this occurs within the economy of the family, and how it plays out differently for different members of a family is also important to recognise. Such recognition can not only help one better appreciate how this household level economy may sometimes maintain and perpetuate entrenched hierarchies and gender inequities, crucially, it can help target health related social protection policies and strategies and make them more responsive to the needs of the most vulnerable in the society and within households.

Perspectives and evaluation on the effect of financial burden relief of medical insurance for people with catastrophic diseases and its influencing factors

Background

Catastrophic disease sufferers face a heavy financial burden and are more likely to fall victim to the "illness-poverty-illness" cycle. Deeper reform of the medical insurance system is urgently required to alleviate the financial burden of individuals with catastrophic diseases.

Methods

Data were obtained from a cross-sectional questionnaire survey conducted in Heilongjiang in 2021, and logistic regression and restricted cubic spline model was used to predict the core factors related to medical insurance that alleviate the financial burden of people with catastrophic diseases.

Results

Overall, 997 (50.92%) medical insurance-related professionals negatively viewed financial burden relief for people with catastrophic diseases. Factors influencing its effectiveness in relieving the financial burden were: whether or not effective control of omissions from medical insurance coverage (OR = 4.04), fund supervision (OR = 2.47) and degree of participation of stakeholders (OR = 1.91). Besides, the reimbursement standards and the regional and population benefit package gap also played a role. The likelihood of financial burden relief increased by 21 percentage points for each unit increase in the level of stakeholder discourse power in reform.

Conclusion

China's current medical insurance policies have not yet fully addressed the needs of vulnerable populations, especially the need to reduce their financial burden continuously. Future reform should focus on addressing core issues by reducing the uninsured, enhancing the width and depth of medical insurance coverage, improving the level and capacity of medical insurance governance that provides more discourse power for the vulnerable population, and building a more responsive and participatory medical insurance governance system.

Attributes of Psychosocial Distress from the Perspectives of Head-and-Neck Cancer Patients - A Thematic Analysis

Objectives

Patients diagnosed with head-and-neck cancer (HNC) face unique challenges in comparison to other types of cancers. Sources of psychosocial distress (PSD) are multifactorial and recognising the key attributes would facilitate better understanding of the experienced distress, potentially enabling directed intervention strategies. The present research was conducted to explore the key attributes of PSD from HNC patients' perspective to develop a tool.

Material and Methods

The study adopted a qualitative approach. The data were collected from nine HNC patients receiving radiotherapy through focus group discussion. Data were transcribed, read and reread through for searching the meanings and patterns, to familiarise with the data and obtain ideas on experiences related to PSD. Similar experiences identified across the dataset were sorted and then collated into themes. Detailed analysis of themes and related quotes of the participants are reported with each theme.

Results

The codes generated from the study are grouped under four major themes; 'Irksome symptoms are distressing,' 'Distressing physical disability inflicted by the situation,' 'Social Curiosity - a distressing element' and 'Distressing uncertainty of future'. The attributes of PSD and the magnitude of psychosocial problems were reflected in the findings.

Conclusion

Psychosocial health of HNC patients is greatly impacted due to disease and/or treatment. Dynamic patterns of attributes identified from the study contributed to developing a tool on PSD. The findings of this study also necessitate the need for constructing an intervention for reducing PSD based on the attributes from the HNC patient's perspective.

Impact of public-funded health insurances in India on health care utilisation and financial risk protection: a systematic review

OBJECTIVE

Universal Health Coverage aims to address the challenges posed by healthcare inequalities and inequities by increasing the accessibility and affordability of healthcare for the entire population. This review provides information related to impact of public-funded health insurance (PFHI) on financial risk protection and utilisation of healthcare.

DESIGN

Systematic review.

DATA SOURCES

Medline (via PubMed, Web of Science), Scopus, Social Science Research Network and 3ie impact evaluation repository were searched from their inception until 15 July 2020, for English-language publications.

ELIGIBILITY CRITERIA

Studies giving information about the different PFHI in India, irrespective of population groups (above 18 years), were included. Cross-sectional studies with comparison, impact evaluations, difference-in-difference design based on before and after implementation of the scheme, pre-post, experimental trials and quasi-randomised trials were eligible for inclusion.

DATA EXTRACTION AND SYNTHESIS

Data extraction was performed by three reviewers independently. Due to heterogeneity in population and study design, statistical pooling was not possible; therefore, narrative synthesis was performed.

OUTCOMES

Utilisation of healthcare, willingness-to-pay (WTP), out-of-pocket expenditure (including outpatient and inpatient), catastrophic health expenditure and impoverishment.

RESULTS

The impact of PFHI on financial risk protection reports no conclusive evidence to suggest that the schemes had any impact on financial protection. The impact of PFHIs such as Rashtriya Swasthy Bima Yojana, Vajpayee Arogyashree and Pradhan Mantri Jan Arogya Yojana showed increased access and utilisation of healthcare services. There is a lack of evidence to conclude on WTP an additional amount to the existing monthly financial contribution.

CONCLUSION

Different central and state PFHIs increased the utilisation of healthcare services by the beneficiaries, but there was no conclusive evidence for reduction in financial risk protection of the beneficiaries.

REGISTRATION

Not registered.

Multilevel population and socioeconomic variation in health insurance coverage in India

OBJECTIVES

This study explores population-level variation in different types of health insurance coverage in India. We aimed to estimate the extent to which contextual factors at community, district, and state levels may contribute to place-based inequalities in coverage after accounting for household-level socioeconomic factors.

METHODS

We used data from the 2015-2016 National Family Health Survey in India, which provides the most recent and comprehensive information available on reports of different types of household health insurance coverage. We used multilevel regression models to estimate the relative contribution of different population levels to variation in coverage by national, state, and private health insurance schemes.

RESULTS

Among 601,509 households in India, 29% reported having coverage in 2015-2016. Variation in each type of coverage existed between population levels before and after adjusting for differences in the distribution of household socioeconomic and demographic factors. For example, the state level accounted for 36% of variation in national scheme coverage and 41% of variation in state scheme coverage after adjusting for household characteristics. In contrast, the community level was the largest contextual source of variation in private insurance coverage (accounting for 24%). Each type of coverage was associated with higher socioeconomic status and urban location.

CONCLUSIONS

Contextual factors at community, district, and state levels contribute to variation in household health insurance coverage even after accounting for socioeconomic and demographic factors. Opportunities exist to reduce disparities in coverage by focusing on drivers of place-based differences at multiple population levels. Future research should assess whether new insurance schemes exacerbate or reduce place-based disparities in coverage.

Whether the industrial workers of slums have access to job insurance?

Purpose

Securing a job in an industry is a boon for most of the slum dwellers. When the primary earner of a slum household suffers from occupational illness and injuries, without insurance coverage or partial coverage of insurance, this boon may become a curse in the long run. The occupational security and safety along with the fact that whether such workers are insured is an important aspect and has a close link with the expenditure on illness. Thus, the accessibility to employees’ insurance in the risky industrial occupation, particularly for slum dwellers, is crucial to protect them from falling into poverty. Studies on occupational health of the poor workers are either limited to informal sectors or remain industry specific and the analysis of their accessibility to job insurance is rarely done. The paper aims to discuss these issues.

Design/methodology/approach

The research questions are framed to analyze the types of insurance accessible to workers across various industries; the accessibility to insurance, however, varying across risk intensities of various industries; and the determinants of insurance accessibility of the industrial workers living in slums. The determinants of accessibility of job insurance are analyzed with a binary Logit model. A multi-stage random sampling technique is used to collect the primary data from 320 industrial workers living in the slums of the Indian state of West Bengal.

Findings

The industrial workers, irrespective of the types of industries, are exposed to a high-risk category without proper job insurance. The higher industrial income is not adequate to prevent financial hardships. Access to insurance is more likely for the respondents with job tenure of more than two years and less likely for the workers who are working for more than eight hours per day.

Social implications

This study provides a significant insight to the policymakers concerning health dynamics of the slum dwellers, which can improve their livelihood.

Originality/value

The analysis of the industry-specific risk intensities with accessibility to insurance contributes to understanding the coverage of the insurance scheme for the workers in slums.