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Garg S, Bebarta KK, Tripathi N, Keshri VR. Impact of Government-Funded Health Insurance on Out-of-Pocket Expenditure and Quality of Hospital-Based Care in Indian States of Madhya Pradesh and Maharashtra. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2024; 22:815-825. [PMID: 39183223 DOI: 10.1007/s40258-024-00911-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/08/2024] [Indexed: 08/27/2024]
Abstract
BACKGROUND With its clear focus on financial protection, government-funded health insurance (GFHI) stands out among the strategies for universal health coverage (UHC) implemented by low-to-middle income countries globally. Since 2018, India has implemented a GFHI programme called the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY), which covers 500 million individuals. The current study aims to evaluate the performance of GFHI in meeting its key objectives of improving access, quality and financial protection for hospital-based care in two large central Indian states: Madhya Pradesh and Maharashtra. METHODS The study measures access in terms of utilisation of inpatient care. Financial protection was measured in terms of catastrophic health expenditure which was defined as the incidence of out-of-pocket expenditure (OOPE) above thresholds of 10% and 25% of annual household expenditure. Patient-satisfaction with care was taken as an indicator of quality. A household survey was conducted in 2023, covering a multi-stage sample of 11,569 and 12,384 individuals in Madhya Pradesh and Maharashtra, respectively. Multi-variate analyses were conducted to find the effect of GFHI-enrolment on the desired outcomes. The instrumental variable method was applied to address potential endogeneity in insurance enrolment. Additionally, propensity score matching was done to ensure robustness. RESULTS Around 71% and 63% of surveyed individuals were enrolled under GFHI in Madhya Pradesh and Maharashtra, respectively. The hospitalisation rate did not differ much between the GFHI-enrolled and non-enrolled population. The average OOPE on hospitalisation was similar for the GFHI-enrolled and non-enrolled patients. The OOPE and catastrophic health expenditure in private hospitals remained very high, irrespective of GFHI enrolment. The pattern was similar in both states. Multi-variate adjusted models showed that GFHI had no significant effect on utilisation, quality, OOPE and catastrophic health expenditure. The above results were confirmed by propensity score matching. CONCLUSIONS Coverage by GFHI enrolment was ineffective in improving access, quality or financial protection for inpatient hospital care despite 5 years of implementation of the programme. Long-standing supply-side gaps and poor regulation of private providers continue to hamper the effectiveness of GFHI in India.
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Affiliation(s)
- Samir Garg
- State Health Resource Centre, Chhattisgarh, Raipur, India
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Garg S, Bebarta KK, Tripathi N. The Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) after four years of implementation - is it making an impact on quality of inpatient care and financial protection in India? BMC Health Serv Res 2024; 24:919. [PMID: 39135015 PMCID: PMC11321205 DOI: 10.1186/s12913-024-11393-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 08/01/2024] [Indexed: 08/15/2024] Open
Abstract
BACKGROUND India launched a national health insurance scheme named Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) in 2018 as a key policy for universal health coverage. The ambitious scheme covers 100 million poor households. None of the studies have examined its impact on the quality of care. The existing studies on the impact of AB-PMJAY on financial protection have been limited to early experiences of its implementation. Since then, the government has improved the scheme's design. The current study was aimed at evaluating the impact of AB-PMJAY on improving utilisation, quality, and financial protection for inpatient care after four years of its implementation. METHODS Two annual waves of household surveys were conducted for years 2021 and 2022 in Chhattisgarh state. The surveys had a sample representative of the state's population, covering around 15,000 individuals. Quality was measured in terms of patient satisfaction and length of stay. Financial protection was measured through indicators of catastrophic health expenditure at different thresholds. Multivariate adjusted models and propensity score matching were applied to examine the impacts of AB-PMJAY. In addition, the instrumental variable method was used to address the selection problem. RESULTS Enrollment under AB-PMJAY was not associated with increased utilisation of inpatient care. Among individuals enrolled under AB-PMJAY who utilised private hospitals, the proportion incurring catastrophic health expenditure at the threshold of 10% of annual consumption expenditure was 78.1% and 70.9% in 2021 and 2022, respectively. The utilisation of private hospitals was associated with greater catastrophic expenditure irrespective of AB-PMJAY coverage. Enrollment under AB-PMJAY was not associated with reduced out-of-pocket expenditure or catastrophic health expenditure. CONCLUSIONS AB-PMJAY has achieved a large coverage of the population but after four years of implementation and an evidence-based increase in reimbursement prices for hospitals, it has not made an impact on improving utilisation, quality, or financial protection. The private hospitals contracted under the scheme continued to overcharge patients, and purchasing was ineffective in regulating provider behaviour. Further research is recommended to assess the impact of publicly funded health insurance schemes on financial protection in other low- and middle-income countries.
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Affiliation(s)
- Samir Garg
- State Health Resource Centre, Chhattisgarh, Raipur, India.
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Sharma SK, Nambiar D, Sankar H, Joseph J, Surendran S, Benny G. Gender-specific inequalities in coverage of Publicly Funded Health Insurance Schemes in Southern States of India: evidence from National Family Health Surveys. BMC Public Health 2023; 23:2414. [PMID: 38049794 PMCID: PMC10696875 DOI: 10.1186/s12889-023-17231-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 11/15/2023] [Indexed: 12/06/2023] Open
Abstract
BACKGROUND Publicly Funded Health Insurance Schemes (PFHIS) are intended to play a role in achieving Universal Health Coverage (UHC). In countries like India, PFHISs have low penetrance and provide limited coverage of services and of family members within households, which can mean that women lose out. Gender inequities in relation to financial risk protection are understudied. Given the emphasis being placed on achieving UHC for all in India, this paper examined intersecting gender inequalities and changes in PFHIS coverage in southern India, where its penetrance is greater and of longer duration. DATA AND METHODS This study used the fourth (NFHS-4, 2015-16) and fifth (NFHS-5, 2019-21) rounds of India's National Family Health Survey for five southern states: namely, Andhra Pradesh, Karnataka, Kerala, Tamil Nadu, and Telangana. The World Health Organization's Health Equity Assessment Toolkit (HEAT) Plus and Stata were used to analyse PFHIS coverage disaggregated by seven dimensions of inequality. Ratios and differences for binary dimensions; Between Group Variance and Theil Index for unordered dimensions; Absolute and Relative Concentration Index (RCI) for ordered dimensions were computed separately for women and men. RESULTS Overall, PFHIS coverage increased significantly (p < 0.001) among women and men in Andhra Pradesh, and Kerala from NFHS-4 to NFHS-5. Overall, men had higher PFHIS coverage than women, especially in Andhra Pradesh, Tamil Nadu, and Telangana in both surveys. In both absolute and relative terms, PFHIS coverage was concentrated among older women and men across all states; age-related inequalities were higher among women than men in both surveys in Andhra Pradesh, Kerala, and Telengana. The magnitude of education-related inequalities was twice as high as among women in Telangana (RCINFHS-4: -12.23; RCINFHS-5: -9.98) and Andhra Pradesh (RCINFHS-4: -8.05; RCINFHS-5: -7.84) as compared to men in Telangana (RCINFHS-4: -5.58; RCINFHS-5: -2.30) and Andhra Pradesh (RCINFHS-4: -4.40; RCINFHS-5: -3.12) and these inequalities remained in NFHS-5, suggesting that lower education level women had greater coverage. In the latter survey, a high magnitude of wealth-related inequality was observed in women (RCINFHS-4: -15.78; RCINFHS-5: -14.36) and men (RCINFHS-4: -20.42; RCINFHS-5: -13.84) belonging to Kerala, whereas this inequality has decreased from NFHS-4 to NFHS-5., again suggestive of greater coverage among poorer populations. Caste-related inequalities were higher in women than men in both surveys, the magnitude of inequalities decreased between 2015-16 and 2019-20. CONCLUSIONS We found gender inequalities in self-reported enrolment in southern states with long-standing PFHIS. Inequalities favoured the poor, uneducated and elderly, which is to some extend desirable when rolling out a PFHIS intended for harder to reach populations. However, religion and caste-based inequalities, while reducing, were still prevalent among women. If PFHIS are to truly offer financial risk protection, they must address the intersecting marginalization faced by women and men, while meeting eventual goals of risk pooling, indicated by high coverage and low inequality across population sub-groups.
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Affiliation(s)
| | - Devaki Nambiar
- Healthier Societies, The George Institute for Global Health, New Delhi, India
- Faculty of Medicine, University of New South Wales, Sydney, Australia
- Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, India
| | - Hari Sankar
- The George Institute for Global Health, New Delhi, India
| | - Jaison Joseph
- The George Institute for Global Health, New Delhi, India
| | | | - Gloria Benny
- The George Institute for Global Health, New Delhi, India
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Garg S, Bebarta KK, Tripathi N. Performance of India's national publicly funded health insurance scheme, Pradhan Mantri Jan Arogaya Yojana (PMJAY), in improving access and financial protection for hospital care: findings from household surveys in Chhattisgarh state. BMC Public Health 2020; 20:949. [PMID: 32546221 PMCID: PMC7298746 DOI: 10.1186/s12889-020-09107-4] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 06/12/2020] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND A national Publicly Funded Health Insurance (PFHI) scheme called Pradhan Mantri Jan Arogaya Yojana (PMJAY) was launched by government of India in 2018. PMJAY seeks to cover 500 million persons with an annual cover of around 7000 USD per household. PMJAY claims to be the largest government funded health scheme globally and has attracted an international debate as a policy for Universal Health Coverage. India's decade-long experience of the earlier national and state-specific PFHI schemes had shown poor effectiveness in financial protection. Most states in India have completed a year of implementation of PMJAY but no evaluations are available of this important scheme. METHODS The study was designed to find out the effect of enrolment under PMJAY in improving utilisation of hospital services and financial protection in Chhattisgarh which has been a leading state in implementing PFHI in terms of enrolment and claims. The study analyses three repeated cross-sections. Two of the cross-sections are from National Sample Survey (NSS) health rounds - year 2004 when there was no PFHI and 2014 when the older PFHI scheme was in operation. Primary data was collected in 2019-end to cover the first year of PMJAY implementation and it formed the third cross-section. Multivariate analysis was carried out. In addition, Propensity Score Matching and Instrumental Variable method were applied to address the selection problem in insurance. RESULTS Enrollment under PMJAY or other PFHI schemes did not increase utilisation of hospital-care in Chhattisgarh. Out of Pocket Expenditure (OOPE) and incidence of Catastrophic Health Expenditure did not decrease with enrollment under PMJAY or other PFHI schemes. The size of OOPE was significantly greater for utilisation in private sector, irrespective of enrollment under PMJAY. CONCLUSION PMJAY provided substantially larger vertical cover than earlier PFHI schemes in India but it has not been able to improve access or financial protection so far in the state. Though PMJAY is a relatively new scheme, the persistent failure of PFHI schemes over a decade raises doubts about suitability of publicly funded purchasing from private providers in the Indian context. Further research is recommended on such policies in LMIC contexts.
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Affiliation(s)
- Samir Garg
- State Health Resource Centre, Raipur, Chhattisgarh India
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Menon GR, Singh L, Sharma P, Yadav P, Sharma S, Kalaskar S, Singh H, Adinarayanan S, Joshua V, Kulothungan V, Yadav J, Watson LK, Fadel SA, Suraweera W, Rao MVV, Dhaliwal RS, Begum R, Sati P, Jamison DT, Jha P. National Burden Estimates of healthy life lost in India, 2017: an analysis using direct mortality data and indirect disability data. LANCET GLOBAL HEALTH 2020; 7:e1675-e1684. [PMID: 31708148 DOI: 10.1016/s2214-109x(19)30451-6] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 09/13/2019] [Accepted: 10/07/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Many countries, including India, seek locally constructed disease burden estimates comprising mortality and loss of health to aid priority setting for the prevention and treatment of diseases. We created the National Burden Estimates (NBE) to provide transparent and understandable disease burdens at the national and subnational levels, and to identify gaps in knowledge. METHODS To calculate the NBE for India, we combined 2017 UN death totals with national and subnational mortality rates for 2010-17 and causes of death from 211 166 verbal autopsy interviews in the Indian Million Death Study for 2010-14. We calculated years of life lost (YLLs) and years lived with disability (YLDs) for 2017 using published YLD-YLL ratios from WHO Global Health Estimates. We grouped causes of death into 45 groups, including ill-defined deaths, and summed YLLs and YLDs to calculate disability-adjusted life-years (DALYs) for these causes in eight age groups covering rural and urban areas and 21 major states of India. FINDINGS In 2017, there were about 9·7 million deaths and 486 million DALYs in India. About three quarters of deaths and DALYs occurred in rural areas. More than a third of national DALYs arose from communicable, maternal, perinatal, and nutritional disorders. DALY rates in rural areas were at least twice those of urban areas for perinatal and nutritional conditions, chronic respiratory diseases, diarrhoea, and fever of unknown origin. DALY rates for ischaemic heart disease were greater in urban areas. Injuries caused 11·4% of DALYs nationally. The top 15 conditions that accounted for the most DALYs were mostly those causing mortality (ischaemic heart disease, perinatal conditions, chronic respiratory diseases, diarrhoea, respiratory infections, cancer, stroke, road traffic accidents, tuberculosis, and liver and alcohol-related conditions), with disability mostly due to a few conditions (nutritional deficiencies, neuropsychiatric conditions, vision and other sensory loss, musculoskeletal disorders, and genitourinary diseases). Every condition that was common in one part of India was uncommon elsewhere, suggesting state-specific priorities for disease control. INTERPRETATION The NBE method quantifies disease burden using transparent, intuitive, and reproducible methods. It provides a simple, locally operable tool to aid policy makers in priority setting in India and other low-income and middle-income countries. The NBE underlines the need for many more countries to collect nationally representative cause of death data, paired with focused surveys of disability. FUNDING Ministry of Health and Family Welfare, Government of India.
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Affiliation(s)
- Geetha R Menon
- Indian Council of Medical Research, Ansari Nagar, New Delhi, India.
| | - Lucky Singh
- Indian Council of Medical Research, Ansari Nagar, New Delhi, India
| | - Palak Sharma
- Indian Council of Medical Research, Ansari Nagar, New Delhi, India
| | - Priyanka Yadav
- Indian Council of Medical Research, Ansari Nagar, New Delhi, India
| | - Shweta Sharma
- Indian Council of Medical Research, Ansari Nagar, New Delhi, India
| | | | - Harpreet Singh
- Indian Council of Medical Research, Ansari Nagar, New Delhi, India
| | | | - Vasna Joshua
- Indian Council of Medical Research, Ansari Nagar, New Delhi, India
| | | | - Jeetendra Yadav
- Indian Council of Medical Research, Ansari Nagar, New Delhi, India
| | - Leah K Watson
- Centre for Global Health Research, St Michael's Hospital, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Shaza A Fadel
- Centre for Global Health Research, St Michael's Hospital, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Wilson Suraweera
- Centre for Global Health Research, St Michael's Hospital, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | | | - R S Dhaliwal
- Indian Council of Medical Research, Ansari Nagar, New Delhi, India
| | - Rehana Begum
- Centre for Global Health Research, St Michael's Hospital, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Prabha Sati
- Centre for Global Health Research, St Michael's Hospital, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Dean T Jamison
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, CA, USA
| | - Prabhat Jha
- Centre for Global Health Research, St Michael's Hospital, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.
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Nandi S, Schneider H. Using an equity-based framework for evaluating publicly funded health insurance programmes as an instrument of UHC in Chhattisgarh State, India. Health Res Policy Syst 2020; 18:50. [PMID: 32450870 PMCID: PMC7249418 DOI: 10.1186/s12961-020-00555-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 03/27/2020] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Universal health coverage (UHC) has provided the impetus for the introduction of publicly funded health insurance (PFHI) schemes in the mixed health systems of India and many other low- and middle-income countries. There is a need for a holistic understanding of the pathways of impact of PFHI schemes, including their role in promoting equity of access. METHODS This paper applies an equity-oriented evaluation framework to assess the impacts of PFHI schemes in Chhattisgarh State by synthesising literature from various sources and highlighting knowledge gaps. Data were collected from an extensive review of publications on PFHI schemes in Chhattisgarh since 2009, including empirical studies from the first author's PhD and grey literature such as programme evaluation reports, media articles and civil society campaign documents. The framework was constructed using concepts and frameworks from the health policy and systems research literature on UHC, access and health system building blocks, and is underpinned by the values of equity, human rights and the right to health. RESULTS The analysis finds that evidence of equitable enrolment in Chhattisgarh's PFHI scheme may mask many other inequities. Firstly, equitable enrolment does not automatically lead to the acceptability of the scheme for the poor or to equity in utilisation. Utilisation, especially in the private sector, is skewed towards the areas that have the least health and social need. Secondly, related to this, resource allocation patterns under PFHI deepen the 'infrastructure inequality trap', with resources being effectively transferred from tribal and vulnerable to 'better-off' areas and from the public to the private sector. Thirdly, PFHI fails in its fundamental objective of effective financial protection. Technological innovations, such as the biometric smart card and billing systems, have not provided the necessary safeguards nor led to greater accountability. CONCLUSION The study shows that development of PFHI schemes, within the context of wider neoliberal policies promoting private sector provisioning, has negative consequences for health equity and access. More research is needed on key knowledge gaps related to the impact of PFHI schemes on health systems. An over-reliance on and rapid expansion of PFHI schemes in India is unlikely to achieve UHC.
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Affiliation(s)
- Sulakshana Nandi
- School of Public Health, University of the Western Cape, Bellville, South Africa
- Public Health Resource Network, 29, New Panchsheel Nagar, Raipur, Chhattisgarh 492001 India
| | - Helen Schneider
- School of Public Health, UWC/MRC Health Services to Systems Unit, University of the Western Cape, Bellville, South Africa
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Aggarwal A, Haq SA. Rheumatology workforce issues in South Asia: Challenges and solutions. Int J Rheum Dis 2020; 23:443-447. [PMID: 31960604 DOI: 10.1111/1756-185x.13793] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 12/27/2019] [Accepted: 12/29/2019] [Indexed: 01/24/2023]
Affiliation(s)
- Amita Aggarwal
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Syed Atiqul Haq
- Department of Rheumatology, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh
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Nandi S, Vračar A, Pachauli C. Resisting privatization and marketization of health care: People’s Health Movement’s experiences from India, Philippines and Europe. SAÚDE EM DEBATE 2020. [DOI: 10.1590/0103-11042020s103] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
ABSTRACT For the last three decades, healthcare systems have been under pressure to adapt to a neoliberal world and incorporate market principles. The introduction of market-based instruments, increasing competition among health care providers, introducing publicly -funded private sector provisioning of healthcare through health insurance financing systems to replace public provisioning of health care, promoting individual responsibility for health and finally, the introduction of market relations through privatization, deregulation and decentralization of health care have been some common elements seen globally. These reforms, undertaken under the guise of increasing efficiency and quality through competition and choice, have in fact harmed the physical, emotional and mental health of communities around the world and also contributed to a significant rise in inequities in health and healthcare access. They have weakened the public healthcare systems of countries and led to commercialization of healthcare. This article presents three case studies of resistance, to the commercialization of health care, by the People’s Health Movement (PHM) and associated networks. It aims to contribute to the understanding of the way neoliberal reforms, including those imposed under structural adjustment programmes and some promoted under the Universal Health Coverage (UHC) paradigm, have impacted country-level health systems and access of people to health care, and bring out lessons from the resistance against these reforms.
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Affiliation(s)
- Sulakshana Nandi
- Jan Swasthya Abhiyan, India; People’s Health Movement Global, India
| | - Ana Vračar
- People’s Health Movement Global, India; People’s Health Movement Europe, India
| | - Chhaya Pachauli
- People’s Health Movement Global, India; Prayas Centre for Health Equity
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Garg S, Chowdhury S, Sundararaman T. Utilisation and financial protection for hospital care under publicly funded health insurance in three states in Southern India. BMC Health Serv Res 2019; 19:1004. [PMID: 31882004 PMCID: PMC6935172 DOI: 10.1186/s12913-019-4849-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 12/17/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Many LMICs have implemented Publicly Funded Health Insurance (PFHI) programmes to improve access and financial protection. The national PFHI scheme implemented in India for a decade has been recently modified and expanded to cover free hospital care for 500 million persons. Since increase in annual cover amount is one of the main design modifications in the new programme, the relevant policy question is whether such design change can improve financial protection for hospital care. An evaluation of state-specific PFHI programmes with vertical cover larger than RSBY can help answer this question. Three states in Southern India - Andhra Pradesh, Karnataka and Tamil Nadu have been pioneers in implementing PFHI with a large insurance cover. METHODS The current study was meant to evaluate the PFHI in above three states in improving utilisation of hospital services and financial protection against expenses of hospitalization. Two cross-sections from National Sample Survey's health rounds, the 60th round done in 2004 and the 71st round done in 2014 were analysed. Instrumental Variable method was applied to address endogeneity or the selection problem in insurance. RESULTS Enrollment under PFHI was not associated with increase in utilisation of hospital care in the three states. Private hospitals dominated the empanelment of facilities under PFHI as well as utilisation. Out of Pocket Expenditure and incidence of Catastrophic Health Expenditure did not decrease with enrollment under PFHI in the three states. The size of Out of Pocket Expenditure was significantly greater for utilisation in private sector, irrespective of insurance enrollment. CONCLUSION PFHI in the three states used substantially larger vertical cover than national scheme in 2014. The three states are known for their good governance. Yet, the PFHI programmes in all three states failed in fulfilling their fundamental purpose. Increasing vertical cover of PFHI and using either 'Trusts' or Insurance-companies as purchasers may not give desired results in absence of adequate regulation. The study raises doubts regarding effectiveness of contracting under PFHIs to influence provider-behavior in the Indian context. Further research is required to find solutions for addressing gaps that contribute to poor financial outcomes for patients under PFHI.
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Affiliation(s)
- Samir Garg
- State Health Resource Centre, Chhattisgarh, Raipur, India
| | | | - T. Sundararaman
- Formerly Professor, School of Health Systems Studies, Tata Institute of Social Sciences, Mumbai, India
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Nandi S, Schneider H. When state-funded health insurance schemes fail to provide financial protection: An in-depth exploration of the experiences of patients from urban slums of Chhattisgarh, India. Glob Public Health 2019; 15:220-235. [PMID: 31405325 DOI: 10.1080/17441692.2019.1651369] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
This paper explores the dynamics of access under the state-funded universal health insurance scheme in Chhattisgarh, India, and specifically the relationship between choice, affordability and acceptability. A qualitative case study of patients from the slums of Raipur City incurring significant heath expenditure despite using insurance, was conducted, examining the way patients and their families sought to navigate and negotiate hospitalisation under the scheme. Eight purposefully selected ('revelatory') instances of patients (and their families) utilising private hospitals are presented. Patients and their family exercised their agency to the extent that they could. Negotiations on payments took place at every stage, from admission to post-hospitalisation. Once admitted, however, families rapidly lost the initiative, and faced mounting costs, and increasingly harsh interactions with providers. The paper analyses how these outcomes were produced by a combination of failures of key regulatory mechanisms (notably the 'smart card'), dominant norms of care as a market transaction (rather than a right), and wider cultural acceptance of illegal informal healthcare payments. The unfavourable normative and cultural context of (especially) private sector provisioning in India needs to be recognised by policy makers seeking to ensure financial risk protection through publicly financed health insurance.
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Affiliation(s)
- Sulakshana Nandi
- School of Public Health, University of the Western Cape, Bellville, South Africa.,Public Health Resource Network, Raipur, Chhattisgarh, India
| | - Helen Schneider
- School of Public Health, UWC/MRC Health Services to Systems Unit, University of the Western Cape, Bellville, South Africa
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Gautham M, Bruxvoort K, Iles R, Subharwal M, Gupta S, Jain M, Goodman C. Investigating the nature of competition facing private healthcare facilities: the case of maternity care in Uttar Pradesh, India. Health Policy Plan 2019; 34:450-460. [PMID: 31302699 PMCID: PMC6735944 DOI: 10.1093/heapol/czz056] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/24/2019] [Indexed: 12/02/2022] Open
Abstract
The private healthcare sector in low- and middle-income countries is increasingly seen as of public health importance, with widespread interest in improving private provider engagement. However, there is relatively little literature providing an in-depth understanding of the operation of private providers. We conducted a mixed methods analysis of the nature of competition faced by private delivery providers in Uttar Pradesh, India, where maternal mortality remains very high. We mapped health facilities in five contrasting districts, surveyed private facilities providing deliveries and conducted in-depth interviews with facility staff, allied providers (e.g. ambulance drivers, pathology laboratories) and other key informants. Over 3800 private facilities were mapped, of which 8% reported providing deliveries, mostly clustered in cities and larger towns. 89% of delivery facilities provided C-sections, but over half were not registered. Facilities were generally small, and the majority were independently owned, mostly by medical doctors and, to a lesser extent, AYUSH (non-biomedical) providers and others without formal qualifications. Recent growth in facility numbers had led to intense competition, particularly among mid-level facilities where customers were more price sensitive. In all facilities, nearly all payment was out-of-pocket, with very low-insurance coverage. Non-price competition was a key feature of the market and included location (preferably on highways or close to government facilities), medical infrastructure, hotel features, staff qualifications and reputation, and marketing. There was heavy reliance on visiting consultants such as obstetricians, surgeons and anaesthetists, and payment of hefty commission payments to agents who brought clients to the facility, for both new patients and those transferring from public facilities. Building on these insights, strategies for private sector engagement could include a foundation of universal facility registration, adaptation of accreditation schemes to lower-level facilities, improved third-party payment mechanisms and strategic purchasing, and enhanced patient information on facility availability, costs and quality.
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Affiliation(s)
- Meenakshi Gautham
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17, Tavistock Place, London, UK
| | - Katia Bruxvoort
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17, Tavistock Place, London, UK.,Department of Research and Evaluation, Kaiser Permanente Southern California, 100 S. Los Robles, Pasadena, CA, USA
| | - Richard Iles
- School of Economic Sciences, Washington State University, Pullman, WA, USA
| | - Manish Subharwal
- IMPACT Partners in Social Development, JE-1/1, LGF, Khirki Extension, Malviya Nagar, New Delhi, India
| | - Sanjay Gupta
- IMPACT Partners in Social Development, JE-1/1, LGF, Khirki Extension, Malviya Nagar, New Delhi, India
| | - Manish Jain
- IMPACT Partners in Social Development, JE-1/1, LGF, Khirki Extension, Malviya Nagar, New Delhi, India
| | - Catherine Goodman
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17, Tavistock Place, London, UK
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Balsari S, Fortenko A, Blaya JA, Gropper A, Jayaram M, Matthan R, Sahasranam R, Shankar M, Sarbadhikari SN, Bierer BE, Mandl KD, Mehendale S, Khanna T. Reimagining Health Data Exchange: An Application Programming Interface-Enabled Roadmap for India. J Med Internet Res 2018; 20:e10725. [PMID: 30006325 PMCID: PMC6064038 DOI: 10.2196/10725] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Revised: 05/25/2018] [Accepted: 06/09/2018] [Indexed: 11/17/2022] Open
Abstract
In February 2018, the Government of India announced a massive public health insurance scheme extending coverage to 500 million citizens, in effect making it the world’s largest insurance program. To meet this target, the government will rely on technology to effectively scale services, monitor quality, and ensure accountability. While India has seen great strides in informational technology development and outsourcing, cellular phone penetration, cloud computing, and financial technology, the digital health ecosystem is in its nascent stages and has been waiting for a catalyst to seed the system. This National Health Protection Scheme is expected to provide just this impetus for widespread adoption. However, health data in India are mostly not digitized. In the few instances that they are, the data are not standardized, not interoperable, and not readily accessible to clinicians, researchers, or policymakers. While such barriers to easy health information exchange are hardly unique to India, the greenfield nature of India’s digital health infrastructure presents an excellent opportunity to avoid the pitfalls of complex, restrictive, digital health systems that have evolved elsewhere. We propose here a federated, patient-centric, application programming interface (API)–enabled health information ecosystem that leverages India’s near-universal mobile phone penetration, universal availability of unique ID systems, and evolving privacy and data protection laws. It builds on global best practices and promotes the adoption of human-centered design principles, data minimization, and open standard APIs. The recommendations are the result of 18 months of deliberations with multiple stakeholders in India and the United States, including from academia, industry, and government.
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Affiliation(s)
- Satchit Balsari
- Beth Israel Deaconess Medical Center, Harvard Medical School, Department of Emergency Medicine, Boston, MA, United States.,Harvard FXB Center for Health and Human Rights, Boston, MA, United States
| | - Alexander Fortenko
- NewYork-Presyterian Hospital, Emergency Medicine, New York, NY, United States
| | - Joaquín A Blaya
- The Human Diagnosis Project, Washington DC, DC, United States
| | | | | | | | | | - Mark Shankar
- Harvard Business School, Boston, MA, United States
| | | | - Barbara E Bierer
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Kenneth D Mandl
- Boston Children's Hospital, Computational Health Informatics Program, Boston, MA, United States.,Harvard Medical School, Department of Pediatrics and Department of Biomedical Informatics, Boston, MA, United States
| | | | - Tarun Khanna
- Harvard Business School, Boston, MA, United States
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13
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Nandi S, Schneider H, Garg S. Assessing geographical inequity in availability of hospital services under the state-funded universal health insurance scheme in Chhattisgarh state, India, using a composite vulnerability index. Glob Health Action 2018; 11:1541220. [PMID: 30426889 PMCID: PMC6237177 DOI: 10.1080/16549716.2018.1541220] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 10/23/2018] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Countries are increasingly adopting health insurance schemes for achieving Universal Health Coverage. India's state-funded health insurance scheme covers hospital care provided by 'empanelled' private and public hospitals. OBJECTIVE This paper assesses geographical equity in availability of hospital services under the universal health insurance scheme in Chhattisgarh state. METHODS The study makes use of district data from the insurance scheme and government surveys. Selected socio-economic indicators are combined to form a composite vulnerability index, which is used to rank and group the state's 27 districts into tertiles, named as highest, middle and lowest vulnerability districts (HVDs, MVDs, LVDs). Indicators of hospital service availability under the scheme - insurance coverage, number of empanelled private/public hospitals, numbers and amounts of claims - are compared across districts and tertiles. Two measures of inequality, difference and ratio, are used to compare availability between tertiles. RESULTS The study finds that there is a geographical pattern to vulnerability in Chhattisgarh state. Vulnerability increases with distance from the state's centre towards the periphery. The highest vulnerability districts have the highest insurance coverage, but the lowest availability of empanelled hospitals (3.4 hospitals per 100,000 enrolled in HVDs, vs 8.2/100,000 enrolled in LVDs). While public sector hospitals are distributed equally, the distribution of private hospitals across tertiles is highly unequal, with higher availability in LVDs. The number of claims (per 100,000 enrolled) in the HVDs is 3.5-times less than that in the LVDs. The claim amounts show a similar pattern. CONCLUSIONS Although insurance coverage is higher in the more vulnerable districts, availability of hospital services is inversely proportional to vulnerability and, therefore, the need for these services. Equitable enrolment in health insurance schemes does not automatically translate into equitable access to healthcare, which is also dependent on availability and specific dynamics of service provision under the scheme.
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Affiliation(s)
- Sulakshana Nandi
- School of Public Health, University of the Western Cape, Bellville, South Africa
- Public Health Resource Network, Chhattisgarh, Raipur, India
| | - Helen Schneider
- School of Public Health, UWC/MRC Health Services to Systems Unit, University of the Western Cape, Bellville, South Africa
| | - Samir Garg
- State Health Resource Centre, Chhattisgarh, Raipur, India
- School of Health Systems Studies, Tata Institute of Social Sciences, Mumbai, India
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