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Feng Z, Chen Q, Jiao L, Ma X, Atun R, Geldsetzer P, Bärnighausen T, Chen S. The impact of health insurance on hypertension care: a household fixed effects study in India. BMC Public Health 2024; 24:2287. [PMID: 39175008 PMCID: PMC11342611 DOI: 10.1186/s12889-024-19759-1] [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: 09/27/2023] [Accepted: 08/12/2024] [Indexed: 08/24/2024] Open
Abstract
INTRODUCTION Hypertension is highly prevalent in India, but the proportion of patients achieving blood pressure control remains low. Efforts have been made to expand health insurance coverage nationwide with the aim of improving overall healthcare access. It is critical to understand the role of health insurance coverage in improving hypertension care. METHODS We used secondary data from the nationally representative sample of adults aged 15-49 years from the 2015-2016 National Family Health Survey (NFHS) in India. We defined the hypertension care cascade as four successive steps of (1) screened, (2) diagnosed, (3) treated, and (4) controlled, and operationalized these variables using blood pressure measurements and self-reports. We employed household fixed effect models that conceptually matched people with and without insurance within the household, to estimate the impact of insurance coverage on the likelihood of reaching each care cascade step, while controlling for a wide range of additional individual-level variables. RESULTS In all 130,151 included individuals with hypertension, 20.4% reported having health insurance. For the insured hypertensive population, 79.8% (95% Confidence Interval: 79.3%-80.3%) were screened, 49.6% (49.0%-50.2%) diagnosed, 14.3% (13.9%-14.7%) treated, and 7.9% (7.6%-8.2%) controlled, marginally higher than the percentages for the uninsured 79.8% (79.5%-80.0%), 48.2% (47.9%-48.6%), 13.3% (13.1%-13.5%), and 7.5% (7.4%-7.7%) for each cascade step, respectively. From the household fixed effects model, health insurance did not show significant impact on the hypertension care cascade, with the estimated relative risks of health insurance 0.97 (0.93-1.02), 0.97 (0.91-1.03), 0.95 (0.77-1.30), and 0.97 (0.65-1.10) for each cascade step, respectively. We further performed stratified analyses by sociodemographic and behavioral risk factors and a sensitivity analysis with district fixed effects, all of which yielded results that confirmed the robustness of our main findings. CONCLUSIONS Health insurance did not show significant impact on improving hypertension care cascade among young and middle-aged adults with hypertension in India. Innovative strategies for overcoming practical barriers to healthcare services in addition to improving financial access are needed to address the large unmet need for hypertension care.
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Affiliation(s)
- Zixuan Feng
- The Harold and Inge Marcus Department of Industrial and Manufacturing Engineering, The Pennsylvania State University, University Park, PA, USA
| | - Qiushi Chen
- The Harold and Inge Marcus Department of Industrial and Manufacturing Engineering, The Pennsylvania State University, University Park, PA, USA.
| | - Lirui Jiao
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Xuedi Ma
- Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Rifat Atun
- Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, USA
| | - Pascal Geldsetzer
- Division of Primary Care and Population Health, Stanford University, Stanford, CA, USA
- Chan Zuckerberg Biohub, San Francisco, CA, USA
| | - Till Bärnighausen
- Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, USA
- Faculty of Medicine and University Hospital, Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany
| | - Simiao Chen
- Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
- Faculty of Medicine and University Hospital, Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany.
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Aashima, Sharma R. An Examination of Inter-State Variation in Utilization of Healthcare Services, Associated Financial Burden and Inequality: Evidence from Nationally Representative Survey in India. INTERNATIONAL JOURNAL OF SOCIAL DETERMINANTS OF HEALTH AND HEALTH SERVICES 2024; 54:206-223. [PMID: 38465616 DOI: 10.1177/27551938241230761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
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.
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Affiliation(s)
- Aashima
- University School of Management and Entrepreneurship, Delhi Technological University, New Delhi, India
| | - Rajesh Sharma
- Department of Humanities and Social Sciences, National Institute of Technology Kurukshetra, Haryana, India
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Sharma D, Chauhan AS, Guinness L, Mehndiratta A, Dhiman A, Singh M, Prinja S. Understanding the extent of economic evidence usage for informing policy decisions in the context of India's national health insurance scheme: Ayushman Bharat Pradhan Mantri Jan Aarogya Yojana (PM-JAY). BMJ Glob Health 2024; 9:e015079. [PMID: 38857943 PMCID: PMC11168173 DOI: 10.1136/bmjgh-2024-015079] [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: 01/15/2024] [Accepted: 05/29/2024] [Indexed: 06/12/2024] Open
Abstract
INTRODUCTION Ayushman Bharat Pradhan Mantri Jan Aarogya Yojana (PM-JAY) is one of the world's largest tax-funded insurance schemes. The present study was conducted to understand the decision-making process around the evolution (and revision) of health benefit packages (HBPs) and reimbursement rates within PM-JAY, with a specific focus on assessing the extent of use of economic evidence and role of various stakeholders in shaping these policy decisions. METHODS A mixed-methods study was adopted involving in-depth interviews with seven key stakeholders involved in HBP design and reimbursement rates decisions, and a survey of 80 government staff and other relevant stakeholders engaged in the implementation of PM-JAY. The data gathered were thematically analysed, and a coding framework was developed to explore specific themes. Additionally, publicly available documents were reviewed to ensure a comprehensive understanding of the decision-making processes. RESULTS Findings reveal a progressive transition towards evidence-based practices for policy decisions within PM-JAY. The initial version of HBP relied heavily on key criteria like disease burden, utilisation rates, and out-of-pocket expenditures, along with clinical opinion in shaping decisions around the inclusion of services in the HBP and setting reimbursement rates. Revised HBPs were informed based on evidence from a national-level costing study and broader stakeholder consultations. The use of health economic evidence increased with each additional revision with consideration of health technology assessment (HTA) evidence for some packages and reimbursement rates based on empirical cost evidence in the most recent update. The establishment of the Health Financing and Technology Assessment unit further signifies the use of evidence-based policymaking within PM-JAY. However, challenges persist, notably with regard to staff capacity and understanding of HTA principles, necessitating ongoing education and training initiatives. CONCLUSION While substantial progress has been made in transitioning towards evidence-based practices within PM-JAY, sustained efforts and political commitment are required for the ongoing systematisation of processes.
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Affiliation(s)
- Deepshikha Sharma
- Department of Community Medicine and School of Public Health, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Akashdeep Singh Chauhan
- Department of Community Medicine and School of Public Health, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | | | | | | | | | - Shankar Prinja
- Department of Community Medicine and School of Public Health, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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Kafczyk T, Hämel K. Challenges and opportunities in strengthening primary mental healthcare for older people in India: a qualitative stakeholder analysis. BMC Health Serv Res 2024; 24:206. [PMID: 38360656 PMCID: PMC10870524 DOI: 10.1186/s12913-024-10622-y] [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: 01/09/2023] [Accepted: 01/21/2024] [Indexed: 02/17/2024] Open
Abstract
BACKGROUND Primary mental healthcare (PMHC) allows for complex mental health issues in old age to be addressed. India has sought to improve PMHC through legislation, strategies and programmes. This study analyses the challenges and opportunities involved in strengthening PMHC for older persons in India from the perspectives of key stakeholders. METHODS Semistructured interviews were conducted with 14 stakeholders selected from the PMHC system in India and analysed using thematic analysis. First, the analysis was organizationally structured in accordance with the six WHO mental health system domains: (1) policy and legislative framework, (2) mental health services, (3) mental health in primary care, (4) human resources, (5) public information and links to other sectors, and (6) monitoring and research. Second, for each building block, challenges and opportunities were derived using inductive coding. RESULTS This study highlights the numerous challenges that may be encountered when attempting to strengthen age-inclusive PMHC. Among these challenges are poor public governance, a lack of awareness and knowledge among policy-makers and other stakeholders, and existing policies that make unrealistic promises to weak primary healthcare (PHC) structures with an excessive focus on medicalizing mental health problems. Thus, the mental health system often fails to reach vulnerable older people through PHC. Established approaches to comprehensive, family- and community-oriented PHC support attempts to strengthen intersectoral approaches to PMHC that emphasize mental health promotion in old age. Targeting the PHC workforce through age-inclusive mental health education is considered particularly necessary. Experts further argue that adequate monitoring structures and public spending for mental health must be improved. CONCLUSIONS In this study, we aim to elaborate on the mental healthcare developments that may serve to achieve equity in access to mental healthcare in India. Coordinated and collaborative efforts by public and private stakeholders involved in the care of older persons, both with and without lived mental health experiences, as well as their families and communities, are necessary to bring the vision of those policies for PMHC to fruition. The findings presented in this study can also inform future research, policies and practice in other low- and middle-income countries.
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Affiliation(s)
- Tom Kafczyk
- Department of Health Services Research and Nursing Science, School of Public Health, Bielefeld University, Universitaetsstrasse 25, 33651, Bielefeld, Germany.
| | - Kerstin Hämel
- Department of Health Services Research and Nursing Science, School of Public Health, Bielefeld University, Universitaetsstrasse 25, 33651, Bielefeld, Germany
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Ziegler S, Srivastava S, Parmar D, Basu S, Jain N, De Allegri M. A step closer towards achieving universal health coverage: the role of gender in enrolment in health insurance in India. BMC Health Serv Res 2024; 24:141. [PMID: 38279165 PMCID: PMC10821565 DOI: 10.1186/s12913-023-10473-z] [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: 03/30/2023] [Accepted: 12/12/2023] [Indexed: 01/28/2024] Open
Abstract
BACKGROUND There is limited understanding of how universal health coverage (UHC) schemes such as publicly-funded health insurance (PFHI) benefit women as compared to men. Many of these schemes are gender-neutral in design but given the existing gender inequalities in many societies, their benefits may not be similar for women and men. We contribute to the evidence by conducting a gender analysis of the enrolment of individuals and households in India's national PFHI scheme, Rashtriya Swasthya Bima Yojana (RSBY). METHODS We used data from a cross-sectional household survey on RSBY eligible families across eight Indian states and studied different outcome variables at both the individual and household levels to compare enrolment among women and men. We applied multivariate logistic regressions and controlled for several demographic and socio-economic characteristics. RESULTS At the individual level, the analysis revealed no substantial differences in enrolment between men and women. Only in one state were women more likely to be enrolled in RSBY than men (AOR: 2.66, 95% CI: 1.32-5.38), and this pattern was linked to their status in the household. At the household level, analyses revealed that female-headed households had a higher likelihood to be enrolled (AOR: 1.36, 95% CI: 1.14-1.62), but not necessarily to have all household members enrolled. CONCLUSION Findings are surprising in light of India's well-documented gender bias, permeating different aspects of society, and are most likely an indication of success in designing a policy that did not favour participation by men above women, by mandating spouse enrolment and securing enrolment of up to five family members. Higher enrolment rates among female-headed households are also an indication of women's preferences for investments in health, in the context of a conducive policy environment. Further analyses are needed to examine if once enrolled, women also make use of the scheme benefits to the same extent as men do. India is called upon to capitalise on the achievements of RSBY and apply them to newer schemes such as PM-JAY.
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Affiliation(s)
- Susanne Ziegler
- Heidelberg Institute of Global Health, Medical Faculty and University Hospital, Heidelberg University, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany.
- Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH, Friedrich-Ebert-Allee 32+36, 53113, Bonn, Germany.
| | - Swati Srivastava
- Heidelberg Institute of Global Health, Medical Faculty and University Hospital, Heidelberg University, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany
| | - Divya Parmar
- Department of Population Health Sciences, School of Life Course and Population Sciences, King's College London, Weston Education Centre, Cutcombe Road, London, SE5 9RJ, United Kingdom
| | - Sharmishtha Basu
- Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH, B5/1 Safdarjung Enclave, 110029, New Delhi, India
| | - Nishant Jain
- Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH, B5/1 Safdarjung Enclave, 110029, New Delhi, India
| | - Manuela De Allegri
- Heidelberg Institute of Global Health, Medical Faculty and University Hospital, Heidelberg University, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany
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Srivastava S, Bertone MP, Basu S, De Allegri M, Brenner S. Implementation of PM-JAY in India: a qualitative study exploring the role of competency, organizational and leadership drivers shaping early roll-out of publicly funded health insurance in three Indian states. Health Res Policy Syst 2023; 21:65. [PMID: 37370159 DOI: 10.1186/s12961-023-01012-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 06/01/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND The Pradhan Mantri Jan Arogya Yojana (PM-JAY), a publicly funded health insurance scheme, was launched in India in September 2018 to provide financial access to health services for poor Indians. PM-JAY design enables state-level program adaptations to facilitate implementation in a decentralized health implementation space. This study examines the competency, organizational, and leadership approaches affecting PM-JAY implementation in three contextually different Indian states. METHODS We used a framework on implementation drivers (competency, organizational, and leadership) to understand factors facilitating or hampering implementation experiences in three PM-JAY models: third-party administrator in Uttar Pradesh, insurance in Chhattisgarh, and hybrid in Tamil Nadu. We adopted a qualitative exploratory approach and conducted 92 interviews with national, state, district, and hospital stakeholders involved in program design and implementation in Delhi, three state capitals, and two anonymized districts in each state, between February and April 2019. We used a deductive approach to content analysis and interpreted coded material to identify linkages between organizational features, drivers, and contextual elements affecting implementation. RESULTS AND CONCLUSION PM-JAY guideline flexibilities enabled implementation in very different states through state-adapted implementation models. These models utilized contextually relevant adaptations for staff and facility competencies and organizational and facilitative administration, which had considerable scope for improvement in terms of recruitment, competency development, programmatic implementation support, and rationalizing the joint needs of the program and implementers. Adaptations also created structural barriers in staff interactions and challenged implicit power asymmetries and organizational culture, indicating a need for aligning staff hierarchies and incentive structures. At the same time, specific adaptations such as decentralizing staff selection and task shifting (all models); sharing of claims processing between the insurer and state agency (insurance and hybrid model); and using stringent empanelment, accreditation, monitoring, and benchmarking criteria for performance assessment, and reserving secondary care benefit packages for public hospitals (both in the hybrid model) contributed to successful implementation. Contextual elements such as institutional memory of previous schemes and underlying state capacities influenced all aspects of implementation, including leadership styles and autonomy. These variations make comparisons across models difficult, yet highlight constraints and opportunities for cross-learning and optimizing implementation to achieve universal health coverage in decentralized contexts.
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Affiliation(s)
- Swati Srivastava
- Heidelberg Institute of Global Health, Medical Faculty and University Hospital, Heidelberg University, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany.
| | - Maria Paola Bertone
- Institute for Global Health and Development, Queen Margaret University, Edinburgh, EH21 6UU, United Kingdom
| | - Sharmishtha Basu
- Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH, B - 5/1 & 5/2 Ground Floor, Safdurjung Enclave, 110029, New Delhi, Delhi, India
| | - Manuela De Allegri
- Heidelberg Institute of Global Health, Medical Faculty and University Hospital, Heidelberg University, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany
| | - Stephan Brenner
- Heidelberg Institute of Global Health, Medical Faculty and University Hospital, Heidelberg University, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany
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Furtado KM, Raza A, Mathur D, Vaz N, Agrawal R, Shroff ZC. The trust and insurance models of healthcare purchasing in the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana in India: early findings from case studies of two states. BMC Health Serv Res 2022; 22:1056. [PMID: 35982425 PMCID: PMC9389741 DOI: 10.1186/s12913-022-08407-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 07/15/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The Pradhan Mantri Jan Arogya Yojana (PMJAY), a publicly funded health insurance scheme for the poor in India, was launched in 2018. Early experiences of states with various purchasing arrangements can provide valuable insights for its future performance. We sought to understand the institutional agencies and performance of the trust and insurance models of purchasing with respect to; a) Provider contracting b) Claim management c) Implementation costs. METHODS A mixed methods case study design was adopted. Two states, Uttar Pradesh (representing a trust model) and Jharkhand (representing the insurance model) were purposively selected. Data sources included document reviews, key informant interviews, quantitative scheme data from the provider empanelment and claims database, and primary data on costs. Descriptive statistics were reported for quantitative data, content analysis was used for thematic reporting of qualitative data. RESULTS In both models, the state was the final authority on empanelment decisions, with no significant influence of the insurance company. Private hospitals constituted the majority of empanelled providers, with wide variations in district-wise distribution of bed capacities in both states. The urgency of completing empanelment in the early days of the scheme created the need for both states to re-review hospitals and de-empanel those not meeting requirements. Very few quality- accredited private hospitals were empaneled. The trust displayed more oversight of support agencies for claim management, longer processing times, a higher claim rejection rate and numbers of queries raised, as compared to the insurance model. Support agencies in both states faced challenges in assessing the clinical decisions of hospitals. Cost-effectiveness showed mixed results; the trust cost less than the insurance model per beneficiary enrolled, but more per claim generated. CONCLUSIONS Efforts are required to enable a better distribution and ensure quality of care in empanelled hospitals. The adoption of standard treatment guidelines is needed to support hospitals and implementing agencies in better claim management. The oversight of agencies through enforcement of contracts remains vital in both models. Assessing the comparative performance of trusts and insurance companies in more states at later stages of scheme implementation, would be further useful to determine their cost-effectiveness as purchasers.
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Affiliation(s)
| | - Arif Raza
- Goa Institute of Management, Poriem, Sattari, Goa, India, 403505
| | | | - Nafisa Vaz
- Goa Institute of Management, Poriem, Sattari, Goa, India, 403505
| | - Ruchira Agrawal
- National Health Authority, Ministry of Health and Family Welfare, Government of India, New Delhi, India
| | - Zubin Cyrus Shroff
- Alliance for Health Policy and Systems Research, World Health Organization, Geneva, Switzerland
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Garg S, Tripathi N, Ranjan A, Bebarta KK. How much do government and households spend on an episode of hospitalisation in India? A comparison for public and private hospitals in Chhattisgarh state. HEALTH ECONOMICS REVIEW 2022; 12:27. [PMID: 35522382 PMCID: PMC9078002 DOI: 10.1186/s13561-022-00372-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 04/26/2022] [Indexed: 05/31/2023]
Abstract
BACKGROUND Improvements in the financing of healthcare services are important for developing countries like India to make progress towards universal health coverage. Inpatient-care contributes to a big share of total health expenditure in India. India has a mixed health-system with a sizeable presence of private hospitals. Existing studies show that out-of-pocket expenditure (OOPE) incurred per hospitalisation in private hospitals was greater than public facilities. But, such comparisons have not taken into account the healthcare spending by government. METHODS For a valid comparison between public and for-profit private providers, this study in Indian state of Chhattisgarh assessed the combined spending by government and households per episode of hospitalisation. The supply-side and demand-side spending from public and private sources was taken into account. The study used two datasets: a) household survey for data on hospital utilisation, OOPE, cash incentives received by patients and claims raised under publicly funded health insurance (PFHI) schemes (n = 903 hospitalisation episodes) b) survey of public facilities to find supply-side government spending per hospitalisation (n = 64 facilities). RESULTS Taking into account all relevant demand and supply side expenditures, the average total spending per day of hospitalisation was INR 2833 for public hospitals and INR 6788 for private hospitals. Adjusted model for logarithmic transformation of OOPE while controlling for variables including case-mix showed that a hospitalisation in private hospitals was significantly more expensive than public hospitals (coefficient = 2.9, p < 0.001). Hospitalisations in private hospitals were more likely to result in a PFHI claim (adjusted-odds-ratio = 1.45, p = 0.02) and involve a greater amount than public hospitals (coefficient = 0.27, p < 0.001). Propensity-score matching models confirmed the above results. Overall, supply-side public spending contributed to 16% of total spending, demand-side spending through PFHI to 16%, cash incentives to 1% and OOPE to 67%. OOPE constituted 31% of total spending per episode in public and 86% in private hospitals. CONCLUSIONS Government and households put together spent substantially more per hospitalisation in private hospitals than public hospitals in Chhattisgarh. This has important implications for the allocative efficiency and the desired public-private provider-mix. Using public resources for purchasing inpatient care services from private providers may not be a suitable strategy for such contexts.
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Affiliation(s)
- Samir Garg
- State Health Resource Centre, Raipur, Chhattisgarh India
| | | | - Alok Ranjan
- Indian Institute of Technology, Jodhpur, India
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Mason T, Whittaker W, Jones A, Sutton M. Did paying drugs misuse treatment providers for outcomes lead to unintended consequences for hospital admissions? Difference-in-differences analysis of a pay-for-performance scheme in England. Addiction 2021; 116:3082-3093. [PMID: 33739485 DOI: 10.1111/add.15486] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 09/24/2020] [Accepted: 03/03/2021] [Indexed: 11/30/2022]
Abstract
AIMS To estimate how a scheme to pay substance misuse treatment service providers according to treatment outcomes affected hospital admissions. DESIGN A controlled, quasi-experimental (difference-in-differences) observational study using negative binomial regression. SETTING Hospitals in all 149 organisational areas in England for the period 2009-2010 to 2015-2016. PARTICIPANTS 572 545 patients admitted to hospital with a diagnosis indicating drug misuse, defined based on International Classification of Diseases 10th Revision (ICD-10) diagnosis codes (37 964 patients in 8 intervention areas and 534 581 in 141 comparison areas). INTERVENTION AND COMPARATORS Linkage of provider payments to recovery outcome indicators in 8 intervention organisational areas compared with all 141 comparison organisational areas in England. Outcome indicators included: abstinence from presenting substance, abstinent completion of treatment and non-re-presentation to treatment in the 12 months following completion. MEASUREMENTS Annual counts of hospital admissions, emergency admissions and admissions including a diagnosis indicating drugs misuse. Covariates included age, sex, ethnic origin and deprivation. FINDINGS For 37 245 patients in the intervention areas, annual emergency admissions were 1.073 times higher during the operation of the scheme compared with non-intervention areas (95% CI = 1.049; 1.097). There were an estimated additional 3 352 emergency admissions in intervention areas during the scheme. These findings were robust to a range of secondary analyses. CONCLUSION A programme in England from 2012 to 2014 to pay substance misuse treatment service providers according to treatment outcomes appeared to increase emergency hospital admissions.
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Affiliation(s)
- Thomas Mason
- Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - William Whittaker
- Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Andrew Jones
- Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Matt Sutton
- Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.,Melbourne Institute, Applied Economic and Social Research, Melbourne, Australia
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Gurung GB, Panza A. Implementation bottlenecks of the National Health Insurance program in Nepal: Paving the path towards Universal Health Coverage: A qualitative study. Int J Health Plann Manage 2021; 37:171-188. [PMID: 34505317 DOI: 10.1002/hpm.3301] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 07/15/2021] [Accepted: 08/11/2021] [Indexed: 11/12/2022] Open
Abstract
Most low and low-middle income countries adopting National Health Insurance (NHI) programs to achieve Universal Health Coverage are struggling to implement the program due to underlying problems at implementation. However, there is a lack of research that focuses on these problems. The Nepal NHI program initiated in 2016 has experienced numerous implementation challenges. This qualitative study delves into the NHI program's inputs and throughputs/implementation bottlenecks. The study based in Nepal's four districts included 28 in-depth interviews, six focus group discussions, and identified 12 themes that pointed to the NHI program's inadequate inputs causing bottlenecks. The analysis employed the Grounded Theory. The main challenges identified were insufficiently defined NHI implementations guidelines, conflicting Act clauses, a lack of HIB organizational guidelines, and inadequate human resources. The major throughput bottlenecks were difficulty enrolling the insurees, the inability to select the health providers competitively and to act as a prudent purchaser of the services. These inadequate inputs and throughput bottlenecks led to negative outputs such as insurees' high dropouts, and low coverage of poor households. The NHI program's sustainability might be at stake if the identified problems persist, further exacerbated by the plummeting economic situation in the country due to COVID-19.
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Affiliation(s)
- Gaj Bahadur Gurung
- College of Public Health Sciences, Chulalongkorn University, Bangkok, Thailand
| | - Alessio Panza
- College of Public Health Sciences, Chulalongkorn University, Bangkok, Thailand
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Khan PK, Perkins JM, Kim R, Mohanty SK, Subramanian SV. Multilevel population and socioeconomic variation in health insurance coverage in India. Trop Med Int Health 2021; 26:1285-1295. [PMID: 34181806 DOI: 10.1111/tmi.13645] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
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.
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Affiliation(s)
- Pijush Kanti Khan
- Department of Fertility Studies, International Institute for Population Sciences, Mumbai, India
| | - Jessica M Perkins
- Department of Human and Organizational Development, Peabody College, Vanderbilt University, Nashville, Tennessee, USA
| | - Rockli Kim
- Division of Health Policy and Management, College of Health Sciences, Korea University, Seoul, Republic of Korea.,Interdisciplinary Program in Precision Public Health, Department of Public Health Sciences, Graduate School of Korea University, Seoul, Republic of Korea.,Harvard Center for Population and Development Studies, Cambridge, Massachusetts, USA
| | - Sanjay K Mohanty
- Department of Fertility Studies, International Institute for Population Sciences, Mumbai, India
| | - Sankaran V Subramanian
- Harvard Center for Population and Development Studies, Cambridge, Massachusetts, USA.,Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
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Mukherjee I, Coban MK, Bali AS. Policy capacities and effective policy design: a review. POLICY SCIENCES 2021; 54:243-268. [PMID: 33846660 PMCID: PMC8026391 DOI: 10.1007/s11077-021-09420-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/27/2021] [Indexed: 05/14/2023]
Abstract
Effectiveness has been understood at three levels of analysis in the scholarly study of policy design. The first is at the systemic level indicating what entails effective formulation environments or spaces making them conducive to successful design. The second reflects more program level concerns, surrounding how policy tool portfolios or mixes can be effectively constructed to address complex policy objectives. The third is a more specific instrument level, focusing on what accounts for and constitutes the effectiveness of particular types of policy tools. Undergirding these three levels of analysis are comparative research concerns that concentrate on the capacities of government and political actors to devise and implement effective designs. This paper presents a systematic review of a largely scattered yet quickly burgeoning body of knowledge in the policy sciences, which broadly asks what capacities engender effectiveness at the multiple levels of policy design? The findings bring to light lessons about design effectiveness at the level of formulation spaces, policy mixes and policy programs. Further, this review points to a future research agenda for design studies that is sensitive to the relative orders of policy capacity, temporality and complementarities between the various dimensions of policy capacity.
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Affiliation(s)
- Ishani Mukherjee
- School of Social Sciences, Singapore Management University, 90 Stamford Road, Level 4, Singapore, 178903 Singapore
| | - M. Kerem Coban
- GLODEM, Koc University, Rumelifeneri Yolu, 34450 Istanbul, Turkey
| | - Azad Singh Bali
- The School of Politics & International Relations; The Crawford School of Public Policy, The Australian National University, University Avenue, Acton, ACT 2600 Australia
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Allegri MD, Srivastava S, Strupat C, Brenner S, Parmar D, Parisi D, Walsh C, Mahajan S, Neogi R, Ziegler S, Basu S, Jain N. Mixed and Multi-Methods Protocol to Evaluate Implementation Processes and Early Effects of the Pradhan Mantri Jan Arogya Yojana Scheme in Seven Indian States. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17217812. [PMID: 33114480 PMCID: PMC7663328 DOI: 10.3390/ijerph17217812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 10/15/2020] [Accepted: 10/22/2020] [Indexed: 11/16/2022]
Abstract
In September 2018, India launched Pradhan Mantri Jan Arogya Yojana (PM-JAY), a nationally implemented government-funded health insurance scheme to improve access to quality inpatient care, increase financial protection, and reduce unmet need for the most vulnerable population groups. This protocol describes the methodology adopted to evaluate implementation processes and early effects of PM-JAY in seven Indian states. The study adopts a mixed and multi-methods concurrent triangulation design including three components: 1. demand-side household study, including a structured survey and qualitative elements, to quantify and understand PM-JAY reach and its effect on insurance awareness, health service utilization, and financial protection; 2. supply-side hospital-based survey encompassing both quantitative and qualitative elements to assess the effect of PM-JAY on quality of service delivery and to explore healthcare providers' experiences with scheme implementation; and 3. process documentation to examine implementation processes in selected states transitioning from either no or prior health insurance to PM-JAY. Descriptive statistics and quasi-experimental methods will be used to analyze quantitative data, while thematic analysis will be used to analyze qualitative data. The study design presented represents the first effort to jointly evaluate implementation processes and early effects of the largest government-funded health insurance scheme ever launched in India.
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Affiliation(s)
- Manuela De Allegri
- Heidelberg Institute of Global Health, Medical Faculty and University Hospital, Heidelberg University, 69120 Heidelberg, Germany; (S.S.); (S.B.); (D.P.); (C.W.)
- Correspondence: ; Tel.: +49-(0)6221-56-35056
| | - Swati Srivastava
- Heidelberg Institute of Global Health, Medical Faculty and University Hospital, Heidelberg University, 69120 Heidelberg, Germany; (S.S.); (S.B.); (D.P.); (C.W.)
| | - Christoph Strupat
- German Development Institute/Deutsches Institut für Entwicklungspolitik (DIE), 53113 Bonn, Germany;
| | - Stephan Brenner
- Heidelberg Institute of Global Health, Medical Faculty and University Hospital, Heidelberg University, 69120 Heidelberg, Germany; (S.S.); (S.B.); (D.P.); (C.W.)
| | - Divya Parmar
- Centre for Global Health and Health Partnerships, School of Population Health and Environmental Sciences, King’s College London, London SE5 9RJ, UK;
| | - Diletta Parisi
- Heidelberg Institute of Global Health, Medical Faculty and University Hospital, Heidelberg University, 69120 Heidelberg, Germany; (S.S.); (S.B.); (D.P.); (C.W.)
| | - Caitlin Walsh
- Heidelberg Institute of Global Health, Medical Faculty and University Hospital, Heidelberg University, 69120 Heidelberg, Germany; (S.S.); (S.B.); (D.P.); (C.W.)
| | - Sahil Mahajan
- IQVIA Consulting and Information Services India, New Delhi 110001, India;
| | - Rupak Neogi
- Nielsen India Private Limited, Gurugram 122002, India;
| | - Susanne Ziegler
- Indo-German Social Security Programme (IGSSP), Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH, New Delhi 110029, India; (S.Z.); (S.B.); (N.J.)
| | - Sharmishtha Basu
- Indo-German Social Security Programme (IGSSP), Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH, New Delhi 110029, India; (S.Z.); (S.B.); (N.J.)
| | - Nishant Jain
- Indo-German Social Security Programme (IGSSP), Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH, New Delhi 110029, India; (S.Z.); (S.B.); (N.J.)
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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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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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Maurya D. Understanding public health insurance in India: A design perspective. Int J Health Plann Manage 2019; 34:e1633-e1650. [DOI: 10.1002/hpm.2856] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 07/05/2019] [Accepted: 07/08/2019] [Indexed: 11/05/2022] Open
Affiliation(s)
- Dayashankar Maurya
- Healthcare Management Program T A Pai Management Institute Manipal 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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