Social health insurance for the poor: lessons from a health insurance programme in Karnataka, India

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)

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.

Gender-specific inequalities in coverage of Publicly Funded Health Insurance Schemes in Southern States of India: evidence from National Family Health Surveys

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.

Effects of a free health insurance programme for the poor on health service utilisation and financial protection in Senegal

INTRODUCTION

Implemented in 2013 in Senegal, the Programme National de Bourses de Sécurité Familiale (PNBSF) is a national cash transfer programme for poor households. Besides reducing household poverty and encouraging children's school attendance, an objective of the PNBSF is to expand health coverage by guaranteeing free enrolment in community-based health insurance (CBHI) schemes. In this paper, we provide the first assessment of the PNBSF free health insurance programme on health service utilisation and health-related financial protection.

METHODS

We collected household-level and individual-level cross-sectional data on health insurance in 2019-2020 within the Niakhar Population Observatory in rural Senegal. We conducted a series of descriptive analyses to fully describe the application of the PNBSF programme in terms of health coverage. We then used multivariate logistic and Poisson regression models within an inverse probability weighting framework to estimate the effect of being registered in a CBHI through the PNBSF-as compared with having no health insurance or having voluntarily enrolled in a CBHI scheme-on a series of outcomes.

RESULTS

With the exception of health facility deliveries, which were favoured by free health insurance, the PNBSF did not reduce the unmet need for healthcare or the health-related financial risk. It did not increase individuals' health service utilisation in case of health problems, did not increase the number of antenatal care visits and did not protect households against the risk of forgoing medical care and of catastrophic health expenditure.

CONCLUSION

We found limited effects of the PNBSF free health insurance on health service utilisation and health-related financial protection, although these failures were not necessarily due to the provision of free health insurance per se. Our results point to both implementation failures and limited programme outcomes. Greater commitment from the state is needed, particularly through strategies to reduce barriers to accessing covered healthcare.

Successes and obstacles in implementing social health insurance in developing and middle-income countries: A scoping review of 5-year recent literatures

Social health insurance (SHI) is a form of health finance mechanism that had been implemented in many countries to achieve universal health care (UHC). To emulate the successes of SHI in many developed countries, many developing and middle-income countries (MICs) have attempted to follow suit. However, the SHI implementation has problems and obstacles. Many more obstacles were observed despite some successes. This scoping review aimed to study the various developments of SHI globally in its uses, implementation, successes, and obstacles within the last 5 years from 2017 to 2021. Using three databases (i.e., PubMed, EBSCO, and Google Scholar), we reviewed all forms of articles on SHI, including gray literature. The PRISMA-ScR protocol was adapted as the guideline. We used the following search terms: social health insurance, national health insurance, and community health insurance. A total of 57,686 articles were screened, and subsequently, 46 articles were included in the final review. Results showed that the majority of SHI studies were in China and African countries, both of which were actively pursuing SHI programs to achieve UHC. China was still regarded as a developing country. There were also recent experiences from other Asian countries, but only a few from South America. Implementing SHI to achieve UHC was desirable but will need to consider several factors and issues. This was especially the case in developing and MICs. Eventually, full UHC would only be possible with a combination of general taxation and SHI.

Crying baby gets the milk? The governmentality of grievance redressal for patient rights violations in Karnataka, India

Background

Patient rights aim to protect the dignity of healthcare-seeking individuals. Realisation of these rights is predicated on effective grievance redressal for the victims of patient rights violations.

Methods

We used a critical case (that yields the most information) of patient rights violations reported in Karnataka state (South India) to explore the power dynamics involved in resolving grievances raised by healthcare-seeking individuals. Using interviews, media reports and other documents pertaining to the case, we explored the ‘governmentality’ of grievance redressal for patient rights violations, that is, the interaction of micropractices and techniques of power employed by actors to govern the processes and outcomes. We also examined whether existing governmentality ensured procedural and substantive justice to care-seeking individuals.

Results

Collective action was necessary by the aggrieved women in terms of protests, media engagement, petitions and follow-up to ensure that the State accepted a complaint against a medical professional. Each institution, and especially the medical professional council, exercised its power by problematising the grievance in its own way which was distinct from the problematisation of the grievance by the collective. The State bureaucracy enacted its power by creating a maze of organisational units and by fragmenting the grievance redressal across various bureaucratic units.

Conclusion

There is a need for measures guaranteeing accountability, transparency, promptness, fairness, credibility and trustworthiness in the patient grievance redressal system. Governmentality as a framework enabled to study how subjects (care-seeking individuals) are rendered governable and resist dominant forces in the grievance redressal system for patient rights violations.

Equity in health insurance schemes enrollment in low and middle-income countries: A systematic review and meta-analysis

Background

Ensuring access to essential quality health services and reducing financial hardship for all individuals regardless of their ability to pay are the main goals of universal health coverage. Various health insurance schemes have been recently implemented in low- and middle-income countries (LMICs) to achieve both of these objectives. We systematically reviewed all available literature to assess the extent to which current health insurance schemes truly reach the poor and underserved populations in LMICs.

Methods

In the systematic review, we searched on PubMed, Web of Science, EconLit and Google Scholar to identify eligible studies which captured health insurance enrollment information in LMICs from 2010 up to September 2019. Two authors independently selected studies, extracted data, and appraised included studies. The primary outcome of interest was health insurance enrollment of the most vulnerable populations relative to enrollment of the best-off subgroups. We classified households both with respect to their highest educational attainment and their relative wealth and used random-effects meta-analysis to estimate average enrollment gaps.

Results

48 studies from 17 countries met the inclusion criteria. The average enrollment rate into health insurance schemes for vulnerable populations was 36% with an inter-quartile range of 26%. On average, across countries, households from the wealthiest subgroup had 61% higher odds (95% CI: 1.49 to 1.73) of insurance enrollment than households in the poorest group in the same country. Similarly, the most educated groups had 64% (95% CI: 1.32 to 1.95) higher odds of enrollment than the least educated groups.

Conclusion

The results of this study show that despite major efforts by governments, health insurance schemes in low-and middle-income countries are generally not reaching the targeted underserved populations and predominantly supporting better-off population groups. Current health insurance designs should be carefully scrutinized, and the extent to which health insurance can be used to support the most vulnerable populations carefully re-assessed by countries, which are aiming to use health insurance schemes as means to reach their UHC goals. Furthermore, studies exploring best practices to include vulnerable groups in health insurance schemes are needed.

Registration

Not available

Supplementary Information

The online version contains supplementary material available at 10.1186/s12939-021-01608-x.

Making Health Insurance Pro-poor: Lessons from 20 Developing Countries

The last 20 years have seen a substantial growth in research on the extent to which health sector reforms are pro-poor or pro-rich. What has been missing is knowledge synthesis work to derive operational lessons from the empirical research. This article fills the gap for the most popular form of health financing reform, health insurance. Based on publications covering 20 developing countries, we find that health insurance is no panacea for improving equity in the health sector. More importantly, we find certain design elements of health insurance can increase the likelihood of tackling inequality in the health sector in developing countries.

Beyond coverage: a qualitative study exploring the perceived impact of Gabon's health insurance plan on access to and quality of prenatal care

BACKGROUND

Access to affordable and adequate healthcare in a health system determines the universal health coverage achievement for all residents in a country. Achieving access to healthcare requires the availability of a financing system that ensures access to and provision of adequate care, regardless of the ability to pay. In sub-Saharan Africa, accessibility, use and coverage of prenatal visits are very low and poor, which reduces the quality of care. This paper explored the impact of a social health insurance scheme on the quality of antenatal care in Gabon.

METHODS

This qualitative study involved the analysis of data collected from semi-structured interviews and non-participant observations to assess the quality of antenatal care. The study elicited perceptions on the demand side (pregnant women) and the supply side (health professionals) in health facilities. Fifteen semi-structured interviews were conducted with pregnant women (aged between 15 and 49) and 5 with health professionals, who each had a seniority of at least 10 years, at different levels of care. Nine non-participant observations were also conducted. Coded transcripts were reviewed and analyzed using the Canadian Institute for Public Administration of Citizen-Centered Services model as an analytical guide.

RESULTS

On the demand side, women were generally satisfied with the prenatal services they receive in health facilities. However, complaints were made about the rudeness of some nurses, the high price of the delivery kit (50,000 XAF), and the fact that some essential medicines for maternity are not covered. On the supply side, participants agreed that compulsory health insurance is important in providing antenatal care access to those who need it the most. However, some problems remain. The participants outlined some logistical problems and a lack of medical equipment, including the stock of drugs, disinfectants, and the absence of clean water.

CONCLUSION

Understanding the perceptions of pregnant women and health professionals regarding the quality of antenatal care can help to inform refinements to methods through which the services can be better provided. In addition, the study findings are vital to increasing the use of care, as well as combating high maternal mortality rates. Compulsory health insurance has improved the accessibility and utilization of healthcare services and has contributed to improved quality of care.

Exploratory qualitative study to understand the underlying motivations and strategies of the private for-profit healthcare sector in urban Bangladesh

OBJECTIVES

This paper explores the underlying motivations and strategies of formal small and medium-sized formal private for-profit sector hospitals and clinics in urban Bangladesh and their implications for quality and access.

METHODS

This exploratory qualitative study was conducted in Dhaka, Sylhet and Khulna City Corporations. Data collection methods included key informant interviews (20) with government and private sector leaders, in-depth interviews (30) with clinic owners, managers and providers and exit interviews (30) with healthcare clients.

RESULTS

Profit generation is a driving force behind entry into the private healthcare business and the provision of services. However, non-financial motivations are also emphasised such as aspirations to serve the disadvantaged, personal ambition, desire for greater social status, obligations to continue family business and adverse family events.The discussion of private sector motivations and strategies is framed using the Business Policy Model. This model is comprised of three components: products and services, and efforts to make these attractive including patient-friendly discounts and service-packages, and building 'good' doctor-patient relationships; the market environment, cultivated using medical brokers and referral fees to bring in fresh clientele, and receipt of pharmaceutical incentives; and finally, organisational capabilities, in this case overcoming human resource shortages by relying on medical staff from the public sector, consultant specialists, on-call and less experienced doctors in training, unqualified nursing staff and referring complicated cases to public facilities.

CONCLUSIONS

In the context of low public sector capacity and growing healthcare demands in urban Bangladesh, private for-profit engagement is critical to achieving universal health coverage (UHC). Given the informality of the sector, the nascent state of healthcare financing, and a weak regulatory framework, the process of engagement must be gradual. Further research is needed to explore how engagement in UHC can be enabled while maintaining profitability. Incentives that support private sector efforts to improve quality, affordability and accountability are a first step in building this relationship.