Promoting universal financial protection: evidence from the Rashtriya Swasthya Bima Yojana (RSBY) in Gujarat, India

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

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

Utilisation and barriers of social health protection program among its enrolled population of federally administrative areas, Pakistan

OBJECTIVES

The objective of this research is to analyse the extent of utilisation and identify the barriers faced by individuals in the Federally Administrative Area of Pakistan concerning the Social Health Protection Programme.

METHODS

A cross-sectional study was carried out, enrolling permanent residents from Islamabad, Gilgit-Baltistan and Azad Kashmir. The sampling frame was provided by the Sehat Sahulat Programme (SSP) office in Islamabad, using a simple random sampling method. The study used the 'WHO Health Survey 2002' tool, which is validated, to assess the utilisation and barriers of the Social Health Protection Programme.

RESULTS

The study findings indicated that approximately 12% of the participants used the Social Health Protection Programme, while 6.5% experienced barriers in utilisation. The identified barriers were further classified into seeking (3%), reaching (0.25%) and receiving care (3.25%) barriers. A χ2 test of association revealed significant statistical associations between card utilisation and sociodemographic factors such as age and level of education (p value <0.001). Additionally, statistically significant associations were observed with hospitalisation in the last year, duration and frequency of hospitalisation (p value <0.001). However, no statistically significant association was found between the utilisation of SSP and utilisation barriers.

CONCLUSION

The SSP had a low utilisation ratio due to the fact that half of the enrolled households were satisfied with their health conditions and did not feel the need for hospitalisation.

The effectiveness of a government-sponsored health protection scheme in reducing financial risks for the below-poverty-line population in Bangladesh

The Government of Bangladesh is piloting a non-contributory health protection scheme called Shasthyo Surokhsha Karmasuchi (SSK) to increase access to quality essential healthcare services for the below-poverty-line (BPL) population. This paper assesses the effect of the SSK scheme on out-of-pocket expenditure (OOPE) for healthcare, catastrophic health expenditure (CHE) and economic impoverishment of the enrolled population. A comparative cross-sectional study was conducted in Tangail District, where the SSK was implemented. From August 2019 to March 2020, a total of 2315 BPL households (HHs) (1170 intervention and 1145 comparison) that had at least one individual with inpatient care experience in the last 12 months were surveyed. A household is said to have incurred CHE if their OOPE for healthcare exceeds the total (or non-food) HH's expenditure threshold. Multiple regression analysis was performed using OOPE, incidence of CHE and impoverishment as dependent variables and SSK membership status, actual BPL status and benefits use status as the main explanatory variables. Overall, the OOPE was significantly lower (P < 0.01) in the intervention areas (Bangladeshi Taka (BDT) 23 366) compared with the comparison areas (BDT 24 757). Regression analysis revealed that the OOPE, CHE incidence at threshold of 10% of total expenditure and 40% of non-food expenditure and impoverishment were 33% (P < 0.01), 46% (P < 0.01), 42% (P < 0.01) and 30% (P < 0.01) lower, respectively, in the intervention areas than in the comparison areas. Additionally, HHs that utilized SSK benefits experienced even lower OOPE by 92% (P < 0.01), CHE incidence at 10% and 40% threshold levels by 72% (P < 0.01) and 59% (P < 0.01), respectively, and impoverishment by 27% at 10% level of significance. These findings demonstrated the significant positive effect of the SSK in reducing financial burdens associated with healthcare utilization among the enrolled HHs. This illustrates the importance of the nationwide scaling up of the scheme in Bangladesh to reduce the undue financial risk of healthcare utilization for those in poverty.

A step closer towards achieving universal health coverage: the role of gender in enrolment in health insurance in India

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.

A Systematic Review of the World's Largest Government Sponsored Health Insurance Scheme for 500 Million Beneficiaries in India: Pradhan Mantri Jan Arogya Yojana

BACKGROUND AND OBJECTIVE

In pursuit of universal health coverage, India has launched the world's largest government-sponsored health insurance scheme, Pradhan Mantri Jan Arogya Yojana (PM-JAY) in 2018. This study aims to provide a holistic review of the scheme's impact since its inception.

METHODS

We reviewed studies (based on interviews or surveys) published from September 2018 to January 2023, which were retrieved from PubMed, Web of Science, and Scopus database. The main outcomes studied were: (1) awareness; (2) utilization of scheme; (3) experiences; (4) financial protection; and (5) challenges encountered by both beneficiaries and healthcare providers.

RESULTS

A total of 18 studies conducted across 14 states and union territories of India were reviewed. The findings revealed that although PM-JAY has become a familiar name, there remains a low level of awareness regarding various facets of the scheme such as benefits entitled, hospitals empanelled, and services covered. The scheme is benefitting the poor and vulnerable population to access healthcare services that were previously unaffordable to them. However, financial protection provided by the scheme exhibited mixed results. Several challenges were identified, including continued spending by beneficiaries on drugs and diagnostic tests, delays in issuance of beneficiary cards, and co-payments demanded by healthcare providers. Additionally, private hospitals expressed dissatisfaction with low health package rates and delays in claims reimbursement.

CONCLUSIONS

Concerted efforts such as population-wide dissemination of clear and complete knowledge of the scheme, providing training to healthcare providers, addressing infrastructural gaps and concerns of healthcare providers, and ensuring appropriate stewardship are imperative to achieve the desired objectives of the scheme in the long-run.

Examining the Effectiveness of Financial Protection Schemes in Reducing Health Inequality

Health protection schemes such as health insurance and financial assistance provide immense help and support to access health care services, especially to the poor and marginalized section of society. India is witness to low health-related expenditure, and the society's socioeconomic and demographic structure further drops health care access to the new bottom. Consequently, inequality in health care access is highly observed across many socioeconomic attributes. The condition of Bihar, the poorest state of India, is more alarming. The analysis suggests that financial support in terms of universal health insurance coverage considerably reduces out-of-pocket expenditure and thus health inequality. Further, the low health insurance coverage is not solely due to a lack of institutional commitment and implementation process; the cognitive behavior and attitude of people are equally responsible for low health care access. An intensive awareness program to show the benefit of the health insurance scheme and sensitization of people against the social stigma is important to provide better health care access and reduce health inequality.

Evolution of Government-funded health insurance for universal health coverage in India

India has run multiple Government-Funded Health Insurance schemes (GFHIS) over the past decades to ensure affordable healthcare. We assessed GFHIS evolution with a special focus on two national schemes - Rashtriya Swasthya Bima Yojana (RSBY) and Pradhan Mantri Jan Arogya Yojana (PMJAY). RSBY suffered from a static financial coverage cap, low enrollment, inequitable service supply, utilization, etc. PMJAY expanded coverage and mitigated some of RSBY's drawbacks. Investigating equity in PMJAY's supply and utilization across geography, sex, age, social groups, and healthcare sectors depicts several systemic skews. Kerala and Himachal Pradesh with low poverty and disease burden use more services. Males are more likely to seek care under PMJAY than females. Mid-age population (19-50 years) is a common group availing services. Scheduled Caste and Scheduled Tribe people have low service utilization. Most hospitals providing services are private. Such inequities can lead the most vulnerable populations further into deprivation due to healthcare inaccessibility.

Does the presence of health insurance and health facilities improve access to healthcare for major morbidities among Indigenous communities and older widows in India? Evidence from India Human Development Surveys I and II

In this paper, we examine whether access to treatment for major morbidity conditions is determined by the social class of the person who needs treatment. Secondly, we assess whether health insurance coverage and the presence of a PHC have any significant impact on the utilisation of health services, either public or private, for treatment and, more importantly, whether the presence of health insurance and PHC modify the treatment use behaviour for the two excluded communities of interest namely Indigenous communities and older widows using data from two rounds (2005 and 2012) of the nationally representative India Human Development Survey (IHDS). We estimated a multilevel mixed effects model with treatment for major morbidity as the outcome variable and social groups, older widows, the presence of a PHC and the survey wave as the main explanatory variables. The results confirmed access to treatment for major morbidity was affected by social class with Indigenous communities and older widows less likely to access treatment. Health insurance coverage did not have an effect that was large enough to induce a positive change in the likelihood of accessing treatment. The presence of a functional PHC increased the likelihood of treatment for all social groups except Indigenous communities. This is not surprising as Indigenous communities generally live in locations where the terrain is more challenging and decentralised healthcare up to the PHC might not work as effectively as it does for others. The social class to which one belongs has a significant impact on the ability of a person to access healthcare. Efforts to address inequity needs to take this into account and design interventions that are decentralised and planned with the involvement of local communities to be effective. Merely addressing one or two barriers to access in an isolated fashion will not lead to equitable access.

Explaining Caste-Based Disparities in Enrollment for National Health Insurance Program in India: a Decomposition Analysis

BACKGROUND

Caste plays a significant role in individual healthcare access and health outcomes in India. Discrimination against low-caste communities contributes to their poverty and poor health outcomes. The Rashtriya Swasthya Bima Yojana (RSBY), a national health insurance program, was created to improve healthcare access for the poor. This study accounts for caste-based disparities in RSBY enrollment in India by decomposing the contributions of relevant factors.

METHODS

Using the data from the 2015-2016 round of the National Family Health Survey, we compare RSBY enrollment rates of low-caste and high-caste households. We use a non-linear extension of Oaxaca-Blinder decomposition and estimate two models by pooling coefficients across the comparison groups and all caste groups. Enrollment differentials are decomposed into individual- and household-level characteristics, media access, and state-level fixed effects, allowing 2000 replications and random ordering of variables.

RESULTS

The analysis of 480,766 households show that scheduled tribe households have the highest enrollment (18.85%), followed by 14.13% for scheduled caste, 10.67% for other backward caste, and 9.33% for high caste. Household factors, family head's characteristics, media access, and state-level fixed effects account for a 32% to 52% gap in enrollment. More specifically, the enrollment gaps are attributable to differences in wealth status, educational attainment, residence, family size, dependency ratio, media access, and occupational activities of the households.

CONCLUSIONS

Weaker socio-economic status of low-caste households explains their high RSBY enrollments.

Role of publicly funded health insurance in financial protection of the elderly from hospitalisation expenditure in India-findings from the longitudinal aging study

BACKGROUND

The elderly face a greater burden of illnesses than other age groups and have a more frequent need of healthcare, including in-patient hospitalisations. Catastrophic expenditure on hospitalisation of the elderly poses a significant challenge to India's aim of achieving Universal Health Coverage (UHC). India has implemented a policy of Publicly Funded Health Insurance (PFHI) to provide free inpatient care by empanelling private and public hospitals. The existing studies have examined the performance of PFHI in financial protection of the elderly.

METHODS

This study utilised the Longitudinal Ageing Study in India (LASI) Wave 1, conducted in 2017-18. LASI is a large-scale nationally representative survey collecting data on elderly health including illness burden, healthcare use and out of pocket expenditure (OOPE). It covered a sample 72,250 individuals aged 45 or above. Financial Protection was measured in terms of Catastrophic Health Expenditure (CHE). Multivariate analysis was conducted to find effect of PFHI on OOPE-quantile and logistic models were applied for OOPE and CHE respectively. For robustness, Propensity Score Matching (PSM) model was applied.

RESULTS

Of the hospitalisations, 35% had taken place in public hospitals. The mean OOPE for a hospitalisation in public sector was Indian Rupees (INR) 8276, whereas it was INR 49,700 in private facilities. Incidence of CHE was several times greater for using private hospitals as compared to public hospitals. Multi-variate analyses showed that enrolment under PFHI was not associated with lower OOPE or CHE. PSM model also confirmed that PFHI-enrolment had no effect on OOPE or CHE. Use of private facilities was a key determinant of OOPE, irrespective of enrolment under PFHI.

CONCLUSIONS

This was the first study in India to examine the performance of PFHI in the context of catastrophic hospitalisation expenditure faced by the elderly. It found that PFHI was not effective in financial protection of the elderly. The ongoing reliance on a poorly regulated private sector seems to be a key limitation of PFHI policy. Governments need to find more effective ways of protecting the elderly from catastrophic health expenditure if the goal of UHC has to be realized.

Experiences and challenges in accessing hospitalization in a government-funded health insurance scheme: Evidence from early implementation of Pradhan Mantri Jan Aarogya Yojana (PM-JAY) in India

INTRODUCTION

Government-sponsored health insurance schemes can play an important role in improving the reach of healthcare services. Launched in 2018 in India, Pradhan Mantri Jan Aarogya Yojana (PM-JAY) is one of the world's largest government-sponsored health insurance schemes. The objective of this study is to understand beneficiaries' experience of availing healthcare services at the empaneled hospitals in PM-JAY. This study examines the responsiveness of PM-JAY by measuring the prompt attention in service delivery, and access to information by the beneficiaries; financial burden experienced by the beneficiaries; and beneficiary's satisfaction with the experience of hospitalization under PMJAY and its determinants.

METHODS

The study was conducted during March-August 2019. Data were obtained through a survey conducted with 200 PM-JAY beneficiaries (or their caregivers) in the Indian states of Gujarat and Madhya Pradesh. The study population comprised of patients who received healthcare services at 14 study hospitals in April 2019. Prompt attention was measured in the form of a) effectiveness of helpdesk, and b) time taken at different stages of hospitalization and discharge events. Access to information by the beneficiaries was measured using the frequency and purpose of text messages and phone calls from the scheme authorities to the beneficiaries. The financial burden was measured in terms of the incidence and magnitude of out-of-pocket payments made by the beneficiaries separate from the cashless payment provided to hospitals by PMJAY. Beneficiaries' satisfaction was measured on a five-point Likert scale.

RESULTS

Socio-economically weaker sections of the society are availing healthcare services under PM-JAY. In Gujarat, the majority of the beneficiaries were made aware of the scheme by the government official channels. In Madhya Pradesh, the majority of the beneficiaries got to know about the scheme from informal sources. For most of the elements of prompt attention, access to information, and beneficiaries' satisfaction, hospitals in Gujarat performed significantly better than the hospitals in Madhya Pradesh. Similarly, for most of the elements of prompt attention, access to information, and beneficiaries' satisfaction, public hospitals performed significantly better than private hospitals. Incidence and magnitude of out-of-pocket payments were significantly higher in Madhya Pradesh as compared to Gujarat, and in private hospitals as compared to the public hospitals.

CONCLUSION

There is a need to focus on Information, Education, and Communication (IEC) activities for PM-JAY, especially in Madhya Pradesh. Capacity-building efforts need to be prioritized for private hospitals as compared to public hospitals, and for Madhya Pradesh as compared to Gujarat. There is a need to focus on enhancing the responsiveness of the scheme, and timely exchange of information with beneficiaries. There is also an urgent need for measures aimed at reducing the out-of-pocket payments made by the beneficiaries.

How much do government and households spend on an episode of hospitalisation in India? A comparison for public and private hospitals in Chhattisgarh state

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.

Catastrophic Health Expenditure on Private Sector Pharmaceuticals: A Cross-Sectional Analysis from the State of Odisha, India

India has high rates of catastrophic health expenditure (CHE): 16% of Indian households incur CHE. To understand why CHE is so high, we conducted an in-depth analysis in the state of Odisha—a state with high rates of public sector facility use, reported eligibility for public insurance of 80%, and the provision of drugs for free in government-run facilities—yet with the second-highest rates of CHE across India (24%). We collected household data in 2019 representative of the state of Odisha and captured extensive information about healthcare seeking, including the facility type, its sector (private or public), how much was spent out-of-pocket, and where drugs were obtained. We employ Shapley decomposition to attribute variation in CHE and other financial hardship metrics to characteristics of healthcare, controlling for health and social determinants. We find that 36.3% (95% uncertainty interval: 32.7–40.1) of explained variation in CHE is attributed to whether a private sector pharmacy was used and the number of drugs obtained. Of all outpatient visits, 13% are with a private sector chemist, a similar rate as public primary providers (15%). Insurance was used in just 6% of hospitalizations and its use explained just 0.2% (0.1–0.4) of CHE overall. Eighty-six percent of users of outpatient care obtained drugs from the private sector. We estimate that eliminating spending on private drugs would reduce CHE by 56% in Odisha. The private sector for pharmaceuticals fulfills an essential health system function in Odisha—supplying drugs to the vast majority of patients. To improve financial risk protection in Odisha, the role currently fulfilled by private sector pharmacies must be considered alongside existing shortcomings in the public sector provision of drugs and the lack of outpatient care and drug coverage in public insurance programs.

Public health insurance and maternal health care utilization in india: evidence from the 2005-2012 mothers' cohort data

BACKGROUND

The introduction of Janani Suraksha Yojana (JSY) in India, a conditional cash transfer program which incentivized women to deliver at institutions, resulted in a significant increase in institutional births. Another major health policy reform, which could have affected maternal and child health care (MCH) utilization, was the public health insurance scheme (RSBY) launched in 2008. However, there is a noticeable lack of studies that examine how RSBY had impacted on MCH utilization in India. We used data from a cohort of mothers whose delivery had been captured in both the 2005 and 2011/12 rounds of the Indian Human Development Survey (IHDS) to study the impact of health insurance (in particular, the public insurance scheme versus private insurance) on MCH access. We also investigated whether maternal empowerment was a significant correlate that affects MCH utilization.

METHODS

We used the multilevel mixed-effects ordered logistic regression model to account for the clustered nature of our data. We derived indexes for women's empowerment using Principal component analysis (PCA) technique applied to various indicators of women's autonomy and socio-economic status.

RESULTS

Our results indicated that the odds of mothers' MCH utilization levels vary by district, community and mother over time. The effect of the public insurance scheme (RSBY) on MCH utilization was not as strong as privately available insurance. However, health insurance was only significant in models that did not control for household and mother level predictors. Our findings indicated that maternal empowerment indicators - in particular, maternal ability to go out of the house and complete chores and economic empowerment-were associated with higher utilization of MCH services. Among control variables, maternal age and education were significant correlates that increase MCH service utilization over time. Household wealth quintile was another significant factor with mothers belonging to upper quintiles more likely to access and utilize MCH services.

CONCLUSIONS

Change in women's and societal attitude towards maternal care may have played a significant role in increasing MCH utilization over the study period. There might be a need to increase the coverage of the public insurance scheme given the finding that it was less effective in increasing MCH utilization. Importantly, policies that aim to improve health services for women need to take maternal autonomy and empowerment into consideration.

Improving hospital-based processes for effective implementation of Government funded health insurance schemes: evidence from early implementation of PM-JAY in India

Background

Government-sponsored health insurance schemes (GSHIS) aim to improve access to and utilization of healthcare services and offer financial protection to the population. India’s Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PM-JAY) is one such GSHIS. This paper aims to understand how the processes put in place to manage hospital-based transactions, from the time a beneficiary arrives at the hospital to discharge are being implemented in PM-JAY and how to improve them to strengthen the scheme’s operation.

Methods

Guidelines were reviewed for the processes associated with hospital-based transactions, namely, beneficiary authentication, treatment package selection, preauthorization, discharge, and claims payments. Across 14 hospitals in Gujarat and Madhya Pradesh states, the above-mentioned processes were observed, and using a semi-structured interview guide fifty-three respondents were interviewed. The study was carried out from March 2019 to August 2019.

Results

Average turn-around time for claim reimbursement is two to six times higher than that proposed in guidelines and tender. As opposed to the guidelines, beneficiaries are incurring out-of-pocket expenditure while availing healthcare services. The training provided to the front-line workers is software-centric. Hospital-based processes are relatively more efficient in hospitals where frontline workers have a medical/paramedical/managerial background.

Conclusions

There is a need to broaden capacity-building efforts from enabling frontline staff to operate the scheme’s IT platform to developing the technical, managerial, and leadership skills required for them. At the hospital level, an empowered frontline worker is the key to efficient hospital-based processes. There is a need to streamline back-end processes to eliminate the causes for delay in the processing of claim payment requests. For policymakers, the most important and urgent need is to reduce out-of-pocket expenses. To that end, there is a need to both revisit and streamline the existing guidelines and ensure adherence to the guidelines.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07448-3.

Pandemic management in mountainous regions: challenges and opportunities

Globalization has facilitated fast spread of COVID-19 cutting across political boundaries and even the remote locations have not been spared. Spread of the contagion is studied in the Himalayan province of Uttarakhand in India that is generally visited by pilgrims and tourists in large numbers from across the country and abroad. Despite restrictions on travel, the virus has spread even to the remote locations of the province. The study analyzes the efforts put in by the provincial government and the pace of spread as a function of geographical remoteness, together with the constraints faced by the administration and disaster managers in restricting the spread. The study highlights the important lessons which would help the management of future pandemics. The chapter at the same time highlights limited involvement of medical community in disaster management which is generally limited to post-disaster casualty management, triage, first aid, medical care, and psychosocial support.

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

OBJECTIVE

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

DESIGN

Systematic review.

DATA SOURCES

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

ELIGIBILITY CRITERIA

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

DATA EXTRACTION AND SYNTHESIS

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

OUTCOMES

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

RESULTS

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

CONCLUSION

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

REGISTRATION

Not registered.

Financial toxicity in cancer care in India: a systematic review

Although financial toxicity is widely acknowledged to be a potential consequence of costly cancer treatment, little is known about its prevalence and outcome among the Indian population. In this study, we systematically reviewed the prevalence, determinants, and consequences of financial toxicity among patients with cancer in India. 22 studies were included in the systematic review. The determinants of financial toxicity include household income, type of health-care facility used, stage of disease, area of residence, age at the time of diagnosis, recurrent cancer, educational status, insurance coverage, and treatment modality. Financial toxicity was associated with poor quality of life, accumulation of debts, premature entry into the labour market, and non-compliance with therapy. Our findings emphasise the need for urgent strategies to mitigate financial toxicity among patients with cancer in India, especially in the most deprived sections of society. The qualitative evidence synthesised in this systematic review could provide a basis for the development of such interventions to reduce financial toxicity among patients with cancer.

Comparing the average cost of outpatient care of public and for-profit private providers in India

Introduction

Understanding the cost of care associated with different kinds of healthcare providers is necessary for informing the policy debates in mixed health-systems like India’s. Existing studies reporting Out of Pocket Expenditure (OOPE) per episode of outpatient care in public and private providers in India do not provide a fair comparison because they have not taken into account the government subsidies received by public facilities. Public and private health insurance in India do not cover outpatient care and for-profit providers have to meet all their costs out of the payments they take from patients.

Methods

The average direct cost per acute episode of outpatient care was compared for public providers, for-profit formal providers and informal private providers in Chhattisgarh state of India. For public facilities, government subsidies for various inputs were taken into account. Resources used were apportioned using Activity Based Costing. Land provided free to public facilities was counted at market prices. The study used two datasets: a) household survey on outpatient utilisation and OOPE b) facility survey of public providers to find the input costs borne by government per outpatient-episode.

Results

The average cost per episode of outpatient care was Indian Rupees (INR) 400 for public providers, INR 586 for informal private providers and INR 2643 for formal for-profit providers and they managed 39.3, 37.9 and 22.9% of episodes respectively. The average cost for government and households put together was greater for using formal for-profit providers than the public providers. The disease profile of care handled by different types of providers was similar. Volume of patients and human-resources were key cost drivers in public facilities. Close to community providers involved less cost than others.

Conclusions and recommendations

The findings have implications for the desired mix of public and private providers in India’s health-system. Poor regulation of for-profit providers was an important structural cost driver. Purchasing outpatient care from private providers may not reduce average cost. Policies to strengthen public provisioning of curative primary care close to communities can help in reducing cost.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06777-7.

Households' out-of-pocket expenditure for healthcare in Bangladesh: A health financing incidence analysis

BACKGROUND

Despite improvements in many health indicators, providing access to affordable healthcare remains a considerable challenge in Bangladesh. Financing incidence analysis will enable an evaluation of how well the healthcare system performs to achieve equity in health financing. The objective of this study is to assess the burden of out-of-pocket (OOP) cost on different socio-economic groups by assessing the health financing incidence because OOP cost dominates household expenditure on health in Bangladesh.

METHODS

The study was conducted using latest Household Income and Expenditure Survey (HIES) 2016. We focused mainly on four specific indicators: level of monthly household OOP cost on in-patient care, urban-rural differences in OOP cost, socio-economic status differences in different payment mechanisms and the Kakwani index. Descriptive statistics were employed to analyse and summarise the selected variables based on the SES and location of residence (e.g., rural and urban).

RESULTS

The study showed the overall OOP healthcare expenditure was 7.7% of the household monthly income while the poorer income group suffered more and spent up to 35% of their household income on healthcare. The Kakwani index indicated that the poorest quintile spends a greater share of their income on healthcare services than the richest quintile.

CONCLUSIONS

This study observed that OOP cost in Bangladesh is regressive, that is, poorer members of society contribute a greater share of their income. Therefore, policymakers should initiate health reforms for developing and implementing risk-pooling financing mechanisms such as social health insurance to achieve the Universal Health Coverage in Bangladesh.

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.

H, Nambiar D. Empanelment of health care facilities under Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB PM-JAY) in India

Introduction

India’s Pradhan Mantri Jan Arogya Yojana (PM-JAY) is the world’s largest health assurance scheme providing health cover of 500,000 INR (about USD 6,800) per family per year. It provides financial support for secondary and tertiary care hospitalization expenses to about 500 million of India’s poorest households through various insurance models with care delivered by public and private empanelled providers. This study undertook to describe the provider empanelment of PM-JAY, a key element of its functioning and determinant of its impact.

Methods

We carried out secondary analysis of cross-sectional administrative program data publicly available in PM-JAY portal for 30 Indian states and 06 UTs. We analysed the state wise distribution, type and sector of empanelled hospitals and services offered through PM-JAY scheme across all the states and UTs.

Results

We found that out of the total facilities empanelled (N = 20,257) under the scheme in 2020, more than half (N = 11,367, 56%) were in the public sector, while 8,157 (40%) facilities were private for profit, and 733 (4%) were private not for profit entities. State wise distribution of hospitals showed that five states (Karnataka (N = 2,996, 14.9%), Gujarat (N = 2,672, 13.3%), Uttar Pradesh (N = 2,627, 13%), Tamil Nadu (N = 2315, 11.5%) and Rajasthan (N = 2,093 facilities, 10.4%) contributed to more than 60% of empanelled PMJAY facilities: We also observed that 40% of facilities were offering between two and five specialties while 14% of empanelled hospitals provided 21–24 specialties.

Conclusion

A majority of the hospital empanelled under the scheme are in states with previous experience of implementing publicly funded health insurance schemes, with the exception of Uttar Pradesh. Reasons underlying these patterns of empanelment as well as the impact of empanelment on service access, utilisation, population health and financial risk protection warrant further study. While the inclusion and regulation of the private sector is a goal that may be served by empanelment, the role of public sector remains critical, particularly in underserved areas of India.

Payment Arrangements for Private Healthcare Purchasing Under Publicly Funded Systems in Low- and Middle-Income Countries: Issues and Implications

This paper examines private healthcare purchasing under publicly financed health systems in low- and middle-income countries (LMICs) to argue that the payment methods and rates applied to private and public health providers need careful attention to ensure equity, efficiency and quality in healthcare service provision. Specifically, public purchasers should develop a clear mechanism to establish justifiable payment rates for the purchase of private health services under publicly funded systems, using cost information and appropriate engagement with private health providers. In order to determine the validity of payment arrangements with private providers, clarification of the shared roles and responsibilities of public and private healthcare providers is required, including specification of types of services to be delivered by public and private providers, and the services for which public providers receive government budget and salaries above payments for other publicly funded services. In addition, carefully designed payment methods should include incentives to encourage healthcare providers to deliver efficient, equitable and quality health services, which requires consideration of how the healthcare purchasing market is structured. Furthermore, governments should establish sound legal frameworks to ensure that public purchasers establish 'strategic' payment arrangements with healthcare providers and that healthcare providers are able to respond to the incentives sent by the payment arrangements. To deepen understanding of public purchasing of private healthcare services and gain further insight in the LMIC context, in-depth empirical studies are necessary on the payment methods and rates used by public purchasers in a range of settings and the implications of payment arrangements on efficiency, equity and quality in healthcare service provision.

Effect of health insurance program for the poor on out-of-pocket inpatient care cost in India: evidence from a nationally representative cross-sectional survey

BACKGROUND

In India, Out-of-pocket expenses accounts for about 62.6% of total health expenditure - one of the highest in the world. Lack of health insurance coverage and inadequate coverage are important reasons for high out-of-pocket health expenditures. There are many Public Health Insurance Programs offered by the Government that cover the cost of hospitalization for the people below poverty line (BPL), but their coverage is still not complete. The objective of this research is to examine the effect of Public Health Insurance Programs for the Poor on hospitalizations and inpatient Out-of-Pocket costs.

METHODS

Data from the recent national survey by the National Sample Survey Organization, Social Consumption in Health 2014 are used. Propensity score matching was used to identify comparable non-enrolled individuals for individuals enrolled in health insurance programs. Binary logistic regression model, Tobit model, and a Two-part model were used to study the effects of enrolment under Public Health Insurance Programs for the Poor on the incidence of hospitalizations, length of hospitalization, and Out-of- Pocket payments for inpatient care.

RESULTS

There were 64,270 BPL people in the sample. Individuals enrolled in health insurance for the poor have 1.21 higher odds of incidence of hospitalization compared to matched poor individuals without the health insurance coverage. Enrollment under the poor people health insurance program did not have any effect on length of hospitalization and inpatient Out-of-Pocket health expenditures. Logistic regression model showed that chronic illness, household size, and age of the individual had significant effects on hospitalization incidence. Tobit model results showed that individuals who had chronic illnesses and belonging to other backward social group had significant effects on hospital length of stay. Tobit model showed that days of hospital stay, education and age of patient, using a private hospital for treatment, admission in a paying ward, and having some specific comorbidities had significant positive effect on out-of-pocket costs.

CONCLUSIONS

Enrolment in the public health insurance programs for the poor increased the utilization of inpatient health care. Health insurance coverage should be expanded to cover outpatient services to discourage overutilization of inpatient services. To reduce out-of-pocket costs, insurance needs to cover all family members rather than restricting coverage to a specific maximum defined.

Affirmative action, minorities, and public services in India: Charting a future research and practice agenda

The National Health Policy in India mentions equity as a key policy principle and emphasises the role of affirmative action in achieving health equity for a range of excluded groups. We conducted a scoping review of literature and three multi-stakeholder workshops to better understand the available evidence on the impact of affirmative action policies in enhancing the inclusion of ethnic and religious minorities in health, education and governance in India. We consider these public services an important mechanism to enhance the social inclusion of many excluded groups. On the whole, the available empirical evidence regarding the uptake and impact of affirmative action policies is limited. Reservation policies in higher education and electoral constituencies have had a limited positive impact in enhancing the access and representation of minorities. However, reservations in government jobs remain poorly implemented. In general, class, gender and location intersect, creating inter- and intra-group differentials in the impact of these policies. Several government initiatives aimed at enhancing the access of religious minorities to public services/institutions remain poorly evaluated. Future research and practice need to focus on neglected but relevant research themes such as the role of private sector providers in supporting the inclusion of minorities, the political aspects of policy development and implementation, and the role of social mobilisation and movements. Evidence gaps also need to be filled in relation to information systems for monitoring and assessment of social disadvantage, implementation and evaluative research on inclusive policies and understanding how the pathways to inequities can be effectively addressed.

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

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.

The barriers to the full implementation of strategic purchasing and the role of health policy and decision-makers: past, current status, ethical aspects and future challenges

Healthcare systems are complex, multi-level, highly integrated organizations, comprising of different professional figures, institutions, and resources. Such breadth and complexity reflect the multi-dimensionality of the concept of health, which implies the adoption of a holistic approach. Health, rather than merely being the absence of disorders or infirmity, is a highly dynamic state, which represents the abilities of an individual to cope with adverse social, physical and emotional/psychological events and conditions, continuously adapting to them. Ensuring an adequate health state is one of the most important concerns, and the healthcare systems are called to renew themselves in order to meet with the new challenges and health needs. Throughout the last decades, due to demographic shifts and transitions, epidemiological and societal changes, technological achievements and scientific advancements, healthcare systems have undergone an extensive series of reform plans. Therefore, health policy- and decision-makers have made efforts to develop and implement initiatives for preserving the quality of the healthcare provisions. Strategic purchasing is an approach of purchasing that takes into account several health-related issues such as a proper, comprehensive planning of service delivery, the design and selection of the best packages of services and provisions, the appropriate selection of providers and the allocation of economical and financial incentives to provide better services and to motivate managers to adopt appropriate policies to implement strategic purchasing. Here, we intend to consider the various dimensions and aspects that can be effective in strategic purchasing, as well as the main barriers and obstacles that hinder its full implementation.

Using an equity-based framework for evaluating publicly funded health insurance programmes as an instrument of UHC in Chhattisgarh State, India

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.

Utilisation and financial protection for hospital care under publicly funded health insurance in three states in Southern India

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.

The costs of seeking healthcare: Illness, treatment seeking and out of pocket expenditures among the urban poor in Delhi, India

The poor often experience illness and the treatment costs are high and even catastrophic for the poor. This paper reports the extent of illness, treatment-seeking behaviour and out of pocket healthcare expenditures and the determinants of treatment-seeking behaviour and healthcare expenditures among the urban poor living in Delhi. A total of 2,998 households participated in the study. Socio-demographic details, illness experiences (episodic illness in the past 3 months, hospitalisation in the past 1 year and any chronic illness), treatment seeking and healthcare expenditures were collected for all household members through a pretested, interviewer-administered questionnaire. Logistic regressions were carried out for factors associated with treatment-seeking choices. Multiple linear regressions were carried for factors associated with out of pocket expenditures (OOPE). Of the total 15,218 household members (of the 2,998 households), 4,052 (26.6%) experienced episodic illness (mainly fever, respiratory illnesses, food- and waterborne diseases and eye infections) in the past 3 months, 230 (1.5%) were hospitalised and 976 (6.4%) have chronic illness (mainly hypertension, diabetes, arthritis and respiratory problems). Of the 2,998 households, 2,225 (74.2%) households reported at least one event of illness. Unqualified practitioners were the main source of care for episodic illnesses. Perceived seriousness of the illness, having Employees State Insurance Scheme (ESIS) benefit, higher educational status of the head of the household, higher monthly household incomes, belonging other backward castes and settled-migrant status led to seeking formal care. Dengue was the main reason for hospitalisation. Government including ESIS hospitals were mainly utilised for hospitalisation. Healthcare expenditures were higher for private healthcare. Possession of mandatory health insurance was protective against OOPEs. OOPEs were more for the men/boys and for the young. Improving access to government healthcare services is important. Extending the ESIS to the unorganised workers including urban poor migrants should be considered so as to bring them under mandatory social protection.

Financial Impact of Complex Cancer Surgery in India: A Study of Pancreatic Cancer

Purpose

The rapidly increasing burden of cancer in India has profound impacts on health care costs for patients and their families. High out-of-pocket (OOP) expenditure, lack of insurance, and low government expenditure create a vicious cycle, leading to household impoverishment. Complex cancer surgery is now increasingly important for emerging countries; however, little is understood about the macro- and microeconomics of these procedures. After the Lancet Oncology Commission on Global Cancer Surgery, we evaluated the OOP expenditure for patients undergoing pancreatico-duodenectomy (PD) at a government tertiary cancer center in India.

Methods

Prospective data from 98 patients who underwent PD between January 2014 and June 2015 were collected and analyzed. The time frame for consideration of expenses, including all preoperative investigations, was from the first hospital visit to the day of discharge. Catastrophic expenditure was calculated by assessing the percentage of households in which OOP health payments exceeded 10% of the total household income.

Results

The mean expenditure for PD by patients was Rs.295,679.57 (US$74,420, purchasing power parity corrected). This amount was significantly higher among those admitted to a private ward and those with complications. Only 29.6% of the patients had insurance coverage. A total of 76.5% of the sample incurred catastrophic expenditure, and 38% of those with insurance underwent financial catastrophe compared with 93% of those without insurance. The percentage of patients facing catastrophic impact was highest among those in semiprivate wards, at 86.7%, followed by those in public and private wards.

Conclusion

The cost of PD is high and is often unaffordable for a majority of India’s population. A review of insurance coverage policies for better coverage must be considered.

Ayushman Bharat National Health Protection Scheme: an Ethical Analysis

The Ayushman Bharat (Hindi for "India blessed with a long life") scheme is a government health insurance program that will cover about 100 million poor and vulnerable families in India providing up to INR 0.5 million per family per year for secondary and tertiary care hospitalization services. In addition, it also proposes to establish 150,000 health and wellness centers all over the country providing comprehensive primary health care. The beneficiaries of the hospital insurance scheme can avail health care services from both public and empanelled private health facilities. This scheme is one of the largest government-sponsored health insurance schemes in the world. Previous experience with government-financed health insurance schemes in India has shown that they are inequitable, inefficient, and do not provide financial protection. There is a lack of clarity on the budgetary provisions over the years when the utilization is likely to increase. The Ayushman Bharat scheme in its current form strengthens the "for profit" private health sector, requiring greater emphasis on its regulation. The scheme, which has primary, secondary, and tertiary care components, places a great focus on the secondary and tertiary care services and requires more investment in comprehensive primary health care. The potential problems of "profit-motivated" supplier-induced demand by private health care providers and corrupt practices are possible ethical burdens of the scheme. For the Ayushman Bharat to meet the ethical principle of justice, it should first address universal coverage of comprehensive primary health care and move on to hospital insurance in a progressive manner. The scheme should have provisions to strictly regulate secondary and tertiary care hospitalization in the private health sector to prevent misuse. It is the ethical responsibility of the government to ensure a strong and robust public health system, but the current provisioning of the Ayushman Bharat scheme does not do this and the reasons for this are explained in this paper.

Health Insurance: Awareness, Utilization, and its Determinants among the Urban Poor in Delhi, India

This study reports the awareness, access, and utilization of health insurance by the urban poor in Delhi, India. The study included 2998 households from 85 urban clusters spread across Delhi. The data were collected through a pretested, interviewer-administered questionnaire. Logistic regression was performed for determinants of health insurance possession. Only 19% knew about health insurance; 18% had health insurance (8% Employees State Insurance Scheme - ESIS - 8% Central Government Health Scheme - CGHS - 1.4%; Rashtriya Swasthya Bima Yojana (RSBY) - 9.4% of the eligible households). In case of health needs, 95% of CGHS, 71% ESIS beneficiaries, and 9.5% of RSBY beneficiaries utilized the schemes for episodic and chronic illnesses. For hospitalization needs, 54% of RSBY, 86% of ESIS, 100% CGHS utilized respective services. Residential area, migration period, possession of ration card, household size, and occupation of the head of the household were significantly associated with possession of RSBY. RSBY played a limited role in meeting the healthcare needs of the people, thus may not be capable of contributing significantly in the efforts of achieving equity in healthcare for the poor. Relatively, ESIS and CGHS served the healthcare needs of the beneficiaries better. Expansion of ESIS to the informal workers may be considered.

Strategic purchasing for universal health coverage: examining the purchaser-provider relationship within a social health insurance scheme in Nigeria

BACKGROUND

In an attempt to achieve universal health coverage, Nigeria introduced a number of health insurance schemes. One of them, the Formal Sector Social Health Insurance Programme (FSSHIP), was launched in 2005 to provide health cover to federal government and formal private sector employees. It operates with two levels of purchasers, the National Health Insurance Scheme (NHIS) and health maintenance organisations (HMOs). This study critically assesses purchasing arrangements between NHIS, HMOs and healthcare providers and determines how the arrangements function from a strategic purchasing perspective within the FSSHIP.

METHODS

A qualitative study undertaken in Enugu state, Nigeria, data were gathered through reviews of documents, 17 in-depth interviews (IDIs) with NHIS, HMOs and healthcare providers and two focus group discussions (FGDs) with FSSHIP enrolees. A strategic purchasing lens was used to guide data analysis.

RESULTS

The purchasing function was not being used strategically to influence provider behaviour and improve efficiency and quality in healthcare service delivery. For the purchaser-provider relationship, these actions are: accreditation of healthcare providers; monitoring of HMOs and healthcare providers and use of appropriate provider payment mechanisms for healthcare services at every level. The government lacks resources and political will to perform their stewardship role while provider dissatisfaction with payments and reimbursements adversely affected service provision to enrolled members. Underlying this inability to purchase, health services strategically is the two-tiered purchasing mechanism wherein NHIS is not adequately exercising its stewardship role to monitor and guide HMOs to fulfil their roles and responsibilities as purchasing administrators.

CONCLUSIONS

Purchasing under the FSSHIP is more passive than strategic. Governance framework requires strengthening and clarity for optimal implementation so as to ensure that both levels of purchasers undertake strategic purchasing actions. Additional strengthening of NHIS is needed for it to have capacity to play its stewardship role in the FSSHIP.

Quantifying the financial burden of households' out-of-pocket payments on medicines in India: a repeated cross-sectional analysis of National Sample Survey data, 1994-2014

OBJECTIVE

The objective of this research is to generate new evidence on financial implications of medicines out-of-pocket (OOP) payments for households. Another objective is to investigate which disease conditions contributed to a significant proportion of households' financial burden.

SETTING

All Indian states including union territories, 1993-2014.

DESIGN

Repeated cross-sectional household surveys.

DATA

Secondary data of nationwide Consumer Expenditure Surveys for the years 1993-1994, 2004-2005 and 2011-2012 and one wave of Social Consumption: Health for the year 2014 from National Sample Survey Organisation.

OUTCOME MEASURES

OOP expenditure on healthcare in general and medicines in specific.

RESULTS

Total OOP payments and medicines OOP payments were estimated to be 6.77% (95% CI 6.70% to 6.84%) and 4.49% (95% CI 4.45% to 4.54%) of total consumption expenditure, respectively, in the year 2011-2012 which marked significant increase since 1993-1994. These proportions were 11.46% (95% CI 11.36% to 11.56%) and 7.60% (95% CI 7.54% to 7.67%) of non-food expenditure, respectively, in the same year. Total OOP payments and medicines OOP payments were catastrophic for 17.9% (95% CI 17.7% to 18.2%) and 11.2% (95% CI 11.0% to 11.4%) households, respectively, in 2011-2012 at the 10% of total consumption expenditure threshold, implying 29 million households incurred catastrophic OOP payments in the year 2011-2012. Further, medicines OOP payments pushed 3.09% (95% CI 2.99% to 3.20%), implying 38 million persons into poverty in the year 2011-2012. Among the leading cause of diseases that caused significant OOP payments are cancers, injuries, cardiovascular diseases, genitourinary conditions and mental disorders.

CONCLUSIONS

Purchase of medicines constitutes the single largest component of the total OOP payments by households. Hence, strengthening government intervention in providing medicines free in public healthcare facilities has the potential to considerably reduce medicine-related spending and total OOP payments of households and reduction in OOP-induced poverty.

Effectiveness of government strategies for financial protection against costs of hospitalization Care in India

Background

In the past decade, India has seen the introduction of many ‘publicly funded health insurance’ schemes (PFHIs) that claim to cover approximately 300 million people and are essentially forms of purchasing care from both public and private providers to reduce out-of-pocket expenditure (OOPE) for hospitalization.

Methods

Data from a recent government-organized nationwide household survey, The National Sample Survey 71st Round, were used to analyse the effectiveness and equity of tax-funded public health services and PFHIs as distinct but overlapping approaches to financial protection for hospitalization across different socio-economic categories. Cross-tabulation analysis, multivariate logistic regression and propensity score matching were the main analytical methods used.

Results

Government hospitals provide access to 45.6% of all hospitalization needs. Although poorer quintiles use public hospitals more often, even in the poorest quintile, as many as 37.2% are utilizing private hospitals. The average OOPE that a household experiences for hospitalization in public hospitals is approximately only one-fifth of the OOPE for hospitalization in the private sector. PFHI schemes cover 12.8% of the population, and coverage is higher in upper quintiles and in urban areas. Hospitalization rates increase with PFHI coverage, and this occurs with both public and private providers. Propensity score matching shows that PFHI contributes to a marginal reduction (1%) in ‘catastrophic health expenditure incidence at the 25% threshold’ (CHE-25) for the bottom three quintiles. The reported coverage of PFHIs was greater in the upper income quintiles. Utilization of public services was greater in the poorer income quintiles and more marginalized social groups.

Conclusions

Periodic surveys are essential to guide policy choices regarding the appropriate mix of strategies for financial protection in pluralistic systems. There is a need for caution regarding any shift in the role of governments from providing services to purchasing care, given the contexts and limitations of currently available PFHIs. Even with tax-funded public services, although the average OOPE is lower than the care purchased through PFHIs, there is still a modest level of CHE and impoverishment due to health care costs that persist. Both strategies need to be synergized for more effective financial protection.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-5431-8) contains supplementary material, which is available to authorized users.

Analysis of multi drug resistant tuberculosis (MDR-TB) financial protection policy: MDR-TB health insurance schemes, in Chhattisgarh state, India

INTRODUCTION

There are significant financial barriers to access treatment for multi drug resistant tuberculosis (MDR-TB) in India. To address these challenges, Chhattisgarh state in India has established a MDR-TB financial protection policy by creating MDR-TB benefit packages as part of the universal health insurance scheme that the state has rolled out in their effort towards attaining Universal Health Coverage for all its residents. In these schemes the state purchases health insurance against set packages of services from third party health insurance agencies on behalf of all its residents. Provider payment reform by strategic purchasing through output based payments (lump sum fee is reimbursed as per the MDR-TB benefit package rates) to the providers - both public and private health facilities empanelled under the insurance scheme was the key intervention.

AIM

To understand the implementation gap between policy and practice of the benefit packages with respect to equity in utilization of package claims by the poor patients in public and private sector.

METHODS

Data from primary health insurance claims from January 2013 to December 2015, were analysed using an extension of 'Kingdon's multiple streams for policy implementation framework' to explain the implementation gap between policy and practice of the MDR-TB benefit packages.

RESULTS

The total number of claims for MDR-TB benefit packages increased over the study period mainly from poor patients treated in public facilities, particularly for the pre-treatment evaluation and hospital stay packages. Variations and inequities in utilizing the packages were observed between poor and non-poor beneficiaries in public and private sector. Private providers participation in the new MDR-TB financial protection mechanism through the universal health insurance scheme was observed to be much lower than might be expected given their share of healthcare provision overall in India.

CONCLUSION

Our findings suggest that there may be an implementation gap due to weak coupling between the problem and the policy streams, reflecting weak coordination between state nodal agency and the state TB department. There is a pressing need to build strong institutional capacity of the public and private sector for improving service delivery to MDR-TB patients through this new health insurance mechanism.

Is the medical financial assistance program an effective supplement to social health insurance for low-income households in China? A cross-sectional study

BACKGROUND

China uses both social health insurance (SHI) programs and a medical financial assistance (MFA) program to protect the poor from illness-induced financial risks. The MFA provides a dual benefit package targeting low-income families: subsidizing these families' participation in SHI programs, and providing cash aid to protect them from catastrophic health expenditure (CHE). This study aims to investigate: (1) the association between MFA subvention for SHI enrollment and SHI enrollment; (2) the association between MFA cash aid and CHE; and (3) the association between SHI enrollment and CHE in low-income households in China.

METHODS

Using nationally representative data from a comprehensive survey of low-income households in 2014, we construct an estimate of CHE based on out-of-pocket health spending data. Controlling for other covariates, we estimate the three associations using a three-level logistic model.

RESULTS

The MFA program subsidizes 50.1% of low-income households to aid their enrollment in SHI programs and provides cash aid to 24.1% of these households. Multilevel logistic analysis reveals that MFA subvention has no significant association with low-income households' SHI enrollment, that MFA cash aid has no significant association with CHE, and that full SHI enrollment is inversely associated with CHE status.

CONCLUSIONS

The MFA program is currently not an effective supplement to SHI programs in China in terms of promoting SHI enrollment and providing financial risk protection. The Chinese government needs to invest more funds to expand further low-income household enrollment in SHI programs and to widen the benefit package of MFA cash aid.

Income generated by women treated with magnetic resonance imaging-based brachytherapy: A simulation study evaluating the macroeconomic benefits of implementing a high-end technology in a public sector healthcare setting

PURPOSE

To estimate the difference in income generated if all women presenting in our institute over a 5-year period were treated with MRI-based image-guided brachytherapy (MR-IGBT) instead of conventional radiograph-based brachytherapy (CR-BT).

METHODS AND MATERIALS

Outcome data from 463 patients (94 treated with MR-IGBT) treated in our institute was used to simulate cumulative women-days of work and cumulative income over 5 years for 5526 patients expected to be treated in this period. The average daily income for a woman was derived from the National Sample Survey Organization (NSSO) survey data. Outcomes from both unmatched and propensity score-matched data sets were simulated.

RESULTS

The cumulative income in 5 years ranged between Rs 101-168 million if all patients presenting at our institute underwent MR-IGBT. The simulated excess income ranged from Rs 4-45 million after 5 years, which represented 6-66% of the expenditure incurred for acquiring the required equipment and manpower for practicing exclusive MR-IGBT.

CONCLUSIONS

Using outcome data from a prospective cohort of patients treated with MR-IGBT in our institute, we demonstrated that significant economic gains may be realized if MR-IGBT was used instead of CR-BT.

Extending health insurance to the poor in India: An impact evaluation of Rashtriya Swasthya Bima Yojana on out of pocket spending for healthcare

India launched the 'Rashtriya Swasthya Bima Yojana' (RSBY) health insurance scheme for the poor in 2008. Utilising 3 waves (1999-2000, 2004-05 and 2011-12) of household level data from nationally representative surveys of the National Sample Survey Organisation (NSSO) (N = 346,615) and district level RSBY administrative data on enrolment, we estimated causal effects of RSBY on out-of-pocket expenditure. Using 'difference-in-differences' methods on households in matched districts we find that RSBY did not affect the likelihood of inpatient out-of-pocket spending, the level of inpatient out of pocket spending or catastrophic inpatient spending. We also do not find any statistically significant effect of RSBY on the level of outpatient out-of-pocket expenditure and the probability of incurring outpatient expenditure. In contrast, the likelihood of incurring any out of pocket spending (inpatient and outpatient) rose by 30% due to RSBY and was statistically significant. Although out of pocket spending levels did not change, RSBY raised household non-medical spending by 5%. Overall, the results suggest that RSBY has been ineffective in reducing the burden of out-of-pocket spending on poor households.

Impact of Publicly Financed Health Insurance Schemes on Healthcare Utilization and Financial Risk Protection in India: A Systematic Review

Several publicly financed health insurance schemes have been launched in India with the aim of providing universalizing health coverage (UHC). In this paper, we report the impact of publicly financed health insurance schemes on health service utilization, out-of-pocket (OOP) expenditure, financial risk protection and health status. Empirical research studies focussing on the impact or evaluation of publicly financed health insurance schemes in India were searched on PubMed, Google scholar, Ovid, Scopus, Embase and relevant websites. The studies were selected based on two stage screening PRISMA guidelines in which two researchers independently assessed the suitability and quality of the studies. The studies included in the review were divided into two groups i.e., with and without a comparison group. To assess the impact on utilization, OOP expenditure and health indicators, only the studies with a comparison group were reviewed. Out of 1265 articles screened after initial search, 43 studies were found eligible and reviewed in full text, finally yielding 14 studies which had a comparator group in their evaluation design. All the studies (n-7) focussing on utilization showed a positive effect in terms of increase in the consumption of health services with introduction of health insurance. About 70% studies (n-5) studies with a strong design and assessing financial risk protection showed no impact in reduction of OOP expenditures, while remaining 30% of evaluations (n-2), which particularly evaluated state sponsored health insurance schemes, reported a decline in OOP expenditure among the enrolled households. One study which evaluated impact on health outcome showed reduction in mortality among enrolled as compared to non-enrolled households, from conditions covered by the insurance scheme. While utilization of healthcare did improve among those enrolled in the scheme, there is no clear evidence yet to suggest that these have resulted in reduced OOP expenditures or higher financial risk protection.

The need for better evidence to evaluate the health & economic benefits of India's Rashtriya Swasthya Bima Yojana

In this review the existing evidence on the impact of Rashtriya Swasthya Bima Yojana (RSBY) is discussed in the context of international literature available on health insurance. We describe potential pathways through which health insurance can affect health and economic outcomes, discuss evidence from other developing countries, and identify potential biases and inconsistencies in existing studies on RSBY impact. Given the relatively recent introduction of RSBY, lack of quality, verifiable data on utilization patterns, and the absence of reliable evaluation studies, there is a need to exercise caution while assessing the merits of the programme. Considering the enormous potential and cost of the programme, we emphasize the need for a rigorous impact evaluation of RSBY. It will not only help capture the real impact of the scheme, but may also be able to estimate the extent of systemic inefficiencies at the level of the consumer.

A landscape analysis of universal health coverage for mothers and children in South Asia

The United Nations made universal health coverage (UHC) a key health goal in 2012 and it is one of the Sustainable Development Goals' targets. This analysis focuses on UHC for mothers and children in the 8 countries of South Asia. A high level overview of coverage of selected maternal, newborn and child health services, equity, quality of care and financial risk protection is presented. Common barriers countries face in achieving UHC are discussed and solutions explored. In countries of South Asia, except Bhutan and Maldives, between 42% and 67% of spending on health comes from out-of-pocket expenditure (OOPE) and government expenditure does not align with political aspirations. Even where reported coverage of services is good, quality of care is often low and the poorest fare worst. There are strong examples of ongoing successes in countries such as Bhutan, the Maldives and Sri Lanka. Related to this success are factors such as lower OOPE and higher spending on health. To make progress in achieving UHC, financial and non-financial barriers to accessing and receiving high-quality healthcare need to be reduced, the amount of investment in essential health services needs to be increased and allocation of resources must disproportionately benefit the poorest.