Contemporary Universal Health Coverage in India - The Case of Federal State of Odisha (Orissa)

Purpose

The present study assessed the awareness of the public about Biju Swasthya Kalyan Yojana (BSKY), which is a flagship public-funded health insurance scheme of the Government of Odisha. The study also identified its determinants and examined utilisation of the scheme among households in Khordha district of Odisha.

Materials and Methods

Primary data were collected from randomly chosen 150 households using a pretested structured questionnaire from Balipatana block of Khordha district, Odisha. Descriptive statistics and binomial logistic regression were used to substantiate the objectives.

Results

The study found that even though 56.70% of the sample households had heard about BSKY, procedure-specific awareness was low. State government organised BSKY health insurance camp was found to be a major source of knowledge among the sample. The regression model had an R² of 0.414. The Chi² value showed that the model with predictor variables was a good fit. Caste, gender, economic category, health insurance, and awareness about insurance were significant determinants of BSKY awareness. A majority (79.30%) of the sample had the scheme card with them. However, only 12.60% of the cardholders used the card and only 10.67% received benefits. Mean out-of-pocket expenditure (OOPE) faced by the beneficiaries is Rs. 15743.59. Among the beneficiaries, 53.80% financed the OOPE from their savings, 38.50% by borrowing, and 7.70% financed the OOPE by both means.

Conclusion

The study found that even though majority of people had heard about BSKY, they were not aware of its nature, features, and operational procedures. The trend of low benefit received and higher OOPE among the scheme beneficiaries hampers the economic health of the poor. Finally, the study highlighted the need to increase the magnitude of scheme coverage and administrative efficiency.

Awareness of India's national health insurance scheme (PM-JAY): a cross-sectional study across six states

The literature suggests that a first barrier towards accessing benefits of health insurance in low- and middle-income countries is lack of awareness of one's benefits. Yet, across settings and emerging schemes, limited scientific evidence is available on levels of awareness and their determinants. To fill this gap, we assessed socio-demographic and economic determinants of beneficiaries' awareness of the Pradhan Mantri Jan Arogya Yojana (PM-JAY), the national health insurance scheme launched in India in 2018, and their awareness of own eligibility. We relied on cross-sectional household (HH) survey data collected in six Indian states between 2019 and 2020. Representative data of HHs eligible for PM-JAY from 11 618 respondents (an adult representative from each surveyed HH) were used. We used descriptive statistics and multivariable logistic regression models to explore the association between awareness of PM-JAY and of one's own eligibility and socio-economic and demographic characteristics. About 62% of respondents were aware of PM-JAY, and among the aware, 78% knew that they were eligible for the scheme. Regression analysis confirmed that older respondents with a higher educational level and salaried jobs were more likely to know about PM-JAY. Awareness was lower among respondents from Meghalaya and Tamil Nadu. Respondents from Other Backward Classes, of wealthier socio-economic status or from Meghalaya or Gujarat were more likely to be aware of their eligibility status. Respondents from Chhattisgarh were less likely to know about their eligibility. Our study confirms that while more than half of the eligible population was aware of PM-JAY, considerable efforts are needed to achieve universal awareness. Socio-economic gradients confirm that the more marginalized are still less aware. We recommend implementing tailored, state-specific information dissemination approaches focusing on knowledge of specific scheme features to empower beneficiaries to demand their entitled services.

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.

Masking Poverty and Entitlement: RSBY in Selected Districts of West Bengal

In 2008, India launched a flagship national health insurance programme, the Rashtriya Swasthya Bima Yojana (RSBY) for those living below the poverty line (BPL). 1 Using qualitative methods and thematic analysis, this exploratory study of poor women from three selected districts of West Bengal sought to gauge reasons for low registration and factors affecting choice of institutional healthcare among those who had registered for the RSBY. In particular, we sought to understand the underlying factors, if any, which affect judgements on institutional healthcare.

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.

Study of Awareness, Enrollment, and Utilization of Rashtriya Swasthya Bima Yojana (National Health Insurance Scheme) in Maharashtra, India

INTRODUCTION

Government of India launched a social health protection program called Rashtriya Swasthya Bima Yojana (RSBY) in the year 2008 to provide financial protection from catastrophic health expenses to below poverty line households (HHs). The objectives of the current paper are to assess the current status of RSBY in Maharashtra at each step of awareness, enrollment, and utilization. In addition, urban and rural areas were compared, and social, political, economic, and cultural (SPEC) factors responsible for the better or poor proportions, especially for the awareness of the scheme, were identified.

METHODS

The study followed mixed methods approach. For quantitative data, a systematic multistage sampling design was adopted in both rural and urban areas covering 6000 HHs across 22 districts. For qualitative data, five districts were selected to conduct Stakeholder Analysis, Focused Group Discussions, and In-Depth Interviews with key informants to supplement the findings. The data were analyzed using innovative SPEC-by-steps tool developed by Health Inc.

RESULTS

It is seen that that the RSBY had a very limited success in Maharashtra. Out of 6000 HHs, only 29.7% were aware about the scheme and 21.6% were enrolled during the period of 2010-2012. Only 11.3% HHs reported that they were currently enrolled for RSBY. Although 1886 (33.1%) HHs reported at least one case of hospitalization in the last 1 year, only 16 (0.3%) HHs could actually utilize the benefits during hospitalization. It is seen that at each step, there is an increase in the exclusion of eligible HHs from the scheme. The participants felt that such schemes did not reach their intended beneficiaries due to various SPEC factors.

DISCUSSION AND CONCLUSION

The results of this study were quite similar to other studies done in the recent past. RSBY might still be continued in Maharashtra with modified focus along with good and improved strategy. Various other similar schemes in India can definitely learn few important lessons such as the need to improve awareness, issuing prompt enrollment cards with proper details, achieving universal enrollment, ongoing and prompt renewal, and ensuring proper utilization by proactively educating the vulnerable sections.

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

Background

India’s health expenditure is met mostly by households through out-of-pocket (OOP) payments at the time of illness. To protect poor families, the Indian government launched a national health insurance scheme (RSBY). Those below the national poverty line (BPL) are eligible to join the RSBY. The premium is heavily subsidised by the government. The enrolled members receive a card and can avail of free hospitalisation care up to a maximum of US$ 600 per family per year. The hospitals are reimbursed by the insurance companies. The objective of our study was to analyse the extent to which RSBY contributes to universal health coverage by protecting families from making OOP payments.

Methods

A two-stage stratified sampling technique was used to identify eligible BPL families in Patan district of Gujarat, India. Initially, all 517 villages were listed and 78 were selected randomly. From each of these villages, 40 BPL households were randomly selected and a structured questionnaire was administered. Interviews and discussions were also conducted among key stakeholders.

Results

Our sample contained 2,920 households who had enrolled in the RSBY; most were from the poorer sections of society. The average hospital admission rate for the period 2010–2011 was 40/1,000 enrolled. Women, elderly and those belonging to the lowest caste had a higher hospitalisation rate. Forty four per cent of patients who had enrolled in RSBY and had used the RSBY card still faced OOP payments at the time of hospitalisation. The median OOP payment for the above patients was US$ 80 (interquartile range, $16–$200) and was similar in both government and private hospitals. Patients incurred OOP payments mainly because they were asked to purchase medicines and diagnostics, though the same were included in the benefit package.

Conclusions

While the RSBY has managed to include the poor under its umbrella, it has provided only partial financial coverage. Nearly 60% of insured and admitted patients made OOP payments. We plea for better monitoring of the scheme and speculate that it is possible to enhance effective financial coverage of the RSBY if the nodal agency at state level would strengthen its stewardship and oversight functions.