Government health insurance and spatial peer effects: New evidence from India

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.

Pandemics and technology engagement: New evidence from m-Health intervention during COVID-19 in India

Information provision for social welfare via cheap technological media is now a widely available tool used by policymakers. Often, however, an ample supply of information does not translate into high consumption of information due to various frictions in demand, possibly stemming from the pecuniary and non-pecuniary cost of engagement, along with institutional factors. We test this hypothesis in the Indian context using a unique data set comprising 2 million call records of enrolled users of ARMMAN, a Mumbai-based nongovernmental organization that sends timely informational calls to mobile phones of less-privileged pregnant women. The strict lockdown induced by COVID-19 in India was an unexpected shock on engagement with m-Health technology, in terms of both reductions in market wages and increased time availability at home. Using a difference-in-differences design on unique calls tracked at the user-time level with fine-grained time-stamps on calls, we find that during the lockdown period, the call durations increased by 1.53 percentage points. However, technology engagement behavior exhibited demographic heterogeneity increasing relatively after the lockdown for women who had to borrow the phones vis-à-vis phone owners, for those enrolled in direct outreach programs vis-à-vis self-registered women, and for those who belonged to the low-income group vis-à-vis high-income group. These findings are robust with coarsened exact matching and with a placebo test for a 2017-2018 sample. Our results have policy implications around demand-side frictions for technology engagement in developing economies and maternal health.

Willingness to pay for community-based health insurance and associated factors in Ethiopia: A systematic review and meta-analysis

In Ethiopia, there is low enrollment and a wide discrepancy in willingness to pay for community-based health insurance schemes, and there is a lack of nationally representative data on willingness to pay for community-based health insurance. Thus, this systematic review and meta-analysis aimed to estimate the pooled prevalence of willingness to pay for community-based health insurance and associated factors in Ethiopia. This was developed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Databases such as PubMed/Medline, CINAHL, African Journals Online, and Google Scholar searches were performed to retrieve available published and unpublished studies from December 15 to May 17, 2022. Two independent reviewers screened the retrieved articles. Critical quality appraisal was performed using the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument. To investigate the sources of heterogeneity, subgroup analysis and meta-regression were performed based on region, study setting (rural/urban), and sample size. RevMan software and STATA 14 software were used for the statistical analysis. A random-effect model was used to estimate the effect size at a 95% confidence interval. A total of 190 studies were retrieved, and six studies were included in the final meta-analysis. The pooled prevalence of willingness to pay for community-based health insurance was 78 (95% confidence interval: 74, 81). A subgroup analysis by region indicated the lowest proportion of willingness to pay community-based health insurance in the Oromia region, 76% (95% confidence interval: 68, 84), and the highest in the Amhara region, 79% (95% confidence interval: 77, 81). Nearly three in four households were willing to pay for community-based health insurance in Ethiopia. Thus, awareness of willingness to pay community-based health insurance is mandatory to improve the implementation of community-based health insurance.

Willingness to join and pay for community-based health insurance and associated determinants among urban households of Cameroon: case of Douala and Yaounde

Background

The risks associated with direct health spending are high in Cameroon, where almost all household income is spent on health care. Moreover, there is no real social security in Cameroon because of the lack of a universal social protection system.

Objectives

This study aimed to assess the willingness of Cameroonian urban dwellers to subscribe and the amount to pay for voluntary (VCHI) or compulsory community-based health insurance (CCHI).

Methods

A cross-sectional study based on a three-stage stratified cluster random sampling design using a bidding game style based on the contingent valuation approach was performed to in the two largest urban areas of Cameroon (Douala and Yaoundé) evaluate the willingness to pay for the VCHI and CCHI.

Results

The results shown that 46% of respondent were willing to join the CCHI and 41% for VCHI. Furthermore, household income, working sector, chronic disease, health priority, and family size were factors mostly associated (p < 0.001) with the willingness to join CCHI or VCHI. Increase in household income has a positive effect on household's desire for both CCHI and VCHI. While for VCHI, increase of children number resulted in an increment of the premium, contrary to the occurrence of chronic ailment which led in the decrease of the bid.

Conclusions

From the results, it is clear that city dwellers in Cameroon are ready to join and pay for community health insurance. This willingness was related to their financial power which resulted in an average insurance premium of 9.03 USD and 8.17 USD, respectively for CCHI and VCHI. That bid was found to be enough for an implementation of these types of health insurance in Cameroon.

Did India's price control policy for coronary stents create unintended consequences?

In February 2017, India capped the retail price of coronary stents and restricted the channel margin to bring Percutaneous Transluminal Coronary Angioplasty (PTCA) procedure, which uses coronary stents, within reach of millions of patients who previously could not afford it. Prior research shows that care providers respond to such regulations in a way that compensates for their loss in profits because of price control. Therefore, price control policies often introduce unintended consequences, such as distortions in clinical decision making. We investigate such distortions through empirical analysis of claims data from a representative public insurance program in the Indian state of Karnataka. Our data comprises 25,769 insurance claims from 69 private and seven public hospitals from February 2016 to February 2018. The public insurance context is ideal for investigating distortions in clinical decisions as the price paid by patients, and thereby access to the treatment, does not change after price control. We find that the change in the average volume of PTCA procedures per hospital per month after price control disproportionately increased when compared to the change in the clinical alternative - Coronary Artery Bypass Graft (CABG) procedures. This increase corresponds to 6% of the average number of PTCA procedures and 28% of the average number of CABG procedures before the price control. In addition, disproportionate increase in PTCA procedures occurred only among private hospitals, indicating the possibility of profit-maximization intentions driving the clinical choices. Such clinical distortions can have negative implications for patient health outcomes in the long run. We discuss alternative policies to improve access and affordability to healthcare products and services which are likely to not suffer from similar distortions.

The effect of consensus on demand for voluntary micro health insurance in rural India

INTRODUCTION

This study deals with examining factors that catalyze demand for community-based micro health insurance (MHI) schemes. We hypothesize that demand for health insurance is a collective decision in the context of informality and poverty. Our hypothesis challenges the classical theory of demand which posits individual expected diminishing utility. We examine factors beyond the traditional exogenous variables.

METHODS

This study uses data collected through a household survey conducted among self-help groups in rural India in the states of Uttar Pradesh and Bihar before the implementation of three community-based MHI schemes. Additional information was extracted from the management information system maintained by the schemes. At the first step, we compared the estimated probability of a household joining the scheme (obtained by applying logistic regression) to the actual uptake. In the next step, we analyzed the role of consensus within groups on demand for health insurance (by applying ordinary least square regressions).

RESULTS

The results of the logistic regressions indicated that exogenous household characteristics could not explain the probability of joining health insurance. We observed that group consensus on several critical issues, such as the price of the insurance, perceptions about exposure to adverse health events, and perceptions of the quality of service of local health care providers, was the important determinant of demand for insurance.

CONCLUSION

Based on the analysis, we reject the null hypothesis that demand is an individual decision at the household level. The analysis upholds the assumption that demand is created through a process of consensus building on perceptions of risk exposure, welfare gains from the insurance, and quality of local health care provision. Success in catalyzing demand for health insurance in the informal sector depends on encouraging group dialog.