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Kanwal S, Kumar D, Chauhan R, Raina SK. Measuring the Effect of Ayushman Bharat-Pradhan Mantri Jan Aarogya Yojna (AB-PMJAY) on Health Expenditure among Poor Admitted in a Tertiary Care Hospital in the Northern State of India. Indian J Community Med 2024; 49:342-348. [PMID: 38665468 PMCID: PMC11042133 DOI: 10.4103/ijcm.ijcm_713_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 11/02/2023] [Indexed: 04/28/2024] Open
Abstract
Background Ayushman Bharat-Pradhan Mantri Jan Aarogya Yojna (AB-PMJAY) as a financial risk protection scheme intends to reduce catastrophic health expenditure (CHE), especially among poor. The current study was carried out to assess the utility of AB-PMJAY in terms of reduction in CHE from before and after admission in a tertiary hospital in the northern state of India. Methodology It was a hospital-based cross-sectional study carried out from August 2020 to October 2021 at a public tertiary hospital of Himachal Pradesh, India. Data were collected from surgery- and medicine-allied (SA and MA) specialties. Along with socio-demographic details, information for total monthly family expenditure (TMFE), out-of-pocket expenditure (OOPE), and indirect illness-related expenditure (IIE) was recorded before and after hospital admission. CHE was considered as more than 10.0% OOPE of THFE and more than 40.0% of capacity to pay (CTP). Results A total of 336 participants with a mean age of 46 years were recruited (MA: 54.6%). The majority (~93.0%) of participants had illness of fewer than 6 months. The mean TMFE was observed to be INR 4213.1 (standard deviation: 2483.7) and found to be similar across specialties. The OOPE share of TMFE declined from 76.1% (before admission) to 30.0% (after admission). Before admission, CHE was found among 65.5% (10.0% of THFE) and 54.2% (40.0% of CTP) participants. It reduced to about 29.0% (based on both THE and CTP) after admission to hospital. Conclusion AB-PMJAY scheme found to be useful in reducing CHE in a tertiary hospital.
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Affiliation(s)
- Shweta Kanwal
- Department of Community Medicine, Dr. Rajendra Prasad Government Medical College, Kangra at Tanda, Himachal Pradesh, India
| | - Dinesh Kumar
- Department of Community Medicine, Dr. Rajendra Prasad Government Medical College, Kangra at Tanda, Himachal Pradesh, India
| | - Raman Chauhan
- Department of Community Medicine, Dr. Rajendra Prasad Government Medical College, Kangra at Tanda, Himachal Pradesh, India
| | - Sunil Kumar Raina
- Department of Community Medicine, Dr. Rajendra Prasad Government Medical College, Kangra at Tanda, Himachal Pradesh, India
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Aashima, Sharma R. Is health insurance really benefitting Indian population? Evidence from a nationally representative sample survey. Int J Health Plann Manage 2024; 39:293-310. [PMID: 37910629 DOI: 10.1002/hpm.3716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Revised: 10/01/2023] [Accepted: 10/05/2023] [Indexed: 11/03/2023] Open
Abstract
BACKGROUND Universal health coverage (UHC) is the centrepiece of the sustainable development goals and aims to ensure access to essential and quality healthcare services to all without facing financial hardships. Several health insurance programmes have been launched in India to progress towards UHC. OBJECTIVE This study aims to assess the impact of health insurance (overall health insurance, government sponsored health insurance (GSHI), and private voluntary health insurance) on accessibility and utilization of inpatient care, out-of-pocket health expenditure (OOPE), catastrophic health expenditure (CHE), and impoverishment in India. DATA AND METHODOLOGY The 75th round of National Sample Survey Office was used in the study, which covered 555,115 individuals, 113,823 households, and 91,445 hospitalization incidence all over India. Descriptive statistics, multivariable logistic regression, and propensity score matching (PSM) methods were employed. RESULTS Enrolment under health insurance has impacted the accessibility and utilization pattern of hospitalization to some extent for the insured. PSM showed that enrolment under GSHI schemes reduced OOPE by INR 3314 (USD 49) and CHE incidence by 1%-4% at various thresholds. Among poor persons, there was a marginal but statistically significant reduction of OOPE among those enrolled under GSHI schemes (p < 0.05). However, GSHI schemes did not statistically significantly reduce the CHE burden for poor persons enrolled (p > 0.05). Furthermore, enrolment under private voluntary health insurance reduced OOPE by INR 13,511 (USD 198) and CHE by 13.47% at 10% threshold, 4.61% at 25% threshold, and 2.65% at 40% threshold. However, its uptake was primarily confined to richer economic quintiles and urban areas that exacerbates equity concerns. All the results were confirmed through robustness measures employed. CONCLUSIONS There is a necessity to increase awareness and uptake of health insurance, along with introducing comprehensive insurance packages covering both inpatient and outpatient care. Also, increasing public health spending, strengthening public healthcare facilities, and improving regulatory implementation of private healthcare providers are imperative to augment financial protection.
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Affiliation(s)
- Aashima
- University School of Management and Entrepreneurship, Delhi Technological University, New Delhi, India
| | - Rajesh Sharma
- University School of Management and Entrepreneurship, Delhi Technological University, New Delhi, India
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Ziegler S, Srivastava S, Parmar D, Basu S, Jain N, De Allegri M. A step closer towards achieving universal health coverage: the role of gender in enrolment in health insurance in India. BMC Health Serv Res 2024; 24:141. [PMID: 38279165 PMCID: PMC10821565 DOI: 10.1186/s12913-023-10473-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 12/12/2023] [Indexed: 01/28/2024] Open
Abstract
BACKGROUND There is limited understanding of how universal health coverage (UHC) schemes such as publicly-funded health insurance (PFHI) benefit women as compared to men. Many of these schemes are gender-neutral in design but given the existing gender inequalities in many societies, their benefits may not be similar for women and men. We contribute to the evidence by conducting a gender analysis of the enrolment of individuals and households in India's national PFHI scheme, Rashtriya Swasthya Bima Yojana (RSBY). METHODS We used data from a cross-sectional household survey on RSBY eligible families across eight Indian states and studied different outcome variables at both the individual and household levels to compare enrolment among women and men. We applied multivariate logistic regressions and controlled for several demographic and socio-economic characteristics. RESULTS At the individual level, the analysis revealed no substantial differences in enrolment between men and women. Only in one state were women more likely to be enrolled in RSBY than men (AOR: 2.66, 95% CI: 1.32-5.38), and this pattern was linked to their status in the household. At the household level, analyses revealed that female-headed households had a higher likelihood to be enrolled (AOR: 1.36, 95% CI: 1.14-1.62), but not necessarily to have all household members enrolled. CONCLUSION Findings are surprising in light of India's well-documented gender bias, permeating different aspects of society, and are most likely an indication of success in designing a policy that did not favour participation by men above women, by mandating spouse enrolment and securing enrolment of up to five family members. Higher enrolment rates among female-headed households are also an indication of women's preferences for investments in health, in the context of a conducive policy environment. Further analyses are needed to examine if once enrolled, women also make use of the scheme benefits to the same extent as men do. India is called upon to capitalise on the achievements of RSBY and apply them to newer schemes such as PM-JAY.
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Affiliation(s)
- Susanne Ziegler
- Heidelberg Institute of Global Health, Medical Faculty and University Hospital, Heidelberg University, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany.
- Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH, Friedrich-Ebert-Allee 32+36, 53113, Bonn, Germany.
| | - Swati Srivastava
- Heidelberg Institute of Global Health, Medical Faculty and University Hospital, Heidelberg University, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany
| | - Divya Parmar
- Department of Population Health Sciences, School of Life Course and Population Sciences, King's College London, Weston Education Centre, Cutcombe Road, London, SE5 9RJ, United Kingdom
| | - Sharmishtha Basu
- Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH, B5/1 Safdarjung Enclave, 110029, New Delhi, India
| | - Nishant Jain
- Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH, B5/1 Safdarjung Enclave, 110029, New Delhi, India
| | - Manuela De Allegri
- Heidelberg Institute of Global Health, Medical Faculty and University Hospital, Heidelberg University, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany
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Aashima, Sharma R. A Systematic Review of the World's Largest Government Sponsored Health Insurance Scheme for 500 Million Beneficiaries in India: Pradhan Mantri Jan Arogya Yojana. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2024; 22:17-32. [PMID: 37801262 DOI: 10.1007/s40258-023-00838-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/14/2023] [Indexed: 10/07/2023]
Abstract
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.
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Affiliation(s)
- Aashima
- University School of Management and Entrepreneurship, Delhi Technological University, New Delhi, India
| | - Rajesh Sharma
- Department of Humanities and Social Sciences, National Institute of Technology Kurukshetra, Kurukshetra, 136119, Haryana, India.
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Sharma SK, Joseph J, D HS, Nambiar D. Assessing inequalities in publicly funded health insurance scheme coverage and out-of-pocket expenditure for hospitalization: findings from a household survey in Kerala. Int J Equity Health 2023; 22:197. [PMID: 37759247 PMCID: PMC10537906 DOI: 10.1186/s12939-023-02005-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 09/05/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND Increasing financial risk protection is a key feature of Universal Health Coverage and the path towards health for all. Publicly Funded Health Insurance Schemes (PFHIS) have been considered as one of the pathways to safeguard against financial shocks and potentially reduce Out-of-Pocket Expenditure (OOPE). The south Indian state of Kerala has roughly a decade-long experience in implementing PFHIS. To date, there have been very few assessments of the coverage of these schemes and their impact on expenditure. Aiming to fill this gap, we explored the extent of and inequalities in insurance coverage, as well as choice of providers, and median cost of hospitalization in Kerala among insured and uninsured individuals. METHODS A cross-sectional household survey was conducted in four districts of Kerala as part of a larger health systems research study from July-October 2019. We employed multistage random sampling to collect data from 13,064 individuals covering 3234 households in the catchment area of eight primary health care facilities. We used descriptive statistics, bivariate and multivariate analysis. We evaluated socioeconomic disparities using an absolute measure of inequality-the Slope Index of Inequality (SII) and a relative measure-the Relative Concentration Index (RCI). RESULTS A substantial proportion of our study respondents reported that they were covered by PFHIS (45.8%). Respondents belonging to lowest and middle wealth quintiles of household had significantly greater odds of being covered by insurance than respondents belonging to the richest wealth quintile. The negative magnitude of RCI [-16.8% (95%CI: -25.3, -8.4)] and SII [-21.5% (95%CI: -36.1, -7.0)] suggest a higher concentration of PFHIS coverage among the poor. Median OOPE for hospitalisation at private health facilities was INR 9000 (approx. USD 108.70) among those covered by PFHIS, whereas it was INR 10500 (approx. USD 126.82) at private health facilities among those not covered by insurance. CONCLUSION While PFHIS seems to be appropriately targeting poorer populations, among the insured, OOPE for hospitalization persists. Among the uninsured, population subgroups with advantage are spending the greatest amount, raising questions about whether those facing relative disadvantage are forgoing care altogether or seeking care using cheaper, public avenues. Further policy action to more effectively reduce financial burden among left behind eligible populations under PFHIS will be essential to UHC progress in the state.
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Affiliation(s)
| | - Jaison Joseph
- The George Institute for Global Health, New Delhi, India.
| | - Hari Sankar D
- The George Institute for Global Health, New Delhi, India
| | - Devaki Nambiar
- The George Institute for Global Health, New Delhi, India
- Faculty of Medicine, University of New South Wales, Sydney, Australia
- Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, India
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Mohanty SK, Upadhyay AK, Maiti S, Mishra RS, Kämpfen F, Maurer J, O'Donnell O. Public health insurance coverage in India before and after PM-JAY: repeated cross-sectional analysis of nationally representative survey data. BMJ Glob Health 2023; 8:e012725. [PMID: 37640493 PMCID: PMC10462969 DOI: 10.1136/bmjgh-2023-012725] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Accepted: 08/08/2023] [Indexed: 08/31/2023] Open
Abstract
INTRODUCTION The provision of non-contributory public health insurance (NPHI) to marginalised populations is a critical step along the path to universal health coverage. We aimed to assess the extent to which Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (PM-JAY)-potentially, the world's largest NPHI programme-has succeeded in raising health insurance coverage of the poorest two-fifths of the population of India. METHODS We used nationally representative data from the National Family Health Survey on 633 699 and 601 509 households in 2015-2016 (pre-PM-JAY) and 2019-2021 (mostly, post PM-JAY), respectively. We stratified by urban/rural and estimated NPHI coverage nationally, and by state, district and socioeconomic categories. We decomposed coverage variance between states, districts, and households and measured socioeconomic inequality in coverage. For Uttar Pradesh, we tested whether coverage increased most in districts where PM-JAY had been implemented before the second survey and whether coverage increased most for targeted poorer households in these districts. RESULTS We estimated that NPHI coverage increased by 11.7 percentage points (pp) (95% CI 11.0% to 12.4%) and 8.0 pp (95% CI 7.3% to 8.7%) in rural and urban India, respectively. In rural areas, coverage increased most for targeted households and pro-rich inequality decreased. Geographical inequalities in coverage narrowed. Coverage did not increase more in states that implemented PM-JAY. In Uttar Pradesh, the coverage increase was larger by 3.4 pp (95% CI 0.9% to 6.0%) and 4.2 pp (95% CI 1.2% to 7.1%) in rural and urban areas, respectively, in districts exposed to PM-JAY and the increase was 3.5 pp (95% CI 0.9% to 6.1%) larger for targeted households in these districts. CONCLUSION The introduction of PM-JAY coincided with increased public health insurance coverage and decreased inequality in coverage. But the gains cannot all be plausibly attributed to PM-JAY, and they are insufficient to reach the goal of universal coverage of the poor.
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Affiliation(s)
- Sanjay K Mohanty
- Department of Population and Development, International Institute for Population Sciences, Mumbai, Maharashtra, India
| | | | - Suraj Maiti
- International Institute for Population Sciences, Mumbai, Maharashtra, India
| | - Radhe Shyam Mishra
- International Institute for Population Sciences, Mumbai, Maharashtra, India
| | | | - Jürgen Maurer
- Department of Economics and Lausanne Center for Health Economics, Behavior and Policy, Faculty of Business and Economics (HEC), University of Lausanne, Lausanne, Switzerland
| | - Owen O'Donnell
- Erasmus University Rotterdam, Rotterdam, The Netherlands
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Ambade M, Rajpal S, Kim R, Subramanian SV. Socioeconomic and geographic variation in coverage of health insurance across India. Front Public Health 2023; 11:1160088. [PMID: 37492139 PMCID: PMC10365087 DOI: 10.3389/fpubh.2023.1160088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 04/10/2023] [Indexed: 07/27/2023] Open
Abstract
Introduction In India, regular monitoring of health insurance at district levels (the most essential administrative unit) is important for its effective uptake to contain the high out of pocket health expenditures. Given that the last individual data on health insurance coverage at district levels in India was in 2016, we update the evidence using the latest round of the National Family Health Survey conducted in 2019-2021. Methods We use the unit records of households from the latest round (2021) of the nationally representative National Family Health Survey to calculate the weighted percentage (and 95% CI) of households with at least one member covered by any form of health insurance and its types across socio-economic characteristics and geographies of India. Further, we used a random intercept logistic regression to measure the variation in coverage across communities, district and state. Such household level study of coverage is helpful as it represents awareness and outreach for at least one member, which can percolate easily to the entire household with further interventions. Results We found that only 2/5th of households in India had insurance coverage for at least one of its members, with vast geographic variation emphasizing need for aggressive expansion. About 15.5% were covered by national schemes, 47.1% by state health scheme, 13.2% by employer provided health insurance, 3.3% had purchased health insurance privately and 25.6% were covered by other health insurance schemes (not covered above). About 30.5% of the total variation in coverage was attributable to state, 2.7% to districts and 9.5% to clusters. Household size, gender, marital status and education of household head show weak gradient for coverage under "any" insurance. Discussion Despite substantial increase in population eligible for state sponsored health insurance and rise in private health insurance companies, nearly 60% of families do not have a single person covered under any health insurance scheme. Further, the existing coverage is fragmented, with significant rural/urban and geographic variation within districts. It is essential to consider these disparities and adopt rigorous place-based interventions for improving health insurance coverage.
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Affiliation(s)
- Mayanka Ambade
- Laxmi Mittal and Family South Asia Institute, Harvard University, India Office, New Delhi, India
| | - Sunil Rajpal
- Department of Economics, FLAME University, Pune, Maharashtra, India
- Interdisciplinary Program in Precision Public Health, Department of Public Health Sciences, Graduate School of Korea University, Seoul, Republic of Korea
| | - Rockli Kim
- Interdisciplinary Program in Precision Public Health, Department of Public Health Sciences, Graduate School of Korea University, Seoul, Republic of Korea
- Division of Health Policy and Management, College of Health Science, Korea University, Seoul, Republic of Korea
| | - S. V. Subramanian
- Harvard Center for Population and Development Studies, Cambridge, MA, United States
- Department of Social and Behavioral Sciences, Harvard T. H. Chan School of Public Health, Boston, MA, United States
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Dubey S, Deshpande S, Krishna L, Zadey S. Evolution of Government-funded health insurance for universal health coverage in India. THE LANCET REGIONAL HEALTH. SOUTHEAST ASIA 2023; 13:100180. [PMID: 37383549 PMCID: PMC10305876 DOI: 10.1016/j.lansea.2023.100180] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 02/23/2023] [Accepted: 03/07/2023] [Indexed: 06/30/2023]
Abstract
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.
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Affiliation(s)
- Sweta Dubey
- Association for Socially Applicable Research (ASAR), Pune, India
| | - Swasti Deshpande
- Association for Socially Applicable Research (ASAR), Pune, India
- Lalwani Mother and Child Care Hospital, Pune, India
| | - Lokesh Krishna
- Association for Socially Applicable Research (ASAR), Pune, India
- Department of Community Medicine, King Edward Memorial Hospital and Seth Gordhandas Sunderdas Medical College, Mumbai, India
| | - Siddhesh Zadey
- Association for Socially Applicable Research (ASAR), Pune, India
- Department of Surgery, Duke University School of Medicine, Durham, NC, USA
- Dr. D.Y. Patil Medical College, Hospital, and Research Centre Pune, Maharashtra, India
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Palal D, Jadhav SL, Gangurde S, Thakur K, Rathod H, S J, Verma P, Nallapu S, Revikumar A, Nair GR. People's Perspective on Out-of-Pocket Expenditure for Healthcare: A Qualitative Study From Pune, India. Cureus 2023; 15:e34670. [PMID: 36909087 PMCID: PMC9993438 DOI: 10.7759/cureus.34670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/02/2023] [Indexed: 02/08/2023] Open
Abstract
Background Out-Of-Pocket Expenditure (OOPE) directly reflects the burden of health expenses that households bear. Despite the availability of social security schemes providing healthcare benefits, a high proportion of Indian households are still incurring OOPE. In order to recognize the reasons behind OOPE, a comprehensive understanding of people's attitudes and behavior is needed. Methodology By purposive sampling, 16 in-depth interviews were conducted using an interview guide in the catchment area of urban and rural health centers of a tertiary healthcare hospital. Interviews were conducted in Marathi and Hindi and were audio tape-recorded after taking informed consent. The interviews were transcribed and translated into English, followed by a thematic analysis. Results Although most participants knew that government hospitals provide facilities and experienced doctors, inconvenience and unsatisfactory quality deter them from utilizing government facilities. A few had experiences with government schemes; almost all concur that the formality and procedure of claiming insurance are cumbersome and all have had bad experiences. Cost of medications and consultation accounted for the majority of the healthcare expenditures. While some participants had benefitted from insurance, few regretted not enrolling in one. Conclusion The awareness regarding government schemes was derisory. Government-financed health insurance schemes and their utilization are crucial to reducing OOPE. Efforts should be made to increase accessibility to public healthcare services. Nevertheless, there is potential to redress the barriers to improve scheme utilization.
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Affiliation(s)
- Deepu Palal
- Community Medicine, Dr. D. Y. Patil Medical College Hospital and Research Centre, Pune, IND
| | - Sudhir L Jadhav
- Community Medicine, Dr. D. Y. Patil Medical College Hospital and Research Centre, Pune, IND
| | - Shweta Gangurde
- Community Medicine, Dr. D. Y. Patil Medical College Hospital and Research Centre, Pune, IND
| | - Kavita Thakur
- Community Medicine, Dr. D. Y. Patil Medical College Hospital and Research Centre, Pune, IND
| | - Hetal Rathod
- Community Medicine, Dr. D. Y. Patil Medical College Hospital and Research Centre, Pune, IND
| | - Johnson S
- Community Medicine, Dr. D. Y. Patil Medical College Hospital and Research Centre, Pune, IND
| | - Prerna Verma
- Community Medicine, Dr. D. Y. Patil Medical College Hospital and Research Centre, Pune, IND
| | - Sandeep Nallapu
- Community Medicine, Dr. D. Y. Patil Medical College Hospital and Research Centre, Pune, IND
| | - Akhil Revikumar
- Community Medicine, Dr. D. Y. Patil Medical College Hospital and Research Centre, Pune, IND
| | - Gayatri R Nair
- Community Medicine, Dr. D. Y. Patil Medical College Hospital and Research Centre, Pune, IND
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Kamath R, Brand H. A Critical Analysis of the World's Largest Publicly Funded Health Insurance Program: India's Ayushman Bharat. Int J Prev Med 2023; 14:20. [PMID: 37033284 PMCID: PMC10080577 DOI: 10.4103/ijpvm.ijpvm_39_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 09/23/2022] [Indexed: 04/11/2023] Open
Abstract
Background Launched in September 2018, the ABPMJAY is the world's largest publicly funded health insurance (PFHI) program with population coverage of 500 million. A systematic review was conducted. Methods A comprehensive literature search was conducted in four databases: PubMed, Web of Science, Scopus, and Google Scholar. The literature search was conducted with the search terms: "Ayushman Bharat OR ABPMJAY OR modicare AND RSBY." The search was set to title and abstract. Gray literature and government websites were also searched for relevant documents. A total of 881 documents were identified (PubMed: 53, Web of Science: 46, Scopus: 97, Google Scholar: 681, government websites: two, and gray literature: two). Fifty-two duplicates were identified. After the elimination of the duplicates, 829 unique documents were identified. These 829 unique citations were then subjected to a review of title and abstract independently by 2 reviewers. Six-hundred and ninety-two articles were rejected after review of title and abstract. One-hundred and thirty-seven articles were screened for full text independently by two reviewers. Sixty-six articles were rejected after review of the full text. Disagreements were resolved by discussion. Seventy-one unique articles were included in the final review. To attain the objective of the study, which is to critically analyze and provide an overview of Ayushman Bharat, a narrative synthesis was performed. Results Seven themes were identified from the review: (1) health and wellness centers (HWCs); (2) out-of-pocket health expenditure (OOPHE); (3) fraud; (4) upcoding and provision of unnecessary medical care; (5) moving focus away from primary care; (6) coverage; and (7) lop-sided access, exclusion at the periphery, and brain drain. There is very little impact evidence of the ABPMJAY available. Conclusions The government could plan impact evaluation studies in every state that the ABPMJAY is functional in. Any high-quality feedback generated might enable the National Health Authority, the government body leading and coordinating the ABPMJAY, to take necessary steps operationally and advice the government on strategy. Another concern is that the ABPMJAY PFHI might negatively impact the ongoing process of continuous strengthening and development of the government health-care system at all levels-primary, secondary, and tertiary. Continual recalibration and course corrections on the basis of high-quality feedback might enable ABPMJAY reduce catastrophic OOPHE for 500 million Indians. This is more than 6% of humanity: the largest block of people served by a single PFHI in history.
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Affiliation(s)
- Rajesh Kamath
- Department of Health Innovation, Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, Karnataka, India
- Address for correspondence: Dr. Rajesh Kamath, Cabin Number 65, 1 Floor, Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal - 576 104, Karnataka, India. E-mail:
| | - Helmut Brand
- Department of International Health, Care and Public Health Research Institute – CAPHRI, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
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Ambade PN, Pakhale S, Rahman T. Explaining Caste-Based Disparities in Enrollment for National Health Insurance Program in India: a Decomposition Analysis. J Racial Ethn Health Disparities 2022:10.1007/s40615-022-01374-8. [PMID: 35994172 DOI: 10.1007/s40615-022-01374-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 05/24/2022] [Accepted: 07/15/2022] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Preshit Nemdas Ambade
- Ottawa Hospital Research Institute, Box 511, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada.
| | - Smita Pakhale
- Ottawa Hospital Research Institute, Box 511, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada
| | - Tauhidur Rahman
- Department of Agricultural & Resource Economics, College of Agriculture and Life Sciences, University of Arizona, Tucson, AZ, 85721-0078, USA
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12
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Laverty RB, Jindal RM. Unconditional cash transfer to reduce the burden of unmet surgical needs. Ann Med Surg (Lond) 2022; 80:104185. [PMID: 35866009 PMCID: PMC9293727 DOI: 10.1016/j.amsu.2022.104185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 07/10/2022] [Indexed: 11/25/2022] Open
Abstract
Recent years have seen scandals involving international humanitarian organizations. Short term surgical missions from high to low- and middle-income countries have been criticized as ‘parachute’ missions. There are significant surgical unmet needs in low- and middle-income countries. Universal health coverage has been underutilized in low- and middle-income countries for surgical conditions. We suggest a two-fold solution: first, restructuring of aid organizations by splitting them into smaller units to make them transparent and responsive to local needs. Secondly, unconditional cash transfer directly to beneficiaries giving them a choice to select physician and hospital for surgical treatment.
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13
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Boby JM, Rajappa S, Mathew A. Financial toxicity in cancer care in India: a systematic review. Lancet Oncol 2021; 22:e541-e549. [PMID: 34856151 DOI: 10.1016/s1470-2045(21)00468-x] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 07/29/2021] [Accepted: 07/30/2021] [Indexed: 12/21/2022]
Abstract
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.
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Affiliation(s)
| | - Senthil Rajappa
- Department of Medical Oncology, Basavatarakam Indo American Cancer Hospital and Research Institute, Hyderabad, India
| | - Aju Mathew
- Malankara Orthodox Syrian Church Medical College, Kolenchery, India.
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14
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Shewamene Z, Tiruneh G, Abraha A, Reshad A, Terefe MM, Shimels T, Lemlemu E, Tilahun D, Wondimtekahu A, Argaw M, Anno A, Abebe F, Kiros M. Barriers to uptake of community-based health insurance in sub-Saharan Africa: a systematic review. Health Policy Plan 2021; 36:1705-1714. [PMID: 34240185 DOI: 10.1093/heapol/czab080] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 05/06/2021] [Accepted: 06/24/2021] [Indexed: 11/13/2022] Open
Abstract
In the past two decades, community-based Health Insurance (CBHI) is expanding in most of sub-Saharan African countries with the aim of improving equitable access to health services for the informal sector population. However, population enrolment into CBHI and membership renewals thereafter remains stubbornly low. The purpose of this systematic review is to generate an evidence to better understand barriers to uptake of CBHI in sub-Saharan African countries. We systematically searched for relevant studies from databases: PubMed, Scopus, Cumulative Index of Nursing and Allied Health Literature (CINAHL), PsychInfo, ProQest, Excerpta Medica dataBASE (EMBASE) and Africa-Wide Information. The search strategy combined detailed terms related to (i) CBHI, (ii) enrolment/renewal and (iii) sub-Saharan African countries. A narrative synthesis of findings was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The protocol for this systematic review was registered with International Prospective Register of Systematic Reviews (PROSPERO) (ref: CRD42020183959). The database search identified 4055 potential references from which 15 articles reporting on 17 studies met the eligibility criteria. The findings revealed that barriers to uptake of CBHI in sub-Saharan Africa were multidimensional in nature. Lack of awareness about the importance of health insurance, socio-economic factors, health beliefs, lack of trust towards scheme management, poor quality of health services, perceived health status and limited health benefit entitlements were reported as barriers that affect enrolments into CBHI and membership renewals. The methodological quality of studies included in this review has been found to be mostly suboptimal. The overall findings of this systematic review identified major barriers of CBHI uptake in sub-Saharan African countries which may help policymakers to make evidence-informed decisions. Findings of this review also highlighted that further research with a robust methodological quality, depth and breadth is needed to help better understand the factors that limit CBHI uptake at individual, societal and structural levels in sub-Saharan Africa.
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Affiliation(s)
| | | | | | | | | | - Tariku Shimels
- Saint Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | | | | | | | - Muluken Argaw
- Ethiopian Health Insurance Agency, Addis Ababa, Ethiopia
| | - Alemu Anno
- Ethiopian Health Insurance Agency, Addis Ababa, Ethiopia
| | | | - Mizan Kiros
- Federal Ministry of Health, Addis Ababa, Ethiopia
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15
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Dwivedi R, Pradhan J, Athe R. Measuring catastrophe in paying for healthcare: A comparative methodological approach by using National Sample Survey, India. Int J Health Plann Manage 2021; 36:1887-1915. [PMID: 34196030 DOI: 10.1002/hpm.3272] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Revised: 06/19/2021] [Accepted: 06/20/2021] [Indexed: 11/07/2022] Open
Abstract
Healthcare expenditure significantly varies among various segments of the population. The appropriate measures of catastrophic health expenditure (CHE) will help to unravel the real burden of spending among households. Present study provides a link between the theoretical insights from Grossman's model and various methodological approaches for the estimation of CHE by using data from the three rounds of nationally representative Consumer Expenditure Surveys, India. Statistical analysis has been carried out by using multivariate logistic regression to identify the major determinants of CHE. Findings indicate that the occurrence of CHE has increased during 1993-2012. Rural residents and households with varying age composition such as with higher numbers of children and elderly were at higher risk. Economic status is significantly associated with CHE and increased demand for healthcare. The measurements differ as per the methodological approaches of CHE and definition of household's capacity to pay. Approach-based variations in the results can be of key importance in determining trends and magnitude in CHE. Despite these variations in measurements, study finds a limited incidence of CHE among the disadvantaged segment of the population though a greater share was devoted to health expenditure in recent years. Better risk pooling mechanism is required to address the healthcare needs of the disadvantaged segment such as elderly, children, poor and rural population in India.
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Affiliation(s)
- Rinshu Dwivedi
- Department of Science and Humanities, Indian Institute of Information Technology, Trichy, Tamil Nadu, India
| | - Jalandhar Pradhan
- Department of Humanities and Social Sciences, National Institute of Technology, Rourkela, Odisha, India
| | - Ramesh Athe
- Department of Humanities and Sciences, Indian Institute of Information Technology, Dharwad, Karnataka, India
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16
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Importance of Evidence-Based Health Insurance Reimbursement and Health Technology Assessment for achieving Universal Health Coverage and Improved Access to Health in India. Value Health Reg Issues 2021; 24:24-30. [DOI: 10.1016/j.vhri.2020.04.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 03/18/2020] [Accepted: 04/17/2020] [Indexed: 12/20/2022]
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17
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RamPrakash R, Lingam L. Why is women's utilization of a publicly funded health insurance low?: a qualitative study in Tamil Nadu, India. BMC Public Health 2021; 21:350. [PMID: 33579249 PMCID: PMC7881649 DOI: 10.1186/s12889-021-10352-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 01/28/2021] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND The continuing impetus for universal health coverage has given rise to publicly funded health insurance schemes in lower-middle income countries. However, there is insufficient understanding of how universal health coverage schemes impact gender equality and equity. This paper attempts to understand why utilization of a publicly funded health insurance scheme has been found to be lower among women compared to men in a southern Indian state. It aims to identify the gender barriers across various social institutions that thwart the policy objectives of providing financial protection and improved access to inpatient care for women. METHODS A qualitative study on the Chief Minister's Comprehensive Health Insurance Scheme was carried out in urban and rural impoverished localities in Tamil Nadu, a southern state in India. Thirty-three women and 16 men who had a recent history of hospitalization and 14 stakeholders were purposefully interviewed. Transcribed interviews were content analyzed based on Naila Kabeer's Social Relations Framework using gender as an analytical category. RESULTS While unpacking the navigation pathways of women to utilize publicly funded health insurance to access inpatient care, gender barriers are found operating at the household, community, and programmatic levels. Unpaid care work, financial dependence, mobility constraints, and gender norms emerged as the major gender-specific barriers arising from the household. Exclusions from insurance enrollment activities at the community level were mediated by a variety of social inequities. Market ideologies in insurance and health, combined with poor governance by State, resulted in out-of-pocket health expenditures, acute information asymmetry, selective availability of care, and poor acceptability. These gender barriers were found to be mediated by all four institutions-household, community, market, and State-resulting in lower utilization of the scheme by women. CONCLUSIONS Health policies which aim to provide financial protection and improve access to healthcare services need to address gender as a crucial social determinant. A gender-blind health insurance can not only leave many pre-existing gender barriers unaddressed but also accentuate others. This paper stresses that universal health coverage policy and programs need to have an explicit focus on gender and other social determinants to promote access and equity.
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Affiliation(s)
- Rajalakshmi RamPrakash
- Loyola Institute of Business Administration, Loyola College Campus, Nungambakkam, Chennai, 600034 Tamil Nadu India
| | - Lakshmi Lingam
- Tata Institute of Social Sciences, V.N. Purav Marg, Deonar, Mumbai, 400088 India
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18
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Nambiar D, Bhaumik S, Pal A, Ved R. Assessing cardiovascular disease risk factor screening inequalities in India using Lot Quality Assurance Sampling. BMC Health Serv Res 2020; 20:1077. [PMID: 33238995 PMCID: PMC7687829 DOI: 10.1186/s12913-020-05914-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 11/10/2020] [Indexed: 02/07/2023] Open
Abstract
Background Cardiovascular diseases (CVDs) are the leading cause of mortality in India. India has rolled out Comprehensive Primary Health Care (CPHC) reforms including population based screening for hypertension and diabetes, facilitated by frontline health workers. Our study assessed blood pressure and blood sugar coverage achieved by frontline workers using Lot Quality Assurance Sampling (LQAS). Methods LQAS Supervision Areas were defined as catchments covered by frontline workers in primary health centres in two districts each of Uttar Pradesh and Delhi. In each Area, 19 households for each of four sampling universes (males, females, Above Poverty Line (APL) and Below Poverty Line (BPL)) were visited using probability proportional to size sampling. Following written informed consent procedures, a short questionnaire was administered to individuals aged 30 or older using tablets related to screening for diabetes and hypertension. Using the LQAS hand tally method, coverage across Supervision Areas was determined. Results A sample of 2052 individuals was surveyed, median ages ranging from 42 to 45 years. Caste affiliation, education levels, and occupation varied by location; the sample was largely married and Hindu. Awareness of and interaction with frontline health workers was reported in Uttar Pradesh and mixed in Delhi. Greater coverage of CVD risk factor screening (especially blood pressure) was seen among females, as compared to males. No clear pattern of inequality was seen by poverty status; some SAs did not have adequate BPL samples. Overall, blood pressure and blood sugar screening coverage by frontline health workers fell short of targeted coverage levels at the aggregate level, but in all sites, at least one area was crossing this threshold level. Conclusion CVD screening coverage levels at this early stage are low. More emphasis may be needed on reaching males. Sex and poverty related inequalities must be addressed by more closely studying the local context and models of service delivery where the threshold of screening is being met. LQAS is a pragmatic method for measuring program inequalities, in resource-constrained settings, although possibly not for spatially segregated population sub-groups. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-020-05914-y.
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Affiliation(s)
- Devaki Nambiar
- George Institute for Global Health, 311-312, Third Floor, Elegance Tower, Plot No. 8, Jasola District Centre, New Delhi, 110025, India. .,Faculty of Medicine, University of New South Wales, Sydney, Australia. .,Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, India. .,Bernard Lown Scholars for Cardiovascular Health Program, Harvard T. H. Chan School of Public Health, Boston, USA.
| | - Soumyadeep Bhaumik
- George Institute for Global Health, 311-312, Third Floor, Elegance Tower, Plot No. 8, Jasola District Centre, New Delhi, 110025, India.,Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Anita Pal
- Department of Education and Education Technology, University of Hyderabad, Hyderabad, India
| | - Rajani Ved
- Bernard Lown Scholars for Cardiovascular Health Program, Harvard T. H. Chan School of Public Health, Boston, USA.,National Health Systems Resource Centre, New Delhi, India
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19
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Harish R, Suresh RS, Rameesa S, Laiveishiwo PM, Loktongbam PS, Prajitha KC, Valamparampil MJ. Health insurance coverage and its impact on out-of-pocket expenditures at a public sector hospital in Kerala, India. J Family Med Prim Care 2020; 9:4956-4961. [PMID: 33209828 PMCID: PMC7652147 DOI: 10.4103/jfmpc.jfmpc_665_20] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 06/10/2020] [Accepted: 06/18/2020] [Indexed: 11/04/2022] Open
Abstract
Background Health insurance coverage ensures protection from catastrophic health-care expenditure, especially to the underprivileged sections of society. Health insurance schemes such as Ayushman Bharat are coming up in addition to the existing schemes such as Rashtriya Swasthya Bima Yojana in India. The objectives are to find the health insurance coverage and its impact on out-of-pocket (OOP) expenditure for public sector tertiary health-care hospitalization. Methods A cross-sectional study was conducted at a tertiary care hospital in Kerala. Insurance coverage was assessed among patients seeking inpatient care in various medical and surgical departments. OOP expenses incurred for those receiving and not receiving insurance coverage were compared. In addition, factors influencing enrolment and availing of insurance schemes were determined. Results The coverage of health insurance was found to be 74%. Awareness campaigns and activities of local self-government (LSG) departments were the important reasons for enrolment and availing, respectively. Significantly lower OOP expenditures occurred in insured persons with regard to expenses incurred for treatment procedures (P = 0.019), investigations (P = 0.004), and medicines (P = 0.001). Among the enrolled patients, 45% expressed dissatisfaction regarding available services. Conclusion A quarter of patients still remain out of insurance coverage. All patients are incurring OOP expenditures, though the insured patients have significantly lower OOP expenses. The role of primary care providers and LSG is pivotal in creating awareness and ensuring enrolment. Availing services depend on the availability of resources at the respective institution. Improvements in enrolment and use of health insurance should ultimately result in improved patient satisfaction.
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Affiliation(s)
- Ravindran Harish
- Interns, Department of Community Medicine, Government Medical College,Thiruvananthapuram, Kerala, India
| | - Ranjana S Suresh
- Interns, Department of Community Medicine, Government Medical College,Thiruvananthapuram, Kerala, India
| | - S Rameesa
- Interns, Department of Community Medicine, Government Medical College,Thiruvananthapuram, Kerala, India
| | - P M Laiveishiwo
- Interns, Department of Community Medicine, Government Medical College,Thiruvananthapuram, Kerala, India
| | - Prosper Singh Loktongbam
- Interns, Department of Community Medicine, Government Medical College,Thiruvananthapuram, Kerala, India
| | - K C Prajitha
- Junior Resident, Department of Community Medicine, Government Medical College,Thiruvananthapuram, Kerala, India
| | - Mathew J Valamparampil
- PhD Student, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
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20
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Sriram S, Khan MM. 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. BMC Health Serv Res 2020; 20:839. [PMID: 32894118 PMCID: PMC7487854 DOI: 10.1186/s12913-020-05692-7] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 08/31/2020] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Shyamkumar Sriram
- Department of Health Services Policy and Management, University of South Carolina, Columbia, SC, USA.
| | - M Mahmud Khan
- Department of Health Services Policy and Management, University of South Carolina, Columbia, SC, USA
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21
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Bhojani U, Madegowda C, Prashanth NS, Hebbar P, Mirzoev T, Karlsen S, Mir G. Affirmative action, minorities, and public services in India: Charting a future research and practice agenda. Indian J Med Ethics 2020; 4 (NS):265-273. [PMID: 31791932 DOI: 10.20529/ijme.2019.062] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
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.
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Affiliation(s)
- Upendra Bhojani
- Faculty & Wellcome Trust/DBT India Alliance Fellow, Institute of Public Health, Bengaluru, INDIA
| | - C Madegowda
- Secretary, Zilla Budakattu Soligara Abhivruddhi Sangha, Chamarajanagar, INDIA; Senior Research Associate, Ashoka Trust for Research in Ecology and the Environment, Bengaluru INDIA
| | - N S Prashanth
- Faculty and Wellcome Trust/DBT India Alliance fellow, Institute of Public Health, Bengaluru, INDIA
| | - Pragati Hebbar
- Faculty & Wellcome Trust/DBT India Alliance Fellow, Institute of Public Health, Bengaluru INDIA
| | - Tolib Mirzoev
- Associate Professor of International Health Policy and Systems, Nuffield Centre for International Health and Development, University of Leeds, Leeds, UK
| | - Saffron Karlsen
- Senior Lecturer, School of Sociology, Politics and International Studies, University of Bristol, Bristol, UK
| | - Ghazala Mir
- Associate Professor, Faculty of Medicine and Health, School of Medicine, University of Leeds, Leeds, UK
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22
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Nandi S, Schneider H. Using an equity-based framework for evaluating publicly funded health insurance programmes as an instrument of UHC in Chhattisgarh State, India. Health Res Policy Syst 2020; 18:50. [PMID: 32450870 PMCID: PMC7249418 DOI: 10.1186/s12961-020-00555-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 03/27/2020] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Universal health coverage (UHC) has provided the impetus for the introduction of publicly funded health insurance (PFHI) schemes in the mixed health systems of India and many other low- and middle-income countries. There is a need for a holistic understanding of the pathways of impact of PFHI schemes, including their role in promoting equity of access. METHODS This paper applies an equity-oriented evaluation framework to assess the impacts of PFHI schemes in Chhattisgarh State by synthesising literature from various sources and highlighting knowledge gaps. Data were collected from an extensive review of publications on PFHI schemes in Chhattisgarh since 2009, including empirical studies from the first author's PhD and grey literature such as programme evaluation reports, media articles and civil society campaign documents. The framework was constructed using concepts and frameworks from the health policy and systems research literature on UHC, access and health system building blocks, and is underpinned by the values of equity, human rights and the right to health. RESULTS The analysis finds that evidence of equitable enrolment in Chhattisgarh's PFHI scheme may mask many other inequities. Firstly, equitable enrolment does not automatically lead to the acceptability of the scheme for the poor or to equity in utilisation. Utilisation, especially in the private sector, is skewed towards the areas that have the least health and social need. Secondly, related to this, resource allocation patterns under PFHI deepen the 'infrastructure inequality trap', with resources being effectively transferred from tribal and vulnerable to 'better-off' areas and from the public to the private sector. Thirdly, PFHI fails in its fundamental objective of effective financial protection. Technological innovations, such as the biometric smart card and billing systems, have not provided the necessary safeguards nor led to greater accountability. CONCLUSION The study shows that development of PFHI schemes, within the context of wider neoliberal policies promoting private sector provisioning, has negative consequences for health equity and access. More research is needed on key knowledge gaps related to the impact of PFHI schemes on health systems. An over-reliance on and rapid expansion of PFHI schemes in India is unlikely to achieve UHC.
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Affiliation(s)
- Sulakshana Nandi
- School of Public Health, University of the Western Cape, Bellville, South Africa
- Public Health Resource Network, 29, New Panchsheel Nagar, Raipur, Chhattisgarh 492001 India
| | - Helen Schneider
- School of Public Health, UWC/MRC Health Services to Systems Unit, University of the Western Cape, Bellville, South Africa
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Khetrapal S, Acharya A, Mills A. Assessment of the public-private-partnerships model of a national health insurance scheme in India. Soc Sci Med 2019; 243:112634. [PMID: 31698205 PMCID: PMC6891235 DOI: 10.1016/j.socscimed.2019.112634] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 10/09/2019] [Accepted: 10/18/2019] [Indexed: 11/08/2022]
Abstract
A single hospital admission can deplete household resources so considerably as to induce impoverishment, especially in the Indian context of low government healthcare expenditure. Rashtriya Swasthya Bima Yojana (RSBY) was a national health insurance scheme for below-poverty-line Indian families, to provide improved access to hospitalization and greater financial protection via a public-private-partnership employing private sector implementation capacity. Study objectives were to understand governance (including regulatory) environment and contract arrangements; evaluate expansion of services to beneficiaries; and assess compliance of providers and user satisfaction. A case study approach in two districts met the need for in-depth information on scheme functioning, and RSBY implementation was examined between 2011 and 13 in Patiala (Punjab) and Yamunanagar (Haryana). Methods included 20 key stakeholder interviews, analysis of secondary datasets on beneficiaries and claims, primary data collection in 31 public and private hospitals and in greater depth in 12 hospitals, and an exit survey of 751 patients. Enrolled and non-enrolled hospitals were mapped in each district and service availability of enrolled hospitals assessed; enrollee characteristics were analysed; for the 12 hospitals, information was obtained on structural quality and process of care, and patient satisfaction and out-of-pocket payments. The Indian states and the government of India did not specify formal regulatory and implementation procedures in detail and states largely contracted out their functions to private insurance firms. Findings show regulatory weaknesses, and contractual breaches. Enrolment rates were low in both districts and more so for Patiala and there was limited access to services. There was little difference in process of care between public and private hospitals, though the structural capacity of private hospitals was better than public hospitals. RSBY helped improve accessibility and gave some degree of financial protection to patients. It also actively engaged with existing resources in the Indian health care and insurance markets.
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Affiliation(s)
- Sonalini Khetrapal
- Former PhD student, Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK.
| | - Arnab Acharya
- Honorary Associate Professor, Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Anne Mills
- Deputy Director & Provost and Professor of Health Economics and Policy, London School of Hygiene and Tropical Medicine, London, UK
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Basavaiah G, Rent PD, Rent EG, Sullivan R, Towne M, Bak M, Sirohi B, Goel M, Shrikhande SV. Financial Impact of Complex Cancer Surgery in India: A Study of Pancreatic Cancer. J Glob Oncol 2019; 4:1-9. [PMID: 30241272 PMCID: PMC6223534 DOI: 10.1200/jgo.17.00151] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
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.
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Affiliation(s)
- Guruchanna Basavaiah
- Guruchanna Basavaiah, Mahesh Goel, and Shailesh V. Shrikhande, Tata Memorial Centre, Mumbai; Priyanka D. Rent, K.S. Hegde Medical Academy, Mangalore; Eugene G. Rent, A.J. Hospital and Research Centre, Mangalore, India; Richard Sullivan, King's College London, Guys and St Thomas' NHS Foundation Trust; Margaret Towne, London School of Hygiene & Tropical Medicine; Bhawna Sirohi, Barts Cancer Institute, London, United Kingdom; and Marieke Bak, VU University, Amsterdam, Netherlands
| | - Priyanka D Rent
- Guruchanna Basavaiah, Mahesh Goel, and Shailesh V. Shrikhande, Tata Memorial Centre, Mumbai; Priyanka D. Rent, K.S. Hegde Medical Academy, Mangalore; Eugene G. Rent, A.J. Hospital and Research Centre, Mangalore, India; Richard Sullivan, King's College London, Guys and St Thomas' NHS Foundation Trust; Margaret Towne, London School of Hygiene & Tropical Medicine; Bhawna Sirohi, Barts Cancer Institute, London, United Kingdom; and Marieke Bak, VU University, Amsterdam, Netherlands
| | - Eugene G Rent
- Guruchanna Basavaiah, Mahesh Goel, and Shailesh V. Shrikhande, Tata Memorial Centre, Mumbai; Priyanka D. Rent, K.S. Hegde Medical Academy, Mangalore; Eugene G. Rent, A.J. Hospital and Research Centre, Mangalore, India; Richard Sullivan, King's College London, Guys and St Thomas' NHS Foundation Trust; Margaret Towne, London School of Hygiene & Tropical Medicine; Bhawna Sirohi, Barts Cancer Institute, London, United Kingdom; and Marieke Bak, VU University, Amsterdam, Netherlands
| | - Richard Sullivan
- Guruchanna Basavaiah, Mahesh Goel, and Shailesh V. Shrikhande, Tata Memorial Centre, Mumbai; Priyanka D. Rent, K.S. Hegde Medical Academy, Mangalore; Eugene G. Rent, A.J. Hospital and Research Centre, Mangalore, India; Richard Sullivan, King's College London, Guys and St Thomas' NHS Foundation Trust; Margaret Towne, London School of Hygiene & Tropical Medicine; Bhawna Sirohi, Barts Cancer Institute, London, United Kingdom; and Marieke Bak, VU University, Amsterdam, Netherlands
| | - Margaret Towne
- Guruchanna Basavaiah, Mahesh Goel, and Shailesh V. Shrikhande, Tata Memorial Centre, Mumbai; Priyanka D. Rent, K.S. Hegde Medical Academy, Mangalore; Eugene G. Rent, A.J. Hospital and Research Centre, Mangalore, India; Richard Sullivan, King's College London, Guys and St Thomas' NHS Foundation Trust; Margaret Towne, London School of Hygiene & Tropical Medicine; Bhawna Sirohi, Barts Cancer Institute, London, United Kingdom; and Marieke Bak, VU University, Amsterdam, Netherlands
| | - Marieke Bak
- Guruchanna Basavaiah, Mahesh Goel, and Shailesh V. Shrikhande, Tata Memorial Centre, Mumbai; Priyanka D. Rent, K.S. Hegde Medical Academy, Mangalore; Eugene G. Rent, A.J. Hospital and Research Centre, Mangalore, India; Richard Sullivan, King's College London, Guys and St Thomas' NHS Foundation Trust; Margaret Towne, London School of Hygiene & Tropical Medicine; Bhawna Sirohi, Barts Cancer Institute, London, United Kingdom; and Marieke Bak, VU University, Amsterdam, Netherlands
| | - Bhawna Sirohi
- Guruchanna Basavaiah, Mahesh Goel, and Shailesh V. Shrikhande, Tata Memorial Centre, Mumbai; Priyanka D. Rent, K.S. Hegde Medical Academy, Mangalore; Eugene G. Rent, A.J. Hospital and Research Centre, Mangalore, India; Richard Sullivan, King's College London, Guys and St Thomas' NHS Foundation Trust; Margaret Towne, London School of Hygiene & Tropical Medicine; Bhawna Sirohi, Barts Cancer Institute, London, United Kingdom; and Marieke Bak, VU University, Amsterdam, Netherlands
| | - Mahesh Goel
- Guruchanna Basavaiah, Mahesh Goel, and Shailesh V. Shrikhande, Tata Memorial Centre, Mumbai; Priyanka D. Rent, K.S. Hegde Medical Academy, Mangalore; Eugene G. Rent, A.J. Hospital and Research Centre, Mangalore, India; Richard Sullivan, King's College London, Guys and St Thomas' NHS Foundation Trust; Margaret Towne, London School of Hygiene & Tropical Medicine; Bhawna Sirohi, Barts Cancer Institute, London, United Kingdom; and Marieke Bak, VU University, Amsterdam, Netherlands
| | - Shailesh V Shrikhande
- Guruchanna Basavaiah, Mahesh Goel, and Shailesh V. Shrikhande, Tata Memorial Centre, Mumbai; Priyanka D. Rent, K.S. Hegde Medical Academy, Mangalore; Eugene G. Rent, A.J. Hospital and Research Centre, Mangalore, India; Richard Sullivan, King's College London, Guys and St Thomas' NHS Foundation Trust; Margaret Towne, London School of Hygiene & Tropical Medicine; Bhawna Sirohi, Barts Cancer Institute, London, United Kingdom; and Marieke Bak, VU University, Amsterdam, Netherlands
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Kusuma YS, Pal M, Babu BV. Health Insurance: Awareness, Utilization, and its Determinants among the Urban Poor in Delhi, India. J Epidemiol Glob Health 2018; 8:69-76. [PMID: 30859791 PMCID: PMC7325807 DOI: 10.2991/j.jegh.2018.09.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 09/06/2018] [Indexed: 11/12/2022] Open
Abstract
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.
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Affiliation(s)
- Yadlapalli S. Kusuma
- Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Manisha Pal
- Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Bontha V. Babu
- Socio-Behavioural and Health Systems Research Division, Indian Council of Medical Research, New Delhi, India
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Downey L, Rao N, Guinness L, Asaria M, Prinja S, Sinha A, Kant R, Pandey A, Cluzeau F, Chalkidou K. Identification of publicly available data sources to inform the conduct of Health Technology Assessment in India. F1000Res 2018; 7:245. [PMID: 29770210 PMCID: PMC5930391 DOI: 10.12688/f1000research.14041.2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/13/2018] [Indexed: 11/20/2022] Open
Abstract
Background: Health technology assessment (HTA) provides a globally-accepted and structured approach to synthesising evidence for cost and clinical effectiveness alongside ethical and equity considerations to inform evidence-based priorities. India is one of the most recent countries to formally commit to institutionalising HTA as an integral component of the heath resource allocation decision-making process. The effective conduct of HTA depends on the availability of reliable data. Methods: We draw from our experience of collecting, synthesizing, and analysing health-related datasets in India and internationally, to highlight the complex requirements for undertaking HTA, and explore the availability of such data in India. We first outlined each of the core data components required for the conduct of HTA, and their availability in India, drawing attention to where data can be accessed, and different ways in which researchers can overcome the challenges of missing or low quality data. Results: We grouped data into the following categories: clinical efficacy; cost; epidemiology; quality of life; service use/consumption; and equity. We identified numerous large local data sources containing epidemiological information. There was a marked absence of other locally-collected data necessary for informing HTA, particularly data relating to cost, service use, and quality of life. Conclusions: The introduction of HTA into the health policy space in India provides an opportunity to comprehensively assess the availability and quality of health data capture across the country. While epidemiological information is routinely collected across India, other data inputs necessary for HTA are not readily available. This poses a significant bottleneck to the efficient generation and deployment of HTA into the health decision space. Overcoming these data gaps by strengthening the routine collection of comprehensive and verifiable health data will have important implications not only for embedding economic analyses into the priority setting process, but for strengthening the health system as a whole.
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Affiliation(s)
- Laura Downey
- Institute of Global Health Innovation, Imperial College London, London, W2 1NY, UK.,International Decision Support Initative, London, W2 1NY, UK
| | - Neethi Rao
- Institute of Global Health Innovation, Imperial College London, London, W2 1NY, UK.,International Decision Support Initative, London, W2 1NY, UK
| | - Lorna Guinness
- Institute of Global Health Innovation, Imperial College London, London, W2 1NY, UK.,International Decision Support Initative, London, W2 1NY, UK
| | - Miqdad Asaria
- Institute of Global Health Innovation, Imperial College London, London, W2 1NY, UK.,International Decision Support Initative, London, W2 1NY, UK
| | - Shankar Prinja
- Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Anju Sinha
- Indian Council of Medical Research, New Delhi, 110029, India
| | - Rajni Kant
- Indian Council of Medical Research, New Delhi, 110029, India
| | - Arvind Pandey
- National Institute of Medical Statistics , New Delhi, 110058, India
| | - Francoise Cluzeau
- Institute of Global Health Innovation, Imperial College London, London, W2 1NY, UK.,International Decision Support Initative, London, W2 1NY, UK
| | - Kalipso Chalkidou
- Institute of Global Health Innovation, Imperial College London, London, W2 1NY, UK.,International Decision Support Initative, London, W2 1NY, UK.,Centre for Global Development , London, SW1Y 4TE, UK
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Downey L, Rao N, Guinness L, Asaria M, Prinja S, Sinha A, Kant R, Pandey A, Cluzeau F, Chalkidou K. Identification of publicly available data sources to inform the conduct of Health Technology Assessment in India. F1000Res 2018; 7:245. [PMID: 29770210 PMCID: PMC5930391 DOI: 10.12688/f1000research.14041.1] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/13/2018] [Indexed: 07/30/2023] Open
Abstract
Background: Health technology assessment (HTA) provides a globally-accepted and structured approach to synthesising evidence for cost and clinical effectiveness alongside ethical and equity considerations to inform evidence-based priorities. India is one of the most recent countries to formally commit to institutionalising HTA as an integral component of the heath resource allocation decision-making process. The effective conduct of HTA depends on the availability of reliable data. Methods: We draw from our experience of collecting, synthesizing, and analysing health-related datasets in India and internationally, to highlight the complex requirements for undertaking HTA, and explore the availability of such data in India. We first outlined each of the core data components required for the conduct of HTA, and their availability in India, drawing attention to where data can be accessed, and different ways in which researchers can overcome the challenges of missing or low quality data. Results: We grouped data into the following categories: clinical efficacy; cost; epidemiology; quality of life; service use/consumption; and equity. We identified numerous large local data sources containing epidemiological information. There was a marked absence of other locally-collected data necessary for informing HTA, particularly data relating to cost, service use, and quality of life. Conclusions: The introduction of HTA into the health policy space in India provides an opportunity to comprehensively assess the availability and quality of health data capture across the country. While epidemiological information is routinely collected across India, other data inputs necessary for HTA are not readily available. This poses a significant bottleneck to the efficient generation and deployment of HTA into the health decision space. Overcoming these data gaps by strengthening the routine collection of comprehensive and verifiable health data will have important implications not only for embedding economic analyses into the priority setting process, but for strengthening the health system as a whole.
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Affiliation(s)
- Laura Downey
- Institute of Global Health Innovation, Imperial College London, London, W2 1NY, UK
- International Decision Support Initative, London, W2 1NY, UK
| | - Neethi Rao
- Institute of Global Health Innovation, Imperial College London, London, W2 1NY, UK
- International Decision Support Initative, London, W2 1NY, UK
| | - Lorna Guinness
- Institute of Global Health Innovation, Imperial College London, London, W2 1NY, UK
- International Decision Support Initative, London, W2 1NY, UK
| | - Miqdad Asaria
- Institute of Global Health Innovation, Imperial College London, London, W2 1NY, UK
- International Decision Support Initative, London, W2 1NY, UK
| | - Shankar Prinja
- Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Anju Sinha
- Indian Council of Medical Research, New Delhi, 110029, India
| | - Rajni Kant
- Indian Council of Medical Research, New Delhi, 110029, India
| | - Arvind Pandey
- National Institute of Medical Statistics , New Delhi, 110058, India
| | - Francoise Cluzeau
- Institute of Global Health Innovation, Imperial College London, London, W2 1NY, UK
- International Decision Support Initative, London, W2 1NY, UK
| | - Kalipso Chalkidou
- Institute of Global Health Innovation, Imperial College London, London, W2 1NY, UK
- International Decision Support Initative, London, W2 1NY, UK
- Centre for Global Development , London, SW1Y 4TE, UK
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Kundu D, Sharma N, Chadha S, Laokri S, Awungafac G, Jiang L, Asaria M. Analysis of multi drug resistant tuberculosis (MDR-TB) financial protection policy: MDR-TB health insurance schemes, in Chhattisgarh state, India. HEALTH ECONOMICS REVIEW 2018; 8:3. [PMID: 29374822 PMCID: PMC5787110 DOI: 10.1186/s13561-018-0187-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/09/2017] [Accepted: 01/18/2018] [Indexed: 05/09/2023]
Abstract
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.
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Affiliation(s)
- Debashish Kundu
- International Union Against Tuberculosis and Lung Disease (The Union), South-East Asia Office, C-6, Qutub Institutional Area, New Delhi, 110016 India
| | - Nandini Sharma
- Department of Community Medicine, Maulana Azad Medical College, New Delhi, India
| | - Sarabjit Chadha
- International Union Against Tuberculosis and Lung Disease (The Union), South-East Asia Office, C-6, Qutub Institutional Area, New Delhi, 110016 India
| | - Samia Laokri
- Universite Libre de Bruxelles, Brussels, Belgium
| | - George Awungafac
- African Society of Laboratory Medicine; Ministry of Health, Cameroon, Yaoundé, Cameroon
| | - Lai Jiang
- Center for Instructional Psychology and Technology, Faculty of Psychology and Education Science, KU Leuven, Leuven, Belgium
| | - Miqdad Asaria
- Global Health and Development, Imperial College London; Centre for Health Economics, University of York, York, United Kingdom
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Awareness and utilization of Rashtriya Swasthaya Bima Yojana and its implications for access to health care by the poor in slum areas of Delhi. Health Syst (Basingstoke) 2017. [DOI: 10.1057/s41306-017-0022-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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