Changes in addressing inequalities in access to hospital care in Andhra Pradesh and Maharashtra states of India: a difference-in-differences study using repeated cross-sectional surveys

Abstract

ObjectivesTo compare the effects of the Rajiv Aarogyasri Health Insurance Scheme of Andhra Pradesh (AP) with health financing innovations including the Rashtriya Swasthya Bima Yojana (RSBY) in Maharashtra (MH) over time on access to and out-of-pocket expenditure (OOPE) on hospital inpatient care.Study designA difference-in-differences (DID) study using repeated cross-sectional surveys with parallel control.SettingNational Sample Survey Organisation of India (NSSO) urban and rural ‘first stratum units’, 863 in AP and 1008 in MH.MethodsWe used two cross-sectional surveys: as a baseline, the data from the NSSO 2004 survey collected before the Aarogyasri and RSBY schemes were launched; and as postintervention, a survey using the same methodology conducted in 2012.Participants8623 households in AP and 10 073 in MH.Main outcome measuresAverage OOPE, large OOPE and large borrowing per household per year for inpatient care, hospitalisation rate per 1000 population per year.ResultsAverage expenditure, large expenditures and large borrowings on inpatient care had increased in MH and AP, but the increase was smaller in AP across these three measures. DIDs for average expenditure and large borrowings were significant and in favour of AP for the rural and the poorest households. Hospitalisation rates also increased in both states but more so in AP, although the DID was not significant and the subgroup analysis presented a mixed picture.ConclusionsHealth innovations in AP had a greater beneficial effect on inpatient care-related expenditures than innovations in MH. The Aarogyasri scheme is likely to have contributed to these impacts in AP, at least in part. However, OOPE increased in both states over time. Schemes such as the Aarogyasri and RSBY may result in some positive outcomes, but additional interventions may be required to improve access to care for the most vulnerable sections of the population.

Does public health system provide adequate financial risk protection to its clients? Out of pocket expenditure on inpatient care at secondary level public health institutions: Causes and determinants in an eastern Indian state

“…Evaluating the impact of state‐specific insurance scheme known as Rajiv Aarogyasri , in Andhra Pradesh, one study concluded that these schemes have increased hospitalisation rate as well as OOP among insurers. Comparing this with Maharastra, this study pointed out that the benefits in Andhra Pradesh are more than Maharashtra …”

Out of pocket expenditure on surgical and nonsurgical conditions in Odisha

“…[20] Several studies in India reported that insured households incurred OOPE due to hospitalization. [2122]…”

Assessing geographical inequity in availability of hospital services under the state-funded universal health insurance scheme in Chhattisgarh state, India, using a composite vulnerability index

“…Studies in India assessing the equity impact of the publicly-financed insurance schemes have mainly examined equity in insurance coverage. Lower enrolments have been found in remote rural areas, poorer districts, socio-economically vulnerable groups, indigenous communities and female-headed households [34–36]. A few studies of utilization of hospital care under state-funded health insurance in India have found inequities based on caste, economic status, education and urban–rural residence [36–38].…”

“…Where geographical equity has been studied, the focus has been on differences between urban and rural areas or between regions or states [34,36–39]. For example, Narayana [34] found inequitable distribution of empanelled hospitals, especially of private hospitals, within six Indian states.…”