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

Abstract

BackgroundIn the past decade, India has seen the introduction of many ‘publicly funded health insurance’ schemes (PFHIs) that claim to cover approximately 300 million people and are essentially forms of purchasing care from both public and private providers to reduce out-of-pocket expenditure (OOPE) for hospitalization.MethodsData from a recent government-organized nationwide household survey, The National Sample Survey 71st Round, were used to analyse the effectiveness and equity of tax-funded public health services and PFHIs as distinct but overlapping approaches to financial protection for hospitalization across different socio-economic categories. Cross-tabulation analysis, multivariate logistic regression and propensity score matching were the main analytical methods used.ResultsGovernment hospitals provide access to 45.6% of all hospitalization needs. Although poorer quintiles use public hospitals more often, even in the poorest quintile, as many as 37.2% are utilizing private hospitals. The average OOPE that a household experiences for hospitalization in public hospitals is approximately only one-fifth of the OOPE for hospitalization in the private sector. PFHI schemes cover 12.8% of the population, and coverage is higher in upper quintiles and in urban areas. Hospitalization rates increase with PFHI coverage, and this occurs with both public and private providers. Propensity score matching shows that PFHI contributes to a marginal reduction (1%) in ‘catastrophic health expenditure incidence at the 25% threshold’ (CHE-25) for the bottom three quintiles. The reported coverage of PFHIs was greater in the upper income quintiles. Utilization of public services was greater in the poorer income quintiles and more marginalized social groups.ConclusionsPeriodic surveys are essential to guide policy choices regarding the appropriate mix of strategies for financial protection in pluralistic systems. There is a need for caution regarding any shift in the role of governments from providing services to purchasing care, given the contexts and limitations of currently available PFHIs. Even with tax-funded public services, although the average OOPE is lower than the care purchased through PFHIs, there is still a modest level of CHE and impoverishment due to health care costs that persist. Both strategies need to be synergized for more effective financial protection.Electronic supplementary materialThe online version of this article (10.1186/s12889-018-5431-8) contains supplementary material, which is available to authorized users.

Equity and Elderly Health in India: Reflections from 75th Round National Sample Survey, 2017-18, amidst the COVID-19 Pandemic

“…Publicly funded health insurance (PFHI) coverage and tax based subsidized public provisioning are the two major strategies used by the government for providing nancial risk protection in India [17].…”

“…For CHE-10 and CHE-25, other than the above mentioned independent variables, choice of provider (public or private) was used. To understand factors affecting living arrangements and economic independence in the elderly population, chances of 'living alone', and chances of 'being dependent' were dependent variables, with same independent variables (except economic independence and living arrangments) mentioned above for the logit model hospitalization, These variables have been included based on suggestions from existing literature [11][12][13][14][15][16] . No multicollinearity was found among independent variables.…”

Progress towards universal health coverage in the context of rheumatic diseases in India

“…On the other hand, most of the recently launched government insurance schemes started with the promise of cashless hospitalized care for those below poverty line and unorganized workers, do not show any impact on reduction of financial hardships. Other studies have also shown this limitation of insurance sector in assisting financial protection of patients with all health conditions . The strategy for financial protection has to depend largely on public provisioning; but re‐examining the package of services in insurance schemes and better monitoring as well as regulation of private health care providers may help insurance programs improve access and financial protection by utilising the relatively economic and ethical private health care providers.…”

“…Out of pocket expenditure for hospitalization was calculated by subtracting reimbursements by insurance companies and other sources from the total medical expenditure and transportation cost. However, across India only 2% of hospitalisations had reimbursements in the preceding 1 year …”

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

“…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]. …”