From primary health care to universal health coverage—one step forward and two steps back

Sanders, David; Nandi, Sulakshana; Labonté, Ronald; Vance, Carina; Damme, Wim Van

doi:10.1016/s0140-6736(19)31831-8

Cited by 65 publications

(57 citation statements)

References 3 publications

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“…More recent studies have indicated that these problems continue under the PMJAY [135]. Provider capture remains a central issue in the performance of PFHI-based policies to achieve UHC in the Indian context [136].…”

Section: Discussionmentioning

confidence: 99%

Using an equity-based framework for evaluating publicly funded health insurance programmes as an instrument of UHC in Chhattisgarh State, India

Nandi

Schneider

2020

Health Res Policy Sys

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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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Section: Discussionmentioning

confidence: 99%

Using an equity-based framework for evaluating publicly funded health insurance programmes as an instrument of UHC in Chhattisgarh State, India

Nandi

Schneider

2020

Health Res Policy Sys

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“…The likelihood of insurance benefit being appropriated by powerful providers has been a longstanding problem in LMIC contexts [51]. The possibility of 'provider capture' has been pointed out [12]. Researchers have also highlighted the role of unnecessary or costly medical procedures being used by providers under such schemes [8,12].…”

Section: Discussionmentioning

confidence: 99%

“…PMJAY claims to be the largest health insurance or assurance scheme in the world, fully financed by government The launch of PMJAY as a key policy in Indian healthcare has been hailed as an important step towards UHC [6]. It has also attracted a vigorous international debate on its merits and suitability for Indian health system [6][7][8][9][10][11][12][13]. The experience of RSBY in India has been well documented and its effectiveness in financial protection was found to be poor [14][15][16][17][18][19][20][21][22][23][24].…”

Section: Introductionmentioning

confidence: 99%

Performance of India’s national publicly funded health insurance scheme, Pradhan Mantri Jan Arogaya Yojana (PMJAY), in improving access and financial protection for hospital care: findings from household surveys in Chhattisgarh state

Garg

Bebarta

Tripathi

2020

Preprint

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Background:A national Publicly Funded Health Insurance (PFHI) scheme called Pradhan Mantri Jan Arogaya Yojana (PMJAY) was launched by government of India in 2018. PMJAY seeks to cover 500 million persons with an annual cover of around 7000 USD per household. PMJAY claims to be the largest government funded health scheme globally and has attracted an international debate as a policy for Universal Health Coverage. India’s decade-long experience of the earlier national and state-specific PFHI schemes had shown poor effectiveness in financial protection. Most states in India have completed a year of implementation of PMJAY but no evaluations are available of this important scheme.Methods:The study was designed to find out the effect of enrolment under PMJAY in improving utilisation of hospital services and financial protection in Chhattisgarh which has been a leading state in implementing PFHI in terms of enrolment and claims. The study analyses three repeated cross-sections. Two of the cross-sections are from National Sample Survey (NSS) health rounds – year 2004 when there was no PFHI and 2014 when the older PFHI scheme was in operation. Primary data was collected in 2019-end to cover the first year of PMJAY implementation and it formed the third cross-section. Multivariate analysis was carried out. In addition, Propensity Score Matching and Instrumental Variable method were applied to address the selection problem in insurance.Results:Enrollment under PMJAY or other PFHI schemes did not increase utilisation of hospital-care in Chhattisgarh. Out of Pocket Expenditure (OOPE) and incidence of Catastrophic Health Expenditure did not decrease with enrollment under PMJAY or other PFHI schemes. The size of OOPE was significantly greater for utilisation in private sector, irrespective of enrollment under PMJAY.Conclusion:PMJAY provided substantially larger vertical cover than earlier PFHI schemes in India but it has not been able to improve access or financial protection so far in the state. Though PMJAY is a relatively new scheme, the persistent failure of PFHI schemes over a decade raises doubts about suitability of publicly funded purchasing from private providers in the Indian context. Further research is recommended on such policies in LMIC contexts.

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“…He championed comprehensive primary health care and community health workers as a solution. Just the week before he died, The Lancet published a Comment 3 in which David pointed out that universal health coverage without primary health care was likely to benefit commercial interests rather than people's health.…”

Section: Tribute To David Sanders From the People's Health Movementmentioning

confidence: 99%

Tribute to David Sanders from the People's Health Movement

Baum¹,

Serag

Lloyd³

2019

The Lancet

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From primary health care to universal health coverage—one step forward and two steps back

Cited by 65 publications

References 3 publications

Using an equity-based framework for evaluating publicly funded health insurance programmes as an instrument of UHC in Chhattisgarh State, India

Using an equity-based framework for evaluating publicly funded health insurance programmes as an instrument of UHC in Chhattisgarh State, India

Performance of India’s national publicly funded health insurance scheme, Pradhan Mantri Jan Arogaya Yojana (PMJAY), in improving access and financial protection for hospital care: findings from household surveys in Chhattisgarh state

Tribute to David Sanders from the People's Health Movement

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