EXAMINING THE ROLE OF HEALTH INSURANCE: ACCESS, EQUITY, AND FINANCIAL RISK PROTECTION OF HEALTH CARE IN INDIA

Abstract

In India, several health insurance programmes have been launched over the years to provide financial risk protection against burgeoning health expenditure. Health insurance is crucial given the rising disease burden of non-communicable diseases and injuries, growing share of private health sector, low public health spending (1.15% of gross domestic product), and high burden of out-of-pocket health expenditure (OOPE) (50.6% of the health expenditure) in India. The study first analysed the enrolment in different health insurance programmes and inequalities in health insurance enrolment at national, state, and intra-state levels over the years. The study than gauged the sub-national variations in utilization pattern and financial risk due to seeking care. The inequalities present in access to care, utilization of private providers, and the detrimental effect due to occurrence of OOPE were also analysed. Furthermore, the impact of health insurance on accessibility to inpatient care, utilization pattern of inpatient care, and financial risk protection at national and sub-national levels were examined. Lastly, the initial findings of the recently launched government sponsored health insurance scheme, Pradhan Mantri Jan Arogya Yojana (PM-JAY) was reviewed to comprehend the actual implementation and the experiences and challenges encountered under the scheme by both users and providers. The study provides a comprehensive picture from evolution of the health insurance to the impact of health insurance in providing access to care and financial risk protection to beneficiaries at national as well as across the states. The study used data from the rounds of the National Sample Survey on health and morbidity, titled, “Household Social Consumption: Health”. For the analysis, descriptive statistics, multivariable logistic regression, propensity score matching, concentration index (CI), and decomposition analysis were employed in the study. Additionally, systematic review of studies exploring the aspects related to the recent GSHI scheme, PM-JAY was also done. vi We observed that, enrolment under health insurance increased from nearly 1% in 2004 to nearly 15% in 2014 and 2018. It varied substantially at inter and intra-state levels. A few states such as Mizoram, Andhra Pradesh, Chhattisgarh, and Meghalaya, reported a substantial increase in health insurance enrolment over the years. By contrast, in states such as Bihar, Madhya Pradesh, Jharkhand, Uttar Pradesh, Sikkim, and Manipur, health insurance enrolment remains low across the survey years. The enrolment was consistently higher in urban areas than rural areas across all survey years (2004 (3.13% versus 0.36%), 2014 (18.02% versus 14.06%), and 2018 (19.06% versus 14.07%)). Notably, enrolment under health insurance was statistically significantly concentrated among wealthier individuals in India as well as across most states/union territories. We also observed variations across states in terms of utilization pattern of seeking care and financial burden. The financial burden due to seeking care further varies on the basis of type of care and healthcare provider used. The financial burden in terms of catastrophic health expenditure (CHE) and impoverishment was observed to be high in India. In India, 5.56%, 2.56%, and 1.53% of households experienced CHE at 10%, 25%, 40% threshold respectively, and 1.9% of households were pushed below poverty line, respectively due to OOPE on hospitalization. On the other hand, due to incurring OOPE on outpatient care, 11.66%, 5.77%, and 3.47% of households experienced CHE at 10%, 25%, and 40% threshold respectively and 4.0% of the households experienced impoverishment. States such as Andhra Pradesh, Telangana, Kerala, Maharashtra, Uttar Pradesh, and Odisha reported the highest financial burden due to seeking care. Even among the states with good health insurance enrolment, such as, Kerala, Chhattisgarh, Andhra Pradesh, Telangana, and Rajasthan substantial financial burden due to hospitalization was observed. Outpatient care puts higher burden on patients and their family members in comparison to inpatient care, however, health insurance schemes in India majorly keeps outpatient care outside its ambit. The socio-economic inequalities were vii also prevalent in case of accessibility to care, utilization of private provider, and detrimental effect of accessing care. Furthermore, it was observed that overall enrolment under health insurance has improved the accessibility to inpatient care across most states. However, the impact of health insurance on utilization pattern of hospitalization was found to be low and limited to few states. Also, health insurance enrolment was found to be effective in reducing the financial burden to some extent among insured. In states/UTs such as, Maharashtra, Andhra Pradesh, Karnataka, Kerala, Mizoram, Delhi, and Telangana, health insurance lowers the financial risk (OOPE and catastrophic health expenditure at 10% threshold) due to seeking inpatient care for insured. Notably, financial burden due to seeking inpatient care was observed to be substantially higher among private providers irrespective of health insurance status. Lastly, several challenges including, low level of awareness regarding various facets of the scheme, continued spending by beneficiaries on drugs and diagnostic tests, co-payments demanded by healthcare providers, reimbursement issues, and low health packages rates were observed in previous government sponsored health insurance schemes and continued in recent government sponsored health insurance scheme, PM-JAY as well, that contributes to the sub-optimal outcomes of health insurance in India. There is a need for multidimensional, comprehensive, and innovative awareness programmes, and strengthened implementation efforts at state level to increase health insurance enrolment in India. Additionally, it is imperative to increase public health spending, strengthen public health infrastructure, regulate private providers, ensure availability of medicines and diagnostics services, and include outpatient services under the ambit of health insurance, to augment financial protection in India. Furthermore, concerted efforts, such as creating in-depth knowledge about benefits and features of health insurance schemes among beneficiaries, addressing infrastructural gaps, and enhancing stewardship to restrict malpractices of providers, viii are necessary to achieve the desired objectives of the health insurance programmes in the long run in India.