Abstract
Several publicly financed health insurance schemes have been launched in India with the aim of providing universalizing health coverage (UHC). In this paper, we report the impact of publicly financed health insurance schemes on health service utilization, out-of-pocket (OOP) expenditure, financial risk protection and health status. Empirical research studies focussing on the impact or evaluation of publicly financed health insurance schemes in India were searched on PubMed, Google scholar, Ovid, Scopus, Embase and relevant websites. The studies were selected based on two stage screening PRISMA guidelines in which two researchers independently assessed the suitability and quality of the studies. The studies included in the review were divided into two groups i.e., with and without a comparison group. To assess the impact on utilization, OOP expenditure and health indicators, only the studies with a comparison group were reviewed. Out of 1265 articles screened after initial search, 43 studies were found eligible and reviewed in full text, finally yielding 14 studies which had a comparator group in their evaluation design. All the studies (n-7) focussing on utilization showed a positive effect in terms of increase in the consumption of health services with introduction of health insurance. About 70% studies (n-5) studies with a strong design and assessing financial risk protection showed no impact in reduction of OOP expenditures, while remaining 30% of evaluations (n-2), which particularly evaluated state sponsored health insurance schemes, reported a decline in OOP expenditure among the enrolled households. One study which evaluated impact on health outcome showed reduction in mortality among enrolled as compared to non-enrolled households, from conditions covered by the insurance scheme. While utilization of healthcare did improve among those enrolled in the scheme, there is no clear evidence yet to suggest that these have resulted in reduced OOP expenditures or higher financial risk protection.
Highlights
IntroductionAchieving Universal Health Coverage (UHC) is a major policy goal in health sector globally. [1, 2] Despite the acceptance of UHC at policy level in India, around three-quarters of healthcare spending is borne by households. [3] The recent National Sample Survey (NSS) report reveals that only 12% of the urban and 13% of the rural population is under any kind of health protection coverage. [4] Not surprisingly, nearly 26% of the total health spending by rural households is sourced from either borrowings or selling of assets. [4] Further, OOP spending pushes approximately 3.5% to 6.2% of the India’s population below the poverty line every year. [5,6,7]Traditionally, health care financing in India had been mostly restricted to the supply side, focussing on the strengthening of infrastructure and human resource
Since 2007, several publicly financed health insurance schemes have been launched in India both at the state level such as Rajiv Aarogyasri Health Insurance Scheme (RAS) in Andhra Pradesh [10], Rajiv Gandhi Jeevandayee Arogya Yojana (RGJAY) in Maharashtra [11], Chief Minister’s Comprehensive Health Insurance scheme (CMCHIS) in Tamil Nadu [12], and Rashtriya Swasthya Bima Yojana (RSBY) at the Central level
There is a need to design the schemes and implement safeguards so that the benefits of the risk pooling can be maximized. Benefits of these demand-side financing mechanisms will be not reaped unless the basic health care infrastructure for delivery of primary health services is strong
Summary
Achieving Universal Health Coverage (UHC) is a major policy goal in health sector globally. [1, 2] Despite the acceptance of UHC at policy level in India, around three-quarters of healthcare spending is borne by households. [3] The recent National Sample Survey (NSS) report reveals that only 12% of the urban and 13% of the rural population is under any kind of health protection coverage. [4] Not surprisingly, nearly 26% of the total health spending by rural households is sourced from either borrowings or selling of assets. [4] Further, OOP spending pushes approximately 3.5% to 6.2% of the India’s population below the poverty line every year. [5,6,7]Traditionally, health care financing in India had been mostly restricted to the supply side, focussing on the strengthening of infrastructure and human resource. [15] If the budgets of state sponsored schemes are pooled, it amounts to a significant amount of public exchequer’s money, thereby justifying a need to determine whether these schemes are achieving their desired objectives. In line with this policy need for an appraisal, the Government of India constituted a task force on costing of health services. [17, 18] As a result, there is a need to systematically review evidence in terms of whether these schemes have been able to achieve the objectives of universalizing health care for which they were launched. One of these review focussed on only social and community based health insurance schemes. [20] much of the current interest is on determining success or failure of tax-funded health insurance schemes which cover nearly 14% out of the total 15% population who have any form of health care insurance
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