Prinja Shankar, Kaur Manmeet, Kumar Rajesh
School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India.
Indian J Community Med. 2012 Jul;37(3):142-9. doi: 10.4103/0970-0218.99907.
Indian health system is characterized by a vast public health infrastructure which lies underutilized, and a largely unregulated private market which caters to greater need for curative treatment. High out-of-pocket (OOP) health expenditures poses barrier to access for healthcare. Among those who get hospitalized, nearly 25% are pushed below poverty line by catastrophic impact of OOP healthcare expenditure. Moreover, healthcare costs are spiraling due to epidemiologic, demographic, and social transition. Hence, the need for risk pooling is imperative. The present article applies economic theories to various possibilities for providing risk pooling mechanism with the objective of ensuring equity, efficiency, and quality care. Asymmetry of information leads to failure of actuarially administered private health insurance (PHI). Large proportion of informal sector labor in India's workforce prevents major upscaling of social health insurance (SHI). Community health insurance schemes are difficult to replicate on a large scale. We strongly recommend institutionalization of tax-funded Universal Health Insurance Scheme (UHIS), with complementary role of PHI. The contextual factors for development of UHIS are favorable. SHI schemes should be merged with UHIS. Benefit package of this scheme should include preventive and in-patient curative care to begin with, and gradually include out-patient care. State-specific priorities should be incorporated in benefit package. Application of such an insurance system besides being essential to the goals of an effective health system provides opportunity to regulate private market, negotiate costs, and plan health services efficiently. Purchaser-provider split provides an opportunity to strengthen public sector by allowing providers to compete.
印度卫生系统的特点是庞大的公共卫生基础设施未得到充分利用，以及一个基本不受监管的私人市场，该市场满足了对治疗性医疗的更大需求。高额的自付医疗费用成为获得医疗服务的障碍。在住院患者中，近25%的人因自付医疗费用的灾难性影响而陷入贫困线以下。此外，由于流行病学、人口统计学和社会转型，医疗成本正在螺旋上升。因此，风险共担的需求势在必行。本文将经济理论应用于提供风险共担机制的各种可能性，目的是确保公平、效率和优质护理。信息不对称导致精算管理的私人健康保险（PHI）失灵。印度劳动力中很大一部分是非正规部门劳动力，这阻碍了社会健康保险（SHI）的大规模扩大。社区健康保险计划很难大规模推广。我们强烈建议将税收资助的全民健康保险计划（UHIS）制度化，并发挥私人健康保险的补充作用。发展全民健康保险计划的背景因素是有利的。社会健康保险计划应与全民健康保险计划合并。该计划的福利包应首先包括预防和住院治疗护理，并逐步包括门诊护理。福利包应纳入各州的优先事项。这种保险制度的应用除了对有效卫生系统的目标至关重要外，还提供了监管私人市场、谈判成本和有效规划卫生服务的机会。购买者与提供者分离通过允许提供者竞争，为加强公共部门提供了机会。
