Healthcare Management Program, T A Pai Management Institute, Manipal, India.
Int J Health Plann Manage. 2019 Oct;34(4):e1633-e1650. doi: 10.1002/hpm.2856. Epub 2019 Jul 23.
It is broadly accepted that health policy is crucially affected by contextual conditions. Yet, little is known about how the context limits the effectiveness of public health insurance (PHI) programs and the extent to which these limitations could be overcome. The objective of the paper is to address these issues on the basis of the examination of 17 PHI schemes introduced by federal and state governments in India since independence. Faced with the challenge of simultaneously expanding insurance coverage while containing costs, governments have overwhelmingly favored the latter. At the same time, governments have lacked the capacity to monitor performance, which has led providers to compromise quality in return for low payment rates. While there have been modest improvements in recent years, reform efforts have been hindered by contextual conditions that constrain the use of measures to control profiteering by for-profit agencies. The paper argues that system-wide data on the quality of providers (system-level operational capacity) and the ability of public agencies to monitor quality and link it with payment (organizational-level operational capacity) critically determined the program effectiveness. We demonstrate the interaction between contextual variables, program design elements, and policy capacity linking to performance, arguing for a broader approach to understand PHI performance. We extend the present frameworks on PHI effectiveness that have narrowly focused on the design of health financing functions without factoring unfavorable context and limited policy capacity in developing countries. The paper contributes to improving PHI performance operating in unfavorable contextual conditions in India and elsewhere.
人们普遍认为，卫生政策受到背景条件的极大影响。然而，人们对背景如何限制公共医疗保险（PHI）计划的有效性以及这些限制在多大程度上可以克服知之甚少。本文的目的是在考察印度独立以来联邦和邦政府推出的 17 个 PHI 计划的基础上解决这些问题。面对同时扩大保险覆盖范围和控制成本的挑战，政府压倒性地倾向于后者。与此同时，政府缺乏监督绩效的能力，这导致提供者为了低报酬率而牺牲质量。尽管近年来取得了适度的改善，但改革努力受到了限制，这些限制限制了控制营利性机构牟取暴利的措施的使用。本文认为，提供者质量的系统数据（系统级运营能力）以及公共机构监督质量并将其与支付挂钩的能力（组织级运营能力）对计划的有效性至关重要。我们展示了背景变量、计划设计要素和与绩效相关的政策能力之间的相互作用，主张采取更广泛的方法来理解 PHI 的绩效。我们扩展了现有的 PHI 有效性框架，这些框架狭隘地关注卫生融资功能的设计，而没有考虑发展中国家不利的背景和有限的政策能力。本文有助于提高在印度和其他地方不利背景条件下运作的 PHI 绩效。
