State Health Resource Centre, Chhattisgarh, Raipur, India.
Formerly Professor, School of Health Systems Studies, Tata Institute of Social Sciences, Mumbai, India.
BMC Health Serv Res. 2019 Dec 27;19(1):1004. doi: 10.1186/s12913-019-4849-8.
Many LMICs have implemented Publicly Funded Health Insurance (PFHI) programmes to improve access and financial protection. The national PFHI scheme implemented in India for a decade has been recently modified and expanded to cover free hospital care for 500 million persons. Since increase in annual cover amount is one of the main design modifications in the new programme, the relevant policy question is whether such design change can improve financial protection for hospital care. An evaluation of state-specific PFHI programmes with vertical cover larger than RSBY can help answer this question. Three states in Southern India - Andhra Pradesh, Karnataka and Tamil Nadu have been pioneers in implementing PFHI with a large insurance cover.
The current study was meant to evaluate the PFHI in above three states in improving utilisation of hospital services and financial protection against expenses of hospitalization. Two cross-sections from National Sample Survey's health rounds, the 60th round done in 2004 and the 71st round done in 2014 were analysed. Instrumental Variable method was applied to address endogeneity or the selection problem in insurance.
Enrollment under PFHI was not associated with increase in utilisation of hospital care in the three states. Private hospitals dominated the empanelment of facilities under PFHI as well as utilisation. Out of Pocket Expenditure and incidence of Catastrophic Health Expenditure did not decrease with enrollment under PFHI in the three states. The size of Out of Pocket Expenditure was significantly greater for utilisation in private sector, irrespective of insurance enrollment.
PFHI in the three states used substantially larger vertical cover than national scheme in 2014. The three states are known for their good governance. Yet, the PFHI programmes in all three states failed in fulfilling their fundamental purpose. Increasing vertical cover of PFHI and using either 'Trusts' or Insurance-companies as purchasers may not give desired results in absence of adequate regulation. The study raises doubts regarding effectiveness of contracting under PFHIs to influence provider-behavior in the Indian context. Further research is required to find solutions for addressing gaps that contribute to poor financial outcomes for patients under PFHI.
许多中低收入国家实施了公共资助的健康保险（PFHI）计划，以改善获得医疗服务和财务保障的机会。印度实施了十年的国家 PFHI 计划最近进行了修改和扩大，为 5 亿人提供免费的医院护理。由于新计划的主要设计修改之一是增加年度保险金额，因此相关政策问题是这种设计变更是否可以改善医院护理的财务保障。对具有比 RSBY 更大垂直保险覆盖范围的特定州的 PFHI 计划进行评估可以帮助回答这个问题。印度南部的三个州 - 安得拉邦、卡纳塔克邦和泰米尔纳德邦 - 一直是实施具有大型保险覆盖范围的 PFHI 的先驱。
本研究旨在评估上述三个州的 PFHI 计划在改善医院服务的利用和减轻住院费用的财务负担方面的效果。利用 2004 年进行的第 60 轮全国抽样调查健康轮次和 2014 年进行的第 71 轮全国抽样调查健康轮次的数据进行分析。采用工具变量法来解决保险中的内生性或选择问题。
在这三个州，PFHI 的参保并没有与医院服务利用的增加相关。私立医院在 PFHI 下的设施签约和利用方面占据主导地位。在这三个州，PFHI 的参保并没有降低自付支出和灾难性卫生支出的发生率。无论是否参加保险，在私立部门的利用中，自付支出的规模都明显更大。
在 2014 年，这三个州的 PFHI 计划使用的垂直保险覆盖范围明显大于国家计划。这三个州以良好的治理而闻名。然而，所有三个州的 PFHI 计划都未能实现其基本目的。在缺乏充分监管的情况下，增加 PFHI 的垂直保险覆盖范围并使用信托或保险公司作为购买者，可能不会产生预期的效果。该研究对在印度背景下通过 PFHIs 进行合同承包以影响提供者行为的有效性提出了质疑。需要进一步研究以找到解决导致 PFHI 下患者财务结果不佳的差距的解决方案。
