School of Public Health, University of the Western Cape, Bellville, South Africa.
Public Health Resource Network, 29, New Panchsheel Nagar, Raipur, Chhattisgarh, 492001, India.
Health Res Policy Syst. 2020 May 25;18(1):50. doi: 10.1186/s12961-020-00555-3.
Universal health coverage (UHC) has provided the impetus for the introduction of publicly funded health insurance (PFHI) schemes in the mixed health systems of India and many other low- and middle-income countries. There is a need for a holistic understanding of the pathways of impact of PFHI schemes, including their role in promoting equity of access.
This paper applies an equity-oriented evaluation framework to assess the impacts of PFHI schemes in Chhattisgarh State by synthesising literature from various sources and highlighting knowledge gaps. Data were collected from an extensive review of publications on PFHI schemes in Chhattisgarh since 2009, including empirical studies from the first author's PhD and grey literature such as programme evaluation reports, media articles and civil society campaign documents. The framework was constructed using concepts and frameworks from the health policy and systems research literature on UHC, access and health system building blocks, and is underpinned by the values of equity, human rights and the right to health.
The analysis finds that evidence of equitable enrolment in Chhattisgarh's PFHI scheme may mask many other inequities. Firstly, equitable enrolment does not automatically lead to the acceptability of the scheme for the poor or to equity in utilisation. Utilisation, especially in the private sector, is skewed towards the areas that have the least health and social need. Secondly, related to this, resource allocation patterns under PFHI deepen the 'infrastructure inequality trap', with resources being effectively transferred from tribal and vulnerable to 'better-off' areas and from the public to the private sector. Thirdly, PFHI fails in its fundamental objective of effective financial protection. Technological innovations, such as the biometric smart card and billing systems, have not provided the necessary safeguards nor led to greater accountability.
The study shows that development of PFHI schemes, within the context of wider neoliberal policies promoting private sector provisioning, has negative consequences for health equity and access. More research is needed on key knowledge gaps related to the impact of PFHI schemes on health systems. An over-reliance on and rapid expansion of PFHI schemes in India is unlikely to achieve UHC.
全民健康覆盖（UHC）为印度和许多其他中低收入国家的混合卫生系统引入公共资助的健康保险（PFHI）计划提供了动力。需要全面了解 PFHI 计划的影响途径，包括它们在促进公平获得方面的作用。
本文应用注重公平的评估框架，通过综合各种来源的文献并突出知识空白，评估恰蒂斯加尔邦 PFHI 计划的影响。数据来自对 2009 年以来恰蒂斯加尔邦 PFHI 计划的广泛文献综述，包括第一作者博士论文中的实证研究和灰色文献，如方案评估报告、媒体文章和民间社会运动文件。该框架使用全民健康覆盖、获取和卫生系统构建模块方面的健康政策和系统研究文献中的概念和框架构建，并以公平、人权和健康权的价值观为支撑。
分析发现，恰蒂斯加尔邦 PFHI 计划中公平的参保人数可能掩盖了许多其他不平等现象。首先，公平的参保并不自动导致该计划为穷人所接受或导致利用方面的公平。利用，特别是在私营部门，偏向于卫生和社会需求最低的地区。其次，与此相关的是，PFHI 下的资源分配模式加深了“基础设施不平等陷阱”，资源从部落和弱势群体有效转移到“较富裕”地区，并从公共部门转移到私营部门。第三，PFHI 未能实现其有效财务保护的基本目标。生物识别智能卡和计费系统等技术创新没有提供必要的保障，也没有提高问责制。
研究表明，在更广泛的促进私营部门供应的新自由主义政策背景下，PFHI 计划的发展对健康公平和获取产生了负面影响。需要对与 PFHI 计划对卫生系统的影响相关的关键知识空白进行更多研究。印度对 PFHI 计划的过度依赖和快速扩张不太可能实现全民健康覆盖。
