State Health Resource Centre, Chhattisgarh, Raipur, India.
Appl Health Econ Health Policy. 2024 Nov;22(6):815-825. doi: 10.1007/s40258-024-00911-2. Epub 2024 Aug 25.
With its clear focus on financial protection, government-funded health insurance (GFHI) stands out among the strategies for universal health coverage (UHC) implemented by low-to-middle income countries globally. Since 2018, India has implemented a GFHI programme called the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY), which covers 500 million individuals. The current study aims to evaluate the performance of GFHI in meeting its key objectives of improving access, quality and financial protection for hospital-based care in two large central Indian states: Madhya Pradesh and Maharashtra.
The study measures access in terms of utilisation of inpatient care. Financial protection was measured in terms of catastrophic health expenditure which was defined as the incidence of out-of-pocket expenditure (OOPE) above thresholds of 10% and 25% of annual household expenditure. Patient-satisfaction with care was taken as an indicator of quality. A household survey was conducted in 2023, covering a multi-stage sample of 11,569 and 12,384 individuals in Madhya Pradesh and Maharashtra, respectively. Multi-variate analyses were conducted to find the effect of GFHI-enrolment on the desired outcomes. The instrumental variable method was applied to address potential endogeneity in insurance enrolment. Additionally, propensity score matching was done to ensure robustness.
Around 71% and 63% of surveyed individuals were enrolled under GFHI in Madhya Pradesh and Maharashtra, respectively. The hospitalisation rate did not differ much between the GFHI-enrolled and non-enrolled population. The average OOPE on hospitalisation was similar for the GFHI-enrolled and non-enrolled patients. The OOPE and catastrophic health expenditure in private hospitals remained very high, irrespective of GFHI enrolment. The pattern was similar in both states. Multi-variate adjusted models showed that GFHI had no significant effect on utilisation, quality, OOPE and catastrophic health expenditure. The above results were confirmed by propensity score matching.
Coverage by GFHI enrolment was ineffective in improving access, quality or financial protection for inpatient hospital care despite 5 years of implementation of the programme. Long-standing supply-side gaps and poor regulation of private providers continue to hamper the effectiveness of GFHI in India.
政府资助的医疗保险（GFHI）以其对财务保护的明确关注，在全球中低收入国家实施的全民健康覆盖（UHC）战略中脱颖而出。自 2018 年以来，印度实施了一项名为 Ayushman Bharat Pradhan Mantri Jan Arogya Yojana（AB-PMJAY）的 GFHI 计划，该计划覆盖了 5 亿人。本研究旨在评估 GFHI 在实现其改善基于医院的护理的可及性、质量和财务保护这两个关键目标方面的表现，该研究在印度两个大型中央邦进行：中央邦和马哈拉施特拉邦。
本研究通过住院治疗的利用率来衡量可及性。财务保护通过灾难性卫生支出来衡量，定义为自付支出（OOPE）超过家庭支出的 10%和 25%的发生率。患者对护理的满意度被视为质量的指标。2023 年进行了一项家庭调查，分别对中央邦和马哈拉施特拉邦进行了多阶段抽样，样本量为 11569 人和 12384 人。进行了多变量分析，以确定 GFHI 参保对预期结果的影响。应用工具变量法解决保险参保的潜在内生性问题。此外，还进行了倾向评分匹配以确保稳健性。
在中央邦和马哈拉施特拉邦，分别有 71%和 63%的调查对象参加了 GFHI。在参保和未参保人群中，住院率差异不大。参保和未参保患者的平均住院 OOPE 相似。私人医院的 OOPE 和灾难性卫生支出仍然很高，与 GFHI 参保无关。两种模式在两个邦都很相似。多变量调整模型表明，GFHI 对利用率、质量、OOPE 和灾难性卫生支出没有显著影响。倾向评分匹配也证实了上述结果。
尽管该计划已经实施了 5 年，但 GFHI 的参保覆盖并不能有效改善住院医院护理的可及性、质量或财务保护。长期存在的供应方差距和对私人提供者的监管不善继续阻碍 GFHI 在印度的有效性。
