Several publicly financed health insurance schemes have been launched in India with the aim of providing universalizing health coverage (UHC). In this paper, we report the impact of publicly financed health insurance schemes on health service utilization, out-of-pocket (OOP) expenditure, financial risk protection and health status. Empirical research studies focussing on the impact or evaluation of publicly financed health insurance schemes in India were searched on PubMed, Google scholar, Ovid, Scopus, Embase and relevant websites. The studies were selected based on two stage screening PRISMA guidelines in which two researchers independently assessed the suitability and quality of the studies. The studies included in the review were divided into two groups i.e., with and without a comparison group. To assess the impact on utilization, OOP expenditure and health indicators, only the studies with a comparison group were reviewed. Out of 1265 articles screened after initial search, 43 studies were found eligible and reviewed in full text, finally yielding 14 studies which had a comparator group in their evaluation design. All the studies (n-7) focussing on utilization showed a positive effect in terms of increase in the consumption of health services with introduction of health insurance. About 70% studies (n-5) studies with a strong design and assessing financial risk protection showed no impact in reduction of OOP expenditures, while remaining 30% of evaluations (n-2), which particularly evaluated state sponsored health insurance schemes, reported a decline in OOP expenditure among the enrolled households. One study which evaluated impact on health outcome showed reduction in mortality among enrolled as compared to non-enrolled households, from conditions covered by the insurance scheme. While utilization of healthcare did improve among those enrolled in the scheme, there is no clear evidence yet to suggest that these have resulted in reduced OOP expenditures or higher financial risk protection.

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Impact of Publicly Financed Health Insurance Schemes on Healthcare Utilization and Financial Risk Protection in India: A Systematic Review.

Since the beginning of 1980s, the Iranian health care system has undergone several reforms designed to increase accessibility of health services. Notwithstanding these reforms, out-of-pocket payments which create a barrier to access health services contribute almost half of total health are financing in Iran. This study aimed to provide a greater understanding about the inequality and determinants of the out-of-pocket expenditure (OOPE) and the related catastrophic expenditure (CE) for hospital services in Iran using a nationwide survey data, the 2003 Utilisation of Health Services Survey (UHSS). The concentration index and the Heckman selection model were used to assess inequality and factors associated with these expenditures. Inequality analysis suggests that the CE is concentrated among households in lower socioeconomic levels. The results of the Heckman selection model indicate that factors such as length of stay, admission to a hospital owned by private sector or Ministry of Health and Medical Education, and living in remote areas are positively associated with higher OOPE. Results of the ordered-probit selection model demonstrate that length of stay, lower household wealth index, and admission to a private hospital are major factors contributing to the increase in the probability of CE. Also, we find that households living in East Azarbaijan, Kordestan and Sistan and Balochestan face a higher level of CE. Based on our findings, the current employer-sponsored health insurance system does not offer equal protection against hospital expenditure in Iran. It seems that a single universal health insurance scheme that covers health services for all Iranian—regardless of their employment status—can better protect households from catastrophic health spending.

Out-of-pocket expenditures for hospital care in Iran : who is at risk of incurring catastrophic payments?

A national Publicly Funded Health Insurance (PFHI) scheme called Pradhan Mantri Jan Arogaya Yojana (PMJAY) was launched by government of India in 2018. PMJAY seeks to cover 500 million persons with an annual cover of around 7000 USD per household. PMJAY claims to be the largest government funded health scheme globally and has attracted an international debate as a policy for Universal Health Coverage. India’s decade-long experience of the earlier national and state-specific PFHI schemes had shown poor effectiveness in financial protection. Most states in India have completed a year of implementation of PMJAY but no evaluations are available of this important scheme. The study was designed to find out the effect of enrolment under PMJAY in improving utilisation of hospital services and financial protection in Chhattisgarh which has been a leading state in implementing PFHI in terms of enrolment and claims. The study analyses three repeated cross-sections. Two of the cross-sections are from National Sample Survey (NSS) health rounds – year 2004 when there was no PFHI and 2014 when the older PFHI scheme was in operation. Primary data was collected in 2019-end to cover the first year of PMJAY implementation and it formed the third cross-section. Multivariate analysis was carried out. In addition, Propensity Score Matching and Instrumental Variable method were applied to address the selection problem in insurance. Enrollment under PMJAY or other PFHI schemes did not increase utilisation of hospital-care in Chhattisgarh. Out of Pocket Expenditure (OOPE) and incidence of Catastrophic Health Expenditure did not decrease with enrollment under PMJAY or other PFHI schemes. The size of OOPE was significantly greater for utilisation in private sector, irrespective of enrollment under PMJAY. PMJAY provided substantially larger vertical cover than earlier PFHI schemes in India but it has not been able to improve access or financial protection so far in the state. Though PMJAY is a relatively new scheme, the persistent failure of PFHI schemes over a decade raises doubts about suitability of publicly funded purchasing from private providers in the Indian context. Further research is recommended on such policies in LMIC contexts.

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Performance of India's national publicly funded health insurance scheme, Pradhan Mantri Jan Arogaya Yojana (PMJAY), in improving access and financial protection for hospital care: findings from household surveys in Chhattisgarh state.

The Public Distribution System (PDS) of India plays a crucial role in reducing food insecurity by acting as a safety net by distributing essentials at a subsidised rate. While the PDS forms a cornerstone of government food and nutrition policy, India continues to be home to a large population of hungry and malnourished people. This review seeks to explore the functioning and efficiency of the PDS in achieving food and nutritional security in India. A comprehensive and systematic search using the key terms "food insecurity" OR "food security" AND "Public Distribution System" OR "PDS" OR "TPDS" AND "India" identified 23 articles which met the inclusion criteria. This review draws attention to the lack of published literature in areas of PDS and food security in India. The findings of the review emphasise the role of PDS in tackling hunger and malnutrition while highlighting its limited role in improving food security and childhood mortality due to operational inefficiencies. The PDS has the potential to act as a solution to food insecurity in India if the operational inefficiencies and environmental footprints are addressed by adequate policy reforms.

https://www.mdpi.com/1660-4601/16/17/3221/pdf

The Public Distribution System and Food Security in India

Health insurance, a friend in need? Impacts of formal insurance and crowding out of informal insurance

Empirical research has shown that households in developing countries are unable to sustain current levels of consumption during and after severe health crises due to substantial increase in medical expenditure and/or loss of income. Health events are also found to have an adverse impact on nutritional status and educational attainment of household members. Thus, in this study, we investigate: who are vulnerable to welfare loss from health shocks, what are the household responses to cope with the economic burden of health shocks and if policy responses like state health insurance schemes are effective in reducing the economic vulnerability. We use self-reported measures of health shocks and coping strategies from the longitudinal survey of the ongoing Young Lives project in India [Andhra Pradesh (AP)] to identify the characteristics of vulnerable groups and perform three-level random intercept logistic regression that takes into account contextual or environmental factors. What emerges is socioeconomic status of household (determined by education, wealth, occupation and caste/religious group) and its demographic characteristics like gender of the household head and proportion of elderly and disabled members matter for outcomes related to health events. Households adopt different strategies to cope with the economic costs of ill-health; borrowing is the most widely used strategy. For credit, majority of households rely on informal sources (moneylenders, friends, relatives, etc.) and have little or no access to formal sources. However, health shock to main breadwinner leads to households adopting costly strategies like reducing consumption or sending children to work. We found no evidence that the state health insurance scheme reduced the household welfare loss from health shocks and their coping strategies. The results suggest that health insurance schemes have to be complemented with access to micro-credit and social security schemes for self-employed persons/workers in informal sector to reduce the economic burden faced by households due to health shocks.

Economic vulnerability to health shocks and coping strategies: evidence from Andhra Pradesh, India

https://www.wider.unu.edu/sites/default/files/Publications/Working-paper/PDF/wp2017-195.pdf

Family structure, education and women’s employment in rural India

Purpose – The purpose of this paper is to examine the short‐term stock market interactions between US and six major Asian markets – China, India, Hong Kong, Singapore, South Korea and Taiwan. These six economies along with Japan and Australia have the largest stock exchanges in the Asia‐Pacific region. The importance of the US market to the Asian economies is the prime motivation for a quantitative assessment of its role in this region. The objective of this study is to measure the dynamic stock market interdependence of US and Asian newly industrialized economies (NIEs) (Hong Kong, Singapore, South Korea and Taiwan) and emerging market economies (EMEs) (China and India) post Asian crisis of 1997 and also to capture the market interactions during the sub‐prime crisis.Design/methodology/approach – The study has employed Granger causality tests and generalized forecast error variance decomposition (FEVD) analysis to analyze the fluctuations in and the extent of short‐term interdependence between the US and ...

Dynamic interdependence between US and Asian markets: an empirical study

Effects of parental health shocks on children’s schooling: Evidence from Andhra Pradesh, India

The objectives of the study are three-fold: to investigate who are vulnerable to welfare loss from health shocks, what are the household responses to cope with the economic burden of health shocks and if policy responses like state health insurance scheme

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Sowmya Dhanaraj

Papers

Economic vulnerability to health shocks and coping strategies: evidence from Andhra Pradesh, India

Family structure, education and women’s employment in rural India

Dynamic interdependence between US and Asian markets: an empirical study

Effects of parental health shocks on children’s schooling: Evidence from Andhra Pradesh, India

Health shocks and coping strategies: State health insurance scheme of Andhra Pradesh, India