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

This paper draws implications for the energy and education policies in developing countries based on the insights derived from studying the determinants of household refrigerator ownership in India. In our study the failure of the government policies to ensure reliable public services such as uninterrupted power supply and improving female education levels turn out to be the key stumbling blocks to raising household welfare in India. While a threshold level of household income is necessary for a purchase of a consumer durable, it is not a sufficient condition. Our results for the determinants of refrigerator ownership in India suggest that, even when households have sufficient purchasing power, the duration of a complementary good (electricity for >17 h per day) is critical for the ownership, all else held constant. Also, females in households tend to derive greater utility from the refrigerator usage due to its impact on lowering household burden of work and easing women’s entry into the labour market. Our results confirm the hypothesis that when women bargaining power is proxied by the level of education, households with a female with higher level of education have higher probability of refrigerator ownership.

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From Income to Household Welfare: Lessons from Refrigerator Ownership in India

Household income shocks in developing countries are known to have an impact on the education investments for children In this paper, we explore the effects of various income and expenditure shocks

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Household income dynamics and investment in children: Evidence from India

India being home to the largest number of poor and malnourished population in the world, the tabling of National Food Security Bill has renewed the public pressure for universalization of PDS in India. In this regard, Tamil Nadu’s model of universal PDS has been cited for its success in providing comprehensive food security. This paper puts forward an analytical framework to analyse the resource use efficiency and redistribution achieved in a universal system. An illustrative survey was conducted in Coimbatore-Tiruppur region of Tamil Nadu to assess the merits and demerits of universal system based on the framework developed. The survey covering 154 households seeks to understand the utilization of PDS by the poor and the non-poor households, if there is voluntary exclusion of better-off sections of the population from the system and the reasons behind them. It is found that there is low drop-out of non-poor households from the universal system. This is because around 25% of all households who are eligible for any PDS commodity reported selling one of the commodities or feeding them to livestock. Also, the entitlements of poor to subsidized commodities are reduced in uniform universal system. Based on the theoretical framework and the observations from the survey, we make further recommendations in designing an optimal PDS model.

https://papers.ssrn.com/sol3/Delivery.cfm/SSRN_ID2146476_code1787864.pdf?abstractid=2020130&mirid=5

Universal PDS: Efficiency and Equity Dimensions

This study investigates the relationship between a married woman’s paid work participation and her exposure to intimate partner violence (IPV) in urban India. Results show that due to the male back...

Male Backlash and Female Guilt: Women’s Employment and Intimate Partner Violence in Urban India

Liberalization and globalization of Newly Industrialized Economies have contributed to increased integration of capital markets. This study tests whether convergence of macroeconomic variables and enhanced bilateral trade and financial flows causes greater interdependence of markets. Daily closing indices and quarterly differentials in interest, inflation, growth rates, exchange rates, trade of goods and services, direct and portfolio investment were used. Results revealed that markets of Asia are not immune to shocks originating in US although co-movements of macroeconomic variables do not help in explaining level of interdependence. Portfolio flows were found to be important than trade flows in explaining market interdependence.

Sowmya Dhanaraj

Papers

From Income to Household Welfare: Lessons from Refrigerator Ownership in India

Household income dynamics and investment in children: Evidence from India

Universal PDS: Efficiency and Equity Dimensions

Male Backlash and Female Guilt: Women’s Employment and Intimate Partner Violence in Urban India

Trade, Financial Flows and Stock Market Interdependence: Evidence from Asian Markets