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Evaluating Health Insurance Programmes
An array of bottlenecks has ensured that the numerous health insurance schemes introduced over the years have failed to make any significant dent on the health sector. This article tries to assess these problems by using the “insurance cascade,” a framework that traces the steps from enrolling eligible households to ultimately delivering their benefits. The existing evidence suggests substantial bottlenecks across all cascade steps, with especially large gaps in beneficiaries’ awareness of how to enrol in schemes, what the schemes covers, and how to access scheme benefits.
Catastrophic health spending in India has remained high over the past 15 years despite the introduction of large and comprehensive social health insurance schemes (Pandey et al 2018, 2018b). Understanding why these schemes have not improved financial risk protection is a pressing concern as India advances towards universal health coverage. India recently introduced the Pradhan Mantri Jan Arogya Yojana (PM-JAY), a large national social health insurance scheme that supersedes earlier state and national schemes, and aims to insure nearly 40% of the Indian population with an annual coverage of `5,00,000 (PM-JAY). However, the PM-JAY’s predecessors appear to have had mixed impacts on average and catastrophic health expenditures, despite substantial investments of state and national resources (Sood et al 2014; Selvaraj and Karan 2012; Fan et al 2012; Karan et al 2017). Understanding why these insurance schemes fall short of their goals—and what remedies could be deployed—is especially urgent given the rapid scale-up of PM-JAY.
In this article, we introduce the “insurance cascade,” a framework to systematically evaluate why social health insurance schemes fail to protect beneficiary households against high out-of-pocket spending on covered services. The framework casts the process from enrolling eligible populations to receiving high-quality care at the hospital as a sequence of analytically distinct steps. In this way, the framework provides a tractable way for governments, donor agencies, and health policy researchers to identify bottlenecks in the insurance process and target efforts where they will be most effective. After introducing the insurance cascade, we describe the data and outcome measures that would be required to apply the cascade to each step from enrolment of beneficiaries to the delivery of services. We then bring together and synthesise existing analyses on health insurance in India, describing potential reasons and evidence for bottlenecks at each step. We conclude with a discussion of current knowledge gaps and potential approaches to collecting the data needed to better map the insurance cascade and design interventions to improve financial risk protection of insurance schemes in India and elsewhere.
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