Development of an essential health package requires explicit prioritisation on the basis of a country’s characteristics. A practical framework is presented to determine an EHP, considering coverage and equity perspectives for service delivery, financial protection and morbidity burden in the population. An analysis of morbidity data, unmet need for treatment, and impoverishment due to out-of-pocket spending reveals that a significant reduction in oop expenditure and impoverishment is possible through targeted inclusion of potentially high impoverishment-causing morbidities in EHPs. Such an approach may offer the desired flexibility in decision-making to policymakers, without compromising on benefits transferred to the needy.
This article provides evidence on the impact of the Rashtriya Swasthya Bima Yojana on access to healthcare and financial risk protection; its coverage across selected states and whether the targeting is effective. Overall, just about 11% of households were enrolled and almost half of these households actually belonged to the non-poor category. Although the scheme has increased hospitalisation rate, we do not know if it has enabled people to access the “genuinely needed” inpatient care which they could not afford earlier or whether hospitals are inducing the demand by suggesting unnecessary inpatient care to the people. Disturbingly, it has hardly had any effects on financial protection. These evidences unequivocally indicate that targeted health insurance coupled with a healthcare delivery system dominated by private providers cannot be the means to achieve universal healthcare.
Drawing from the 60th and 68th rounds of National Sample Survey Office, this study evaluates the impact of different (social, commercial and target-oriented) health insurance schemes on access to healthcare use, and cost of care and financing of medical expenses. The results show that though these schemes promote access to healthcare, they also increase the costs manifold. The commercial insurers have not been effective at pooling financial risks and seem to be indulging in maximising individual gain. Given the intrinsic market-failure and information asymmetry between the principal and the agents and difficulties in regulating the insurance-base system, this study advocates financing healthcare through a tax-based system which can be cost-effective for achieving universal healthcare access in India.
This article examines the decline in coverage levels of the Routine Immunisation Programme in the better-governed states across three rounds of the District Level Household and Facility Survey. The analysis points to an urban conundrum where proximity to urban centres is a "risk factor." An understanding of peri-urbanisation processes is essential for improving outcomes and governance in urban health services and the National Urban Health Mission.
This paper proposes an approach to periodically measure the extent of progress towards universal health coverage using a set of indicators that captures the essence of the factors to be considered in moving towards universalisation. It presents the rationale for the approach and demonstrates its use, based on a primary household survey carried out at the district level. Discussing the strengths and limitations of the approach, it points to how these measures could be further refined. The effort is to find a method of measurement that will apply to any of the alternative ways of progressing towards universal health coverage, however defined and implemented.
Evaluating the effectiveness of the "targeting" approach in the Rashtriya Swasthya Bima Yojana, the present study examines the determinants of enrolment, hospitalisation and financial protection for below the poverty line households using data from a large-scale survey conducted in Maharashtra in 2012-13. Almost 50% of BPL households were found to be non-poor and only 30% of them were aware about RSBY. More importantly, the effect of RSBY on catastrophic health expenditure was not found to be statistically significant. Since commercial insurance companies and their third party administrators have limited interest in awareness generation and enrolment, their role may be reviewed and instead an independent public agency should be given responsibility for enrolment of unorganised sector workers. This would be a key step towards achieving universal population coverage. However, in the long run, the government should strengthen the resource-starved public health system.
Any discussion on universal health coverage in India is premature without a comprehensive understanding of public financing of health coverage in the country. This article analyses the government's share of financial resources for health across different agents, with particular focus on resources for health coverage. An attempt is made to separate spending for health in general and health coverage in particular, and to examine the issue of equity. The analysis indicates that the present health coverage system is inadequate and iniquitous, with various systems running at different costs. It suggests consolidating finances and moving towards a more unified system to realise the benefits of efficiency gains.
Universalising health coverage is the current goal of the health service system in India. Tax-funded insurance for poor families is the method chosen for attaining this objective. The Rashtriya Swasthya Bima Yojana was rolled out in 2008 for households below the poverty line, enabling them to access health services in the public and private sectors. However, experience from different countries shows tax-funded insurance systems work well only in settings where public provisioning of healthcare services prevails. State-funded targeted insurance schemes do not seriously mitigate inequitable access to health services in a fundamentally private healthcare delivery market.
For India to improve the existing government health system is far less complex than expanding health insurance. International experience shows the difficulties of regulating an insurance-based system to keep costs down and assure quality.
