Effectiveness of government strategies for financial protection against costs of hospitalization Care in India.

Background: In the past decade, India has seen the introduction of many 'publicly funded health insurance' schemes (PFHIs) that claim to cover approximately 300 million people and are essentially forms of purchasing care from both public and private providers to reduce out-of-pocket expenditure (OOPE) for hospitalization.

Methods: Data from a recent government-organized nationwide household survey, The National Sample Survey 71st Round, were used to analyse the effectiveness and equity of tax-funded public health services and PFHIs as distinct but overlapping approaches to financial protection for hospitalization across different socio-economic categories. Cross-tabulation analysis, multivariate logistic regression and propensity score matching were the main analytical methods used.

Results: Government hospitals provide access to 45.6% of all hospitalization needs. Although poorer quintiles use public hospitals more often, even in the poorest quintile, as many as 37.2% are utilizing private hospitals. The average OOPE that a household experiences for hospitalization in public hospitals is approximately only one-fifth of the OOPE for hospitalization in the private sector. PFHI schemes cover 12.8% of the population, and coverage is higher in upper quintiles and in urban areas. Hospitalization rates increase with PFHI coverage, and this occurs with both public and private providers. Propensity score matching shows that PFHI contributes to a marginal reduction (1%) in 'catastrophic health expenditure incidence at the 25% threshold' (CHE-25) for the bottom three quintiles. The reported coverage of PFHIs was greater in the upper income quintiles. Utilization of public services was greater in the poorer income quintiles and more marginalized social groups.

Conclusions: Periodic surveys are essential to guide policy choices regarding the appropriate mix of strategies for financial protection in pluralistic systems. There is a need for caution regarding any shift in the role of governments from providing services to purchasing care, given the contexts and limitations of currently available PFHIs. Even with tax-funded public services, although the average OOPE is lower than the care purchased through PFHIs, there is still a modest level of CHE and impoverishment due to health care costs that persist. Both strategies need to be synergized for more effective financial protection.