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      Does government health insurance protect households from out of pocket expenditure and distress financing for caesarean and non-caesarean institutional deliveries in India? Findings from the national family health survey (2019-21)

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          Abstract

          Objective

          Institutional deliveries have been promoted in India to reduce maternal and neonatal mortality. While the institutional deliveries have increased, they tend to involve large out of pocket expenditure (OOPE) and distress financing for households. In order to protect the families from financial hardship, publicly funded health insurance (PFHI) schemes have been implemented in India. An expanded national health insurance scheme called the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PMJAY) was launched in 2018. The current study was aimed at evaluating the performance of PFHI in reducing the OOPE and distress financing for the caesarean and non-caesarean institutional deliveries after the launch of PMJAY. This study analysed the nationally representative dataset of the National Family Health Survey (NFHS-5) conducted in 2019-21.

          Results

          Enrollment under PMJAY or other PFHI was not associated with any reduction in out of pocket expenditure or distress financing for caesarean or non-caesarean institutional deliveries across India. Irrespective of the PFHI coverage, the average OOPE in private hospitals was five times larger than public hospitals. Private hospitals showed an excessive rate of using caesarean-section. Utilization of private hospitals was significantly associated with incurring larger OOPE and occurrence of distress financing.

          Supplementary Information

          The online version contains supplementary material available at 10.1186/s13104-023-06335-w.

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          India's Janani Suraksha Yojana, a conditional cash transfer programme to increase births in health facilities: an impact evaluation.

          Stephen S Lim, Lalit Dandona, Joseph A Hoisington … (2010)
          In 2005, with the goal of reducing the numbers of maternal and neonatal deaths, the Government of India launched Janani Suraksha Yojana (JSY), a conditional cash transfer scheme, to incentivise women to give birth in a health facility. We independently assessed the effect of JSY on intervention coverage and health outcomes. We used data from the nationwide district-level household surveys done in 2002-04 and 2007-09 to assess receipt of financial assistance from JSY as a function of socioeconomic and demographic characteristics; and used three analytical approaches (matching, with-versus-without comparison, and differences in differences) to assess the effect of JSY on antenatal care, in-facility births, and perinatal, neonatal, and maternal deaths. Implementation of JSY in 2007-08 was highly variable by state-from less than 5% to 44% of women giving birth receiving cash payments from JSY. The poorest and least educated women did not always have the highest odds of receiving JSY payments. JSY had a significant effect on increasing antenatal care and in-facility births. In the matching analysis, JSY payment was associated with a reduction of 3.7 (95% CI 2.2-5.2) perinatal deaths per 1000 pregnancies and 2.3 (0.9-3.7) neonatal deaths per 1000 livebirths. In the with-versus-without comparison, the reductions were 4.1 (2.5-5.7) perinatal deaths per 1000 pregnancies and 2.4 (0.7-4.1) neonatal deaths per 1000 livebirths. The findings of this assessment are encouraging, but they also emphasise the need for improved targeting of the poorest women and attention to quality of obstetric care in health facilities. Continued independent monitoring and evaluations are important to measure the effect of JSY as financial and political commitment to the programme intensifies. Bill & Melinda Gates Foundation. Copyright 2010 Elsevier Ltd. All rights reserved.
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            Strategies for improving health care seeking for maternal and newborn illnesses in low- and middle-income countries: a systematic review and meta-analysis

            Zohra Lassi, Philippa F Middleton, Zulfiqar Bhutta … (2016)
            Background Lack of appropriate health care seeking for ill mothers and neonates contributes to high mortality rates. A major challenge is the appropriate mix of strategies for creating demand as well as provision of services. Design Systematic review and meta-analysis of experimental studies (last search: Jan 2015) to assess the impact of different strategies to improve maternal and neonatal health care seeking in low- and middle-income countries (LMIC). Results Fifty-eight experimental [randomized controlled trials (RCTs), non-RCTs, and before-after studies] with 310,652 participants met the inclusion criteria. Meta-analyses from 29 RCTs with a range of different interventions (e.g. mobilization, home visitation) indicated significant improvement in health care seeking for neonatal illnesses when compared with standard/no care [risk ratio (RR) 1.40; 95 confidence interval (CI): 1.17–1.68, 9 studies, n=30,572], whereas, no impact was seen on health care seeking for maternal illnesses (RR 1.06; 95% CI: 0.92–1.22, 5 studies, n=15,828). These interventions had a significant impact on reducing stillbirths (RR 0.82; 95% CI: 0.73–0.93, 11 studies, n=176,683), perinatal deaths (RR 0.84; 95% CI: 0.77–0.90, 15 studies, n=279,618), and neonatal mortality (RR 0.80; 95% CI: 0.72–0.89, 20 studies, n=248,848). On GRADE approach, evidence was high quality except for the outcome of maternal health care seeking, which was moderate. Conclusions Community-based interventions integrating strategies such as home visiting and counseling can help to reduce fetal and neonatal mortality in LMIC.
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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

              Samir Garg, Kirtti Kumar Bebarta, Narayan Tripathi (2020)
              Background 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. Methods 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. Results 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. Conclusion 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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                Author and article information

                Contributors
                Samir Garg:
                ORCID: http://orcid.org/0000-0003-4915-0731
                koriya@gmail.com
                Narayan Tripathi: narayanptripathi@gmail.com
                Kirtti Kumar Bebarta: kirtibebarta@gmail.com
                Journal
                Journal ID (nlm-ta): BMC Res Notes
                Journal ID (iso-abbrev): BMC Res Notes
                Title: BMC Research Notes
                Publisher: BioMed Central (London )
                ISSN (Electronic): 1756-0500
                Publication date (Electronic): 22 May 2023
                Publication date PMC-release: 22 May 2023
                Publication date Collection: 2023
                Volume: 16
                Electronic Location Identifier: 85
                Affiliations
                State Health Resource Centre, Chhattisgarh, Raipur India
                Author information
                http://orcid.org/0000-0003-4915-0731
                Article
                Publisher ID: 6335
                DOI: 10.1186/s13104-023-06335-w
                PMC ID: 10204289
                PubMed ID: 37217964
                SO-VID: 63c90f62-7b61-4977-8047-9fc49a53a188
                Copyright © © The Author(s) 2023
                License:

                Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

                History
                Date received : 25 May 2022
                Date accepted : 17 April 2023
                Categories
                Subject: Research Note
                Custom metadata
                issue-copyright-statement © BioMed Central Ltd., part of Springer Nature 2023

                ScienceOpen disciplines: Medicine
                Keywords: institutional deliveries,caesarean,pmjay,ayushman bharat,pradhan mantri jan arogya yojana,out of pocket expenditure,distress financing,india,health insurance,publicly funded health insurance,financial protection,private sector
                Data availability:
                ScienceOpen disciplines: Medicine
                Keywords: institutional deliveries, caesarean, pmjay, ayushman bharat, pradhan mantri jan arogya yojana, out of pocket expenditure, distress financing, india, health insurance, publicly funded health insurance, financial protection, private sector

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