Impact of Government-Funded Health Insurance on Out-of-Pocket Expenditure and Quality of Hospital-Based Care in Indian States of Madhya Pradesh and Maharashtra

Background

With its clear focus on financial protection, government-funded health insurance (GFHI) stands out among the strategies for universal health coverage (UHC) implemented by low-to-middle income countries globally. Since 2018, India has implemented a GFHI programme called the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY), which covers 500 million individuals. The current study aims to evaluate the performance of GFHI in meeting its key objectives of improving access, quality and financial protection for hospital-based care in two large central Indian states: Madhya Pradesh and Maharashtra.

Methods

The study measures access in terms of utilisation of inpatient care. Financial protection was measured in terms of catastrophic health expenditure which was defined as the incidence of out-of-pocket expenditure (OOPE) above thresholds of 10% and 25% of annual household expenditure. Patient-satisfaction with care was taken as an indicator of quality. A household survey was conducted in 2023, covering a multi-stage sample of 11,569 and 12,384 individuals in Madhya Pradesh and Maharashtra, respectively. Multi-variate analyses were conducted to find the effect of GFHI-enrolment on the desired outcomes. The instrumental variable method was applied to address potential endogeneity in insurance enrolment. Additionally, propensity score matching was done to ensure robustness.

Results

Around 71% and 63% of surveyed individuals were enrolled under GFHI in Madhya Pradesh and Maharashtra, respectively. The hospitalisation rate did not differ much between the GFHI-enrolled and non-enrolled population. The average OOPE on hospitalisation was similar for the GFHI-enrolled and non-enrolled patients. The OOPE and catastrophic health expenditure in private hospitals remained very high, irrespective of GFHI enrolment. The pattern was similar in both states. Multi-variate adjusted models showed that GFHI had no significant effect on utilisation, quality, OOPE and catastrophic health expenditure. The above results were confirmed by propensity score matching.

Conclusions

Coverage by GFHI enrolment was ineffective in improving access, quality or financial protection for inpatient hospital care despite 5 years of implementation of the programme. Long-standing supply-side gaps and poor regulation of private providers continue to hamper the effectiveness of GFHI in India.