Essays on Health Insurance Impact and Coverage Related Disparities in India

This dissertation project was aimed at evaluating health disparities that exist in health insurance programs in India and whether these programs have any impact on health service utilization and outcomes for the poor. I assessed these objectives through three independent manuscripts. In the first, I did an empirical analysis studying the effect of wealth status on health insurance enrollment. I found that primarily due to the newly introduced publicly funded health insurance schemes, the health insurance enrollment rates have improved for the marginalized caste groups. However, it was not clear what factors contribute to their higher enrollment rates. I have attempted to answer this question through the second manuscript of the dissertation. With this second manuscript, I analyzed data for India’s national health insurance scheme—Rashtriya Swasthya Bima Yojana (RSBY) and decomposed the enrollment differentials between the marginalized caste groups and the higher caste group. For the third manuscript, I assessed whether the maternal and child health (MCH) services indicators and child mortality outcomes improved after the implementation of the RSBY. For this empirical analysis, I used the difference-in-differences method to compare the selected MCH indicators for the poor versus the non-poor in the pre-and-post implementation period of the RSBY. Based on the results from the manuscripts, I argue that the poor, especially from the marginalized communities in India, are dependent on government programs for healthcare access. The federal and state governments should pay attention to the healthcare financing needs of these communities in future health insurance program implementation.Release after 08/14/202

Wealth Status and Health Insurance Enrollment in India: An Empirical Analysis

Since 2005, health insurance (HI) coverage in India has significantly increased, largely because of the introduction of government-funded pro-poor insurance programs. As a result, the determinants of HI enrollment and their relative importance may have changed. Using National Family Health Survey (NFHS)-4 data, collected in 2015–2016, and employing a Probit regression model, we re-examine the determinants of household HI enrollment. Then, using a multinomial logistic regression model, we estimate the relative risk ratio for enrollment in different HI schemes. In comparison to the results on the determinants of HI enrollment using the NFHS data collected in 2005–2006, we find a decrease in the wealth gap in public HI enrollment. Nonetheless, disparities in enrollment remain, with some changes in those patterns. Households with low assets have lower enrollments in private and community-based health insurance (CBHI) programs. Households with a higher number of dependents have a higher likelihood of HI enrollment, especially in rural areas. In rural areas, poor Scheduled Caste and Scheduled Tribe households are more likely to be enrolled in public HI than the general Caste households. In urban areas, Muslim households have a lower likelihood of enrollment in any HI. The educational attainment of household heads is positively associated with enrollment in private HI, but it is negatively associated with enrollment in public HI. Since 2005–2006, while HI coverage has improved, disparities across social groups remain

Uncovering Geographic Health Disparities: A Secondary Analysis of the Commonwealth Fund International Health Policy Survey

Background: Healthcare delivery faces a myriad of challenges globally with well-documented health inequities between rural and urban populations. Yet, researchers and policy makers have limited understanding of what factors contribute to these inequities. Methods: We analyzed the 2020 Commonwealth Fund International Health Policy (IHP) Survey—a nationally representative self-reported survey of adults from Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, the United Kingdom, and the United States (US). We compared the association of area type (rural or urban) with ten health indicators across three domains: health status and socioeconomic risk factors, affordability of care, and access to care. Logistic regression was used to determine the associations between countries with area type for each factor, controlling for individual’s age and sex. Results: The mean number of geographic health disparities in the 11 countries was 1.9, although there was a wide variation among the 11 nations. The US had statistically significant geographic health disparities in five of the ten indicators, the most of any country. Canada, Norway, and the Netherlands had no statistically significant geographic health disparities. In the US, living in a rural area was associated with having lower odds of having mental health conditions [OR=.89], experiencing material hardship [OR=.87] and higher odds of difficulty accessing after hours care [OR=1.29], having an avoidable emergency department visit in the past two years [OR=2.15], and having a regular provider or place of care [OR= 1.32]. Conclusions: This study has identified geographic health disparities across ten indicators in 11 developed nations. Public health policy makers in the US should look to Canada, Norway, and the Netherlands to improve geographic-based health equity. Keywords: rural health, geography, health disparities, international healt

Addressing Rural Health Challenges in Georgia and Scotland: A Framework for International Collaboration

Background: Rural healthcare delivery is a growing concern in Georgia and globally due to the well-documented issues including affordability, access to care, quality of care, safety of care, and healthcare workforce recruitment and retention. It is a “wicked problem” due to its complexity and pervasiveness. CONVERGE is a collaboration between four universities in Georgia and Scotland (two in each) to address this problem. Methods: A qualitative case study approach was used to identify the contributing factors to successful collaboration as well as the barriers to improve rural health. A purposive sample of the 2021 CONVERGE International Symposium attendees were invited by email to participate in an interview and/or focus group with the research team. Twelve interviews and two focus groups were conducted virtually with a total of 17 participants. The interviews and focus groups were conducted using a semi-structured interview guide that focused on experiences with international collaborations, rural health, and CONVERGE. Data was analyzed using reflexive thematic analysis using NVivo. Results: We identified themes pertaining to three key areas: mechanisms for continuity, fostering symposium engagement, and reflections on rural health globally. First, continuity for international collaborations is contingent upon support, relational and structural factors. Second, symposium engagement required intentionality related to selectivity of leaders and participants, presentation format, and team building. The final theme addresses barriers to addressing rural healthcare needs shared in both countries including enduring structural inequalities, remote access, and ideological resistance preventing substantive change. Conclusion: Findings from this study can be used to improve international academic collaborations by offering a model for fostering continuity and engagement necessary to meaningfully address wicked rural health issues. Keywords: rural health, Georgia, Scotland, qualitative researc