Changes in addressing inequalities in access to hospital care in Andhra Pradesh and Maharashtra states of India: a difference-in-differences study using repeated cross-sectional surveys

Objectives: To compare the effects of the Rajiv Aarogyasri Health Insurance Scheme of Andhra Pradesh (AP) with health financing innovations including the Rashtriya Swasthya Bima Yojana (RSBY) in Maharashtra (MH) over time on access to and out-of-pocket expenditure (OOPE) on hospital inpatient care. Study design: A difference-in-differences (DID) study using repeated cross-sectional surveys with parallel control. Setting: National Sample Survey Organisation of India (NSSO) urban and rural ‘first stratum units’, 863 in AP and 1008 in MH. Methods: We used two cross-sectional surveys: as a baseline, the data from the NSSO 2004 survey collected before the Aarogyasri and RSBY schemes were launched; and as postintervention, a survey using the same methodology conducted in 2012. Participants: 8623 households in AP and 10 073 in MH. Main outcome measures: Average OOPE, large OOPE and large borrowing per household per year for inpatient care, hospitalisation rate per 1000 population per year. Results: Average expenditure, large expenditures and large borrowings on inpatient care had increased in MH and AP, but the increase was smaller in AP across these three measures. DIDs for average expenditure and large borrowings were significant and in favour of AP for the rural and the poorest households. Hospitalisation rates also increased in both states but more so in AP, although the DID was not significant and the subgroup analysis presented a mixed picture. Conclusions: Health innovations in AP had a greater beneficial effect on inpatient care-related expenditures than innovations in MH. The Aarogyasri scheme is likely to have contributed to these impacts in AP, at least in part. However, OOPE increased in both states over time. Schemes such as the Aarogyasri and RSBY may result in some positive outcomes, but additional interventions may be required to improve access to care for the most vulnerable sections of the population

Strengthening primary health systems in India

Crippling out of pocket health expenditure and lack of access to health care among the poor are significant challenges to improving health in India. In the highly populated states of Andhra Pradesh (AP) and Madhya Pradesh (MP), which are home to 154 million people, many live in poverty and suffer high rates of disease and mortality. Leading international health expert Professor Mala Rao has been evaluating health financing schemes in both of these states to assess their effectiveness and efficiency on behalf of organisations such as the UK Department for International Development (DFID), and supported by the Wellcome Trust, IDRC and the Rockefeller Foundation. Rao’s review of the Government of Madhya Pradesh’s State Illness Assistance Fund (SIAF) revealed that the scheme was underused and inequitable. It also exposed a poor data management system and highlighted that access to treatment was complex and burdensome. The review supported the development of more efficient financial support for care of the seriously ill and led to significant improvements such as the constitution of a State Steering Group which was tasked with overseeing the restructuring of the scheme. Government orders reflecting Rao’s recommendations have since resulted in a change to the fund management and delivery, re-negotiated costs with healthcare providers, devolved powers to authorize funds at district level, and better verification of SIAF-funded patients. Subsequently, the World Bank has acknowledged ‘substantial progress’ in the management of the scheme, laying the foundations for the eventual development of a single comprehensive health delivery system. For citizens, the number of annual total approvals for treatment has risen more than threefold, and a new feedback system is now being used to support improved monitoring, evaluation and selection of healthcare providers. A separate assessment of the Government of Andhra Pradesh’s (GoAP) Rajiv Aarogyasri Community Health Insurance scheme indicated a need for hospital-based healthcare schemes to be built on a strong platform of primary (family) care. The assessment also informed the development of a similar scheme in Maharashtra, the 'control' state in the research. Findings from both assessments supported the promotion of comprehensive primary care as the most effective means to reduce healthcare costs and improve health literacy, helping people to better understand their health care entitlements and navigate complex care pathways. In recognition of her work, Rao was appointed by the Chair of the Health Workstream of the UK-India CEO Forum as the Public Health academic expert to lead the development of a White Paper exploring the benefits and practicalities of a primary care partnership between India and the UK. The paper reached a very wide global audience of health policy leaders when it was published in the British Medical Journal in May 2012 (doi:10.1136/bmj.e3151). In India, the paper, and its discussion at a UK-India workshop in 2012, influenced the Government of India to encourage states to plan primary care pilots which would inform the development of comprehensive primary care, as a crucial platform for affordable universal health care. In Kerala, Rao has helped to develop proposals for piloting a new model of care across three primary health centres. In May 2013, the Government of India approved funding for the Government of Kerala to implement the proposal, which if successful, will be replicated across the country to reduce out-of-pocket expenses for outpatient care, provide better and more comprehensive and systematic community based care for people with a wide range of medical conditions, and reduce the need for secondary care.Impact case study - UEL website versionImpact case study submitted to REF2014 assessmen