Equity, access and utilisation in the state-funded universal insurance scheme (RSBY/MSBY) in Chhattisgarh State, India: What are the implications for Universal Health Coverage?

Philosophiae Doctor - PhDUniversal Health Coverage (UHC) has provided the impetus for the introduction of publicly-funded health insurance (PFHI) schemes, involving the private sector, especially in low-and middle-income countries with mixed health systems. Although equity is considered as being core to UHC, the implication of UHC interventions for equity in access (availability, affordability and acceptability) beyond financial protection is inadequately researched. India introduced a national PFHI scheme (Rashtriya Swasthya Bima Yojana) in 2007 which has since then been expanded considerably through the Pradhan Mantri Jan Aarogya Yojana (PMJAY) scheme. However, contestation remains as to whether PFHI schemes are the most appropriate interventions for UHC in India. Evidence so far provides cause for concern regarding their impact on financial protection and health equity. With PFHI schemes burgeoning globally, there is an urgent need for a holistic understanding of the pathways of impact of these schemes, including their roles in promoting equity of access and achievement of UHC objectives. The state-funded universal health insurance scheme (RSBY/MSBY) in Chhattisgarh State provided the opportunity to explore these pathways of impact, especially on vulnerable communities, as the State has a universal health insurance scheme. This PhD aims to study equity, access and utilisation in the state-funded universal insurance scheme in Chhattisgarh State of India, in the context of Universal Health Coverage. It is presented as a thesis by publications

The role of community health workers (CHWS) in addressing social determinants of health in Chhattisgarh, India

Magister Public Health - MPHThe aim of this research was to describe the role of Community Health Workers, in the Mitanin Programme, in addressing social determinants of health in Chhattisgarh State of India, with the view to identify the pathways for strengthening and making recommendations on this aspect of the CHW’s work for existing or future CHW programmes. A comparative case study design using qualitative research methods was adopted for the study, with the sample comprising of two case studies of action on social determinants by CHWs. The definition of a case was ‘successful action by a CHW (Mitanin) or team of CHWs (Mitanins) on nutrition or violence against women in the village or cluster of villages for which the CHW/s are responsible’. The sampling of the cases followed the ‘replication logic’, that is, examination of similar cases to draw general lessons. Data collection was undertaken through In-depth Individual Interviews and Group Interviews with CHWs, community members and programme staff that participated with the CHWs in, and also benefitted from, their action on social determinants. Respondents were identified through a process of snowball sampling. Seventeen in-depth interviews and ten group interviews (total 27) were conducted as part of the study. A broad conceptual framework of the factors facilitating and constraining the action on social determinants by the CHWs, along with the pathways for action on social determinants by the CHWs, along with the pathways for action on social determinants by CHWs and their role, was developed at the start of the research. The analysis was done using this conceptual framework, which was refined during analysis, resulting in an explanatory framework. The analysis was two-fold. Firstly, both cases were analysed and written up separately and then they were analysed together in order to draw cross case conclusions. Thematic analysis was undertaken. Ethical Clearance was obtained from the UWC Senate Research Committee and permission was obtained from the State Health Resource Center, the body coordinating the Mitanin Programme in Chhattisgarh. A Participant Information Sheet and Informed consent forms for both the individual and the group interviews were prepared and administered. The form for the group interview included a confidentiality-binding clause. The study showed that the Mitanins in Durgkondal and Manendragarh (the Blocks under study) had effectively and successfully addressed the issues of nutrition and xvii violence against women as social determinants, in a manner visualized in the initial programme documents. Despite threats to the autonomy of the programme, pressures to formalise the Mitanin’s role, and backlash from vested interests, such action remained sustained, nearly ten years since the start of the programme

Hospital utilization and out of pocket expenditure in public and private sectors under the universal government health insurance scheme in Chhattisgarh State, India: Lessons for universal health coverage

Research on impact of publicly financed health insurance has paid relatively little attention to the nature of healthcare provision the schemes engage. India's National Health Insurance Scheme or RSBY was made universal by Chhattisgarh State in 2012. In the State, public and private sectors provide hospital services in a context of extensive gender, social, economic and geographical inequities. This study examined enrolment, utilization (public and private) and out of pocket (OOP) expenditure for the insured and uninsured, in Chhattisgarh. The Chhattisgarh State Central sample (n = 6026 members) of the 2014 National Sample Survey (71st Round) on Health was extracted and analyzed. Variables of enrolment, hospitalization, out of pocket (OOP) expenditure and catastrophic expenditure were descriptively analyzed. Multivariate analyses of factors associated with enrolment, hospitalization (by sector) and OOP expenditure were conducted, taking into account gender, socio-economic status, residence, type of facility and ailment. Insurance coverage was 38.8%. Rates of hospitalization were 33/1000 population among the insured and 29/1000 among the uninsured. Of those insured and hospitalized, 67.2% utilized the public sector. Women, rural residents, Scheduled Tribes and poorer groups were more likely to utilize the public sector for hospitalizations. Although the insured were less likely to incur out of pocket (OOP) expenditure, 95.1% of insured private sector users and 66.0% of insured public sector users, still incurred costs. Median OOP payments in the private sector were eight times those in the public sector. Of households with at least one member hospitalized, 35.5% experienced catastrophic health expenditures (>10% monthly household consumption expenditure). The study finds that despite insurance coverage, the majority still incurred OOP expenditure. The public sector was nevertheless less expensive, and catered to the more vulnerable groups. It suggests the need to further examine the roles of public and private sectors in financial risk protection through government health insurance

Assessing geographical inequity in availability of hospital services under the state-funded universal health insurance scheme in Chhattisgarh state, India, using a composite vulnerability index

Background: Countries are increasingly adopting health insurance schemes for achieving Universal Health Coverage. India’s state-funded health insurance scheme covers hospital care provided by ‘empanelled’ private and public hospitals. Objective: This paper assesses geographical equity in availability of hospital services under the universal health insurance scheme in Chhattisgarh state. Methods: The study makes use of district data from the insurance scheme and government surveys. Selected socio-economic indicators are combined to form a composite vulnerability index, which is used to rank and group the state’s 27 districts into tertiles, named as highest, middle and lowest vulnerability districts (HVDs, MVDs, LVDs). Indicators of hospital service availability under the scheme – insurance coverage, number of empanelled private/public hospitals, numbers and amounts of claims – are compared across districts and tertiles. Two measures of inequality, difference and ratio, are used to compare availability between tertiles. Results: The study finds that there is a geographical pattern to vulnerability in Chhattisgarh state. Vulnerability increases with distance from the state’s centre towards the periphery. The highest vulnerability districts have the highest insurance coverage, but the lowest availability of empanelled hospitals (3.4 hospitals per 100,000 enrolled in HVDs, vs 8.2/100,000 enrolled in LVDs). While public sector hospitals are distributed equally, the distribution of private hospitals across tertiles is highly unequal, with higher availability in LVDs. The number of claims (per 100,000 enrolled) in the HVDs is 3.5-times less than that in the LVDs. The claim amounts show a similar pattern. Conclusions: Although insurance coverage is higher in the more vulnerable districts, availability of hospital services is inversely proportional to vulnerability and, therefore, the need for these services. Equitable enrolment in health insurance schemes does not automatically translate into equitable access to healthcare, which is also dependent on availability and specific dynamics of service provision under the scheme

Distinct performance profiles on the Brixton test in frontotemporal dementia

From Wiley via Jisc Publications RouterHistory: received 2020-05-30, rev-recd 2020-09-18, pub-electronic 2020-10-15, pub-print 2021-06Article version: VoRPublication status: PublishedThe Brixton Spatial Anticipation Test is a well‐established test of executive function that evaluates the capacity to abstract, follow, and switch rules. There has been remarkably little systematic analysis of Brixton test performance in the prototypical neurodegenerative disorder of the frontal lobes: behavioural variant frontotemporal dementia (bvFTD) or evaluation of the test’s ability to distinguish frontal from temporal lobe degenerative disease. We carried out a quantitative and qualitative analysis of Brixton performance in 76 patients with bvFTD and 34 with semantic dementia (SD) associated with temporal lobe degeneration. The groups were matched for demographic variables and illness duration. The bvFTD group performed significantly more poorly (U = 348, p < .0001, r = .58), 53% of patients scoring in the poor–impaired range compared with 6% of SD patients. Whereas bvFTD patients showed problems in rule acquisition and switching, SD patients did not, despite their impaired conceptual knowledge. Error analysis revealed more frequent perseverative errors in bvFTD, particularly responses unconnected to the stimulus, as well as random responses. Stimulus‐bound errors were rare. Within the bvFTD group, there was variation in performance profile, which could not be explained by demographic, neurological, or genetic factors. The findings demonstrate sensitivity and specificity of the Brixton test in identifying frontal lobe degenerative disease and highlight the clinical value of qualitative analysis of test performance. From a theoretical perspective, the findings provide evidence that semantic knowledge and the capacity to acquire rules are dissociable. Moreover, they exemplify the separable functional contributions to executive performance

Historical exclusion, conflict, health systems and Ill-health among tribal communities in India : a synthesis of three studies

The report aims to consolidate key findings across three studies among tribal populations in India; to understand and explain the diverse nature of health inequities along with processes and historical contexts which create, configure and sustain these inequities; it also questions the existing understanding of health equity. The three research partners explored different facets of health inequities among tribal communities from diverse historical and geographic contexts. A detailed sub-section examines the role of the health system in health inequities experienced by the tribal communities

Struggle Against Outsourcing of Diagnostic Services in Government Facilities: Strategies and Lessons From a Campaign Led by Jan Swasthya Abhiyan (People’s Health Movement) in Chhattisgarh, India

Since 1991, India, like many countries, has undergone a process of ‘liberalisation’ which has entailed an increase in outsourcing of public services through Public Private Partnerships. In December 2012, Chhattisgarh state started the process of outsourcing diagnostics and radiology services in 379 government health facilities. Jan Swasthya Abhiyan (People’s Health Movement) Chhattisgarh mounted a (so far) successful campaign against this move. Drawing on secondary data and the personal experiences and observations of the author, this paper documents Jan Swasthya Abhiyan’s struggle, describing the strategies that were used, their efficacy, the facilitators and challenges. It uses this experience as a basis to reflectively suggest lessons for health activism and the theoretical implications. Jan Swasthya Abhiyan founded its resistance on a detailed evidence-based critique of the proposal that was disseminated, along with demands. The campaign then used multiple strategies, from petitioning the government, to street action, to advocacy with media and bureaucrats. Alliances were built with trade unions and groups working on social justice issues. Privatisation and neo-liberal policies provided a rallying point and framing the issue as a moral argument and in terms of larger concerns for social justice helped build wider solidarity. This experience suggests that the use of evidence and multiple strategies, effective framing of the issue, forging broader alliances, and a sustained campaign can all be important strategies for health activism. It also highlights the need for health activism to continue beyond a single campaign. Staying vigilant, monitoring, evidence building, mobilizing people and continuing to build alliances on such issues are critical tasks for social movements and networks like the People’s Health Movement

When state-funded health insurance schemes fail to provide financial protection: An in-depth exploration of the experiences of patients from urban slums of Chhattisgarh, India

This paper explores the dynamics of access under the state-funded universal health insurance scheme in Chhattisgarh, India, and specifically the relationship between choice, affordability and acceptability. A qualitative case study of patients from the slums of Raipur City incurring significant heath expenditure despite using insurance, was conducted, examining the way patients and their families sought to navigate and negotiate hospitalisation under the scheme. Eight purposefully selected (‘revelatory’) instances of patients (and their families) utilising private hospitals are presented. Patients and their family exercised their agency to the extent that they could. Negotiations on payments took place at every stage, from admission to post-hospitalisation. Once admitted, however, families rapidly lost the initiative, and faced mounting costs, and increasingly harsh interactions with providers. The paper analyses how these outcomes were produced by a combination of failures of key regulatory mechanisms (notably the ‘smart card’), dominant norms of care as a market transaction (rather than a right), and wider cultural acceptance of illegal informal healthcare payments. The unfavourable normative and cultural context of (especially) private sector provisioning in India needs to be recognised by policy makers seeking to ensure financial risk protection through publicly financed health insurance