Implications of delivering healthcare through strategic partnerships under publicly funded health insurance schemes: analysis of equity in access, demand for health services and quality of care in Indian context

Abstract

In forwarding the agenda of Universal Health Coverage (UHC), developing countries, including India, have adopted Publicly Funded Health Insurance Schemes (PFHIs) to serve their impoverished population. When PFHIs are implemented through Public-Private-Partnerships (PPP), they are advocated as a cost-effective solution to address the rising inequalities in healthcare access and poor quality of care in the public health system. India launched a PPP based National PFHI scheme (Rashtriya Swasthya Bima Yojana) in the year 2008 and has recently expanded it as Pradhan Mantri- Jan Aarogya Yojana (PM-JAY), while there exists limited evidence on the effectiveness of PFHIs in achieving health system goals related to equity in access, demand for health services, and quality of care. This dissertation attempts to address this research gap. Using data from the two rounds of NSS (60th and 71st), and adopting the Concentration Index (C.I.) methodology, the first study finds that though there exists pro-rich inequity in inpatient service use it has reduced post-PFHI implementation (2004 C.I.: 0.158; 2014 C.I. 0.112). Inter-state analysis identifies three critical factors for reducing inequalities in healthcare access, effective targeting (greater coverage of poorest proportion), equitable distribution of health centers, and removing socio-economic access barriers. In the second study, the effect of PFHI coverage on the demand for a surgery (hysterectomy) is estimated using Propensity Score Matching (PSM) method. PFHI coverage increases (by about 16%) the probability of undergoing a surgery (hysterectomy). Further, the study finds that patients admitted in a private hospital and with PFHI coverage have significantly higher (21%) probability of undergoing any surgery. Data collected through exit-interviews with patients is analyzed using Multi-group Structural Equation Modelling (SEM) to compare the perceptions of service quality and service satisfaction. Significantly lower perceived service quality (Difference: 0.20 units; p-value: <.01) along with reported administrative delays, longer waiting times, and longer length of stay among PFHI beneficiaries is suggestive of biased care.