sajm





SAJM VOL 30.3 (4)

Polarization in the Utilization of Public Hospitals and GovernmentSponsored Health Insurance (GSHI): The Unique Case of Kerala

Cyril Philip and S Sandhya

DOI: https://doi.org/10.62206/sajm.30.3.2023.73-99

PUBLISHED : 07 NOV 2023

Abstract

This paper examines three objectives. The first objective was to study whether GSHI schemes had an impact on GSHI-related hospitalisations during 2018-2022 only (inter-state analysis), as there was uniform availability of data across all the states during this period. The second objective was to analyse the difference in the utilization of public hospitals for inpatients and outpatient visits between the GSHI-covered and non-covered households, among the top 10 states only, whose GSHI coverage was high (estimated from 75 round of National Sample Survey (NSS), 2017-18). This data was used as it coincides with 2008-2020 period, during which the polarization in the use of public hospitals might have happened in Kerala. The third objective examined whether polarization in the utilization of public hospitals in Kerala varied across various socio-economic sections of the sample population. The results suggested that most of the states, including Kerala, recorded impressive rise in GSHI-hospitalisations during 2018-2022. The interstate analysis, from 75 th th NSS round proved that Kerala has shown polarization in the utilization of public hospitals and further, the disaggregated analysis has shown that the polarization was stronger among socially and economically well-off households compared to poorer households. This again lent credence to the polarization hypothesis. However, among the 14 districts, Wayanad exhibited an opposite polarization in favour of private hospitals. The analysis suggested that GSHI schemes could have created a polarization in the utilization of public hospitals in Kerala during 2008-2020.

Key Words

GSHI, Polarization, Utilization pattern, Public hospitals, Inpatients, Outpatient visits

Author Biography

Cyril Philip
Ph. D. candidate, School of Economi cs, University of Hyderabad, Telangana, India 500046. E-mail: This e-mail address is being protected from spambots. You need JavaScript enabled to view it

S Sandhya
Professor (Retired), School of Economi cs, University of Hyderabad, Telangana, India 500046. E-mail: This e-mail address is being protected from spambots. You need JavaScript enabled to view it

References

  1. Aravindan, K. P., Kunj ikannan, T., Kutty, Raman. , Vi jayakumar, Kayal., Thankappan, K. R., & Elamon, Joy. (2000). Changes in the health status of Kerala, 1987-1997. Discussion paper No.20. Kerala Research Programme on Local Level Development, Centre for Development Studies, Thiruvanthapuram.
  2. Baicker, K., Taubman, S., Allen, H., Bernstein, M., Gruber, J., Newhouse, J. P., Schneider, E. C., Wright, B., Zaslavsky, A. M., & Finkelstein, A. (2013). The Oregon experiment — Effects of medicaid on clinical outcomes. The New England Journal of Medicine, 368(18), 1713-1722. https://doi.org/10.1056/nejmsa12123
  3. Cheng, S. H., & Chiang, T. L. (1997). The effect of universal health insurance on health care utilization in Taiwan. Results from a natural experiment. JAMA, 278(2), 89-93. https://doi.org/10.1001/jama.278.2.89
  4. Chomi, E. N., Mujinja, P., Enemark, U., Hansen, K. S., & Kiwara, A. (2014). Health care seeking behaviour and utilization in a multiple health insurance system: Does insurance affiliation matter? International Journal for Equity in Health, 13(1), 25. https://doi.org/10.1186/1475-9276-13-25
  5. Dandona, L., Dandona, R., Kumar, G. A., Shukla, D. K., Paul, V. K., Balakrishnan, K., Prabhakaran, D., Tandon, N., Salvi, S., Dash, A. P., Nandakumar, A., Patel, V., Agarwal, S. K., Gupta, P. C., Dhaliwal, R. S., Mathur, P., Laxmaiah, A., Dhillon, P. K., Dey, S., … Swaminathan, S. (2017). Nations within a nation: Variations in epidemiological transition across the states of India, 1990–2016 in the Global Burden of Disease Study. The Lancet, 390(10111), 2437-2460. https://doi.org/10.1016/S01406736(17)32804-0
  6. Dilip T. R. (2010). Utilization of inpatient care from private hospitals: Trends emerging from Kerala, India. Health Policy and Planning, 25(5), 437-446. https:// doi.org/10.1093/heapol/czq012 7. Directorate of Economics and Statistics. (2019). Report on Private Medical Institutions in Kerala 2017-18 . Government of Kerala.
  7. Directorate of Economics and Statistics. (2019). Report on Private Medical Institutions in Kerala 2017-18 . Government of Kerala.
  8. Directorate of Health Services. (2019). List of Modern Medical Institutions 201718. Government of Kerala.
  9. Dubey, S., Deshpande, S., Krishna, L., & Zadey, S. (2023). Evolution of Government-funded health insurance for universal health coverage in India. The Lancet Regional Health. Southeast Asia , 13, 100180. https://doi.org/10.1016/ j.lansea.2023.100180
  10. Erlangga, D., Ali, S., & Bloor, K. (2019). The impact of public health insurance on healthcare utilization in Indonesia: Evidence from panel data. International Journal of Public Health, 64 (4), 603-613. https://doi.org/10.1007/s00038-019-01215-2
  11. Furtado, K. M., Raza, A., Mathur, D., Vaz, N., Agrawal, R., & Shroff, Z. C. (2022). The trust and insurance models of healthcare purchasing in the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana in India: Early findings from case studies of two states. BMC Health Services Research, 22(1). https://doi.org/10.1186/s12913- 022-08407-2
  12. Gujarati, D. (2015). Econometrics by Example (2 edition). Palgrave. Macmillan Publishers. nd
  13. Jacob, S. (2014). The Kerala regime and regional disparities in health infrastructure versus outcomes. Indi a Review, 13(1), 58-77. https://doi . org/10. 1080/14736489.2014.873680
  14. Jowett, M., Deolalikar, A., & Martinsson, P. (2004). Health insurance and treatment seeking behaviour: Evidence from a low-income country. Health Economics, 13 (9), 845-857. https://doi.org/10.1002/hec.862
  15. Joy, J. (2019). The Impact of RSBY-CHIS on utilization of Healthcare Services in Kerala. Kerala State Planning Board. https://spb.kerala.gov.in/sites/default/files/ inline-files/RSBYCHIS.pdf
  16. Kerala State Planning Board. (2021). Economic Review 2020. Appendix 6.2.7. Volume 2. Government of Kerala.
  17. Kondo, A., & Shigeoka, H. (2013). Effects of universal health insurance on health care utilization, and supply-side responses: Evidence from Japan. Journal of Public Economics, 99 , 1-23. https://doi.org/10.1016/j.jpubeco.2012.12.004
  18. Kunhikannan, T.P., &Aravindan, K.P. (2000). Changes in the health status of Kerala, 1987-1997 . Discussion paper No. 20. Kerala Research Programme on Local Level Development, Centre for Development Studies, Thiruvananthapuram.
  19. Levesque, J. F., Haddad, S., Narayana, D., & Fournier, P. (2007). Insular pathways to health care in the city: A multilevel analysis of access to hospital care in urban Kerala, India. Tropical Medicine & International Health: TM & IH, 12(7), 802-814. https://doi.org/10.1111/j.1365-3156.2007.01870.x
  20. Mao, W., Zhang, Y., Xu, L., Miao, Z., Dong, D., & Tang, S. (2020). Does health insurance impact health service utilization among older adults in urban China? A nationwide cross-sectional study. BMC Health Services Research, 20(1), 630. https:/ /doi.org/10.1186/s12913-020-05489-8
  21. Mohanty, S. K., and Dwivedi, L. K. (2021). Addressing data and methodological limitations in estimating catastrophic health spending and impoverishment in India, 2004-18. International Journal for Equity in Health, 20(1). https://doi.org/ 10.1186/s12939-021-01421-6
  22. Muraleedharan, M., & Chandak, A. O. (2021). Emerging challenges in the health systems of Kerala, India: Qualitative Analysis of Literature Reviews. Journal of Health Research , 36(2), 242-254. https://doi.org/10.1108/jhr-04-2020-0091
  23. Nair, Manju & Varma, Ravi. (2021). Availability, distribution and utilization of health care services in Kerala. Kerala State Planning Board. Government of Kerala.
  24. National Sample Survey 75 th Round. (2017). Key Indicators of Social Consumption in India: Health. Ministry of Statistics and Programme Implementation. Government of India.
  25. National Statistical Office. (2021). Elderly in India 2021. Ministry of Statistics and Programme Implementation. Government of India.
  26. Philip, N. E., Kannan, S., & Sarma, S. P. (2016). Utilization of comprehensive health insurance scheme, Kerala. Asia-Pacific Journal of Public Health, 28, 77S85S. https://doi.org/10.1177/1010539515602306
  27. Prinja, S., Chauhan, A. S., Karan, A., Kaur, G., & Kumar, R. (2017). Impact of Publicly Financed Health Insurance Schemes on Healthcare Utilization and Financial Risk Protection in India: A Systematic Review. PloS One, 12(2), e0170996. https://doi.org/10.1371/journal.pone.0170996
  28. Reddy, S., and Mary, I. (2013). Aarogyasri scheme in Andhra Pradesh, India: Some critical reflections. Social Change, 43(2), 245-261. https://doi.org/10.1177/ 0049085713492275
  29. Reshmi, B., Unnikrishnan, B., Rajwar, E., Parsekar, S. S., Vijayamma, R., & Venkatesh, B. T. (2021). Impact of public-funded health insurances in India on health care utilization and financial risk protection: A systematic review. BMJ Open , 11(12). https://doi.org/10.1136/bmjopen-2021-050077
  30. Sarma, P. S., Sadanandan, R., Thulaseedharan, J. V., Soman, B., Srinivasan, K., Varma, R. P., Nair, M. R., Pradeepkumar, A. S., Jeemon, P., Thankappan, K. R., & Kutty, R. V. (2019). Prevalence of risk factors of non-communicable diseases in Kerala, India: Results of a cross-sectional study. BMJ Open, 9(11), e027880. https:/ /doi.org/10.1136/bmjopen-2018-02788
  31. Sepehri, A., Sarma, S., & Simpson, W. (2006). Does non-profit health insurance reduce financial burden? Evidence from the Vietnam Living Standards Survey Panel. Health Economics, 15(6), 603-616. https://doi.org/10.1002/hec.1080
  32. Shi, Z., He, P., Zhu, D., Lu, F., & Meng, Q. (2022). Changes in health care utilization and financial protection after integration of the rural and urban social health insurance schemes in Beijing, China. BMC Health Services Research, 22(1), 1226. https://doi.org/10.1186/s12913-022-08602-1
  33. Spaan, E., Mathijssen, J., Tromp, N., McBain, F., ten Have, A., & Baltussen, R. (2012). The impact of health insurance in Africa and Asia: A systematic review. Bulletin of the World Health Organization, 90(9), 685-692. https://doi.org/10.2471/ BLT.12.102301
  34. Thuong, N. T. T. (2020). Impact of health insurance on healthcare utilization patterns in Vietnam: A survey-based analysis with propensity score matching method. BMJ Open, 10(10), e040062. https://doi.org/10.1136/bmjopen-2020-040062
  35. Wagstaff, A. & Pradhan.M. (2005). Insurance health impacts on health and non- medical consumption in a developing country. Policy Research Working Paper 3563. World Bank. https://doi.org/10.1596/1813-9450-3563
  36. Yan, X., Liu, Y., Cai, M., Liu, Q., Xie, X., & Rao, K. (2022). Trends in disparities in healthcare utilization between and within health insurances in China between 2008 and 2018: A repeated cross-sectional study. International Journal for Equity in Health, 21 (1), 30. https://doi.org/10.1186/s12939-022-01633-4
  37. Zhang, F., Shi, X., & Zhou, Y. (2020). The impact of health insurance on healthcare utilization by migrant workers in China. International Journal of Environmental Research and Public Health , 17(6), 1852. MDPI AG. http://dx.doi.org/10.3390/ ijerph17061852
  38. Zhang, L., Chen, R., & Fang, Y. (2023). Effects of urban and rural resident basic medical insurance on healthcare utilization inequality in China. International Journal of Public Health, 68 , 1605521. https://doi.org/10.3389/ijph.2023.16055