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Out of Pocket health Expenditure (OOPE) |
Inpatient OOPE: RSBY-influenced reduction in inpatient OOPE. The evidence is generated from three high methodological studies.14 18 30 The per-capita inpatient expenditure for RSBY-treated households, decreased in both rural and urban areas.14 The impact of RSBY on inpatient expenditure was reduced for unmatched and matched samples, when RSBY was implemented for a minimum of 2 months duration. After removing Uttar Pradesh (UP) and Haryana from the analysis, the triple difference findings (ie, with a second control of non-BPL households) showed a reduction in inpatient expenditure, but the double difference analysis showed an increase in inpatient expenditure due to RSBY. However, none of these findings was statistically significant.18 Both the studies included NSSO data from Andhra Pradesh, Karnataka and Tamil Nadu and used matching and DID methodology for analysis. Sabharwal et al,30 used PSM impact analysis to report that average annual household expenditure on inpatient care was significantly less for RSBY beneficiary households when compared with non-beneficiary households. This study also reported that average annual household expenditure spent on inpatient was higher for RSBY beneficiaries who used the smart card for inpatient expenses than the RSBY beneficiaries who did not use the RSBY smart card. However, a low methodological study32 reported a significant increase in inpatient expenditure for both public and private healthcare, in the state of Maharashtra. This difference was calculated using DID method for the years 2004 and 2012 (after implementation of RSBY in the state). The scheme did not have a significant effect on the OOPE expenditure for inpatient visits.16 19 A good methodological study16 applied the coarsened exact matching and linear and logit regression to report the impact of RSBY on OOPE for inpatient visits, among insured households. No statistically significant difference was reported between RSBY-insured and uninsured households. Another good methodological study,19 applied PSM and DID approach, to find the impact of RSBY on inpatient OOPE in total household expenditure, by dividing treatment districts into Treatment 1 (TT1), ie, March 2010 and Treatment 2 (TT2) group, ie, April 2010 to March 2012. No impact of RSBY on the inpatient OOPE as share of total household expenditure was observed. The probability of incurring 0 OOPE inpatient expenditure was not significantly different for RSBY and non-RSBY families. RSBY increased the probability of incurring inpatient OOPE by 22% (TT1) and 28% (TT2), respectively. However, these findings were not significant.19 Outpatient OOPE: five studies14 16 18 19 30 provided inconclusive information on the effect of RSBY on outpatient OOPE. RSBY had a negative impact on the outpatient expenditure.14 18 According to Azam,14 implementation of RSBY reduced the per capita outpatient expenditure for both rural and urban areas. The outpatient expenditure reduced for RSBY households for the overall matched sample and for the matched sample minus UP and Haryana.18 There was no statistically significant difference between RSBY-insured and uninsured households in terms of OOPE on outpatient visits.16 30 RSBY increased the probability of incurring outpatient OOPE for households participating in RSBY before March 2010, by 23%; however, there was no significant effect on the scheme on outpatient OOPE for the RSBY households between April 2010 and March 2012.19 Total OOPE spending: four studies provided information on total OOPE spending after RSBY implementation.14 16 19 23 RSBY resulted in reduction of total OOPE of the households. The findings of these studies were mostly not significant. Two studies used matching and DID for analysis and two used matching and regression.
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Catastrophic Health Expenditure (CHE) |
Four studies14 16 19 25 provided information on the effect of RSBY on CHE, the RSBY households were less likely to incur CHE for outpatient care, inpatient care and overall CHE. It was observed that beneficiaries of the scheme reported a reduction in CHE; however, one study25 reported that there was no effect of RSBY on CHE. According to Azam,14 the effect was same for both rural and urban households. RSBY increased the likelihood of CHE 25.14 All these findings about the impact of RSBY on CHE were not significant. However, incidence of CHE was significantly reduced for RSBY households with childbirth in last 1 year of data collection.25 Two studies14 19 performed matching and analysed using DID analysis, and other studies16 25 performed matching and linear and logistic regression. The cost of medicines was significantly reduced by 22 INR for RSBY households in the rural areas; however, it increased for the urban households by 28 INR, but this result was not significant.14
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Impoverishment
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The effect of RSBY on impoverishment was not clear. One study16 reported that RSBY had no effect on impoverishment due to OOP on inpatient care and on the total overall probability of impoverishment. However, in another study25 among RSBY enrolled APL households, the incidence of health expenditure induced poverty was significantly increased, that is, APL households were pushed to BPL because of healthcare expenditure. Both the studies performed matching and used regression analysis, linear and logistic regression. |
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Utilisation of healthcare
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Around eight studies14 16 23 26 27 30 32 35 looked at the impact of RSBY on healthcare utilisation. The outcomes assessed by these studies include reporting of illness, hospitalisation rate, outpatient care and inpatient care utilisation and utilisation of hospital services. The impact of RSBY on hospitalisation was assessed by six studies14 23 26 27 32 35; all the studies showed increase in the hospitalisation, of which three studies showed significant increase in hospitalisation among female heads, scheduled tribes and for poorest.27 For women seeking treatment in obstetrics department.26 The studies16 30 suggested increase in both, inpatient and outpatient services. However, the results were significant for inpatient care for one of the studies.16 A study14 assessed the impact of health insurance on reporting morbidity and seeking treatment for illness in both rural and urban areas. The ATT analysis suggested increase in reporting of morbidity, seeking treatment for short-term and long-term illnesses and long-term morbidity in rural India compared with urban India. The increased value ranges from 0.7% to 3.2%. In urban India, the increase in reporting illness by RSBY holders varied from 2.3% to 2.4%, which was not statistically significant.14
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