Metamorphosing Universal Health“Care” into Universal Health“Cover”: Assessing the Performance of National Health Insurance Scheme for Poor in India Using Big Data

Background
In India, nearly 63 million people fell into poverty pit due to gigantic out-of-pocket spending on healthcare. Failure of the government to extend an adequate and all-inclusive public healthcare system led to the introduction of National Health Insurance Scheme (NHIS)/RSBY in 2008 on the pan-India basis with an objective to proffer cashless inpatient care to the poor, predominantly in private hospitals. The Indian government promoted neoclassical ethos of market-driven health sector (via NHIS) where the government merely played the role of a financer-cum-manager while private players performed the role of provider of services. It has often been conjectured that leaving the market in the hands of private players, excludes the poor and marginalized from availing the benefits of programs meant for their welfare. The present paper evaluates the performance and impact of NHIS on marginalized sections and juxtaposes the findings in context of the Keynesian-Neoclassical debate on Universal Healthcare versus Universal Health Cover.

Methods
Unit level RSBY administrative data has been employed from four waves (2008-09 to 2012-13). The data is provided by Ministry of Labour & Employment, Government of India for 281 covered districts (of the 640 in total). The study investigates the extent to which the scheme has been inclusive in terms of it’s coverage (of marginalized) and utilization using cross-tabulations and Multivariate Probit regression models.

Findings
The results show an impressive increase in the coverage and utilization of the scheme between 2008 and 2013 but the districts with a higher concentration of socially deprived caste (Adivasis and Dalits) and religious categories (like Muslims) are still not covered. Furthermore, there is some preliminary evidence regarding “the elite capture” as districts with the greater share of wealthy households exhibit a higher probability of participation. Districts with poor infrastructure are estimated to have a higher probability of non-inclusion in the scheme vis-à-vis others. Interestingly, once a district has enrolled for the scheme, utilization of healthcare services are higher amongst deprived castes and in districts served by public insurance providers.

Conclusion
If placed in the the perspective of providing social security to the poor, the scheme has failed to cover some of the most backward districts of the country comprising of higher proportions of socially and economically deprived population. Further, introducing an insurance program without proper infrastructure in place like health centres, roads and electricity makes the scheme redundant even if it reaches such underdeveloped districts as the micro-health scheme in such cases merely ensures the “availability” without really ensuring “accessibility” of the healthcare service. In a nutshell, NHIS health “cover” has not completely translated into health “care” for the marginalized in the country.