BACKGROUND Many LMICs have implemented Publicly Funded Health Insurance (PFHI) programmes to improve access and financial protection. The national PFHI scheme implemented in India for a decade has been recently modified and expanded to cover free hospital care for 500 million persons. Since increase in annual cover amount is one of the main design modifications in the new programme, the relevant policy question is whether such design change can improve financial protection for hospital care. An evaluation of state-specific PFHI programmes with vertical cover larger than RSBY can help answer this question. Three states in Southern India - Andhra Pradesh, Karnataka and Tamil Nadu have been pioneers in implementing PFHI with a large insurance cover. METHODS The current study was meant to evaluate the PFHI in above three states in improving utilisation of hospital services and financial protection against expenses of hospitalization. Two cross-sections from National Sample Survey's health rounds, the 60th round done in 2004 and the 71st round done in 2014 were analysed. Instrumental Variable method was applied to address endogeneity or the selection problem in insurance. RESULTS Enrollment under PFHI was not associated with increase in utilisation of hospital care in the three states. Private hospitals dominated the empanelment of facilities under PFHI as well as utilisation. Out of Pocket Expenditure and incidence of Catastrophic Health Expenditure did not decrease with enrollment under PFHI in the three states. The size of Out of Pocket Expenditure was significantly greater for utilisation in private sector, irrespective of insurance enrollment. CONCLUSION PFHI in the three states used substantially larger vertical cover than national scheme in 2014. The three states are known for their good governance. Yet, the PFHI programmes in all three states failed in fulfilling their fundamental purpose. Increasing vertical cover of PFHI and using either 'Trusts' or Insurance-companies as purchasers may not give desired results in absence of adequate regulation. The study raises doubts regarding effectiveness of contracting under PFHIs to influence provider-behavior in the Indian context. Further research is required to find solutions for addressing gaps that contribute to poor financial outcomes for patients under PFHI.

中文翻译：

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印度南部三个邦公共资助健康保险下医院护理的利用和财务保护。

背景 许多中低收入国家已经实施了公共资助健康保险 (PFHI) 计划，以改善获得机会和财务保护。印度实施了十年的国家 PFHI 计划最近经过修改和扩大，覆盖了 5 亿人的免费医院护理。由于增加每年的保障金额是新计划的主要设计修改之一，因此相关的政策问题是这种设计改变是否可以改善医院护理的财务保障。对垂直覆盖范围大于 RSBY 的州特定 PFHI 计划进行评估可以帮助回答这个问题。印度南部的三个邦——安得拉邦、卡纳塔克邦和泰米尔纳德邦是实施 PFHI 并提供大量保险的先驱。方法 本研究旨在评估上述三个州的 PFHI 在提高医院服务利用率和住院费用财务保障方面的情况。对国家抽样调查健康轮次的两轮横截面数据（2004 年进行的第 60 轮和 2014 年进行的第 71 轮）进行了分析。应用工具变量方法来解决保险中的内生性或选择问题。结果 在这三个州，参加 PFHI 与医院护理利用率的增加无关。私立医院在 PFHI 设施的建设和利用方面占主导地位。在这三个州，自付费用和灾难性健康支出的发生率并没有随着 PFHI 注册人数的增加而减少。无论是否参加保险，私营部门使用的自付费用规模都要大得多。结论 2014 年，这三个州的 PFHI 使用的垂直覆盖范围比国家计划大得多。这三个州以其良好的治理而闻名。然而，这三个州的 PFHI 计划都未能实现其根本目的。如果缺乏足够的监管，增加 PFHI 的垂直覆盖以及使用“信托”或保险公司作为购买者可能不会产生预期的结果。该研究对 PFHI 下的合同影响印度背景下提供者行为的有效性提出了质疑。需要进一步研究来找到解决方案，以解决导致 PFHI 患者财务状况不佳的差距。