research paper on insurance in india

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• v.11(12); 2021

Original research

Impact of public-funded health insurances in india on health care utilisation and financial risk protection: a systematic review, bhageerathy reshmi.

1 Department of Health Information Management, Manipal College of Health Professions, Manipal Academy of Higher Education (MAHE), Manipal, Karnataka, India

Bhaskaran Unnikrishnan

2 Department of Community Medicine, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, Karnataka, India

3 Department of Health Information, Public Health Evidence South Asia, Prasanna School of Public Health, Manipal Academy of Higher Education (MAHE), Manipal, Karnataka, India

Shradha S Parsekar

Ratheebhai vijayamma.

4 Manipal Institute of Communication, MAHE, Manipal, Karnataka, India

Bhumika Tumkur Venkatesh

Associated data.

bmjopen-2021-050077supp001.pdf

Data are available upon reasonable request. All data relevant to the study are included in the article or uploaded as supplementary information. The datasets used and/or analysed during the current study are available from the corresponding author on request.

Universal Health Coverage aims to address the challenges posed by healthcare inequalities and inequities by increasing the accessibility and affordability of healthcare for the entire population. This review provides information related to impact of public-funded health insurance (PFHI) on financial risk protection and utilisation of healthcare.

Systematic review.

Data sources

Medline (via PubMed, Web of Science), Scopus, Social Science Research Network and 3ie impact evaluation repository were searched from their inception until 15 July 2020, for English-language publications.

Eligibility criteria

Studies giving information about the different PFHI in India, irrespective of population groups (above 18 years), were included. Cross-sectional studies with comparison, impact evaluations, difference-in-difference design based on before and after implementation of the scheme, pre–post, experimental trials and quasi-randomised trials were eligible for inclusion.

Data extraction and synthesis

Data extraction was performed by three reviewers independently. Due to heterogeneity in population and study design, statistical pooling was not possible; therefore, narrative synthesis was performed.

Utilisation of healthcare, willingness-to-pay (WTP), out-of-pocket expenditure (including outpatient and inpatient), catastrophic health expenditure and impoverishment.

The impact of PFHI on financial risk protection reports no conclusive evidence to suggest that the schemes had any impact on financial protection. The impact of PFHIs such as Rashtriya Swasthy Bima Yojana, Vajpayee Arogyashree and Pradhan Mantri Jan Arogya Yojana showed increased access and utilisation of healthcare services. There is a lack of evidence to conclude on WTP an additional amount to the existing monthly financial contribution.

Different central and state PFHIs increased the utilisation of healthcare services by the beneficiaries, but there was no conclusive evidence for reduction in financial risk protection of the beneficiaries.

Registration

Not registered.

Strengths and limitations of this study

• Inclusion of all kinds of empirical evidence to answer the research question about impact of public-funded health insurance (PFHI) schemes in India.
• This is one of the very few reviews that has used a systematic methodology to provide latest evidence on the impact of the newly launched Pradhan Mantri Jan Arogya Yojana scheme in India.
• Choice of quality appraisal tool, due to unavailability of other tools for this kind of study, was a limitation.
• Multiple PFHI (state-specific and central) schemes in India (with different benefit packages) and modifications in the schemes due to changes in central/state governments led to high data heterogeneity.
• Due to heterogeneity in data, we could not provide the pooled estimate via meta-analysis. However, results were explained via a narrative synthesis.

Introduction

India has a complex and mixed healthcare framework with presence of parallel public and private healthcare systems. 1 2 There is a stark difference in government spending on both public and private healthcare. 3 Health policies in India have been guided by the principle of equity with prioritising the needs of the poor and underprivileged. 4 Out-of-pocket expenditure (OOPE) for health is one of the important factors while addressing the inequities in healthcare, and in India, it is an important source of healthcare financing. It is estimated that, in India, around 71% of the healthcare spending is met by OOPE. This not only is an immediate financial burden to the poor households but also pushes the households into a never-ending poverty trap. 5 Health-related OOPE poses a threat to the principle of financial risk protection and adds to the unaffordability and inaccessibility of healthcare for the poor. High OOPE also leads to catastrophic health expenditure (CHE), which is the increase in healthcare payment by a household, beyond the threshold, where the threshold is defined as the household’s income or capacity to pay. This is further divided into catastrophe 1, where healthcare OOPE exceeds by 10% of the household’s consumption expenditure, and catastrophe 2, if OOPE exceeds to more than 40% of the household’s non-food expenditure. The increase in OOPE affects the rural population marginally more than the urban population and the effect of OOPE is more pronounced among the people living below the poverty line (BPL) than those above the poverty line (APL), as BPL people are pushed more into poverty than APL, due to the high OOPE, when measured via the increase in poverty head counts. 5

Over the years, government of India has rolled out different initiatives to address the healthcare-related inequities in India. The public healthcare system was revised and reframed as the National Rural Health Mission in 2005, later restructured as National Health Mission in 2014. 5 6 Other initiatives like Janani Suraksha Yojana and the public funded health insurance (PFHI) schemes such as Rashtriya Swasthya Bima Yojana (RSBY) were also introduced to address the health inequalities, improve health outcomes and provide financial risk protection. 6 Many states sponsored health insurance (HI) schemes, viz., the Vajpayee Arogyashree Scheme (VAS) by Karnataka, Comprehensive Health Insurance Scheme (CHIS) by Kerala and Chief Minister Health Insurance Scheme (CMHIS) by Tamil Nadu, which have been introduced for ensuring financial protection of the vulnerable population.

Challenges posed by healthcare inequalities and inequities like OOPE can also be addressed via the Universal Health Coverage (UHC). The UHC, as defined by the WHO, means that all people and communities can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship. The UHC aims towards increasing the accessibility and affordability of healthcare for the entire population. The definition of UHC is embodied in its three objectives, that is, equity, quality and financial protection. 7

The twelfth 5-year plan of the government of India acknowledges the importance of UHC as it introduces a work plan for achieving UHC for the 1.3 billion population of the country. The agenda for this plan is based on the principle of providing affordable, accessible and good quality healthcare with financial protection to the people of the country. 8 The provision of UHC has been included in the National Health Policy of India (2017). To achieve the UHC, government of India announced the ‘Ayushman Bharat’ programme in 2018 with two initiatives, that is, (a) Health and Wellness center and (b) National health protection scheme —Pradhan Mantri Jan Arogya Yojana (PMJAY), that is intended to cover around 500 million beneficiaries (from vulnerable families) and is intended to cover up to Indian National Rupees (INR) 500 000 per family, per year, for secondary and tertiary hospitalisation. 9

The addition of PMJAY scheme to the various existing PFHI (central and state) schemes aims to increase the UHC, by increasing the affordability and accessibility of good quality healthcare. It is important to assess whether these schemes (including PMJAY) have been proven to be effective in improving health outcomes and providing financial protection to the vulnerable population. Following the principles of UHC, willingness to pay (WTP) for a particular HI scheme can also be used as an indicator to assess the affordability and effectiveness of a scheme in providing good quality healthcare. Additionally, data on beneficiaries willing to pay more or contribute more for a HI scheme (viz., CGHS) indirectly provide information on their satisfaction with the services provided by the scheme, therefore, making it an indicator to assess effectiveness of the scheme. The previous systematic review 10 on assessing the effectiveness of PFHI schemes in India was conducted before complete rolling out of the PMJAY and, therefore, did not include findings on the effectiveness of the scheme (PMJAY). Also, this review 10 did not provide information on the WTP component of assessing impact of the HI schemes. The present review was, therefore, conducted with an aim to provide information related to effectiveness of the central and state-funded HI schemes (including the PMJAY scheme) via healthcare utilisation, WTP and financial risk protection of the beneficiaries. This review was planned to answer the following research question: (a) What is the impact of PFHI schemes on access and utilisation of healthcare, willingness-to-pay and financial risk protection in India?

This systematic review follows the methodology by Cochrane handbook for systematic review of interventions 11 and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist was used to report the review. 12

Criteria for including studies in the review

• Population: population group above 18 years of age enrolled in a PFHI scheme in India.
• Intervention: HI schemes funded by either central or state government, and that covers, range of services such as hospitalisation, out-patient charges, medicine costs, treatment procedures, etc. Different PFHI schemes in India, for example, RSBY, VAS, CMHIS and PMJAY were eligible to be included. Private or community-based HIs were not eligible to be included. Mixture of HIs was excluded provided a study carried out subgroup analysis for PFHIs.
• Comparison: comparison group comprises of people who did not receive any PFHI services.
• Outcomes: this review includes the following outcomes: (a) utilisation of healthcare, (b) WTP, (c) financial risk protection measured in terms of OOPE, CHE and impoverishment.
• Study design: cross-sectional studies with comparison, impact evaluations, difference-in-differences design based on before and after implementation of the scheme, pre–post design, experimental trials and quasi-randomised trials were eligible to be included.

Search methods for identification of studies

Electronic databases such as Medline (via PubMed, Web of Science), SCOPUS, Social Science Research Network and International Initiative for impact evaluation (3ie) repository were searched from their inception until 15 July 2020; however, only English publications, published in the last 10 years were considered. References and forward citations of the included studies were scanned through for any additional eligible studies. Keywords were identified before the initiation of the search. The initial search was carried out in PubMed ( online supplemental file 1 ) and was replicated in other databases. Search was conducted by a designated information scientist.

Supplementary data

Data collection.

Result of search strategy was imported to Endnote V.X7 reference manager software. Duplicates were removed and the unique citations were exported to Microsoft Excel spreadsheet for screening.

Selection of studies

Unique citations were subjected to title and abstract screening independently by two reviewers. Eligible abstracts of all the relevant studies as per the inclusion criteria were included for full-text screening (by BTV, ER and SSP) and relevant ones from these were included for analysis. Before initiating full-text screening, we tried to retrieve the full-text articles by contacting authors of the respective articles and the full texts that were not retrieved were excluded. Disagreements were resolved by discussion or by a third reviewer.

Data extraction

Data extraction was done (by ER, BTV, SSP) using a predesigned data extraction form. Information on variables such as bibliographic details (author names, publication year, journal name); study details (information about the objectives of the study and research question addressed); study setting (name of the state, rural/urban); participant characteristics (age, gender, socioeconomic status, occupation); intervention details (name and type of HI, mode of delivery of the HI, incentives given, healthcare services covered, time duration of seeking HI, any additional HIs); comparison details; outcome details (information about changes in accessibility of healthcare, utilisation of healthcare services, OOPE, WTP, health outcomes like morbidity and mortality, measurement of the outcomes, method used for measurement, time at which the outcome was measured) and study design details (type of study design and analysis) were extracted.

After pilot testing of the data extraction form, it was revised according to the modifications suggested by the team. Disagreements among the reviewers, during data extraction, were resolved by consensus, if still not resolved, third reviewer was approached for resolving the disagreements. Extracted data from all the included studies were cross-checked and independent extraction was done for one-third randomly selected studies.

Methodological quality

The methodological quality of the included studies was assessed using Effective Public Health Practice Project Quality Assessment Tool (EPHPP). 13 This tool assesses methodological quality of the quantitative studies based on questions under the following seven domains, that is, (a) selection bias, (b) study design, (c) confounders, (d) blinding, (e) data collection method, (f) withdrawals and dropouts, (g) intervention integrity and (h) analysis. Quality assessment using this scale was performed independently by reviewers in groups of two. After discussion, global rating for the scale was followed and studies were marked as (1) methodologically strong, if none of the domains had any weak rating, (2) moderate, if at least one domain was marked as weak and (3) weak, if two or more domains were marked as weak. Quality assessment was performed using Microsoft excel spreadsheet.

Data analysis

Due to heterogeneity in data, narrative synthesis was performed to answer the research question. The results are summarised based on outcomes and types of PFHIs. The effect measures of included studies such as mean difference or correlation coefficients with appropriate CI and/or p values are reported.

Public and patient involvement

We did not involve public or patient during the process of this review.

The literature search on electronic databases generated 555 citation yield, out of which 179 were duplicates. Additionally, 17 records were identified from forward and backward reference checking. After title and abstract screening of 393 citations, 157 were included for full-text screening, of which finally 25 articles were included for data synthesis. Schematic representation of the selection process is shown in figure 1 .

PRISMA flow diagram. PFHI, public-funded health insurance; PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Characteristics of included studies

The summary of study characteristics is given in table 1 and the detailed characteristics of included studies are given in online supplemental file 1 .

Summary characteristics of included studies

Impact of PFHI on financial risk protection, utilisation of healthcare and WTP

This systematic review provides evidence on the impact of different PFHI schemes that have been operational in India. These schemes are funded by the central government, viz., RSBY, CGHS, Employee State Insurance Scheme, Swavlamban, Nirmaya-Disability Health Insurance Scheme and PMJAY and by the state governments like VAS (Karnataka), Rajiv Arogya Shree (Andhra Pradesh) and CHIS (Tamil Nadu). The eligibility criteria and benefits offered under each scheme vary according to different state governments. More information on these PFHI schemes is given in box 1 .

Central and state-sponsored PFHI schemes in India

Central-funded health insurance schemes

• Rashtriya Swasthya Bima Yojana—RSBY (2008) is a central-funded health insurance scheme in which 75% of the annual premium is provided by the central government and rest 25% by the state governments. In-patient expenditure of upto Indian National Rupees (INR) 30 000 per family per annum is insured for below poverty line families. Unorganised sector is also covered under this scheme.
• Prime Minister’s Jan Arogya Yojana—PMJAY (2018) is a fully government sponsored scheme, which provides a cover of INR 500 000 per family per year in government empanelled public and private hospitals of India, for secondary and tertiary-level hospitalisation. Vulnerable and below the poverty line (BPL) families are eligible to avail the services under this scheme.
• Central Government Health Scheme (1954) is eligible for central government employees and pensioners enrolled under the scheme. According to this scheme, inpatient services at the government empanelled hospitals, outpatient services including medicines, consultation by experts, maternity and child health services (family welfare) and medical consultation for alternative system of medicines are covered.
• Swavlamban (2015), this is a central-funded health insurance scheme for people with disabilities. Eligible population includes BPL and differently abled people with blindness, hearing impairment, leprosy-cured, locomotor disability, mental illness, etc. A sum of INR 200 000 per annum is covered and treatment of pre-existing illness is covered under the scheme.
• Nirmaya-Disability Health Insurance Scheme (2008), this central-funded health insurance scheme is specifically for people with Cerebral Palsy, autism, multiple disabilities and mental retardation. Services of upto INR 100 000 are covered under this scheme.
• Employee State insurance Scheme—Employee State Insurance Scheme(1952), this scheme is funded by the employers and staff contributions and is applicable to employees of factories and establishments drawing wages upto INR 15 000 a month. Under this scheme, a number of benefits to protect the employees or workers from illness, disability and death are paid to the beneficiaries. Benefits such as sickness benefit (70% of wages), temporary disablement benefit (90% of last wage), permanent disability benefit (90% of wage), maternity benefit (100% of wage), dependent benefit (90% of wage), INR 10000 to dependents for funeral expenses in case of death of the employees and other benefits like vocational and physical rehabilitation are given to the beneficiaries.

State government-funded health insurance schemes

• Aarogyasri Scheme (2007), this scheme is by the Telangana state and BPL families belonging to the state are eligible. Benefits include cashless transactions for treatment of extreme illness, for up to INR 200 000 per year, covered under the scheme.
• Ayushman Bharat—Mahatma Gandhi Rajasthan Swasthya Bima Yojana (2019), this scheme is by the government of Rajasthan and is formed by merging PMJAY scheme and Bhamashah Swasthya Bima Yojana. All the Rajasthani families belonging to BPL category are covered under this scheme. Under this scheme, an insured amount of INR 50 000and INR 450 000 are provided for secondary and tertiary illness, respectively.
• Chief Minister’s Comprehensive Health Insurance Scheme (2012), this is a state-funded HI scheme by government of Tamil Nadu. People belonging to families of less than INR 72 000 are annual earning or less and members of unorganised labour welfare boards, including their families are eligible. Services and benefits of up to INR 500 000 per family per year are covered under the scheme.
• Deen Dayal Swasthaya Seva Yojana (2016), by Goa government, for residents of Goa (residing for at least 5 years), central and state government employees already covered under other government health insurance benefits are eligible. Benefits include cashless inpatient services under government empanelled services. Annual coverage of upto INR 250 000 for a family of three and INR 400 000 for a family of four or more is given. Beneficiaries have to provide an annual premium of INR 200–300 to avail the benefits of the scheme.
• Dr YSR Aarogyasri Scheme (Formerly called Rajiv Arogyasri Community Health Insurance Scheme)−2007, by the Andhra Pradesh government, this scheme covers BPL families from Andhra Pradesh. Under this scheme, free end-to-end cashless services are provided for patients undergoing treatment for therapies listed by the network hospitals. Free outpatient assessments are done for patients not undergoing treatment under the sited therapies.
• Vajpayee Arogaya Shree (2009), this scheme is funded by the government of Karnataka and is applicable for BPL families from rural and urban areas of Karnataka. A total of INR 150 000 is reimbursed for services provided to five members of the beneficiary family, an extra sum of INR 50 000 per annum is provided in case-to-case basis.
• West Bengal Health for All Employees and Pensioners Cashless Medical Treatment Scheme (2014), previously known as ‘West Bengal Health Scheme’, by the government of West Bengal, this scheme is for West Bengal government employees, pensioners and their family members. Benefits include reimbursement for in-patient services in the state empaneled hospitals and outpatient services for 15 diseases mentioned in the scheme. Cashless medical treatment for up to INR 100 000 is provided for inpatient treatment.
• Yeshasvini co-operative farmer’s healthcare scheme (2003), by government of Karnataka, this scheme is for farmers who are members of the cooperative societies. According to this scheme, beneficiaries from the rural areas have to contribute INR 250 (for general category) and INR 50 (for SC/ST families) per annum. Beneficiaries from the urban areas have to contribute INR 710 (for general category) and INR 110 (for SC/ST) per annum. Benefits include inpatient services, discount rates for lab investigations, tests, outpatient services and medical emergency services due to mishaps during farming or any other agriculture related work.

Summary of the impact findings of RSBY and other PFHIs is given in tables 2 and 3 , respectively, and the detailed synthesis is provided in online supplemental file 1 .

Impact of RSBY on financial risk protection and healthcare utilisation

APL, Above poverty line; ATT, Average Treatment Effect on Treated; DID, Difference in Differences; NSSO, National Sample Survey Office; OOPE, out-of-pocket expenditure; PSM, Propensity Score Matching; RSBY, Rashtriya Swasthya Bima Yojana.

Impact of other public-funded health insurance (PFHI) schemes on financial risk protection and healthcare utilisation

OLS, Ordinary Least Squares.

Financial risk protection

Twenty-one studies measured financial risk protection, of which 17 were of strong methodological quality, 14–30 3 of moderate methodological quality 31–33 and 1 weak methodological quality. 34 Nine studies 14 16 18 19 23 25 30 32 34 reported the impact of RSBY alone on financial protection. Thirteen studies 15 17 20–22 24 26–29 31–33 provided information on the effect of different PFHI schemes (including state insurance schemes) on financial risk protection.

Three high methodological quality studies reported a reduction in in-patient OOPE for RSBY households; 14 18 30 however, the findings were not significant. One low methodological study stated that after implementation of RSBY in Maharashtra state, there was a significant increase in in-patient expenditure for both public and private healthcare. 32 RSBY did not have a significant effect on in-patient OOPE as a share of total health expenditure, this was reported by two good methodological studies. 16 19 The findings for the impact of RSBY on outpatient OOPE were mixed as out of five good methodological quality studies, two studies mentioned that RSBY led to a reduction in outpatient OOPE, 14 18 two studies reported that RSBY did not have any impact on the outpatient OOPE 16 30 and one study reported that the probability of incurring increased after implementation of RSBY. 19 It was reported that the RSBY households were less likely to incur CHE for outpatient care, in-patient care and overall CHE; 14 16 19 however, one high methodological quality study reported that there was no impact of RSBY on CHE. 25 All these findings were non-significant. The effect of RSBY on impoverishment was not clear as one study reported that RSBY had no effect on impoversihment, 16 whereas another study reported an increase in impoverishment among the Above Poverty Line (APL) housholds. 25

For other PFHI schemes, the findings for effect of HI schemes on financial risk protection were mixed. Three studies reported a reduction in OOPE for insured households, 20 21 26 whereas another study reported no effect on OOPE. 24 For households insured under VAS and RAS, no effect of these schemes was seen on OOPE. 17 One study reported a reduction in in-patient drug expenditure for RAS households; 15 however, other studies reported an increase in-patient household expenditure. 27 32 For CHIS in Tamil Nadu, one study reported no association of CHIS with size of OOPE 17 and another study reported an increase in OOPE in-patient expenditure. 33 It was reported that CHE was reduced for households enrolled under different PFHI schemes, 21 28 however, specifically for VAS, one study reported reduction in CHE, 31 and another study reported no association between CHE and insurance. 17 For CHIS and RAS, no association was reported for CHE and insurance schemes. 15 17 Enrolment in PMJAY did not decrease the OOPE or CHE of the enrolled households. 29

Due to mixed evidence reported for the impact of PFHI schemes on different financial risk protection parameters, it is not possible to conclude whether these schemes have proven to be beneficial in reducing financial risk of the beneficiaries. A summary of these findings is given in tables 2 and 3 .

Access and utilisation of health services

Overall, 16 studies assessed the impact of PFHI on access and utilisation of health services ( tables 2 and 3 ). The HI programmes were RSBY, 14 16 23 26 27 30 32 35 VAS 36 37 RAS, 17 27 32 CHIS 20 21 24 26 33 and PMJAY. 29 Of the 16 studies, 13 studies 14 16 17 20 21 23 24 26 27 29 30 36 37 were assessed to be of strong methodological quality, 32 33 2 were assessed as of moderate quality and 35 1 was rated as weak quality. The analysis that was carried out majorly to look at the impact was logistic regression, profit models and other types. The outcomes that were reported include reporting of illness or morbidity, hospitalisation rate, outpatient care and in-patient care utilisation, duration of hospitalisation and utilisation of hospital services. Findings demonstrated increased access, utilisation of healthcare (both in rural and urban areas) and hospitalisation for RSBY. 14 16 23 26 27 30 32 35 For other PFHI schemes like VAS, RAS and CHIS, an increase in utilisation of healthcare and in-patient outpatient services was reported. 20 21 24 26 32 33 36 37 No significant difference in healthcare utilisation was reported for PMJAY beneficiaries. 29

Willingness-to-pay

A high methodological study 38 reported WTP for the insurance scheme. A majority (71 per cent) of CGHS beneficiaries considered that their current contribution was low and were willing to contribute more. Only 28 per cent Ex-servicemen Contributory Health Scheme beneficiaries were willing to pay an additional monthly financial contribution for better quality healthcare under the schemes. In comparison to higher employment grade beneficiaries, the CGHS beneficiaries from low employment grade were more willing to pay an additional amount to the existing monthly financial contribution.

This review identified and provided information on the impact of different PFHI schemes (operational in India) on healthcare utilisation, WTP and financial risk protection of the beneficiaries. It was observed that although the utilisation of healthcare services via in-patient and outpatient visits increased for insured beneficiaries, there was inconclusive evidence on the impact of different PFHII schemes on financial risk protection.

Our findings report that there is no conclusive evidence to suggest that RSBY reduced the OOPE and CHE or had an impact on financial risk protection. For other PFHIs including the state-sponsored PFHIs, viz., RAS, VAS and CHIS, the findings suggest a mixed impact of these schemes on OOPE, CHE and impoverishment, leading to inconclusive evidence for financial risk protection. Our findings are similar to another systematic review, 10 which reported lack of substantial evidence for reduction in OOPE or improvement in financial risk protection by PFHI schemes in India.

For financial risk protection, varying results, from different studies for the same PFHI scheme, resulted in mixed findings for this outcome. Therefore, it was a challenge to pool evidence together and conclude on the impact of PFHI schemes on financial risk protection. One of the plausible reasons for this can be the different study designs and analysis methods used by different studies to assess the impact of financial risk protection. Also, difference in benefits packages and implementation of the scheme by various successive governments might have resulted in these mixed findings for this outcome.

One of the reasons for studies reporting no substantial impact of RSBY on financial risk protection can be the limited insurance cover, for example, INR 30 000 annually under RSBY. As the utilisation of healthcare and hospitalisation under RSBY has increased over the years, 10 it is possible that beneficiaries would have been hospitalised for hospital services of more than INR 30 000, leading to additional OOP payment. Hospitalisation for services not offered by the RSBY package and denial of hospitalisation by the empaneled hospitals has also led to an increase in OOPE. 39 Another reason for the negligible impact of RSBY in reducing OOPE, as reported in some of the studies, can be the operational or functional error of the scheme. An important component of the scheme is the insurance companies, which are responsible for enrolling beneficiaries, empaneling hospitals, processing claims and reimbursing money. Delayed reimbursement from the insurance companies leads to hospitals asking beneficiaries to buy medicines and other consumables from outside, which results in high OOPE. Additionally, as there is no incentive for the insurance companies to keep a check on the OOPE payments, hospitals might charge patients or deny reimbursement of money on trivial grounds, leading to high OOPE. 39 Another reason could be (which is based on personal experience of authors) to get an appointment for the surgery in empenelled hospitals, beneficiaries of the PFHIs usually wait for a longer period of time. Therefore, to avoid the delay in treatment, beneficiaries have to resort to OOP.

The impact of PFHIs (other than RSBY) including the state-sponsored schemes was reported to be mixed and inconclusive, similar to another systematic review that reported lack of substantial evidence of impact on OOPE for PFHI operational in low and middle-income countries (LMICs). 40 Additionally, as the functioning of any PFHI scheme depends on the governance, different governance structures and demographic profiles of the states would have led to heterogeneity in results. Poor impact of different PFHIs on financial risk protection (reported in some of the studies) can be attributed to similar factors that affect RSBY, that is, low coverage or benefits offered by the schemes leading to OOPE and CHE even for insured beneficiaries and interference or reimbursement issues due to functioning of insurance companies or ‘trusts’.

This systematic review is the first one that has focused on the impact of PMJAY. Our findings suggest that there is a lack of evidence related to the impact of PMJAY, as only one study reported the poor impact of PMJAY on reduction in OOPE and financial risk protection. The reasons for poor impact can be similar as experienced by the earlier PFHIs schemes that is, problem of ‘double billing’, private providers monopoly and administrative problems. As PMJAY is a relatively new scheme, more evidence is needed to conclude on its impact. Additionally, as the only study included in the review was specifically for the state of Chhattisgarh, availability of evidence from other states is needed to summarise the impact of this scheme.

According to our review, there was an increase in incidence of outpatient and in-patient visits and the utilisation of medical services, however, the healthcare utilisation rate differed between states. The utilisation rate increased both among rural and urban areas for the RSBY and VAS. However, there was one study that assessed healthcare utilisation for PMJAY, and the results reported no significant increase in utilisation of healthcare by the PMJAY enrolees. One plausible reason for these results could be the lack of awareness regarding PMJAY, as it is a relatively new scheme. It is not justified to conclude based on a single study, and at the same time, it is important to look into various other aspects, due to which the results of the PMJAY are insignificant in increasing healthcare utilisation. The healthcare utilisation rate was assessed in terms of reporting morbidity, hospitalisation, utilisation of inpatient and outpatient services.

Overall, majority of the evidence suggests that implementation of PFHI has increased hospitalisation and the utilisation of outpatient care. Our findings are consistent with other systematic reviews, 10 40 that is, PFHIs had a positive influence on utilisation of healthcare and hospitalisation in India and other LMICs. Although there is substantial evidence on the impact of PFHI on healthcare utilisation, more rigorous evaluation studies are required to evaluate the impact of health insurance schemes and especially the newly launched PMJAY.

It was reported that although the participants were willing to pay more, the findings for WTP are inconclusive, because the evidence is generated from a single study and the focus of the insurance was limited.

Strengths and limitations

Our review is the first comprehensive review, which has summarised the impact of PFHI schemes in India (including the new scheme of PMJAY under the Ayushman Bharat) on utilisation of healthcare and financial risk protection. One of the limitations of the review is the choice of quality assessment tool used for critical appraisal of included studies due to absence of any other valid tool for secondary data analysis. Responses to some of the questions and individual domain ratings for the EPHPP tool were subjective, although, before finalising the rating, we had a substantial discussion on every domain rating score. Additionally, the tool is used to assess quality of all the quantitative studies, which makes it very vague. Also, due to heterogeneity in methods, population and types of insurances, we could not perform meta-analysis.

Implications of practice and research

Our systematic review has vast policy and practice implications. Since UHC is one of the important components to achieve the sustainable development goals, the role of PFHI becomes even more important in providing equitable and affordable healthcare access to everyone. Financial risk protection is one of the key components of any PFHI scheme that ensures affordable healthcare for everyone. Poor impact of PFHIs on financial risk protection also indicates failure of the PFHI schemes. More research on PFHIs, especially PMJAY and its effect on financial risk protection and healthcare utilisation, are needed as this scheme is an important component of the Ayushman Bharat scheme under the UHC. Similarly, future studies can consider studying the effect of some of the state-funded insurances such as by the government of Goa and West Bengal, which also includes APL households, for which, currently, there is no evidence.

State and central governments could consider including APL households, especially middle-income group under the purview of PMJAY. There should be mechanisms to check corruption in the process of PFHI enrolment and focus could be provided to ease out the administrative difficulties faced by people at the time of claiming insurance. Future research in form of rigorous qualitative research, formative evaluations and process evaluations should be directed towards the reasons for the failure of different PFHIs in improving financial risk protection of the beneficiaries and demand-side and supply-side barriers to implementation and uptake of PFHI. Research reporting reasons for failure of the PFHIs, in improving financial protection, will help in revising and modifying the functioning and implementation of the PFHI schemes for benefit of the consumers.

PFHI schemes, viz, RSBY, VAS, RAS and CHIS have been operational in India since 2008. These schemes have been impactful in increasing healthcare utilisation in terms of outpatient and in-patient care in both rural and urban areas. However, evidence related to financial risk protection was mixed and inconclusive. The new scheme of Pradhan Mantri Jan Arogya Yojana or PMJAY has incorporated administrative and strategic changes, which were based on the shortcomings of earlier PFHIs, viz., provision of a 24-hour inquiry helpline and increased coverage of healthcare services and benefit package. However, limited evidence available on the impact of PMJAY suggests no improvement in healthcare utilisation and financial risk protection of the beneficiaries. Future research on the impact of PMJAY and reasons for failure of other PFHIs on financial risk protection need to be explored.

Supplementary Material

Acknowledgments.

We acknowledge PHRI-RESEARCH grant by Public Health Foundation of India, with the financial support of Department of Science and Technology to partially support authors to carry out this research. We would like to acknowledge the technical support provided by Public Health Evidence South Asia (PHESA), Prasanna School of Public Health (PSPH), Manipal Academy of Higher Education (MAHE), Manipal. We would like to thank Dr. Jisha B Krishnan, Research Assistant, PHESA, PSPH, MAHE, Manipal for supporting us in the title/abstract screening and quality assessment of the included studies and Dr. Vijay Shree Dhyani, Research Assistant, PHESA, PSPH, MAHE, Manipal, for supporting us in title abstract screening.

Twitter: @ParsekarShrads

Contributors: RB is the guarantor of the review. BTV, ER, RB and SSP conceptualised the topic. RV developed search strategy and conducted the search. SSP carried out title/abstract screening and BTV, ER, SSP carried out full text screening. BTV, ER and SSP extracted first round of data extraction, analysed and synthesised the data for the review. Extracted data from all the included studies was cross-checked and independent extraction was done for one third randomly selected studies by BTV, ER, SSP. Quality assessment was performed by BTV, ER, SSP. BTV, ER, SSP drafted the first version of report, which was further edited by RB, BTV, ER, RV, BU and SSP. All the authors read, provided feedback and approved the final report.

Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests: None declared.

Provenance and peer review: Not commissioned; externally peer reviewed.

Supplemental material: This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

Data availability statement

Ethics statements, patient consent for publication.

Not applicable.

Ethics approval

This study does not involve human participants.

Log in using your username and password

• Search More Search for this keyword Advanced search
• Latest content
• For authors
• Browse by collection
• BMJ Journals More You are viewing from: Google Indexer

You are here

• Volume 11, Issue 4
• Health insurance awareness and its uptake in India: a systematic review protocol
• Article Text
• Article info
• Citation Tools
• Rapid Responses
• Article metrics

• Bhageerathy Reshmi 1 ,
• Bhaskaran Unnikrishnan 2 ,
• http://orcid.org/0000-0002-8824-9198 Shradha S Parsekar 3 ,
• Eti Rajwar 3 ,
• Ratheebhai Vijayamma 4 ,
• http://orcid.org/0000-0002-3338-6478 Bhumika Tumkur Venkatesh 3
• 1 Health Information Management, Manipal College of Health Professionals , Manipal Academy of Higher Education , Manipal , India
• 2 Kasturba Medical College, Mangalore , Manipal Academy of Higher Education , Manipal , India
• 3 Public Health Evidence South Asia, Department of Health Information, Prasanna School of Public Health, Manipal Academy of Higher Education , Manipal Academy of Higher Education , Manipal , India
• 4 Manipal Institute of Communication , Manipal Academy of Higher Education , Manipal , India
• Correspondence to Dr Bhumika Tumkur Venkatesh; bhumika.tv{at}manipal.edu

Introduction Health insurance is one of the important approaches that can help in boosting universal healthcare coverage through improved healthcare utilisation and financial protection. This objectives of this review are to identify various interventions implemented in India to promote awareness of health insurance, and to provide evidence for the effectiveness of such interventions on the awareness and uptake of health insurance by the resident Indian population.

Methods and analysis A systematic review will be carried out based on the Cochrane handbook for systematic reviews of interventions. The review will include experimental and analytical observational studies that have included adult population (>18 years) in India. We will include any intervention, policy or programme that directly or indirectly affects awareness or uptake of health insurance. The following outcomes will be eligible to be included: awareness or health insurance literacy, attitude such as readiness to buy health insurance or decision making, uptake of health insurance, demand-side and supply-side factors for awareness of health insurance, and awareness as a factor for uptake and re-enrolment in health insurance. Databases such as MEDLINE (PubMed), Web of Science, Scopus, 3ie impact evaluation repository and Social Science Research Network will be searched from January 2010 to 15 July 2020. Additionally, important government websites and references of the included studies will be scanned to identify potential records. Three authors, independently, will carry out screening and data extraction. Studies will be categorised into quantitative and qualitative, and mixed-methods synthesis will be employed to analyse the findings.

Ethics and dissemination This review will be based on published studies and will not recruit human participants directly, therefore, ethical clearance is not applicable. We will disseminate the final review findings in a national or international conference and publish in a peer-reviewed journal.

• health economics
• health policy
• public health

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/ .

https://doi.org/10.1136/bmjopen-2020-043122

Statistics from Altmetric.com

Request permissions.

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

Strengths and limitations of this study

This systematic review will use mixed-methods analysis involving findings from quantitative and qualitative studies conducted in India.

We will comprehensively search the evidence in various databases, grey literature and reference and forward citations of included studies, however, the publications will be restricted to English.

We anticipate heterogeneity owing to study designs of potentially included studies, however, to mitigate this challenge we have planned to conduct subgroup analysis based on PROGRESS-Plus framework.

Introduction

Low-income and middle-income countries (LMICs) contribute to around 84% of the world population and 90% of the global burden of disease. 1 People living in the LMICs rely majorly on out-of-pocket payments as the prime source for managing healthcare expenses, that results in a massive demand for services and financial burden of households (usually catastrophic), which in turn leads to impoverishment. 1–5 It is projected that every year approximately 150 million people experience financial catastrophe, by spending more than 40% on health expenses other than food. 6 Families generally spend more than 10% of the household income on illness-related expenses, due to which other household expenses are affected. 2 5 To make it worse, evidence suggests that per capita spending on healthcare in many LMICs is expected to increase in coming years. 4 Additionally, the increased costs of seeking and receiving care can hinder the access to healthcare. 7

The Universal Health Coverage (UHC) is embedded within the Sustainable Development Goals (SDGs) and aims ‘to ensure healthy lives and promote well-being for all at all ages by 2030’. 8 It includes financial risk protection and equal access to quality essential healthcare services. 8 9 In other terms, UHC encourages equitable healthcare 2 and nations across the world are committed to achieving SDGs through UHC. 10

Health insurance is one of the important approaches that can help in boosting UHC through improved healthcare utilisation and financial protection. 7–9 11 There are multiple types of insurance in LMICs that differ with providers (government vs private sector), scales and types of beneficiaries. 8 However, in many LMICs, due lack of acceptability and unwillingness to pay (WTP) premiums, health insurance coverage is limited. 2 4 This increases the risk of excluding vulnerable and at-risk population, who cannot afford to pay health insurance premium. 8 Additionally, the older adults, and the individuals with disability and chronic diseases, have less probability of enrolling in health insurance schemes or their specific needs may not be covered under the scheme. 8

The coverage of health insurance policies or programmes in India is improving, however, the publicly funded health insurance schemes are mostly restricted to socioeconomically backward people or government employees. 12 India’s first health insurance programme, launched in the 1950s, was limited to central government employees and certain low-income population. 11 Over the years, the private healthcare providers’ dominance in quality healthcare service provision can be seen. 11 Nevertheless, many economically backward families are either deprived of healthcare or are pushed into poverty in the absence of financial protection. 11 In 2002, targeted health insurance programmes for low-income households were introduced by central and state governments in partnership with private sector and non-governmental organisations (NGO). Since 2002 (recommendations of National Health Policy 2002), more than 17 health insurance schemes have been launched by various governments in India. 11 The most recent one is ‘Ayushman Bharat’ or Pradhan Mantri Jan Arogya Yojana (PMJAY) (Prime minister’s health assurance scheme) launched in 2018 to achieve UHC. PMJAY is fully financed by the government and seeks to cover 500 million citizens with an annual cover of approximately US$7000 per household. The main aim of the PMJAY is to lessen the economic burden experienced by poor and vulnerable groups for access to healthcare facility. 13

Despite the availability of multiple health insurance schemes, evidence suggests that the uptake of health insurance in India is poor. As per the recently concluded National Sample Survey Office data, there were as low as 14% rural and 18% urban residents of India having some form of health insurance. 14 The low coverage of health insurance was evident in other literature, wherein it was reported to be less than 20%. 5 12 Similarly, other LMICs have reported poor registrations in the national health insurance schemes. 8 9 12 15

There are multiple factors that are responsible for awareness and enrolment in health insurance schemes. 2 4 These factors can be broadly divided into individual (age, gender, education, employment status, marital status), 2 9 16 and household characteristics (wealth, size of family). 1 9 17 Other factors are programme-related (premium amount, rules, regulation and procedures), social capital (trust, networks and group participation, social norms and solidarity and togetherness features of the social organisation of the community), institutional factors (regulatory mechanisms, complaint handling systems and insurance education) and supply-side factors (quality of care and distance of house from the nearest health facility). 2 The aforementioned factors may also determine the consumer preference in selecting the health insurance. 17 Inadequate claim returns, poor accountability and non-transparent operations hinders the uptake of health insurance. 18

In Indian studies, a scant that is, 34% of the participants who did not have health insurance were willing to pay for any health insuance. 5 Previous research in LMICs suggests that financial status of household is positively associated with WTP. 2 4 9 18 Whereas level of education received contradictory findings, that is, a study conducted in Nigeria reported that education was negatively associated with WTP 4 contrary to study conducted in Uganda, 1 Ghana 16 and India. 5 Family who had good perceived health had less probability of getting insurance as compared with those individuals who perceived their health as poor. Similarly, those individuals who had chronic diseases were more inclined to have health insurance than those who did not have chronic diseases. 2 Corruption and mistrust in the health insurance scheme 1 5 18 and expensive plans 5 18 were some of the reasons for non-WTP. Lack of information or health insurance illiteracy is another important reason for non-WTP. 1 5 18

Health insurance literacy is defined as ‘the degree to which individuals have the knowledge, ability and confidence to find and evaluate information about health plans, select the best plan for their own (or their families) financial and health circumstances, and use the plan once enrolled.’ 1 Lack of health insurance literacy or education hinders the uptake of health insurance and in many LMICs health insurance literacy is poor. A study conducted in Uganda reported that about 34% of the studied population were not aware of health insurance. 1 Whereas, proportion of people having inadequate knowledge about health insurance was found to be high in countries such as India (46%), 5 Myanmar (66%) 3 and Hispanic American in the USA (70%). 19

Familiarity or awareness of the insurance schemes increases the utilisation of health insurance and subsequently help in healthcare uptake. 1 2 19 Individuals usually enrol into health insurance because of their personal experiences, awareness or word-of-mouth advertisements. 17 Mass media such as newspaper, radio and television play an important role in making people aware of health insurance schemes. 1 Friends, community meetings, school gatherings and health workers have an influence on increasing the health insurance awareness of the people. 1 Although, aforesaid factors help in increasing the awareness and enrolment in health insurance scheme, some enrollees may not pay premium on regular basis and might not get to know even after health insurance is lapsed. 9 Women farmers, as compared with other occupations, had more odds of unawareness that their insurance was lapsed. 9

It is evident from the above description that there is inadequate awareness of health insurance among general population in LMICs. Knowledge about health insurance can boost individuals’ confidence and self-efficacy; thus, it is an important a priori factor that is required to get enrolled in health insurance scheme. 19 Outreach programmes to increase general knowledge of health insurance and integrating health insurance education within health delivery systems may help to improve the uptake of health insurance. 19 Globally, there are different methods available to promote and raise awareness about different health insurance schemes. However, India is a diverse country with a complex health system and numerous contextual factors. A ‘one size fits all’ approach for any policy or intervention is not suitable for the country. Therefore, it is imperative to understand the different approaches implemented to raise awareness about health insurance in the country. Additionally, due to increased population and a meagre public health spending on healthcare, it is important to understand if the resources are being used appropriately. To ensure this, understanding the effectiveness of such policies is essential, so that focus is directed towards the suitable interventions. ‘Ayushman Bharat Scheme-PMJAY’ is implemented to ensure increased utilisation of the healthcare facilities with financial protection of the beneficiaries. The evidence available on the effectiveness of the PMJAY scheme states no effect of the scheme on utilisation of healthcare and financial protection of enrolled beneficiaries, 13 however, this evidence is limited. Therefore, in the Indian context, it is important to understand if awareness is a factor that has led to decreased utilisation of PMJAY or failure of the other schemes (viz. Rashtriya Swasthya Bima Yojana-RSBY) in securing financial protection of the beneficiaries. 20 Also, it is vital to understand the importance of awareness programmes for success of the health insurance schemes, which will be the focus of this review.

A systematic review will help in synthesising high-quality evidence in a systematic manner, for this important topic of interest. The proposed systematic review will, therefore, identify the different approaches and interventions for increasing health insurance awareness in India and will give information about the impact of these interventions. This review is planned to address the following research questions:

What are the various interventions implemented in India to promote awareness of health insurance?

What is the effectiveness of the above interventions on the awareness and uptake of health insurance by people of India?

Methods and analysis

Methodology for this systematic review will be based on the Cochrane handbook for systematic reviews of interventions 21 and we have adhered to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-Protocols guidelines for reporting this protocol. 22

Criteria for including studies in the review

Population: The review will include studies conducted in India that involve adult population (>18 years). We will consider the studies having household as a unit of analysis, if the head of the family (or the family member who was interviewed) is an adult.

Intervention/exposure: We will include any intervention, policy or programme that directly or indirectly affects awareness of health insurance. The health insurance scheme could be of any type, including but not limited to, public, private, for profit and not-for-profit. Contribution for premiums could be made by individual, NGO, employer or government. There is no restriction on focus of health insurance for example, hospital stay, surgery or critical illness.

Intervention/exposure could be educational, informative, training, technology and m-health or e-health related. The interventions could be focused on raising income threshold to be eligible for health insurance, such as, conditional or unconditional cash transfers that indirectly influences awareness of health insurance. Similarly, training and performance-based financing for healthcare staff or other groups will be eligible for inclusion. The intervention could be a modification of the enrolment procedure, changes in the premium or organisational changes in handling health insurance. Intervention could be directed on general population or targeted groups such as vulnerable population, indigenous groups, community leaders, employees, formal or informal groups and healthcare staff.

Comparison: This review will not restrict the studies based on comparison, as having a comparison group may not always be feasible.

Awareness/health insurance literacy (refers to knowledge of the household head or household member on the presence of insurance schemes, its principles and significance. The outcome measure can be objective or subjective).

Attitude: Readiness to buy health insurance, decision making.

Uptake of health insurance.

Demand-side and supply-side factors for awareness of health insurance.

Awareness of health insurance as a factor for uptake or re-enrolment of health insurance.

Types of study designs: This review will include experimental studies that assessed the effect of intervention to promote awareness and uptake of health insurance. It is sometimes not practical to conduct randomised controlled trials (RCTs) to measure the effect of public health interventions, therefore, the review will also include other study designs. Studies with following designs will be included: RCTs, interrupted time-series studies, difference-in-difference, regression discontinuity designs, statistical matching, quasi-randomised and non-randomised trials. Additionally, this review will include prospective, retrospective, analytical cross-sectional and studies related to process evaluation and policy analysis, if the studies have provided description of intervention or exposure of our interest. Qualitative studies are important source of information about barriers and enabling factors that can complement the findings, therefore, we will also include these types of studies. This review will exclude descriptive cross-sectional (prevalence) studies, commentaries, perspectives, editorials, reviews and conference abstracts. Policy papers that do not provide details of implementation of intervention will not be considered.

Searching and locating the studies

The electronic databases such as MEDLINE (PubMed), Web of Science and Scopus will be searched to identify potential records. Additionally, 3ie impact evaluation repository and Social Science Research Network will be searched. Databases will be searched from January 2010 to 15 July 2020 and publications will be restricted to English language. Ministry of Health and Family Welfare, RSBY, Ayushman Bharat and other state health insurance websites will be searched for reports on the health insurance schemes. We will also scan through references of the included studies for any additional eligible records. After identifying the keywords, initial search will be carried out in PubMed, which will then be replicated in other databases. A designated information scientist will be responsible for conducting search. The preliminary search concepts and key terms are given in table 1 .

• View inline

Search concepts and key words

Applying eligibility and screening the studies

The results of search will be imported to Endnote X7 reference manager software and duplicates will be removed. MS Excel spreadsheet will be used to screen the records. Based on inclusion and exclusion criteria, all the records will be subjected to two stage—title/abstracand full text (FT)—screening process, independently by three (SSP, ER and BTV) reviewers (in pairs). Any disagreements between the reviewers will be resolved by discussion, and senior reviewer will be involved in decision making in case of disagreements between the reviewers. The reasons for excluding FTs will be documented and the PRISMA flow diagram will be provided. A detailed screening protocol will be used as a back-up document to aid the screening process. Table 2 gives detailed screening protocol.

Screening protocol

Data extraction

Data will be extracted independently by three reviewers (SSP, ER and BTV). A predesigned data extraction form will be used for extraction of the data. The data extraction form will be subjected to pilot testing and will be revised as per the suggestions by the reviewers and the experts at this stage. Any disagreements during data extraction will be resolved by consensus supported by the senior reviewer. Data will be extracted based on the characteristics mentioned in the table 3 .

Data extraction format

Critical appraisal of included studies

Effective Public Health Practice Project (EPHPP) tool 23 will be used to assess the methodological quality of quantitative studies (except observational studies) and Newcastle-Ottawa scale (NOS) 24 will be used for the observational studies. The EPHPP rates the study as ‘strong’, ‘moderate’ or ‘weak’ based on eight domains. These domains are selection bias, study design, confounders, blinding, data collection methods, withdrawals and drop-outs, intervention integrity and analysis. 23 NOS rates the study based on three domains viz. selection, comparability and outcome, and the final score ranges between 0 and 10. 24 Reviewers (BTV, ER and SSP), independently in pairs, will appraise the included studies. Any discrepancies between the decisions of reviewers will be resolved by discussion until consensus is achieved. If required, a senior reviewer will be involved as arbitrator and final decision maker to rate the study quality.

Data analysis

Study characteristics consisting of population, intervention/exposure, comparator, outcome, study design components across studies will be tabulated, which will help us to compare and analyse. Subsequently, studies will be categorised into quantitative and qualitative and will be analysed separately. This step will be followed by mixed methods synthesis as suggested by Panda et al . 25

Quantitative studies

Studies will be grouped based on study design, and type of data available (continuous or categorical). If possible, similar studies will be pooled to perform meta-analysis using random effect model. If data are continuous, standardised mean difference will be calculated with 95% CI. For categorical data, OR or risk ratio will be calculated and reported with 95% CI. Meta-analysis will be visually represented with a forest plot. We assume possibility of heterogeneity owing to differences in study design or analysis, intervention, type of insurance and other contextual factors. If heterogeneity exists due to aforementioned components, we will not perform meta-analysis. After ruling out clinical or methodological heterogeneity, we will statistically measure heterogeneity by using I 2 test. If significant heterogeneity (>50%) persists for a particular outcome, meta-analysis will not be conducted. In this case, our focus would be on conducting narrative synthesis and undertaking a subgroup analysis. Key findings of the studies will be summarised in tables/figures or vote counting will be considered. Subgroups could be based on study design, intervention type, insurance type (such as private and public), region and other contextual factors (eg, urban/rural).

Qualitative synthesis

We will carry out thematic analysis as suggested by Thomas and Harden. 26 An iterative process of line-by-line coding will be undertaken as a first step, which will be followed by categorising the codes into code families. Subsequently, a code tree will be created, and themes and subthemes will be generated. Three reviewers (SSP, ER and BTV) will code the data independently and resolve the discrepancies by discussion until consensus is achieved.

Mixed-methods synthesis

The result from both, qualitative and quantitative synthesis will be merged for each outcome. Parallel synthesis will be carried out, and the findings will be summarised narratively. 25 To understand the influence of inequality in uptake of health insurance based on type of insurance, we will explore the possibility of conducting subgroup analysis based on some of the components of PROGRESS ( P lace of residence, R ace/ethnicty/culture/language, O ccupation, G ender, R eligion, E ducation, S ocio-economic status, S ocial capital)-Plus framework. 27

Grading the evidence

We will use the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to evaluate the certainty of evidence for each outcome. 21 Using GRADE profiler software, we will present the main findings of the systematic review in a summary of findings table.

Patient and public involvement

We did not involve patients or public while designing and writing this protocol.

Ethics and dissemination

This review will be based on published studies, therefore, an ethical clearance is not applicable. We have planned following activities to communicate and disseminate the findings of this review. We plan to make at least one national or international conference presentation. We will prepare policy brief to be shared with funder and to get a wider reader, we plan to submit the manuscript to a peer-reviewed journal. On journal publication, we intend to circulate the findings through our social media platform and website.

Acknowledgments

We are grateful to Dr Prachi Pundir, Research Officer, public Health Evidence South Asia, Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, for proof reading the final document.

• Kyasiimire EP ,
• Namyalo PK , et al
• Mirach TH ,
• Demissie GD ,
• Myint C-Y ,
• Pavlova M ,
• Ogundeji YK ,
• Akomolafe B ,
• Ohiri K , et al
• Surendar RAM ,
• Madhumadhi S ,
• Saravanan R
• Seddoh A , et al
• Kuwawenaruwa A ,
• Binyaruka P , et al
• van Hees SGM ,
• O'Fallon T ,
• Hofker M , et al
• Kanmiki EW ,
• Akazili J , et al
• Fadlallah R ,
• El-Jardali F ,
• Hemadi N , et al
• Lagomarsino G ,
• Garabrant A ,
• Adyas A , et al
• Bebarta KK ,
• ↵ NSS 75th Round . Key indicators of social consumption in India health . New Delhi The government of India, MInistry of Statistics and Programme Implementation, National Statistical Office ; 2019 . http://mospi.nic.in/sites/default/files/publication_reports/KI_Health_75th_Final.pdf
• Abiola AO ,
• Ladi-Akinyemi TW ,
• Oyeleye OA , et al
• Michael GC ,
• Grema BA , et al
• Ayanore MA ,
• Kugbey N , et al
• Ghaddar S ,
• Krishnaswami J
• Chauhan AS ,
• Karan A , et al
• Higgins JPT ,
• Chandler J , et al.
• Liberati A ,
• Tetzlaff J , et al
• Effective Public Health Practice Project
• O'Connell D
• Perez Koehlmoos T , et al
• Kavanagh J ,

Twitter @ParsekarShrads

Contributors RB is the guarantor of the review. RB, SSP, ER and BTV conceptualised the manuscript. SSP drafted the first manuscript, which was further edited by ER. RV developed the search strategy. All the authors (RB, BU, SSP, ER, RV and BTV) read, edited, provided feedback and approved the final manuscript.

Funding This work was supported by PHRI-RESEARCH grants awarded by PHFI with the financial support of Department of Science and Technology (DST). We appreciate the technical support provided by public Health Evidence South Asia, Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal.

Disclaimer Funder did not have any role in writing this protocol and decision to submit it for publication.

Competing interests None declared.

Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

Provenance and peer review Not commissioned; externally peer reviewed.

Read the full text or download the PDF:

Handbook of International Insurance pp 641–678 Cite as

An Analysis of the Evolution of Insurance in India

• Tapen Sinha 4 , 5  

2655 Accesses

4 Citations

Part of the book series: Huebner International Series on Risk, Insurance and Economic Security ((HSRI,volume 26))

India had the nineteenth largest insurance market in the world in 2003. Strong economic growth in the last decade combined with a population of over one billion makes it one of the potentially largest markets in the future. Insurance in India has gone through two radical transformations. Before 1956, insurance was private with minimal government intervention. In 1956, life insurance was nationalized and a monopoly was created. In 1972, general insurance was nationalized as well. 255 But, unlike life insurance, a different structure was created for the industry. One holding company was formed with four subsidiaries. As a part of the general opening up of the economy after 1992, a government-appointed committee recommended that private companies should be allowed to operate. It took six years to implement the recommendation. The private sector was allowed into the insurance business in 2000. However, foreign ownership was restricted. No more than 26 percent of any company can be foreign-owned.

The term general insurance is used in Britain and other Commonwealth countries. Elsewhere, the equivalent term is property-casualty insurance or non-life insurance .

This is a preview of subscription content, log in via an institution .

Buying options

• Available as PDF
• Read on any device
• Instant download
• Own it forever
• Compact, lightweight edition
• Dispatched in 3 to 5 business days
• Free shipping worldwide - see info
• Durable hardcover edition

Tax calculation will be finalised at checkout

Purchases are for personal use only

Unable to display preview.  Download preview PDF.

13.6 References

Annual Report of the Ministry of Finance (Section 3, Insurance Division, finmin.nic.in/the_ministry/dept_eco_affairs/budget/annual_report/9596ea3.pdf).

Google Scholar  

Bhattacharya, Saugata and Urjit R. Patel (2003). “Reform strategies in the Indian financial sector,” paper presented to the Conference on India’s and China’s Experience with Reform and Growth, November.

Central Statistical Organization database.

Cummins, David, Mary Weiss, and Hongmin Zi (1997). “Organizational form and efficiency,” Financial Institutions Center, Working Paper No. 97–2, Wharton School, University of Pennsylvania.

Farrell, M. (1957). “The measurement of productive efficiency,” Journal of the Royal Statistical Society , Series A, 120,253–281.

Gazette of India Extraordinary Part III Section 4 (2000). Insurance Regulatory and Development Authority (Investment) Regulations.

General Insurance Corporation (various years). Annual reports.

Guerrero, Victor and Tapen Sinha (2004). “Statistical analysis of market penetration in a mandatory privatized pension market using generalized logistic curves,” Journal of Data Science , 2, 196–211.

Indian Insurance Commissioner’s Report (1929). Her Majesty’s Stationery Office, London.

Insurance Regulatory and Development Authority Annual Report (IRDA) (2002–2003). Appendix III.

IRDA Journal (2004). “Market share for premiums: Life market (March 2003–February 2004),” April, 38–39.

IRDA Journal (2004). “Gross premium underwritten by general insurance companies (April 2003–February 2004),” April, 40.

Life Insurance Corporation (various years). Annual reports.

Malaviya, H. D. (n.d.). “Insurance in India.”

Malhotra Committee Report on Reforms in the Insurance Sector (1994). Government of India, Ministry of Finance, New Delhi.

Office of Economic and Cultural Development (2003). OECD Handbook on Insurance , Paris.

Press Trust of India (2004). “India leads the world in road accident deaths,” wire report, January 3.

Rajagopalan, R. (2004). “Valuing the term insurance products in the Indian market,” paper presented to the Fifth Global Conference of the Actuaries, January 25, New Delhi.

Rao, G. V. (2003). “Playing it safe,” IRDA Journal , November, 14–16.

Rodrik, Dani and Arvind Subramanian (2004). “Why India can grow at seven percent,” Economic and Political Weekly , April 17.

Sigma (2003). “World insurance in 2002.” Swiss Re.

Srinivasan, K. K. (2003). “Transition from tariff model of pricing non-life insurance in emerging markets: Issues & prospects,” paper presented to the Seventh Conference of the Asia Pacific Risk an Insurance Association Conference, Bangkok, July 23.

Swain, Shitanshu (2004). “LIC refusing to see the writing on the wall,” Financial Express , April 19.

Swiss Reinsurance Company database.

Tripathi, Dwijendra (2004). The Oxford History of Indian Business (Oxford University Press, Oxford).

Vaidyanathan, L. S. (1934). “Mortality experience of assured lives in India, 1905-1925,” Journal of the Institute of Actuaries , 60, 5–66.

Vaidyanathan, L. S. (1939). “Mortality experience of assured lives in India, 1925–1935,” Journal of the Institute of Actuaries , 70, 42–71.

Wilson, Dominic and Rupa Purushothaman (2003). “Dreaming with BRICs: The Path to 2050,” Goldman and Sachs, Global Economics Paper No. 99, October.

Download references

Author information

Authors and affiliations.

Institute Tecnologico Autonomo de Mexico, Mexico

Tapen Sinha

University of Nottingham, Nottingham

You can also search for this author in PubMed   Google Scholar

Editor information

Editors and affiliations.

Fox School of Business and Management, Temple University, USA

J. David Cummins

AUDENCIA Nantes School of Management, France

Bertrand Venard

Rights and permissions

Reprints and permissions

Copyright information

© 2007 Springer Science+Business Media, LLC

About this chapter

Cite this chapter.

Sinha, T. (2007). An Analysis of the Evolution of Insurance in India. In: Cummins, J.D., Venard, B. (eds) Handbook of International Insurance. Huebner International Series on Risk, Insurance and Economic Security, vol 26. Springer, Boston, MA. https://doi.org/10.1007/978-0-387-34163-7_13

Download citation

DOI : https://doi.org/10.1007/978-0-387-34163-7_13

Publisher Name : Springer, Boston, MA

Print ISBN : 978-0-387-34162-0

Online ISBN : 978-0-387-34163-7

eBook Packages : Mathematics and Statistics Mathematics and Statistics (R0)

Share this chapter

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Publish with us

Policies and ethics

• Find a journal
• Track your research

How You Pay Drives What You Choose: Health Savings Accounts versus Cash in Health Insurance Plan Choice

A marked feature of health insurance plan choice is inconsistent choices through the overweighting of premiums relative to out-of-pocket spending. We show that this source of inconsistency disappears when both types of spending come from the same source of designated funds. We focus on the MediSave program in Singapore, whereby residents can pay their health insurance premiums with cash or MediSave funds, but are subject to limits that vary by age and over time. By exploiting variations in those limits, we consistently find that when individuals are able to pay their health insurance premiums with MediSave funds, they are less price sensitive and more willing to enroll in more generous plans—which results in lower spending levels and variance, and lower adverse selection in the market. The results suggest a strong role for mental accounting in insurance decisions.

Lin, Liu, and Yi gratefully acknowledge support from Singapore’s Ministry of Education Academic Research Fund Tier 1 (WBS R-122-000-303- 115). The views expressed herein are those of the authors and do not necessarily reflect the views of the National Bureau of Economic Research.

MARC RIS BibTeΧ

Download Citation Data

• online appendix

Working Groups

More from nber.

In addition to working papers , the NBER disseminates affiliates’ latest findings through a range of free periodicals — the NBER Reporter , the NBER Digest , the Bulletin on Retirement and Disability , the Bulletin on Health , and the Bulletin on Entrepreneurship  — as well as online conference reports , video lectures , and interviews .

The Economic Times daily newspaper is available online now.

Fdi reform 2.0 banking, defence,insurance on table.

The government is examining if foreign direct investment norms (FDI) for banking, insurance and defence can be further liberalised, after rules were relaxed for the space and satellite sectors recently.

Ok, Tata, bye: Six things that can treat India’s EV range-anxiety.

This app is striking at the core of Uber, Ola business model and succeeding.

What India’s most powerful investigative agency is about?

India Inc is under-reporting work-related injuries. Why?

Amid slackening revenue-growth for IT majors, there is a silver lining

Stock Radar: Raymond records range breakout after 7 months on daily chart. Time to buy?

Find this comment offensive?

Choose your reason below and click on the Report button. This will alert our moderators to take action

Reason for reporting:

Your Reason has been Reported to the admin.

To post this comment you must

Log In/Connect with:

Fill in your details:

Will be displayed

Will not be displayed

Share this Comment:

Uh-oh this is an exclusive story available for selected readers only..

Worry not. You’re just a step away.

Prime Account Detected!

It seems like you're already an ETPrime member with

Login using your ET Prime credentials to enjoy all member benefits

Log out of your current logged-in account and log in again using your ET Prime credentials to enjoy all member benefits.

You’re reading this story from ET newspaper.

Unlock epaper & other members-only benefits with etprime., new financial year offer: flat 20% off, enjoy reading for special offer, your current plan does not offer access to newspaper articles, upgrade to unlock complete access to exclusive stories, epaper & all market tools..

Exclusive Economic Times Stories, Editorials & Expert opinion across 20+ sectors

Stock analysis. Market Research. Industry Trends on 4000+ Stocks

​Get 1 Year Complimentary Subscription of TOI+ worth Rs.799/-​

Stories you might be interested in