Sunday, April 11, 2021

Women left behind — Rajasthan health insurance scheme has a gender gap: Study

Girls in Rajasthan stand in a queue with their Aadhar playing cards | Representational picture | PTI

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Over the previous 15 years, India’s central authorities and quite a few state governments have put in place medical health insurance programmes that entitle low-income households to free healthcare at public and empanelled personal hospitals. Well being fairness and common well being protection are express targets of those programmes. In new analysis (Dupas and Jain 2021), we research gender fairness within the Bhamashah Swasthya Bima Yojana (BSBY)1 medical health insurance programme, which was launched within the state of Rajasthan in 2015, and is comparable in design to the nationwide Pradhan Mantri Jan Arogya Yojana (PMJAY)2.

Our place to begin is a dataset of insurance coverage claims filed for all 4.2 million hospital visits between 2015 and 2019.3, together with affected person age, gender, residence handle, hospital visited, dates of admission and discharge, and repair(s) obtained. We geo-coded hospital places and affected person addresses, which allowed us to calculate proximity to hospitals and the space travelled for each hospital go to. Lastly, we linked the insurance coverage information to the 2011 Census and information on three rounds of village-level (gram panchayat4) elections5. To our data, the dataset we compiled from these varied sources is the primary dataset of its sort in India and permits us to check care-seeking underneath insurance coverage with uncommon granularity.

Additionally learn: Why the pandemic recession hurts Indian ladies extra

Massive gender disparities in hospital visits underneath insurance coverage

Females account for under 45% of all hospital visits, with the largest gaps amongst kids underneath 15 years (33%) and adults 50 years and older (43%) (Determine 1). These gaps are far bigger than may be defined by Rajasthan’s skewed inhabitants intercourse ratio. We additionally present that variations in underlying well being wants can’t account for these gaps: throughout a number of well being circumstances, the feminine share of hospital visits underneath BSBY is over 10 proportion factors decrease than can be anticipated primarily based on gender-specific sickness prevalence estimates from the World Burden of Illness (GBD) research for India. Primarily based on this comparability, we estimate that there are over 225,000 lacking feminine hospital visits between 2017 and 2019 for nephrology, cardiology, and oncology care alone.

Determine 1. Age-specific feminine share of hospital visits underneath insurance coverage

Sources: Census (2011); 71st (2014) and seventy fifth (2017) rounds of the Nationwide Pattern Survey (NSS); BSBY Claims database 2015-2019.
Word: (i) The blue bars symbolize the share of insurance coverage claims inside every group which might be for females. (ii) The pink diamonds are the feminine share of the inhabitants, and the inexperienced diamonds are the feminine share of the poorer half of the inhabitants, which approximates the BSBY-eligible inhabitants.

These outcomes are according to gender disparities documented in different insurance coverage programmes in India (Shaikh et al. 2018). On account of these gaps, public spending is successfully pro-male. Even inclusive of obstetric care, programme spending on females in 2019 amounted to 44.4% of whole spending. In distinction, within the US, round 57% of yearly Medicaid spending is on females.

Biased family useful resource allocation contributes to gender disparities

Whereas there could also be a number of elements that create female-specific limitations to healthcare utilisation (for instance, lack of secure transport), we offer proof that gender-biased useful resource allocation inside the family performs a big function. To reveal this, we construct on the instinct that, within the presence of gender bias, any prices of care-seeking will amplify gender disparities. First, we use surveys carried out with sufferers to doc widespread out-of-pocket (OOP) fees by hospitals, for care that must be free underneath the programme.6 Females are considerably much less prone to utilise hospitals or companies with increased OOP fees, suggesting that these fees deter care-seeking for females. Feminine utilisation additionally decreases sharply with distance to the closest hospital, one other measure of care price. Lastly, even households that do search look after females, are seen to journey considerably additional for male than for feminine care. Collectively, these outcomes present robust proof that households worth and allocate extra assets to the well being of males than females.

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Decreasing the price of care-seeking doesn’t cut back gender disparities

We use the empanelment of latest hospitals close to villages – which reduces the space to the closest personal BSBY hospital – to look at what occurs to gender disparities when the price of care-seeking is diminished. Each feminine and male hospital visits improve instantly and considerably, however the feminine share of visits stays unchanged. This will appear counterintuitive, however within the presence of gender bias, lowering the prices of care might improve feminine utilisation however fail to cut back gender disparities as a result of households choose to spend their marginal rupee on males over females. This helps clarify why the feminine share of visits decreases over 4 years of implementation, even because the programme expands and whole utilisation will increase considerably (Determine 2). Though the programme expanded quickly, going from roughly half 1,000,000 hospital visits in 2016 to 1.2 million visits in 2019 (excluding childbirths), the feminine share of visits decreased over this era. Increasing entry alone is inadequate to shut gender gaps.

Determine 2. Programme growth and gender disparities 

Supply: BSBY claims information.
Word: (i) The blue strong line is the whole hospital visits every year between 2016 and 2019, excluding childbirths. (ii) The black dashed line is the feminine share of all hospital visits over the identical interval (similar to the right-hand vertical axis). 

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Publicity to feminine leaders helps cut back gender gaps in utilisation

Prior literature has proven that, within the Indian context, publicity to feminine leaders in authorities can cut back bias in perceptions of, and aspirations for, ladies and improve investments in feminine well being (Beaman et al. 2009, Beaman et al. 2012, Bhalotra and Clots-Figueras 2014). We exploit randomised reservations for ladies in gram panchayats throughout three five-year phrases between 2005 and 2015, to check whether or not native feminine political illustration helps mitigate disparities in utilisation of medical health insurance in Rajasthan.7 The feminine share of hospital visits in a panchayat will increase by 0.8 to 1 proportion level with every reserved electoral time period, amongst kids and ladies of childbearing age. The proof means that these results are pushed by long-term will increase in maternal and youngster well being investments, and feminine company in villages with repeated publicity to feminine leaders – slightly than by way of elevated consciousness of BSBY. Nevertheless, the advantages of reservations don’t lengthen to aged ladies.

Concluding remarks

Our discovering that a big common well being protection coverage has not diminished gender disparities over 4 years of implementation goes towards the overall assumption that increasing geographical entry and lowering the prices of healthcare will mechanically cut back inequalities. Such gender-neutral insurance policies might improve feminine ranges of utilisation however closing gender gaps requires methods that explicitly goal limitations to feminine care-seeking and gender bias. 


  1. BSBY is a cashless medical health insurance scheme of the state authorities of Rajasthan. Underneath this scheme, these lined underneath the Nationwide Meals Safety Act (NFSA) and Rashtriya Swasthya Bima Yojana (RSBY) are eligible for remedy advantages of as much as Rs. 30,000 for normal sicknesses and Rs. 3 lakh for important illnesses.
  2. PMJAY is among the two elements of the Ayushman Bharat Yojana (Nationwide Well being Safety Mission), which was launched in 2018. PMJAY is a medical health insurance programme that goals to cut back the monetary burden on poor and susceptible teams, arising out of catastrophic hospitalisation episodes.
  3. The dataset was obtained from the state authorities of Rajasthan, underneath a MoU (Memorandum of Understanding) between the federal government and J-PAL (Abdul Latif Jameel Poverty Motion Lab) South Asia.
  4. A gram panchayat is the cornerstone of a neighborhood self-government organisation in India of the Panchayati Raj system on the village or small-town stage and has a sarpanch as its elected head.
  5. These information had been obtained from the State Election Fee of Rajasthan.
  6. We sampled random subsets of hospital visits on a rolling foundation between October 2017 and August 2018, and carried out cellphone surveys (N = 20,969) with sufferers utilizing contact numbers included within the claims information. The pattern lined personal hospital visits throughout 13 totally different companies, in addition to public hospital visits for childbirths and haemodialysis.
  7. The 73rd Modification of the Structure required that one-third of all council members and Sarpanch seats be reserved for ladies in every five-year time period, with reserved seats chosen randomly with alternative from the checklist of Gram Panchayats earlier than every election.

Pascaline Dupas is a Professor of Economics at Stanford College. Radhika Jain is Asia Well being Coverage Postdoctoral Analysis Fellow at Stanford College. Views are private.

This text was first printed by Concepts for India (I4I).

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