Assessing geographical inequity in availability of hospital services under the state-funded universal health insurance scheme in Chhattisgarh state, India, using a composite vulnerability index

Background: Countries are increasingly adopting health insurance schemes for achieving Universal Health Coverage. India's state-funded health insurance scheme covers hospital care provided by 'empanelled' private and public hospitals. Objective: This paper assesses geographical equity in availability of hospital services under the universal health insurance scheme in Chhattisgarh state. Methods: The study makes use of district data from the insurance scheme and government surveys. Selected socio-economic indicators are combined to form a composite vulnerability index, which is used to rank and group the state's 27 districts into tertiles, named as highest, middle and lowest vulnerability districts (HVDs, MVDs, LVDs). Indicators of hospital service availability under the scheme - insurance coverage, number of empanelled private/public hospitals, numbers and amounts of claims - are compared across districts and tertiles. Two measures of inequality, difference and ratio, are used to compare availability between tertiles. Results: The study finds that there is a geographical pattern to vulnerability in Chhattisgarh state. Vulnerability increases with distance from the state's centre towards the periphery. The highest vulnerability districts have the highest insurance coverage, but the lowest availability of empanelled hospitals (3.4 hospitals per 100,000 enrolled in HVDs, vs 8.2/100,000 enrolled in LVDs). While public sector hospitals are distributed equally, the distribution of private hospitals across tertiles is highly unequal, with higher availability in LVDs. The number of claims (per 100,000 enrolled) in the HVDs is 3.5-times less than that in the LVDs. The claim amounts show a similar pattern. Conclusions: Although insurance coverage is higher in the more vulnerable districts, availability of hospital services is inversely proportional to vulnerability and, therefore, the need for these services. Equitable enrolment in health insurance schemes does not automatically translate into equitable access to healthcare, which is also dependent on availability and specific dynamics of service provision under the scheme.