Jaipur: Women from poor households made about 235,000 fewer hospital visits compared to men for seven gender-neutral disease categories between January 2017 and October 2019, a new study analysing a Rajasthan state health insurance scheme has estimated. The Bhamashah Swasthya Bima Yojana aims to provide health insurance to about 46 million persons living below the poverty line, as a step towards universal and equitable access to healthcare in the state, per the study.

Pascaline Dupas and Radhika Jain of Stanford University studied data of insurance claims from 4.2 million hospital visits under the Bhamashah scheme from its launch in December 2015 till October 2019, and the study was published as a National Bureau of Economic Research working paper. The study was conducted in partnership with the Rajasthan state government.

Women made up 45% of hospital visits under the Bhamashah scheme between January 2017 and October 2019, though their share in the population is 48%, per the study. The gender gap is starker for girls and older women. The share of girls in children aged under 10 years who visited the hospital under this insurance programme was 33%, though their share of this age group's population is 47%; among those aged above 50 years, women are 51%, yet their share of hospital visits under this insurance programme was 43%.

"We were struck by this discrepancy in the data. We were not expecting such a large [gender] difference," Dupas, an economist and professor at Stanford University, told IndiaSpend. In most other developed countries for which such data have been analysed, subsidised healthcare usually caters to those who otherwise don't have access to it, added Jain, a postdoctoral fellow in Asia Health Policy at Stanford University, US.

The Bhamashah scheme was named after Bhama Shah, a fabled general and minister in the erstwhile kingdom of Mewar. It was renamed the Ayushman Bharat Mahatma Gandhi Rajasthan Swasthya Bima Yojana (AB-MGRSBY) in 2019 but is still commonly known as Bhamashah scheme in Rajasthan. The scheme has otherwise been largely seen as successful, with poor residents able to afford health services they would otherwise would have been impoverished by, IndiaSpend had reported in June 2018. Between 2016 and 2019, over 2.5 million patients visited hospitals under this programme, Jain and Dupas found.

But unless "explicit attention is paid to gender" through "explicit protection" and careful linking of benefits to the needs of the target populations, such as poor women, unemployed men and female-headed households, a move towards universal health coverage can fail to achieve gender balance or improve equity, and may even exacerbate gender inequity, according to a 2017 review of health financing reforms and their impact on gender in India.

Gender bias is deeply entrenched in India; son preference leads to sex-selective abortions--between 2016 and 2018, only 899 girls were born for every 1,000 boys (compared to the usual ratio of 952 girls per 1,000 boys) and girls are breastfed for shorter durations. Even after girls grow up, they are less likely to access healthcare, especially for illnesses considered "minor", and families spend less on women's health than on men's health.

Any effort towards universal healthcare in India must at inception be aligned with the broader goals of improving the status of women and girls or be destined to fail, said a comment in The Lancet medical journal in 2011. Just providing health insurance without initiatives addressing deep gender bias will not reduce the gender gap in accessing even subsidised healthcare, economists told us.

Better health infrastructure, primary healthcare

Increased awareness about the Bhamashah scheme over time meant that more women and men overall used the programme, but it did not reduce the gender disparity in hospital visits, the study found. Women made up a lower proportion of those who used the insurance than men, with their share reducing from 47% in 2016 to 44% of all hospital visits in 2019.

Using estimates of disease burdens from the Global Burden of Disease (GBD), 2019, the study calculated that women made over 235,000 fewer hospital visits for care than they should have. This is calculated for seven specialities that made up 54% of all hospital visits under the Bhamashah scheme. For instance, if 80% of males with kidney disease, as estimated by the GBD, received hospital care and only 50% of females did, the missing visits in the study are the equivalent of that 30-percentage-point gap.

From the start of the Bhamashah scheme in December 2015 to October 2019, the programme has spent approximately Rs 2,600 crore ($370 million). As much as 60% of all non-childbirth reimbursements under the programme were for male patients, the study found. Even if obstetric care is included, claims for treatment of women made up less than half (43%) of the total Bhamashah scheme spending. Even "public spending is male-biased" if a gender neutral policy such as health insurance does nothing to reduce the gender gap in access to healthcare, said Jain.

The findings are similar to a University of Oxford study from June 2018 of hospital claims data under the Rajiv Aarogyasri Community Health Insurance Scheme, a state government programme in Andhra Pradesh which provided access to free hospital care for poor households, between 2008 and 2012. Women had a lower share of hospitalisations (42%) and formed a smaller share of reimbursements (39%) for sex-neutral health problems than men, the study had found. Women were nearly 50% of Andhra Pradesh's population in 2011.

Dupas and Jain also found that the further a hospital is from the house, the less likely women were to seek treatment. With every additional 10 km women need to travel, their share of hospital visits under the Bhamashah scheme reduced by 1.5 percentage points, they found.

Healthcare needs to be close to everyone, with well equipped health clinics (sub centres) close to villages, with well trained healthcare workers and medical personnel, who are required to reach out to all members of the family, including women, and even help them get to healthcare centres when needed, said Nachiket Mor, an economist and visiting scientist at The Banyan Academy of Leadership in Mental Health.

Lower spending on female health as out-of-pocket expenditure persists

Overall, health insurance coverage in India is low--about 14% of the rural population and 19% of the urban population had any kind of health expenditure coverage between July 2017 and June 2018, according to the National National Sample Survey's Health In India report, July 2020. Of these, about 13% of the rural and 9% of the urban population were covered by government health insurance. This excludes the national health insurance programme, the Pradhan Mantri Jan Arogya Yojana, which replaced the erstwhile Rashtriya Swasthya Bima Yojana in September 2018. About 498.7 million people had health insurance coverage in the financial year 2019-20, the finance ministry informed Parliament on March 15, 2021, about 37% of the population in 2020.

Even those who have health insurance end up paying from their pocket for health expenses. For instance, care is supposed to be absolutely free under the Bhamashah scheme but about 28% of patients visiting private hospitals were charged for their care and made average payments of Rs 1,400 per visit, Dupas and Jain's study found. This is one of the reasons for the underutilisation of health insurance by women--female share of hospital visits for a service under Bhamashah decreased by 1.32 percentage points with every Rs 1,000 spent out of pocket, the study found.

By just offering to pay partly for hospital care when a person chooses to access it does not change how families make decisions on health expenditure, and they are likely to make decisions how they always have, within the prevailing gender norms, said Mor.

In rural India, households spent 43%, 37% and 22% more on men's health expenses than on women in government, private and charitable hospitals respectively. In urban India, households spent 15%, 20% and 31% more on men's health expenses than on women in government, private and charitable hospitals, respectively.

Slow-changing gender norms

Dupas and Jain tried to test whether political reservation for women at the panchayat level in Rajasthan increased hospital visits by women. They found that these have slow, small impacts, with each reserved election cycle increasing the female share of hospital visits among children under 15 years by 0.85 percentage points.

The authors hypothesise that this could happen because of several reasons: Women in positions of authority may reduce gender bias, raise aspirations for females and increase households' willingness to invest in female health; female leaders might increase young women's agency, enabling them to seek care for themselves and their children; and female leaders may prioritise and invest more resources in health, particularly that of women and girls.

But overall, despite electoral reservations, more awareness of the Bhamashah programme over the years and more hospitals empanelled under the scheme, the gender gap in seeking treatment persists because of the enduring gender norms in families. There has been little research on how this disparity can be reduced, the authors told IndiaSpend.

Solutions to this problem are hard, said Jain. "Different kinds of interventions can be experimented with across the country to see what might work," she added. For instance, one of the interventions that they had thought of testing was whether phone calls or text messages to women about the programme might get more of them to seek treatment.

In the UK, if a woman misses her preventive check for cervical cancer, the National Health Service will send her reminders, explained Mor. Even after several reminders, if she does not show up, a healthcare worker will reach out to find out why the screening was missed, said Mor. Just providing health insurance is not going to solve India's health problems or its gender inequality in health access, he explained.

There could be learnings from several such state programmes and the national insurance programme, the data of which would be a "gold mine", said Dupas. There might be some aspects of a programme that could be incorporated in other programmes to reduce gender disparities or, those aspects that need to be avoided because they increase gender disparities, she explained.

For instance, the erstwhile Rashtriya Swasthya Bima Yojana national insurance programme allowed enrollment of only five members of a household, and households which had more than five members were less likely to enroll daughters, a 2012 study had found.

State and national insurance programmes should be monitored in real time to understand and evaluate them and make changes to respond to issues that might crop up, Dupas said.

Without these efforts, health insurance, even if it provides comprehensive coverage, and reaches everyone whom it is supposed to, will be insufficient to provide healthcare to the most vulnerable, including women and those living in remote areas, Mor added. "There is value to such insurance schemes only if combined with universal healthcare access."

It is critical to evaluate and know the gender disparities in health programmes, because they have the potential to impact any future programmes too, such as the national Covid-19 vaccination campaign, said Dupas and Jain.

Currently, there is a gender gap in vaccinations countrywide, with 46% of doses administered to women as of July 4 while their estimated share in the population is 48.5%, per official data. In Rajasthan, too, only 46% of doses have been administered to women. "As long as this gender gap persists, there is little that can change in healthcare gender gaps in all sorts of interventions," said Dupas.

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