This article was first published by the social and political economy portal IndiaSpend.

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 analyzing 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 program 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 program 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 analyzed, subsidized 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.

This opinion piece was first published in the economics and policy portal Ideas for India.

Equity in healthcare is a key goal of health policy in India. Analyzing administrative data from Rajasthan, this article highlights substantial gender gaps in the utilization of subsidized hospital care under the state health insurance program. These disparities persist despite substantial program expansion and seem to be driven by households being less willing to allocate resources to female vis-à-vis male health.

Over the past 15 years, India’s central government and numerous state governments have put in place health insurance programmes that entitle low-income households to free healthcare at public and empanelled private hospitals. Health equity and universal health coverage are explicit goals of these programs. In new research, we study gender equity in the Bhamashah Swasthya Bima Yojana (BSBY)1 health insurance program, which was launched in the state of Rajasthan in 2015, and is similar in design to the national Pradhan Mantri Jan Arogya Yojana (PMJAY).

Our starting point is a dataset of insurance claims filed for all 4.2 million hospital visits between 2015 and 2019, including patient age, gender, residence address, hospital visited, dates of admission and discharge, and service(s) received. We geo-coded hospital locations and patient addresses, which allowed us to calculate proximity to hospitals and the distance traveled for every hospital visit. Finally, we linked the insurance data to the 2011 Census and data on three rounds of village-level (gram panchayat) elections. To our knowledge, the dataset we compiled from these various sources is the first dataset of its type in India and allows us to study care-seeking under insurance with unusual granularity.

Shorenstein APARC is pleased to share that Radhika Jain, our 2019-22 Asia Health Policy Postdoctoral Fellow, is the recipient of the inaugural Adam Wagstaff Award for Outstanding Research on the Economics of Healthcare Financing and Delivery in Low- and middle-Income Countries. Hosted by the International Health Economics Association (iHEA), the award recognizes Jain’s excellent paper, "Private Hospital Behavior Under Government Health Insurance in India." She received the award on July 13 at a special session of the iHEA 2021 Congress.

Jain is a health economist working on public health policy in India. Her research focuses on the role of the private sector in the country’s health system, frictions in health care markets, socioeconomic and gender inequality, and health policy design. Her award-winning paper provides the first large-scale evidence on the behavior of private hospitals within public health insurance programs in India. In a major policy shift away from direct public provision of health care, the Indian government has been expanding health insurance programs that contract private hospitals for service delivery and pay them at fixed rates for services. Until now, however, there has been little empirical evidence on the behavior of private hospitals within these programs. 

Earlier this year, Jain presented the results of her study as part of the Asia Health Policy Program’s 2020-21 colloquium series, "Health, Medicine, and Longevity: Exploring Public and Private Roles.” Watch the conversation here:

For her research, Jain used over 1.6 million insurance claims, 20,000 patient surveys, and a policy-induced natural experiment that changed hospital reimbursement rates. Her study reveals that private hospitals in India engage in coding manipulation to increase revenues at government expense and charge patients out-of-pocket for care against program rules. As a result, almost half of all patients pay for care that should be free, and these payments constitute a 35% markup over the price the government pays. The charges decrease if reimbursement rates increase, but hospitals capture approximately half the increased reimbursements.

Jain's findings indicate that hospitals exploit market frictions and poor program enforcement to capture a substantial share of the public subsidy as profit. “In contexts of weak oversight,” she writes, “profit-motivated private agents systematically flout program rules to increase their revenues at considerable expense to the government and patients.”

She also finds, however, that hospital non-compliance partially compensates for prices set too low to meet the participation constraints of agents. Reimbursement rates, says Jain, are a significant policy lever that drives agent behavior, and simply increasing monitoring without appropriate price-setting may increase compliance but decrease service provision.

Jain’s research shows that market structure — a factor rarely taken into account in social policy design in lower-income contexts — can affect the extent to which public subsidies benefit citizens. Her findings provide broader insights into contracting the private sector for delivering health and other social services in settings with limited institutional capacity for monitoring and optimal price-setting.

On our podcast, Jain discusses her efforts to develop measures that improve how health systems serve vulnerable populations and her collaborative research with Stanford development economist Pascaline Dupas on how India's COVID-19 lockdown affected access to non-COVID-related health care and outcomes. Listen here:

The Adam Wagstaff Award honors the legacy of the late Adam Wagstaff, who was a research manager in the Development Research Group of the World Bank and former president of iHEA, and celebrates his lifelong commitment to improving healthcare financing and delivery and promoting equity in low- and middle-income countries. The award also contributes to iHEA’s efforts to promote excellence in health economics globally and advance internationalization through greater inclusion of low- and middle-income country researchers.

Congratulations, Dr. Jain, on this well-deserved honor!

This blog post was first published by the Australian Strategic Policy Institute's The Strategist analysis and commentary site.

The Quad is stronger than ever. The informal ‘minilateral’ grouping of Australia, India, Japan and the United States has in the past year held its first stand-alone ministerial meeting and its first leaders’ summit, and launched an ambitious project to deliver Covid-19 vaccines. This ‘golden age’ of the Quad is a product of newfound Indian enthusiasm for the grouping, in turn, spurred by the military crisis in Ladakh, where India faces ongoing Chinese troop incursions across the two countries’ disputed border.

But the Quad is not bulletproof. Some experts have suggested that the economic and diplomatic effects of the devastating second wave of the pandemic in India will preoccupy the Indian government, sapping the Quad of capacity for any new initiatives. Others counter that India remains committed to competition with China—which is what really matters for the Quad—although its partners always expected ‘two steps forward, one step back’ from India.

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Related: On the Conversation Six podcast, Tarapore discusses the policy paper on which this blog post is based with Jawaharlal Nehru University Professor of International Politics Rajesh Rajagopalan. Listen:

The pandemic may well prove to be a hiccup in the Quad’s evolution, but a potentially much larger disruption may come from the ongoing Ladakh crisis itself. As I argue in a new ASPI Strategic Insights paper, the crisis has greatly increased the risk of a border war between India and China, which would present a defining test of the Quad. A possible war could either strengthen or enervate the Quad—depending on how India and its partners, including Australia, act now to shape the strategic environment.

Risk is a function of likelihood and consequence. The likelihood of war on the India–China border is still low—both countries would prefer to avoid it—but has risen since the crisis began. Both countries have greatly expanded their military deployments on the border and backed them with new permanent infrastructure to resupply and reinforce them. China has proved its revisionist intent with large and costly military incursions, although its specific objectives and plans remain unknown. And the interaction of both countries’ military strategies and doctrines would, on the threshold of conflict, promote escalation.

The consequences of a possible conflict would be dire for both belligerents and for the region. China — assuming it is the provocateur of conflict—would likely face some political rebuke from states that consider themselves its competitors, but it will work strenuously to reduce those costs, and would likely have priced them in to its calculations of whether to fight. India will suffer high tactical costs on the border, and may also suffer wider harm if China uses coercive cyberattacks against strategic or dual-use targets.

In a costly war, the repercussions may spill over to damage India’s recently developing strategic partnerships, especially with the United States and Australia. Despite generally favorable views of the US, the Indian strategic elite still harbors some latent suspicions. This was highlighted in two episodes in April 2021, when the US Navy conducted a freedom of navigation patrol through the Indian exclusive economic zone, and when the US was slow in delivering Covid-19 vaccine raw materials and other relief. Both instances quickly receded from the Indian public imagination—thanks to quick correctives from Washington—but they did reveal that, under some conditions, Indian perceptions of its new partnerships can be quickly colored by distrust.

A China–India border war may create exactly those conditions. There is a chance that conflict may result in a redoubled Indian commitment to the Quad, if New Delhi judges that it has no option but to seek more external assistance. Conversely, unless a conflict is managed well by India and its partners, it is more likely to result in Indian disaffection with the Quad. India deepened Quad cooperation during the Ladakh crisis partly as a deterrent signal to China, and partly because the Quad is still full of promise. However, after a conflict—when China hasn’t been deterred and has probably imposed significant costs on India—the Quad’s utility would have been tested, and probably not ameliorated India’s wartime disadvantage.

The task before Quad governments is to be sensitized to this risk and implement mitigation strategies before a possible conflict, to buttress the coalition in advance. As I outline in the ASPI paper, they could do this at three levels. First, they could offer operational support—such as intelligence or resupply of key equipment, as the US already has done in the Ladakh crisis—although Quad partners’ role here would be limited. Second, they could provide support in other theatres or domains—with a naval show of force, for example, although cyber operations would probably be more meaningful in deterring conflict or dampening its costs. Third, they could provide political and diplomatic support — signaling to Beijing that a conflict would harm its regional political standing.

For Quad members, the main goal would be to deter conflict in the first place, and, failing that, to preserve the long-term strategic partnership with India for the sake of maintaining as powerful and energetic a coalition as possible to counterbalance China in the long term.