Preface
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been directed to public delivery or would have stayed outside the health sector itself. Also, most state schemes were created to address public supply constraints at the secondary and tertiary levels. Nevertheless, some schemes have shown an intent to improve the capacity of public provision beyond what was available in the public health system. For example, schemes in Kerala and AP have provided the public hospitals with an additional source of financing that has been used to upgrade infrastructure and introduce new services. Is there any information on the impact of the GSHISs on access to and utilization of health services? What about issues of moral hazard? Available utilization data suggest that insurance coverage has resulted in higher utilization of covered services among beneficiaries. However, impact on utilization is best measured through beneficiary and household surveys applying rigorous methodologies. Recent evaluation data from the Yeshasvini scheme show that affiliation (and the resulting financial access) resulted in increased utilization— a utilization rate of between 6 percent and 7 percent higher among insured members than among their uninsured peers. Since both groups were matched for health status, it was unlikely that adverse selection had caused this higher utilization. Lower-income members increased utilization by a still significant 2 percent. Research using administrative data identified some factors that affect utilization. In an analysis of 16,000 claims in 2007 and 2008 from R. Aarogyasri (AP), distance from cities where most empaneled facilities demanded by the beneficiaries were located was found to be negatively associated with utilization. Similarly, in an analysis of RSBY claims data from 75 districts, the authors reported that utilization was related to the distance between blocks and the towns where empaneled hospitals are located. Nevertheless, other factors that increased the probability of utilization were detected through regression analysis of the claims data from 18 districts (3,600 villages): being elderly, being literate, residing in a district with a large number of empaneled hospitals, having access to transportation, and living in a village where other insured villagers have already been treated through the scheme. Is there any evidence of impact on reducing financial burden or reducing out-of-pocket payments? A major objective common to all schemes is to reduce the financial burden of health spending on the poor. From the fact that all schemes are cashless (or nearly so) and provide coverage for hospitalization, a case can be made that they have reduced the financial burden on the poor, at least for the covered inpatient services. However,