Government health insurance for people below poverty line in India: quasi-experimental evaluation of insurance and health outcomes

The present study shows the health care benefits of an insurance programme in Karnataka, a south Indian state. However, we need to look at some aspects of the study before accepting the results.

An information on how 33 causes for hospitalization were derived at needs detailed explanation since there could be variations in the population regarding morbidity and mortality. And only two-thirds of the study population could tell the self reported cause of admission in the hospital can possibly lead to reporting bias due to a large number of people not reporting the conditions and their characteristics might be different from responders. A clarification regarding this may be given so that possible bias could be eliminated. It is also essential to know how may health centres, tertiary care hospitals had reports of the patients shown in their hospitals who were enrolled for the Vajpayee Arogyashree Scheme (VAS). In general, out patient records in the general government hospitals are not complete and details about the patient records for routine out patient visits might not be available. In this context, it is essential to know about the veracity, quality of records maintained in the empanelled hospitals. Did the investigators checked on this aspect and what is their observation ?

An important indicator is the cause of death used in the study. Was it based on the available records or other methods such as verbal autopsy or combination needs clarity ? If it is based on available records, how many patients had actually had a death certificate certifying the cause of death and what were the proportion of causes of death available in the insured and non insured regions ? Usually, the cause of death report is of much concern and the reporting is incomplete in all the states of India. It is also essential to know the pattern of causes of death in the insured and non insured regions and find out which causes could have been averted or preventable from the perspective of health care delivery system improvements in services. This could be mentioned in the discussion. There are limitations to verbal autopsy reported deaths as well. Verbal autopsy should not be considered as a Gold standard and its limitations should be considered due to reporting bias of respondents, and cause of death ascertainment by coders. Sometimes, the information given by respondents are low and cannot predict the cause of death. Such possible bias should be considered before accepting the results.