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Changes in addressing inequalities in access to hospital care in Andhra Pradesh and Maharashtra states of India: a difference-in-differences study using repeated cross-sectional surveys
  1. Mala Rao1,2,
  2. Anuradha Katyal3,
  3. Prabal V Singh3,
  4. Amit Samarth4,
  5. Sofi Bergkvist3,
  6. Manjusha Kancharla5,
  7. Adam Wagstaff6,
  8. Gopalakrishnan Netuveli7,
  9. Adrian Renton1
  1. 1Institute for Health and Human Development, University of East London, London, UK
  2. 2Administrative Staff College of India, Hyderabad, Andhra Pradesh, India
  3. 3ACCESS Health International, Hyderabad, Andhra Pradesh, India
  4. 4SughaVazhvu Healthcare, Thanjavur, Tamil Nadu, India
  5. 5Indian School of Business, Hyderabad, Andhra Pradesh, India
  6. 6Development Research Group (DECRG), The World Bank, Washington, DC, USA
  7. 7Institute for Health and Human Development, University of East London & ESRC International Centre for Life Course Studies in Society and Health, University College London, London, UK
  1. Correspondence to Dr Mala Rao; m.rao{at}


Objectives To compare the effects of the Rajiv Aarogyasri Health Insurance Scheme of Andhra Pradesh (AP) with health financing innovations including the Rashtriya Swasthya Bima Yojana (RSBY) in Maharashtra (MH) over time on access to and out-of-pocket expenditure (OOPE) on hospital inpatient care.

Study design A difference-in-differences (DID) study using repeated cross-sectional surveys with parallel control.

Setting National Sample Survey Organisation of India (NSSO) urban and rural ‘first stratum units’, 863 in AP and 1008 in MH.

Methods We used two cross-sectional surveys: as a baseline, the data from the NSSO 2004 survey collected before the Aarogyasri and RSBY schemes were launched; and as postintervention, a survey using the same methodology conducted in 2012.

Participants 8623 households in AP and 10 073 in MH.

Main outcome measures Average OOPE, large OOPE and large borrowing per household per year for inpatient care, hospitalisation rate per 1000 population per year.

Results Average expenditure, large expenditures and large borrowings on inpatient care had increased in MH and AP, but the increase was smaller in AP across these three measures. DIDs for average expenditure and large borrowings were significant and in favour of AP for the rural and the poorest households. Hospitalisation rates also increased in both states but more so in AP, although the DID was not significant and the subgroup analysis presented a mixed picture.

Conclusions Health innovations in AP had a greater beneficial effect on inpatient care-related expenditures than innovations in MH. The Aarogyasri scheme is likely to have contributed to these impacts in AP, at least in part. However, OOPE increased in both states over time. Schemes such as the Aarogyasri and RSBY may result in some positive outcomes, but additional interventions may be required to improve access to care for the most vulnerable sections of the population.


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