title: Can health insurance improve access to quality care for the Indian poor?
abstract: OBJECTIVE
  Recently, the Indian government launched health insurance schemes for the poor both to protect them from high health spending and to improve access to high-quality health services. This article aims to review the potentials of health insurance interventions in order to improve access to quality care in India based on experiences of community health insurance schemes.
  
  
  METHODS
  PubMed, Ovid MEDLINE (R), All EBM Reviews, CSA Sociological Abstracts, CSA Social Service Abstracts, EconLit, Science Direct, the ISI Web of Knowledge, Social Science Research Network and databases of research centers were searched up to September 2010. An Internet search was executed.
  
  
  METHODS
  One thousand hundred and thirty-three papers were assessed for inclusion and exclusion criteria. Twenty-five papers were selected providing information on eight schemes.
  
  
  METHODS
  A realist review was performed using Hirschman's exit-voice theory: mechanisms to improve exit strategies (financial assets and infrastructure) and strengthen patient's long voice route (quality management) and short voice route (patient pressure).
  
  
  RESULTS
  All schemes use a mix of measures to improve exit strategies and the long voice route. Most mechanisms are not effective in reality. Schemes that focus on the patients' bargaining position at the patient-provider interface seem to improve access to quality care.
  
  
  CONCLUSIONS
  Top-down health insurance interventions with focus on exit strategies will not work out fully in the Indian context. Government must actively facilitate the potential of CHI schemes to emancipate the target group so that they may transform from mere passive beneficiaries into active participants in their health.
authors.affiliation: Research Centre for Longitudinal and Life Course Studies, Department of Sociology, University of Antwerp, Antwerp, Belgium. joris.michielsen@ua.ac.be
authors.forename: Joris
authors.initials: J
authors.lastname: Michielsen
authors.forename: Bart
authors.initials: B
authors.lastname: Criel
authors.forename: Narayanan
authors.initials: N
authors.lastname: Devadasan
authors.forename: Werner
authors.initials: W
authors.lastname: Soors
authors.forename: Edwin
authors.initials: E
authors.lastname: Wouters
authors.forename: Herman
authors.initials: H
authors.lastname: Meulemans
mesh_terms: D005260:Female; D006297:Health Services Accessibility; D006801:Humans; D007194:India; D019458:Insurance Coverage; D007348:Insurance, Health; D008297:Male; D011203:Poverty; D011787:Quality of Health Care