title: Has the Rajiv Aarogyasri Community Health Insurance Scheme of Andhra Pradesh Addressed the Educational Divide in Accessing Health Care?
abstract: BACKGROUND
  Equity of access to healthcare remains a major challenge with families continuing to face financial and non-financial barriers to services. Lack of education has been shown to be a key risk factor for 'catastrophic' health expenditure (CHE), in many countries including India. Consequently, ways to address the education divide need to be explored. We aimed to assess whether the innovative state-funded Rajiv Aarogyasri Community Health Insurance Scheme of Andhra Pradesh state launched in 2007, has achieved equity of access to hospital inpatient care among households with varying levels of education.
  
  
  METHODS
  We used the National Sample Survey Organization 2004 survey as our baseline and the same survey design to collect post-intervention data from 8623 households in the state in 2012. Two outcomes, hospitalisation and CHE for inpatient care, were estimated using education as a measure of socio-economic status and transforming levels of education into ridit scores. We derived relative indices of inequality by regressing the outcome measures on education, transformed as a ridit score, using logistic regression models with appropriate weights and accounting for the complex survey design.
  
  
  RESULTS
  Between 2004 and 2012, there was a 39% reduction in the likelihood of the most educated person being hospitalised compared to the least educated, with reductions observed in all households as well as those that had used the Aarogyasri. For CHE the inequality disappeared in 2012 in both groups. Sub-group analyses by economic status, social groups and rural-urban residence showed a decrease in relative indices of inequality in most groups. Nevertheless, inequalities in hospitalisation and CHE persisted across most groups.
  
  
  CONCLUSIONS
  During the time of the Aarogyasri scheme implementation inequalities in access to hospital care were substantially reduced but not eliminated across the education divide. Universal access to education and schemes such as Aarogyasri have the synergistic potential to achieve equity of access to healthcare.
authors.affiliation: Department of Primary Care and Public Health, Imperial College London, London, United Kingdom.
authors.forename: Mala
authors.initials: M
authors.lastname: Rao
authors.affiliation: Oxford Policy Management, Delhi, India.
authors.forename: Prabal Vikram
authors.initials: PV
authors.lastname: Singh
authors.affiliation: ACCESS Health International, Hyderabad, India.
authors.forename: Anuradha
authors.initials: A
authors.lastname: Katyal
authors.affiliation: SughaVazhvu Healthcare, Thanjavur, India.
authors.forename: Amit
authors.initials: A
authors.lastname: Samarth
authors.affiliation: ACCESS Health International, Hyderabad, India.
authors.forename: Sofi
authors.initials: S
authors.lastname: Bergkvist
authors.affiliation: Institute for Health and Human Development, University of East London, London, United Kingdom.
authors.forename: Adrian
authors.initials: A
authors.lastname: Renton
authors.affiliation: Institute for Health and Human Development, University of East London, London, United Kingdom.|ESRC International Centre for Life Course Studies in Society and Health, University College London, London, United Kingdom.
authors.forename: Gopalakrishnan
authors.initials: G
authors.lastname: Netuveli
mesh_terms: D003153:Community Health Services; D005260:Female; D006266:Health Education; D000069576:Health Equity; D006297:Health Services Accessibility; D006801:Humans; D007194:India; D007348:Insurance, Health; D008297:Male; D012959:Socioeconomic Factors