title: Impact of community-based health insurance in rural India on self-medication & financial protection of the insured.
abstract: OBJECTIVE
  The evidence-base of the impact of community-based health insurance (CBHI) on access to healthcare and financial protection in India is weak. We investigated the impact of CBHI in rural Uttar Pradesh and Bihar s0 tates of India on insured households' self-medication and financial position.
  
  
  METHODS
  Data originated from (i) household surveys, and (ii) the Management Information System of each CBHI. Study design was "staggered implementation" cluster randomized controlled trial with enrollment of one-third of the treatment group in each of the years 2011, 2012 and 2013. Around 40-50 per cent of the households that were offered to enroll joined. The benefits-packages covered outpatient care in all three locations and in-patient care in two locations. To overcome self-selection enrollment bias, we constructed comparable control and treatment groups using Kernel Propensity Score Matching (K-PSM). To quantify impact, both difference-in-difference (DiD), and conditional-DiD (combined K-PSM with DiD) were used to assess robustness of results.
  
  
  RESULTS
  Post-intervention (2013), self-medication was less practiced by insured HHs. Fewer insured households than uninsured households reported borrowing to finance care for non-hospitalization events. Being insured for two years also improved the HH's location along the income distribution, namely insured HHs were more likely to experience income quintile-upgrade in one location, and less likely to experience a quintile-downgrade in two locations.
  
  
  CONCLUSIONS
  The realized benefits of insurance included better access to healthcare, reduced financial risks and improved economic mobility, suggesting that in our context health insurance creates welfare gains. These findings have implications for theoretical, ethical, policy and practice considerations.
authors.affiliation: Micro Insurance Academy, New Delhi, India and Institute of Health Policy & Management, Erasmus University, Rotterdam, The Netherlands.
authors.forename: David M
authors.initials: DM
authors.lastname: Dror
authors.affiliation: Micro Insurance Academy, New Delhi, India and Institute of Health Policy & Management, Erasmus University, Rotterdam, The Netherlands; Public Health Foundation of India, Gurgaon, India, .
authors.forename: Arpita
authors.initials: A
authors.lastname: Chakraborty
authors.affiliation: Micro Insurance Academy, New Delhi, India and Institute of Health Policy & Management, Erasmus University, Rotterdam, The Netherlands.
authors.forename: Atanu
authors.initials: A
authors.lastname: Majumdar
authors.affiliation: Micro Insurance Academy, New Delhi, India and Institute of Health Policy & Management, Erasmus University, Rotterdam, The Netherlands.
authors.forename: Pradeep
authors.initials: P
authors.lastname: Panda
authors.affiliation: Tel Aviv University, Rabin Medical Center, Petah Tikva, Israel.
authors.forename: Ruth
authors.initials: R
authors.lastname: Koren
mesh_terms: D005191:Family Characteristics; D006297:Health Services Accessibility / Q000191:economics* / Q000592:standards; D006801:Humans; D007194:India; D007348:Insurance, Health / Q000191:economics*; D012424:Rural Population