Has the Rajiv Aarogyasri Community Health Insurance Scheme of Andhra Pradesh Addressed the Educational Divide in Accessing Health Care?

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.
Findings
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.
Conclusion
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.