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BackgroundTo achieve the Sustainable Development Goals, Indian States have implemented different strategies to arrest high out-of-pocket expenditure (OOPE) and to increase equity into healthcare system. Tamil Nadu (TN) and Rajasthan have implemented free medicine scheme in all public hospitals and West Bengal (WB) has devised Fair Price Medicine Shop (FPMS) scheme, a public-private-partnership model in the state. In this background, the objectives of the paper are to -Study the utilization pattern of public in-patient care facilities for the states,Examine the effectiveness of the strategies adopted by the states to arrest high OOPE andAnalyze the extent of equity in public in-patient care services in the states.MethodsNational Sample Survey (71st and 60th round) data, Detailed Demand for Grants of the state governments and the National Rural/Urban Health Mission data have been used for the study. Exploratory data analysis and benefit incidence analysis have been applied to estimate the utilization, OOPE and extend of equity in the states.ResultsThe results show that overall utilization of public facilities in TN and Rajasthan has increased substantially; whereas, utilization of public facility has decreased in WB even among the poorest. In addition, OOPE for both medical and medicine is the highest in WB among three states for public sector hospitalizations. Surprisingly, OOPE on medicine is the highest for the poorest class of WB. Analysis showed that the mismatch between actual need and FPMS drug-list has led to high OOPE in the state. Overall, benefit incidence of public subsidy is the highest among the poorest class in all the states. However, geographical sector-wise inequity in public subsidy distribution persists in the states. Analysis of cost of inpatient care shows that TN provides the maximum subsidy for hospitalization and WB provides the minimum. An inverse relationship between utilization of inpatient care and public subsidy has been observed from the analysis.ConclusionIn conclusion we could say that TN & Rajasthan have successfully implemented their health financing strategies to reduce the health expenditure burden. However, policy-level changes are required to improve the situation in WB.Electronic supplementary materialThe online version of this article (10.1186/s12913-018-3633-5) contains supplementary material, which is available to authorized users.

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Background: Out of eight commonly agreed Millennium Development Goals (MDG), six are related to the attainment of Universal Health Coverage (UHC) throughout the globe. This universalization of health status suggests policies to narrow the gap in access and benefit sharing between different socially and economically underprivileged classes with that of the better placed ones and a consequent expansion of subsidized healthcare appears to be a common feature for most of the developing nations. The National Health Policy in India (2002) suggests expansion of market-based care for the affording class and subsidized care for the deserving class of the society. So, the benefit distribution of this limited public support in health sector is important to examine to study the welfare consequences of the policy. This paper examines the nature of utilization to inpatient care by different socio-economic groups across regions and gender in West Bengal (WB), India. The benefit incidence of public subsidies across these socio-economic groups has also been verified for different types of services like medicines, diagnostics and professional care etc. Methods: National Sample Survey Organization (NSSO) has collected information on all hospitalized cases (60 th round, 2004) with a recall period of 365 days from the sampled households through stratified random sampling technique. The data has been used to assess utilization of healthcare services during hospitalization and the distribution of public subsidies among the patients of different socio-economic background; a Benefit Incidence Analysis (BIA) has also been carried out. Results: Analysis shows that though the rate of utilization of public hospitals is quite high, other complementary services like medicine, doctor and diagnostic tests are mostly purchased from private market. This leads to high Out-of-Pocket (OOP) expenditure. Moreover, BIA reveals that the public subsidies are mostly enjoyed by the relatively better placed patients, both socially and economically. The worse situation is observed for gender related inequality in access and benefit from public subsidies in the state. Conclusion: Focused policies are required to ensure proper distribution of public subsidies to arrest high OOP expenditure. Drastic change in policy targeting is needed to secure equity without compromising efficiency.

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This article focuses on analysing the efficiency of secondary-level government-run hospitals in West Bengal, a medium performer state in terms of health indicators, in India. Two main objectives of this article are (1) to measure the technical efficiency of the same and (2) to identify the factors determining their inefficiency. For the first purpose, output-oriented data envelopment analysis (DEA) under variable returns to scale has been used. For the second purpose, we have used two-part regression models, first showing why some hospitals are efficient while others are not and, secondly, what are the factors that determine the relative efficiency of inefficient hospitals. We have used different forms of regression models for both types. The results show that the overall mean efficiency of all hospitals is 0.728, suggesting that on average the hospitals could produce at least 37 per cent more of output with same input volume if they had produced efficiently. The results also reveal that the highest contributor to slack is the group D staff, followed by doctors. It is found that increase in average length of stay, availability of free medicine from the hospital, ratio between doctor and non-doctor staff strength, outpatient bed day and share of emergency admission significantly decrease the efficiency of a hospital, while the ratio of nurses to non-nurses affects it positively. The article concludes with policy suggestions based on the analysis that decrease in average length of stay (ALOS) by better medical intervention and improved quality of care would definitely allow for more patients to be treated, while increase in nursing staff vis-à-vis other staff would also result in better care. Furthermore, as far as availability of medicines is concerned, the policy should not be to reduce access and coverage, but should rather centre round improving the quality of the drugs procured and distributed through the hospitals. The article concludes that the main source of inefficiency in a specialist hospital in a typical developing country is not just resource crunch, but huge gaps in planning and implementation by the central authorities as well as managerial inefficiency of the local hospital establishment. The determinants that play a vital role in increasing efficiency levels also indicate that most of the inefficiencies can be tackled either with long-term planning or by quick intercession by the hospital authority itself.