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2026 - Volume 9 - Number 1

Financial Protection under Public Health Insurance among Socially and Economically Backward Workers: A Comparative Study of Cherthala and Ambalapuzha Taluks in Kerala

Shaji Athul P. * ORCID: 0009-0004-0736-6643
University of Kerala,St. Michael’s College, Department of Economics, Alappuzha, INDIA

K. P. Binil
University of Kerala,St. Michael’s College, Department of Economics, Alappuzha, INDIA

Open Journal for Research in Economics, 2026, 9(1), 11-22 * https://doi.org/10.32591/coas.ojre.0901.02011r
Received: 10 January 2026 ▪ Revised: 22 March 2026 ▪ Accepted: 20 May 2026

LICENCE: Creative Commons Attribution 4.0 International License.

ARTICLE (Full Text - PDF)

ABSTRACT:

Publicly financed health insurance schemes are integral to Universal Health Coverage in India, but their ability to offer financial protection to socially and economically disadvantaged workers has been debated. Over the last two decades, universal public health insurance has been gaining acceptance in low- and middle-income countries, but few studies have examined the impact of public health insurance on out-of-pocket (OOP) expenditure in an Indian context using a between and within compare design context setting: Cherthala and Ambalapuzha taluks in Alappuzha district, Kerala. Using mixed methods approach, this study investigates the protective effect of public health insurance on inpatient OOP expenditure among the most marginalized workers. Based on primary data on insured patients in government taluk hospitals, government medical colleges and large private hospitals, the study explores the incidence of hospitalization, choice of provider and the extent and determinants of inpatient OOP expenditure. Methods — A fully quantitative analysis integrates descriptive statistics with multivariate regression to measure the relationship between insurance status, the type of hospital (private vs. The results show that although public health insurance increases access to inpatient care for workers from socially and economically disadvantaged groups, it still offers only limited financial protection. Patients with insurance still bear high levels of OOP costs, especially for private hospitals, medicines, diagnostics and for longer stay relating to chronic illness. There is significant taluk-level variation in the comparative results which are attributable to the type, spread of health infrastructure, availability of public sector services and dependence of private sector providers. Even with a relatively better public health system in Kerala, people with insurance cover are not protected from financial vulnerability, especially informal and marginalized workers. It highlights the inadequacies of hospital-centric insurance models in environments with fragmented health systems and poverty. To convert insurance coverage into effective financial protection for vulnerable populations, it is critical to re-enforce public provisioning, broaden the benefit packages beyond inpatient care, and regulate private sector costs.

KEY WORDS: public health insurance, financial protection, out-of-pocket expenditure, unorganized workers, health equity, Kerala.

CORRESPONDING AUTHOR:
Binil. K. P., University of Kerala, St. Michael’s College, Department of Economics, Alappuzha, INDIA.

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