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Verschenen in de reeks Monografien van de Vakgroep
Maatschappelijke Gezondheidkunde, Universiteit Gent ISBN-NUMMER :
ISBN-NUMMER : 9789078344216 Wettelijk Depot: D/2012/4531/1
Druk : Grafische dienst, Instituut voor Tropische Geneeskunde,
Antwerpen
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i
Abbreviations
ACCORD Action for Community Organisation, Rehabilitation and
Development (an NGO)
CHExp Catastrophic Health Expenditure
CHI Community Health Insurance
CI Confidence Interval
df Degrees of Freedom
DHAN Development for Humane Action and Network (an NGO)
FFS Fee-for-service
FWWB Forum for World Women Banking
GDP Gross Domestic Product
KKVS Kadamalai Kalanjiam Vattara Sangam (an NGO)
NCAER National Council for Applied Economic Research
NGO Non-governmental Organisation
NRHM National Rural Health Mission
OOP Out-of-pocket payment
OR Odds Ratio
RCMS Rural Co-operative Medical Scheme
RSBY Rashtriya Swasthya Bima Yojana (National Health Insurance
Scheme)
SEWA Self-employed Women's Association (an NGO)
SHI Social Health Insurance
THE Total Health Expenditure
US$ US Dollars
WHO The World Health Organization
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ii
AcknowledgementsThis thesis is dedicated to my mother who prayed
to the zillion Gods of the Hindu pantheon to bless
me with a PhD. Every time I returned from Antwerp, she would
hopefully ask did you submit your thesis?
Yet another inspiration was Prof. Jean-Marie Jacque and his wife
Nadine Menier. Without these two guardian angels, the long, dark
and cold days in Antwerp would have been unbearable. The warmth and
love that they showered on me will always be etched in my memory.
Jean-Marie, I know that you will be there watching over me when I
defend my thesis.
A close friend warned me that embarking on a PhD at the age of
43 was dangerous for the family. At the end, you will have either a
wife or a PhD, not both. I am happy to say that Roopa has proved my
friend wrong. She stood by me during this entire period, taking
care of the children and our parents single-handedly. I would like
to thank you Roopa for walking with me along this arduous path.
My children accused me of having HIV (health insurance virus)
because it was health insurance at the dining table, on a family
vacation and in my sleep. Having to share their father with the HIV
for seven years was not very comfortable. Thank you, Gayu and Vasu,
for being so patient with me.
Patrick my coach raised the bar high enough to stretch me. I do
not think that I always lived upto his expectations, but I did my
best. Bart was as patient and kind as always, helping me keep the
balance between the quantitative and qualitative aspects of my
research. I would never have embarked on this lonesome journey, had
it not been for Wims influence. He was the first to put the idea
into my head and supported me throughout the voyage. Between the
three of them, I learnt a lot of science but also the ability to
look at life through the lens of hypothesis.
There are many others, each one who helped me on this academic
adventure. All the staff and community at ACCORD, SEWA and KKVS who
helped me with the data collection, opened their houses and their
hearts and let me be part of their joy and suffering. Gaja, who
helped me with the data, my accounts and bore the brunt of my
frustration during the writing phase. My sincere thanks to Suja,
who intervened on my behalf with BTM Ganapathy. I am sure that this
helped me, especially in the last stages of this odyssey when I
nearly gave up. And finally let me not forget the Director General
for Development Co-operation (DGDC) who provided me with a generous
fellowship through the Institute of Tropical Medicine, Antwerp
(ITM). And last but not the least, a thank you to the Sir Ratan
Tata Trust, (SRTT), Mumbai for financing my research
activities.
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ContentsAbbreviations .......................... i
Acknowledgements .. ii
Contents .............. iii
Summary (Dutch) .............. 1
Summary (English) ............... 7
Chapter 1: Introduction .. 13
1.1: India .. 13
1.2: Problems of access to health care and financial protection
.. 17
1.3: Hypothesis & Research Objectives 19
Chapter 2: Literature review .. 21
2.1: Health insurance ... 21
2.2: Community health insurance .. 22
2.3: Access to care ............ 27
2.4: Financial protection .. 31
2.5: Quality of care ... 38
2.6: Conclusions ... 44
Chapter 3: Context of the study .. 45
3.1: ACCORD CHI scheme 46
3.2: KKVS CHI scheme ............ 47
3.3: SEWA CHI scheme .. 48
Chapter 4: Published and Accepted papers . 51
Article 1: The landscape of community health insurance in India:
an overview based on 10 case studies ..
51
Article 2: Community health insurance in Gudalur, India,
increases access to hospital care ..
64
Article 3: Indian community health insurance schemes provide
partial protection against catastrophic health expenditure ...
76
Article 4: Community health insurance schemes & patient
satisfaction: evidence from India
88
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iv
Chapter 5: General discussion 99
5.1: Summary of main findings . 99
5.2: Strengths and limitations of the research . 102
5.3: Lessons for India and the world . 103
5.4: The way forward 105
5.5: Strengthening CHI schemes in India . 107
5.6: Conclusions ... 113
Appendix 1: Iatrogenic poverty Editorial. Tropical Medicine and
International Health ... 116
Appendix 2: Community health in developing countries. In:
Heggenhougen K, Quah S. Eds. International Encyclopedia of public
health. San Diego: Academic Press; 2008. 782-791 ..
122
References . 135
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Summary(Dutch)Lokale ziekteverzekering (Community Health
Insurance) draagt bij aan universele toegang tot gezondheidszorg in
India
De Indische economie is in de laatste drie decennia
verdrievoudigd in omvang. Desondanks bleven de
overheidsuitgaven voor gezondheidszorg opmerkelijk laag: US$ 5
per persoon per jaar. Dit noopt gebruikers van
gezondheidszorg tot aanzienlijke eigen bijdragen (out-of-pocket
betalingen in het Engels - afgekort OOP). Voor de
armste en meest kwetsbare huishoudens betekent dit vaak ofwel
verzaken aan noodzakelijke medische zorg ofwel
zich in de schulden steken met verdere verarming tot gevolg.
Om het hoofd te bieden aan deze problematiek hebben meerdere
Indische niet-gouvernementele organisaties
(NGOs) lokale ziekteverzekeringssystemen opgestart (Community
Health Insurance in het Engels - afgekort CHI).
CHI wordt gedefinieerd als een non-profit
verzekeringsarrangement dat zich in eerste instantie richt op
huishoudens
in de informele sector, dat stoelt op een solidaire bundeling
van gezondheidsrisicos, en met structurele
mogelijkheden voor inspraak van de leden van de
ziekteverzekering in het beheer van het systeem. CHI systemen
zijn exponentieel gegroeid in India in de afgelopen tien jaar,
deels onder impuls van de microkrediet beweging.
In theorie is CHI - door zijn combinatie van voorafbetaling en
risicobundeling - een uiterst relevante
strategie om voor mensen in de informele sector de toegang tot
gezondheidszorg te vergemakkelijken. Vandaag is er
in India echter vooralsnog weinig bewijs dat deze CHI systemen
de toegang tot zorg effectief verbeteren en dat ze
mensen inderdaad beschermen tegen catastrofale
gezondheidszorguitgaven (Catastrophic Health Expenditure in het
Engels - afgekort CHExp). De doelstellingen van dit onderzoek
zijn precies om na te gaan of en onder welke
voorwaarden CHI de toegang tot gezondheidszorg verbetert, of
bescherming biedt tegen CHExp, en bijdraagt tot een
grotere tevredenheid van de patint.
Allereerst onderzochten we in detail het opzet en de
implementatie van 10 zorgvuldig uitgekozen CHI
systemen om op die manier tot een beter inzicht te komen in de
verscheidenheid en typologie van CHI in India. Op
basis van deze studie hebben wij drie CHI systemen geselecteerd
om ze dan verder uitvoeriger te analyseren en
evalueren: Action for Community Organisation, Rehabilitation and
Development (ACCORD), Kadamalai Kalanjiam
Vattara Sangam (KKVS) en Self Employed Womens Association
(SEWA). In Accord en KKVS werden enqutes
doorgevoerd in willekeurig gekozen, verzekerde en
niet-verzekerde, huishoudens. Er werd daarbij informatie
verzameld over een aantal sociale en economische kenmerken, het
morbiditeitspatroon, het gedrag in geval van
ziekte en de vraag naar zorg, de gezondheidsuitgaven en de
tevredenheid van de patinten over de gebruikte zorg.
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Aanvullende focusgroepgesprekken met zowel verzekerde als
onverzekerde individuen, met gehospitaliseerde
patinten, en met zorgverstrekkers brachten meer inzicht in de
perceptie van de kwaliteit van de zorg en van de
doeltreffendheid van het CHI systeem. In de drie geselecteerde
CHI systemen werden secundaire data over de
ziekenhuisopnames verzameld op basis van de beschikbare
hospitaalregisters. De toegang tot hospitaalzorg en de
incidentie van CHExp werden eveneens gemeten.
Alle 10 bestudeerde CHI systemen werden door NGOs opgericht met
als doel de toegang tot
gezondheidszorg te verbeteren, het maken van schulden (om zorg
te betalen) te voorkomen, en de lokale
gemeenschappen te empoweren. De CHI systemen richtten zich
expliciet op de armste en meest kwetsbare
huishoudens in de Indische samenleving, meer in het bijzonder
vrouwen en mensen in de laagste kasten en etnische
minderheden. Al deze systemen bouwden op bestaande civiele
organisaties, kapitaliserend op het bestaande sociaal
kapitaal en vertrouwen in deze verenigingen. Men kan het
onderscheid maken tussen drie verschillende types van
CHI, op basis van de rol van de NGO in het geheel. In het
aanbieders type (provider type) is de NGO zowel de
verzekeraar als zorgverstrekker. Dit is het geval bij ACCORD. In
het onderlinge type (mutual type) is de NGO de
verzekeraar die gezondheidszorg aankoopt bij verstrekkers. Dit
is het geval bij KKVS. Tenslotte, in het
gekoppelde type (linked type), gaat de NGO een verzekering aan
met een bestaande verzekeringsmaatschappij die
zorg aankoopt bij zorgverstrekkers, zoals in het geval van
SEWA.
De meeste systemen zijn gebaseerd op vrijwillige aansluiting,
met het individu als eenheid van aansluiting.
Het aantal leden in de verschillende systemen varieert van 1.000
tot 100.000 personen. Premies zijn forfaitair
(community-rated) en variren van US $ 0,5 tot US $ 5 per persoon
per jaar. Al de 10 CHI systemen die we
bestudeerden verzekeren voor de kost van hospitaalzorg, maar
slechts tot op een bepaalde hoogte. Ze bieden een
bescherming aan tegen de meest voorkomende ziekten, maar
chronische en vooraf bestaande aandoeningen worden
vaak uitgesloten. Slechts uitzonderlijk is er sprake van
monitoring- en evaluatiemechanismen van enig niveau. Dit
gebrek aan informatie impliceert dat geen enkel van de
onderzochte CHI systemen over empirisch bewijs beschikte
om de doeltreffendheid van de ziekteverzekering in termen van
toegankelijkheid tot ziekenhuiszorg of in termen van
sociale bescherming van de huishoudens tegen CHExp te evalueren.
De bevraging bij de huishoudens in het
ACCORD systeem toonde aan dat 57% van de verzekerden kleine
gezondheidsproblemen hadden doorgemaakt in de
periode 2004-2005, tegenover 58% bij de niet-verzekerden. De
proportie van personen met een chronische kwaal
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3
bedroeg 5% bij de verzekerden en 2% bij de niet-verzekerden. De
verhoudingen van personen met ernstige
aandoeningen waren respectievelijk 14 en 8%.
In de verzekerde en onverzekerde populaties werden
respectievelijk 92 en 42 per 1.000 mensen per jaar
gehospitaliseerd. Negentig procent van de verzekerde zwangere
vrouwen bevielen in een ziekenhuis, tegenover 45%
van de onverzekerde vrouwen (2 = 8,6; df = 1). Uit de studie
bleek ook dat 65% van de verzekerde patinten met
ernstige aandoeningen werden opgenomen in een ziekenhuis,
vergeleken met 44% bij de niet-verzekerde patinten
(OR 2,2; 95% CI: 1,31, 3,77). Deze hogere gebruiksindex van het
hospitaal in de populatie van verzekerde patinten
werd ook vastgesteld bij de meer kwetsbare groepen in de
bevolking, zoals kinderen, vrouwen, mensen met een
lagere socio-economische status en diegenen die ver van het
ziekenhuis wonen. In het laagste inkomenskwintiel is de
kans op een hospitalisatie voor verzekerde patinten 3,47 keer
hoger dan voor onverzekerden. De verzekeringsstatus
blijft een belangrijke determinant van verhoogd hospitaalgebruik
ook na correctie voor verstorende (confounding)
factoren zoals leeftijd, geslacht, afstand van het ziekenhuis en
aanwezigheid van reeds bestaande aandoeningen.
Deze studie toont duidelijk aan dat het ACCORD CHI systeem leidt
tot een verbeterde toegang van
hospitaalzorg, ook voor de armste en meest kwetsbare groepen in
de samenleving. Mogelijke verklaringen voor deze
gunstige impact zijn het uitgebreide dienstenpakket dat aan de
verzekerden aangeboden wordt, de betaalbare en
gesubsidieerde premies, het vertrouwen in kwalitatieve
zorgverstrekkers, en de derdebetalersregeling.
Uit onze data analyse blijkt dat er in 2003 en 2004 in het geval
van ACCORD en SEWA respectievelijk 683
en 3.152 hospitaalopnames waren. Alle door ACCORD verzekerde
patinten werden opgenomen in een non-profit
ziekenhuis, terwijl de door SEWA verzekerden vooral opgenomen
werden (86%) in profit voorzieningen. De
gemiddelde ziekenhuisrekening per opname bedroeg US $ 12 voor
ACCORD patinten en US $ 46 voor SEWA
patinten. Het gemiddelde jaarlijks gezinsinkomen bedroeg US $
630 voor patinten verzekerd door ACCORD en
US $ 545 voor deze verzekerd door SEWA.
Bijna drie kwart (74%) van de door ACCORD verzekerde patinten en
38% van de door SEWA
verzekerden hoefden geen eigen betalingen (OOP) te maken op het
tijdstip van de ziekenhuisopname. De andere
patinten werden geconfronteerd met eigen betalingen als gevolg
van remgelden, uitsluiting van het
verzekeringspakket, of beiden. Zonder ziekteverzekering zou 8%
van de families die nu door ACCORD verzekerd
zijn, en 49% van de families door SEWA verzekerd, catastrofale
betalingen (CHExp) ervaren hebben. De CHI
systemen zijn er in geslaagd om de incidentie van CHExp te
verlagen tot 3,5% bij ACCORD en 23% bij SEWA.
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4
Niet alleen halveerde de incidentie van CHExp, maar de
intensiteit van eigen betalingen nam ook af. Zonder
ziekteverzekering zouden de door ACCORD en SEWA verzekerde
families 14% van hun jaarlijks inkomen aan
ziekenhuiskosten gespendeerd hebben, terwijl de CHI systemen dit
cijfer in beide locaties tot 9% herleid hebben. In
het geval van SEWA was de kans op CHExp hoger wanneer de familie
arm was, in geval van gebruik van een
privaat zorgverstrekker en wanneer een chirurgische ingreep
nodig was.
Onze studie van ACCORD en SEWA toonde aan dat beide CHI systemen
financile bescherming boden
tegen OOP en CHExp. Tegelijk was deze bescherming beperkt: een
aantal patinten in beide CHI systemen werden
nog steeds met CHExp geconfronteerd. De belangrijkste redenen
hiervoor waren de lage plafonds in beide
ziekteverzekeringssystemen en de uitsluiting van bepaalde
klinische aandoeningen in het geval van SEWA.
De analyse van de data over tevredenheid toonde aan dat in het
geval van ACCORD respectievelijk 92 en
87% van de verzekerde en onverzekerde patinten tevreden waren
met de verstrekte zorg. In het geval van KKVS
bedroegen de overeenkomstige cijfers 95 en 79%. Het verschil in
tevredenheid tussen verzekerde en onverzekerde
patinten was niet statistisch significant in geval van ACCORD,
maar wel bij KKVS (2 = 7,65; df = 1).
In het geval van ACCORD waren de belangrijkste drivers voor de
hoge tevredenheid bij zowel verzekerde
en onverzekerde patinten de gezondheidszorginfrastructuur
(respectievelijk 84 en 78%), gevolgd door de
intermenselijke relatie met artsen en verpleegkundigen.
Daartegenover staat dat slechts de helft van de patinten, in
zowel verzekerde als onverzekerde populaties, tevreden was met
het zorgproces. Patinten moesten vaak lang
wachten voor ze verzorgd werden, of hun familieleden mochten
niet op bezoek komen. Onverzekerde patinten in
privziekenhuizen werden geconfronteerd met een kleinere kans om
beleefd te worden behandeld door de
zorgverstrekkers en om geneesmiddelen te krijgen van de
ziekenhuisapotheek.
In het geval van KKVS lagen de redenen voor de ruime
tevredenheid enigszins anders. Het merendeel van
de patinten, zowel verzekerden als niet verzekerden, toonde zich
tevreden over de infrastructuur (respectievelijk 86
en 98%) en de dienstverlening van de artsen (respectievelijk 91
en 85%). Een flink aantal verzekerde en
onverzekerde patinten hadden klachten over de nursing
(respectievelijk 47 en 56%) en over het zorgproces
(respectievelijk 84 en 91%).
Ons onderzoek geeft aan dat er weinig verschil is in
tevredenheid tussen verzekerde en onverzekerde
patinten in beide CHI systemen. Deze bevinding kan verklaard
worden door een gebrek aan strategisch
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5
aankoopbeleid (strategic purchasing) van zorg door de betrokken
NGOs. Bovendien werd de tevredenheid gemeten
op een dichotomische schaal. Het gebruik van een bredere schaal
zou vermoedelijk geleid hebben tot een meer
genuanceerd beeld.
Deze studie is een van de weinige die de impact van lokale
ziekteverzekering in India systematisch
gevalueerd heeft. De meerderheid van de CHI systemen in Afrika
en Azi zijn geconcipieerd volgens het provider
type of het mutual type. In India echter zien we de opkomst van
het linked model waarbij de
verzekeringsmaatschappij het financile risico draagt. Dit model
is interessant omdat het gezondheidsrisicos op
grotere schaal bundelt en verdeelt tussen zowel gezonden als
zieken, als tussen rijken en armen.
De resultaten van onze studie tonen aan dat Indische CHI
systemen de toegang tot hospitaalzorg kunnen
verbeteren en de huishoudens op zijn minst gedeeltelijk tegen
CHExp kunnen beschermen. Indien deze systemen
nog doeltreffender willen zijn, moeten er echter een aantal
belangrijke elementen worden aangepakt. CHI systemen
moeten ontworpen worden op een manier waarbij er slechts
uitzonderlijk uitsluitingen zijn die tot OOP leiden,
waarbij de eenheid van aansluiting bij de verzekering het
huishouden is om een preferentile selectie van zieken
(adverse selection) te vermijden, en waarbij er een adequaat
doorverwijssysteem is om oneigenlijk gebruik van zorg
(moral hazard) te voorkomen. Tegelijkertijd moeten de leden van
de CHI systemen meer inzicht verwerven in de
complexiteit van CHI en meer bevoegdheden krijgen om te wegen op
de besluitvorming binnen de CHI systemen. Er
is nood om deze beleidscapaciteit te versterken zodat strategic
purchasing effectief mogelijk wordt en de leden van
de verzekering beter in staat zijn om het systeem te monitoren.
Om de financile duurzaamheid van de CHI systemen
te versterken moet de optie van herverzekering overwogen worden.
Een fusie van verschillende CHI systemen is een
andere relevante piste om de financile leefbaarheid van de
verzekering te verhogen. Een dergelijke schaalvergroting
zal bovendien de onderhandelingspositie van het CHI management
t.o.v. verzekeraars en zorgverstrekkers
versterken. Gelijktijdig zou de Indische overheid een meer
ondersteunend raamwerk moeten creren voor de
ontwikkeling van CHI: o.a. door de uitbouw van een wettelijk
kader voor CHI en de mogelijkheid om deze systemen
met publiek geld te betoelagen zodat ook de armste huishoudens
lid kunnen worden van de verzekering.
De federale Indische regering introduceerde recent een volledig
gesubsidieerd nationaal
ziekteverzekeringssysteem (RSBY) om de allerarmste burgers te
beschermen tegen de kosten van hospitaalzorg. CHI
systemen zouden op twee manieren een nuttige aanvulling kunnen
zijn van RSBY. Ze zouden de couverture van
RSBY kunnen verdiepen door het dekken van de kost van ambulante
zorg. Een tweede manier is om huishoudens die
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6
zich net boven de armoedegrens situeren - en die dus in principe
geen toegang hebben tot het RSBY systeem - een
verzekering aan te bieden tegen de kosten van hospitaalzorg.
Daardoor zou een ruimer deel van de Indische
bevolking beschermd worden tegen de kosten van
gezondheidszorg
Als besluit stellen wij dat CHI systemen in India er effectief
in kunnen slagen om de financile toegankelijkheid tot
hospitaalzorg significant te verbeteren en de huishoudens
bescherming te bieden tegen catastrofale zorguitgaven. Dit
potentieel veronderstelt echter dat deze systemen op een
adequate wijze geconcipieerd en gemplementeerd worden:
de premies moeten betaalbaar zijn, het pakket van zorgen dat
verzekerd is moeten worden uitgebreid, zorgaanbieders
moeten gereguleerd worden, en een vlotte derdebetalersregeling
moet uitgebouwd worden. Op die manier kan CHI
een rele bijdrage leveren tot de verdieping en verbreding van de
sociale gezondheidsbescherming in India.
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7
Summary(English)Indias economy has tripled in size in the last
three decades, yet government spending on health care
remains remarkably meagre: just US$ 5 per person per year. Due
to these low levels of government
spending, patients have to make out-of-pocket (OOP) payments
when they seek care. While many are
able to cope with this, the poor and the vulnerable usually have
to choose between either forgoing
necessary health care or indebtedness and impoverishment when
seeking care.
Some Indian non-governmental organisations (NGOs) have initiated
community health insurance
(CHI) schemes to address this problem. Experts define CHI as any
not-for-profit insurance scheme
aimed primarily at the informal sector, formed on the basis of a
collective pooling of health risks, and
in which the members participate in its management. The number
of CHI schemes in India has grown
exponentially in the past decade, partially fuelled by the
micro-credit movement.
In theory, CHI is a relevant option for the informal sector with
its combination of pre-payment and
risk pooling mechanisms. However, there is little evidence that
Indian CHI schemes increase access to
care and protect against catastrophic health expenditures
(CHExp). The objective of our research was
to investigate whether and under what conditions CHI improves
access to hospital care, provides
protection against CHExp and increases patient satisfaction.
In 2003, we first undertook a detailed case study of 10
purposively selected CHI schemes to improve
our understanding of the variety of CHI schemes in India. Based
on these findings, we selected three
CHI schemes and studied them in greater detail in 2004 and 2005.
The three chosen schemes were
Action for Community Organisation, Rehabilitation and
Development (ACCORD), Kadamalai
Kalanjiam Vattara Sangam (KKVS) and Self Employed Womens
Association (SEWA).
We conducted household surveys in randomly selected insured and
uninsured households at
ACCORD and KKVS. Data on socio-economic characteristics,
morbidity patterns, health-seeking
behaviour, health expenditures and patient satisfaction were
collected. In addition, we conducted
focus group discussions with insured and uninsured individuals,
with hospital patients and providers
in order to understand their perceptions of quality of care and
of the CHI scheme. In all three schemes,
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8
we compiled secondary data on details of hospitalisations from
existing registers and records. We
measured access and the incidence of CHExp.
All 10 CHI schemes studied were initiated by NGOs with the
objective of increasing access to health
care, preventing indebtedness and empowering communities. These
CHI schemes explicitly targeted
the poorest and most vulnerable households in Indian society,
i.e., scheduled castes and tribes, as well
as women. Further, all schemes used existing community
organisations to introduce CHI, thereby
building on prevailing social capital and trust. Three distinct
types of CHI schemes can be
distinguished based on the role of the NGO. In the provider
type, the NGO was both the insurer and
the provider of health care. In the mutual type, the NGO was the
insurer and purchased care from
providers. Finally, in the linked type, the NGO insured the
community with an insurance company and
purchased health care from providers.
Most of the schemes enrolled members on a voluntary basis, with
the individual as the unit of
enrolment. Membership levels in the schemes ranged from 1,000 to
100,000 individuals. Premiums
were community-rated and ranged from US$ 0.5 to US$ 5.0 per
person per year. All 10 schemes
insured against hospitalisation expenses but only up to a
certain amount. While most common
diseases were covered, some conditions such as chronic ailments
and pre-existing conditions were
excluded. All the schemes collected premiums from the enrolled
members. However, to financially
sustain their schemes, six of the ten also received grants from
donors. Very few of the schemes had
proper documentation or monitoring systems. This lack of data
meant that none of these schemes had
empirical evidence to suggest that they increased access to
hospital care or protected families from
CHExp.
The household survey at ACCORD demonstrated that 57% of insured
and 58% of uninsured
individuals experienced minor ailments during the period
2004-2005. The proportion of individuals
with chronic ailments was 5% among the insured and 2% among the
uninsured. The proportions of
insured and uninsured individuals with major ailments were 14%
and 8%, respectively.
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9
The admission rates among the insured and uninsured were 92 and
42 per 1,000 people per year,
respectively. Ninety percent of insured pregnant women delivered
in a hospital, while the
corresponding figure for the uninsured was 45% (2 = 8.6; df =
1). The study also revealed that 65%
of insured patients with major ailments were admitted to a
hospital, compared to 44% of uninsured
patients (OR 2.2; 95% CI 1.31, 3.77). This higher admission rate
among insured patients was also
found in vulnerable groups, such as children, females, people of
lower socioeconomic status and those
living far from a hospital. In the lowest income quintile, the
probability of admission for insured
patients was 3.47 times higher than it was for the uninsured.
Insurance status remained a significant
determinant of increased utilisation of hospital services after
controlling for confounding factors such
as age, gender, distance from a hospital and the presence of
pre-existing ailments.
This study clearly indicates that the ACCORD CHI was able to
increase access to hospital care, even
for the poorest and most vulnerable groups in society. Some
reasons for this may be its comprehensive
benefit package, affordable and subsidised premiums, credible
and effective provider and a cashless
system.
Our analysis of data extracted from the registers at ACCORD and
SEWA showed that, in 2003 and
2004, there were 683 and 3,152 admissions, respectively. All of
the patients insured by ACCORD
were admitted to a not-for-profit hospital, while those insured
by SEWA were mostly admitted (86%)
to private-for-profit facilities. The median hospital bill per
admission was US$ 12 for patients at
ACCORD and US$ 46 for patients at SEWA. The median annual
household income was US$ 630 for
patients insured by ACCORD and US$ 545 for those insured by
SEWA.
Overall, 74% of patients insured by ACCORD and 38% of patients
insured by SEWA did not have to
make any payments at the time of hospitalisation. The rest had
to make out OOP payments because of
co-payments, exclusions or both. Without health insurance, 8% of
the families of patients insured by
ACCORD and 49% of the families of patients insured by SEWA would
have experienced CHExp.
The CHI scheme managed to reduce the incidence of CHExp to 3.5%
at ACCORD and 23% at
SEWA. Not only was the incidence of CHExp halved, but the
intensity of the OOP payment also
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10
decreased. Without the CHI scheme, families of patients insured
by both ACCORD and SEWA would
have spent 14% of their annual income on hospital expenses, but
the CHI scheme reduced this figure
to 9% of annual income in both locations. The chances of
experiencing a CHExp for families of
patients insured by SEWA were increased if the patient was poor,
had gone to a private health care
provider or needed surgery.
Our study of ACCORD and SEWA showed that in both of these
schemes, CHI provided financial
protection against OOP payments and CHExp. However, this
protection was only partial, and some
patients enrolled in both of the schemes still experienced
CHExp. The main reasons for this were the
low upper limits in both schemes and the exclusion of some
clinical conditions at the SEWA scheme.
The analysis of household survey data from ACCORD indicated that
92% and 87% of insured and
uninsured patients, respectively, were satisfied with the care
that they received. At KKVS, the
corresponding figures were 95% and 79%. While the difference in
satisfaction between insured and
uninsured patients was not statistically significant at ACCORD,
it was at KKVS (2 = 7.65; df = 1).
At ACCORD, the main reasons for satisfaction among both the
insured and uninsured were the health
care infrastructure (84% and 78%, respectively), followed by the
interpersonal interaction with the
doctors and nurses. However, only about half of the patients,
both insured and uninsured, were
satisfied with the care process. This was because either they
had to wait for a long time to receive care
or their relatives were not allowed to visit them. Uninsured
patients who sought care in private
hospitals were less likely to be treated courteously and to
receive medications from the hospital
pharmacy.
At KKVS, the reasons for satisfaction were slightly different.
Most of the patients, both insured and
uninsured, were satisfied with the infrastructure (86% and 98%,
respectively) and the doctors
services (91% and 85%, respectively). However, a sizable number
of insured and uninsured patients
were dissatisfied with the nursing care they received (47% and
56%, respectively) and the care
process (84% and 91%, respectively).
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11
Our research indicates that there was little difference in
satisfaction levels between insured and
uninsured patients at both ACCORD and KKVS. This finding may be
attributed to a lack of strategic
purchasing by the respective NGOs. Also, we measured
satisfaction levels on a dichotomous scale.
Had we used a wider scale, we would probably have obtained a
more nuanced response.
This study is one of few that have systematically evaluated the
insurance functions of CHI schemes in
India. Most of the CHI schemes in Africa and Asia adopt either
the provider or the mutual model.
However, in India, we observed the emergence of the linked
model, where the risk-taker is an
insurance company. This model is advantageous in that the risks
are pooled more widely, both
between the healthy and the ill as well as between the rich and
poor.
The evidence from our study demonstrates that Indian CHI schemes
can increase access to hospital
care and at least partially protect families from CHExp.
However, to make them more effective, some
critical issues must be addressed. Design features, such as
minimal exclusions to reduce OOP
payments, enrolment of families as a unit to control adverse
selection and a referral system to prevent
moral hazard, should be addressed. Simultaneously, the community
must be empowered so that its
members understand the complexity of the CHI and are given the
space to make informed decisions.
The capacity of the CHI management should be built up so that
the organisers can purchase care
strategically and monitor the scheme effectively. To increase
financial viability, CHI schemes need to
consider reinsurance with an insurance company. However, another
route to financial viability is to
increase the size of the scheme by federating many CHI schemes
into a single body. This provides the
added advantage that such a federation will be able to negotiate
effectively with both insurance
companies and providers. Concomitantly, the government must
create a more supportive policy
environment for the development of CHI programmes in India. This
could include giving legal
recognition to these entities and providing the necessary
subsidies to permit the poor to enrol.
The government of India recently introduced a fully subsidised
national health insurance scheme
(RSBY) to protect its poorest citizens from incurring hospital
expenses. CHI schemes can
complement the RSBY in two ways. CHI schemes can increase the
depth of cover by covering
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12
ambulatory expenses for RSBY members. The second mechanism is by
targeting the near-poor and
low-income groups, who are also exposed to the challenges of
reduced access and CHExp. These
changes would help with enhancing health security for a larger
section of the Indian population.
To conclude, CHI schemes in India can increase access to
hospital care and protect households from
CHExp, provided that they are properly designed and implemented.
Premiums must be affordable,
benefit packages must be comprehensive, providers must be
regulated, and reimbursements must be
cashless and effortless. Such a scheme can play a crucial role
in increasing the depth and breadth of
social health protection in India.
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13
Chapter1.Introduction
1.1 IndiaIndia is a union of 28 states. It is a democratic
republic with a parliamentary system of government
that is federal in structure.1 India has a population of 1.21
billion, of which 81% are Hindus, 13% are
Muslims, 2% are Christians and 4% belong to various other
religious categories. The median age of
an Indian is 26.2 years and about 30% of Indians are below 15
years of age. While 74% of Indians
(above the age of seven years) are literate, female literacy is
only 65%. Of the 1.21 billion, 69% still
live in rural areas and depend mainly on agriculture for their
livelihood.2
India is a land of contrasts. The diversity of India can be
represented by the fact that there are 14
different official languages, other than Hindi and English,
spoken in the country. The Indian economy
is growing at a steady rate of seven to eight per cent. The per
capita GDP currently is US$ 1271,
however, 37% of the population still live on less than a dollar
per day.3 This situation is even worse if
one considers the lowest strata of Indian society, i.e. the
Scheduled Castes (SC) and Scheduled Tribes
(ST). Despite decades of affirmative action, the social,
economical and political status of this group
has not changed markedly. For example, the literacy rate among
SC and ST populations is only 55%
and 46% respectively.2 The inequality levels in India are very
pronounced; the lowest decile earns
only 3.6% of the national share, while the top decile earns
31%.4
The national government is mainly involved in developing
policies, monitoring and controlling
epidemics and financing certain important disease control
programmes. The Ministry of Health and
Family Welfare at New Delhi has different units for individual
disease control programmes like
malaria, tuberculosis, reproductive health, child health,
substance abuse, family planning and HIV.
Each of these units is responsible for developing, financing and
monitoring the specific disease
control programmes. Implementation of these programmes is the
responsibility of the state
governments.
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14
At the state level, there is a Department of Health and Family
Welfare, which is responsible for
financing and providing health services for its citizens. The
organisation is similar in most states, with
a directorate at the state capital. The next level is the
district health office and the district hospital, one
for each of the 640 districts in the country. Each district
health office is responsible for providing
health services through primary health centres (PHC) and
referral centres (CHC) to one to two million
people. The distribution of these centres is on a normative
basis, one PHC for 20,000 to 30,000 people
and one CHC for 90,000 to 120,000 people. The PHC has a team of
health staff, led by a medical
officer, while the CHC is expected to have a team of at least
five specialists.5 According to
government statistics, in 2010, there was one PHC per 35,191
population and one CHC per 183,702
population, much below the expected norms.6 This is further
compounded by the fact that 63% of the
posts for specialists at the CHC are vacant.
Other than the government health services, there is an array of
private providers. These range from
formal to informal providers. Formal providers are professionals
who have undergone training in
either modern medicine or Indian systems of medicine (e.g.
Ayurveda) and have been licensed to
practice. They may practice as general practitioners or in
hospitals. On the other hand, there are more
than hundreds of thousands of unlicensed practitioners who tap
into the unmet need of the
population.7-9 Most of them are individual practitioners,
providing care of questionable quality.
Neither the formal, nor the informal private practitioners are
regulated by the government.10 All
private practitioners usually charge on a fee-for-service basis
at the time of illness.
The Indian health services are mainly financed by out-of-pocket
payments made by individual patients
at the time of illness (72%). While both national and state
governments provide funds, these account
for only 21% of total health expenditure. Private firms (5%) and
donors (2%) make up the balance.11
In 2000, less than 3% of the population had any form of health
security in the form of health insurance
or employer financed health care.12 Patients had to meet the
entire cost of health care through out-of-
pocket payments (OOP) at the time of illness. This is one of the
main reasons why medical expenses
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15
push more than 63 million Indians below the poverty line every
year.13 For some (7%), seeking care is
not an option; they prefer to suffer rather than experience
catastrophic health expenditure.14
Some key socio-economic and health indicators are listed in
Table 1.. We also provide data about the
worst and best performing states in the country, to capture the
wide differences and inequalities in the
country. Some of the main reasons for this underperformance are
a combination of epidemiological
and demographic transition, an underfunded and dysfunctional
government health service with an
unregulated private health sector.15
While Table 1 provides the average figures, it hides the vast
disparities between the rich and the poor.
Infant mortality rate is more than double among infants
belonging to the poorest quintile (70/1000 live
births) compared to infants belonging to the richest quintile
(29/1000 live births). The story is the
same for perinatal mortality rate (PNMR), a very sensitive
indicator of the health status of a
population. While PNMR among the richest quintile is only 30 per
1000 pregnant women, it is nearly
double for families in the poorest quintile (58 per 1000).16
Nearly 41% of poor pregnant women did not receive any antenatal
care, compared to only 3% of
pregnant women in the richest quintile. Thirteen per cent of
poor pregnant women delivered in a
facility, the rest delivered at home. The figure for
institutional delivery among the richest quintile was
84%. Thirty per cent of those who delivered at home stated cost
as the main deterrent for accessing
delivery services at a facility.
Only 24% of children belonging to the poorest quintile received
full immunisation, compared to 71%
of children in the richest quintile. As immunisation is supposed
to be provided free of cost, this
disparity could be more due to geographical barriers and
availability of the vaccine at the health
centres.
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16
Table 1: Some socio-economic indicators for India, poorest and
best performing states
Indicator India Poorest performing state
Best performing state
Total population in millions2 1,210
Population living on less than US$1 in millions6 448 59 (UP)*
0.6 (J&K)
Per capita income per year in US$17 1271 380 (Bihar) 3,016
(Goa)
Gini coefficient18 0.54 0.59 (Karnataka) 0.42 (Delhi)
Literacy rate of rural females2 59% 46% (Rajasthan) 91%
(Kerala)
Females for 1,000 male children (0-6 years)2 914 830 (Haryana)
971 (Mizoram)
Population per government medical officer in rural areas5
28,014 66,841 (MP) 9,400 (Kerala)
Per capita expenditure on health care by government11
US$ 5.4 US$ 3.9 (Bihar) US$ 75.5 (Goa)
Per capita expenditure on health care by individual families
(through OOP)11
US$ 21.3 US$ 111 (Kerala)
US$ 4.6 (Jharkhand)
Proportion of all households that are impoverished every year
because of health care expenditure13
6.2% 12% (Kerala) 4.1% (Jharkhand)
Proportion of pregnant women who received full antenatal
check-up19
26% 5% (Bihar) 78% (Kerala)
Proportion of children (12-23 months) who received full
immunization19
61% 25% (Ar. P) 84% (Punjab)
Proportion of children (0-5 years) who are under-weight16
42% 60% (MP) 20% (Sikkim)
Infant mortality rate / 1,000 live births20 50 67 (MP) 11
(Goa)
Maternal mortality ratio / 100,000 live births21 212 390 (Assam)
81 (Kerala)
The prevalence of diarrhoea between both the poorest and richest
children was similar (8.8 and 8.3 per
100 children). However, there was a marked difference in
accessibility to oral rehydration therapy
(ORT). While only one third of poor children had access to ORT,
in the richest quintile, 56% of * The names in brackets are those
of the states in India Included registered medical officers at PHC
and medical officers and specialists at CHC.
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17
children had access to ORT. Admission rates among the poorest
was only 32 per 1000 population
compared to 115 per 1000 population among the richest. Children
from poor families were four times
more stunted compared to children from rich families. This
pattern is also reflected among adults,
more than half the women in the poorest quintile had a body mass
index of less than 18.5, compared
to only 18% of women in the richest quintile.
1.2 ProblemsofaccesstohealthcareandfinancialprotectioninIndiaThe
government has an extensive network of primary health centres,
first referral units and hospitals,
especially in rural areas. Unfortunately, the government spends
only US$ 5 per person per year on
health care,11 resulting in understaffed and underequipped
government facilities that do not perform to
their full potential. Though patients need not pay for
government health services, there is evidence to
suggest that patients spend money to receive appropriate care.
Patients must buy medications from
private pharmacies, cover the costs of diagnostic tests and pay
informal fees. A nationally
representative survey revealed that rural patients admitted to
government facilities spend an average
of US$ 70 per admission.14
The private sector in India ranges from individual practitioners
in stand-alone clinics to small
hospitals to multi-specialty enterprises.22 A survey conducted
in the state of Madhya Pradesh revealed
that more than 50% of private practitioners did not have a
formal diploma or degree.23 Private
providers invariably charge patients on a fee-for-service basis.
Because most Indians do not have
health insurance coverage, these charges are met through
out-of-pocket (OOP) payments at the time of
the utilisation of services.11 Patients admitted to private
facilities spend an average of US$159 per
admission.14
These data suggest that patients may face substantial financial
barriers when seeking health care in
India. Evidence from the literature focusing on India indicates
that 5% of rural patients and 2.2% of
urban patients do not seek ambulatory care due to financial
constraints.14 However, the disparity
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18
worsens when one disaggregates the above figures by economic
status. More than 17% of rural poor
do not access care due to financial reasons.
Some patients cannot utilise health services due to financial
constraints; others face problems when
they do use health services. Low incomes and negligible social
health protection imply that many
families have to mortgage or sell their assets to pay the high
medical costs. Narayana (2001) studied
health expenses and access in three different states and found
that 7% and 14% of households in
Chennai and Kerala respectively, spent more than 20% of their
annual income on health care.24 Forty-
one percent of rural families borrowed money, while another 8%
were forced to sell their assets to pay
their hospital bills.14 Krishna reports that medical expenses
were one of the top three reasons for
indebtedness in rural Rajasthan.25 Singh confirmed this finding
in a recent study of indebtedness in
Punjab.26 Garg et al. calculated that the poverty head count
increased by 3.5 points due to health
expenditures.27 In a recent study, Berman et al. estimated that
63 million Indians fell below the
poverty line in 2004 due to medical expenses.13 In extreme
conditions, family members resort to
suicide to escape the cycle of health shocks, indebtedness and
poverty.28
To summarise, Indians are expected to use the underfunded and
poorly functioning government health
services. The low quality of care provided therein results in
patients shifting to the private sector. For
some, this is unaffordable; for others, it can be catastrophic.
Impoverishment due to medical expenses
has been termed iatrogenic poverty.29 One of the main reasons
for this situation is the lack of social
health protection among the Indian population. Only about 3% of
the population has some form of
social protection in health. The majority of this small group
belong to the formal sector and are
protected through either social or private health
insurance.12
Various authors have suggested strengthening prepayment and
pooling mechanisms to tackle this
problem.30-33 This could occur either by improving the existing
tax-based financing system or by
extending health insurance coverage to larger populations or a
mixture of both systems. The Indian
government has been unable to increase government health
spending over the past decade; it has
remained stagnant at 0.9% of the GDP.11 The other alternative is
to expand health insurance coverage.
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19
Although the upper and middle classes are usually protected
through social health insurance, medical
reimbursements or private health insurance,34 the poor
traditionally fall through this safety net. In
response, some non-governmental organisations (NGOs) have
introduced community health insurance
(CHI) to protect the poor. Various actors, both national and
international, have recommended CHI as a
means of protecting the informal sector.36;37
Unfortunately, in India, there is little evidence that these
schemes are successful in terms of increasing
access to quality health care or providing financial protection.
The current study specifically explored
these dimensions of performance; we did not examine other
dimensions of performance like
enrolment rates, renewal rates, financial sustainability,
community empowerment or social
transformation. While these are important, we chose to focus on
the core insurance functions of a
health financing system, i.e., improving access to quality
health care and providing financial
protection.38
1.3 HypothesisCHI schemes in India increase access to quality
health care and protect households from catastrophic
health expenditures. Consequently, they play an important role
in the Indian health system.
1.4 Researchobjectives1. To explore the characteristics of CHI
schemes in India.
2. To determine whether CHI schemes:
a. Increase access to health care for the insured,
b. Protect the insured against catastrophic health expenditures,
and
c. Enhance the satisfaction levels of insured patients.
3. To examine the current and future roles of CHI schemes in the
Indian health system and
propose evidence-based policy recommendations.
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20
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21
Chapter2.Literaturereview
2.1 HealthinsuranceHealth insurance is a financial arrangement
based on prepayment and pooling of funds with the
purpose of sharing health care risks. Traditionally, most
literature on health insurance has
concentrated on social health insurance (SHI) or private health
insurance (PHI).39 Social Health
Insurance (SHI) is a not-for-profit health insurance based on
mandatory enrolment of the employed.
Income rated contributions from both the employee and the
employer help finance health care for the
employee and his / her family. In countries where SHI is mature,
the health insurance fund is also used
to cover the retired, unemployed and disabled. Thus there is
both horizontal and vertical equity, next
to high coverage. Forty six of the 191 WHO countries use SHI
mechanisms to meet more than 25% of
their total health expenditure. Most of these countries are
based in Europe, Latin America and Eastern
Asia.* Private Health Insurance (PHI) on the other hand is a
for-profit entity that is used to meet health
care expenses for those who can afford the risk rated premiums.
PHI is a voluntary insurance and is
fraught with problems of adverse selection, exclusions and cost
escalation. PHI faces low coverage
and very variable depth of coverage. Only four of the 191
countries use PHI mechanisms to meet
more than 25% of their total health expenditure, mainly the
United States of America and South
Africa.* In the last two decades, a new entity - CHI - has crept
into the insurance nomenclature. CHI
has many synonyms, e.g., community-based health insurance,
mutual health organisations, micro
health insurance, or mutuelles de sant. However, the programmes
to which these different descriptors
refer usually share the following characteristics:40
Based on prepayment and pooling of funds to share health care
risks, Organised for local communities, usually in the informal
sector, Some level of involvement of the beneficiary community in
the management of the scheme, Non-profit in character, and
Contribution to the scheme is of a voluntary nature
* Adapted from the Global health observatory:
http://apps.who.int/ghodata/# [accessed on 30/10/11]
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22
For the sake of this literature review, the author proposes the
following working definition of CHI:
any not-for-profit insurance scheme that is aimed primarily at
the informal sector, formed on the
basis of a collective pooling of health risks, and in which the
members participate in its
management.41
CHI is an international and historical phenomenon. While many
traditional societies have developed
forms of risk-sharing for health care, one of the earliest
recorded descriptions of CHI is that of the
sickness funds developed in Germany in the second half of the
nineteenth century.42 Industrial
workers organised these funds by contributing to a common fund
that was used for contingency
expenses, like medical treatments and funerals. Today these
sickness funds have grown and merged to
form the different social health insurance companies. A similar
movement occurred in Japan,43 where
people contributed money into a fund called the Jyorei to
finance prospective health care costs.
2.2 CHIinlowandmiddleincomecountries
CHI developed in Africa in the 1980s, in a context where a
combination of user fees and failing
economies made it difficult to access health care. To improve
access, communities (with the
assistance of external support organisations) began organising
CHI schemes. While there have been
various descriptions of individual schemes,44-50 and their
performance, Bennett was one of the first to
study this movement in a more systematic manner. She
investigated 82 schemes, of which 31 were
located in Africa.51 The characteristics of the schemes in
Africa were as follows:
Organisation by local communities in a specific geographical
setting, Small risk pools, usually with less than 1000 members,
Health care benefits mainly limited to outpatient care, Community
involvement in the management of the scheme, and Providers usually
within the government sector
Following this, the International Labour Organisation (ILO)
released a compendium of 129 schemes
from 26 countries in 2000. This basically listed the schemes and
their main characteristics. There was
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23
no attempt to analyse the effect of CHI on health, health
services or health systems in this document.52
There are currently more than 600 CHI schemes in West Africa,
the numbers are more modest in East
and Central Africa.53
In Asia, China was one of the early adopters of CHI. The Rural
Cooperative Medical System (RCMS)
was initiated in the 1960s as part of a political process. By
the 1970s, it covered more than 90% of the
rural population. Contributions were made from three sources:
income-based household premiums,
collective welfare funds and state subsidies. In turn, the
insured received comprehensive health care
ranging from preventive to primary and secondary care.54
However, in the 1980s, the RCMS rapidly
collapsed with the implementation of economic reforms. There are
now attempts to re-introduce CHI
in China through the New Cooperative Medical Services.55 The
other countries in Asia that have
introduced CHI schemes are Nepal56, Bangladesh57, the
Philippines58, Indonesia and India.59;60 The
schemes varied from country to country; in some the coverage was
limited to emergency transport,
while in other schemes, there was a comprehensive cover against
expenses for ambulatory care and
admissions. In most of the schemes however, there was a
co-payment, resulting in OOP payments at
the time of illness
In India, CHI schemes slowly became popular at the turn of the
twentieth century. The first was
initiated in 1955,59 and the 1990s saw a small spurt of schemes,
mostly initiated by hospitals.
However, the next thrust in CHI schemes came in the early 21st
century, when microfinance
organisations expanded their operations to protect their members
from CHExp. In 2003, there was
about 25 functional CHI schemes, most of which were initiated by
NGOs. Most of these NGOs were
involved in various development activities and introduced CHI
among their target populations with
the purpose of increasing access to health care. These CHI
schemes protected people in the informal
sector, especially farmers, vendors, landless labourers and
women in microfinance groups. Unlike
their African counterparts, the risk pools in the Indian CHI
schemes were larger, covered mostly
hospital care and used private providers.61 While Indian CHI
schemes targeted specific groups across
villages, e.g. women, vendors, farmers association, or
cooperative societies; African CHIs were
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24
limited to their villages. One striking difference between the
African CHI schemes and the Indian CHI
schemes is the role of the community. In the former, the
community played an important role in
designing and managing the scheme, while in India, the
communitys role was usually limited to
collecting premiums. Differences between the Indian and African
CHI schemes are detailed in Table
2.
Table 2: Similarities and differences between Indian and African
schemes40
Indian CHI schemes African CHI schemes
Beginning of the CHI movement Early 1990s Early 1990s
Initiated by Local NGOs Donors and later government
Owned by Local NGOs Local communities or facility or
government
Number of schemes (2003) 25 348
Technical support from None Donors, network of CHI schemes
Financial support from Donors Donors
Average number of members per scheme
More than 10,000, some even more than 100,000
Less than 1,000
Community targeted Organised informal sector, e.g. dairy
cooperatives, agricultural labour unions
Village communities
Insurer NGO or Insurance company Community
Benefit package Mostly only hospital expenses Mostly ambulatory
care
Providers Mostly private-for-profit providers
Mostly government health centres
Provider payment mechanisms Patient pays the provider and is
then reimbursed by the insurer
Insurer pays the provider directly
Communitys involvement Limited High
Management of adverse selection Waiting time, exclusions,
Household as unit of enrolment, waiting time.
Management of moral hazard Pre-authorisation, Co-payments,
Co-payments
Three types of CHI schemes can be distinguished: Type I (or
provider type), where the organiser is
both the insurer and the health care provider; Type II (or
insurer type), where the organiser is the
insurer, but care is purchased from private providers; and Type
III (or linked type), where the
organiser purchases care from private providers and insurance
from private insurance companies.62
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25
Type I CHI schemes were initiated by hospitals, mainly to
protect the poor patients from high medical
bills. These were the earliest forms of CHI schemes introduced
in India and the most famous ones
were the Voluntary Health Services at Chennai; ACCORD at Gudalur
and MGIMS at Wardha.61 Here
the hospital organised the scheme, was the insurer and also the
provider of care.Type III schemes were
the next to evolve. Here NGOs linked up with private insurance
companies to provide coverage
against various risks, especially medical expenses. The basic
characteristic of the linked type was that
the NGO used existing health insurance products to provide
health insurance cover for their
communities. Some of them managed to negotiate with the private
insurance companies to tailor these
products to suit the local requirements. This ranged from making
the premiums affordable, to
simplifying the claims processes. SEWA was representative of
this type. With the growth of the
micro finance movement in India, there were many groups who were
handling finances at the village
level. These groups usually saved money through monthly
contributions and loaned this principal to
those who needed it. They soon realised that one of the main
reasons for defaulting on loan repayment
was a medical event in the household. In order to protect their
loans and to ensure that it is repaid on
time, many of these groups introduced the Type II CHI scheme.
Here the group members were insured
against medical events by paying an annual premium. In the event
of a medical crisis, this fund was
used to pay the bills. Thus the group became the organiser as
well as the insurer of the scheme. KKVS
was representative of this type. The similarities and
differences between the three types are provided
in Table 3.
However, in 2003, there was still very little evidence about the
contexts in which these schemes
functioned, their performance and their role in the Indian
health system. The few studies on Indian
CHI schemes were usually limited to merely describing the
schemes, with little or no analysis of their
impact.63-67 Ranson conducted the first analytical studies and
pointed to some evidence that the Self
Employed Womens Association (SEWA) CHI scheme provided financial
protection68 but did not
improve access to health care69 or improve the quality of
care.70 Aside from these studies, there was
no evidence about the performance of CHI schemes in India. Thus,
we undertook this study to fill this
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26
gap. The two principal variables of performance in the present
study are access to health care and
financial protection.
Table 3: Similarities and differences between the three types of
CHI schemes in India (2003).61
Characteristics Type I (Provider type) Type II (Insurer type)
Type III (Linked type)
Organiser Hospital NGO NGO
Role of organiser Organiser, Provider, Insurer Organiser,
Insurer Organiser
Community Those living in the vicinity of the hospital
Target population of the NGO
Premiums May or may not be collected during a specific
collection period
Specific collection period usually
Premiums Calculated on an adhoc basis Actuarial inputs from
insurance company
Insurer Hospital NGO Private insurance company
Provider The hospital itself Public / private hospitals
Payment to provider
Salaries Fee for service
Claims procedures
Negligible Present; but easy Cumbersome
Reimbursement procedures
Cashless Usually reimbursement to patients, after they pay the
bills
Benefit package Hospitalisation expenses Hospitalisation
expenses, but with exclusions
Co-payments Is the norm Maybe present Nil
Management of adverse selection
Nil Fixed collection time Waiting time, fixed collection time,
exclusions
Management of moral hazard
Co-payments Nil Pre-authorisation
Strengths Quality of care is better.
Not required to check on fraud and supply side moral hazard.
Product is tailored to community requirements
Risk pool is large
Monitoring systems in place
Weaknesses Premiums can be unaffordable Do not have the capacity
to purchase care
Products may not meet local requirements.
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27
2.3 AccesstocareIncreasing access to quality health care is a
policy goal in most low-income countries.32 Governments
want people, especially the vulnerable, to use health services
when needed in order to get optimal
care. However, the poor usually face many barriers, both
financial and non-financial, when attempting
to access health care. Access has been defined as the ability to
secure a specified range of services,
at a specified level of quality, subject to a specified maximum
level of personal inconvenience
and cost, whilst in possession of a specified level of
information.71 Access is about the availability
of quality and affordable health care services. Obviously,
access is not just about supply-side
considerations; there is also a demand-side component to it
(Figure 1).72
When individuals are ill, we can call it true need (a). Patients
have to be aware of their illness and feel
a need for treatment (b felt need). Else it remains an unmet
need (u). They can either seek care (c
expressed need) or forego care (u unmet need) because of various
barriers, such as distance, cost
(direct, indirect and opportunity), and socio-cultural
factors.73 If they receive effective care, then the
need is met (e); otherwise, it remains an unmet need (u). The
dimension of information is a cross-
cutting issue the more the patient is aware about the health and
health services, the more he is
empowered to make informed choices.72 Ensor distinguished
demand- and supply-side barriers to
health care.74
-
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29
supply (i.e., the utilisation of services). Monitoring
utilisation is by no means a perfect measure but is
nevertheless considered as an operational proxy indicator for
access to health care.73 While need may
be seen as potential access, utilisation can be seen as realised
access.
Again, there are many ways to measure utilisation of health
services.76 One could measure the number
of outpatient contacts,77 or the number of admissions or the
number of people who use the emergency
room as a usual source of care.78 In a study in New York, they
measured the ease with which
appointments were made with the care provider as an indicator of
access.79 In our study, we used
hospital admission rates as an indicator of the utilisation of
health services and as a proxy for access to
health care. The reason for focussing on hospital admission
rates in our research was that the different
CHI schemes we studied only offered protection against
hospitalisation expenses for in-patients, and
not for ambulatory care. In our endeavour to assess the
effectiveness of CHI, we therefore proposed to
measure whether CHI was associated with any differences in
admission rates between insured and
uninsured admission rates being considered as a good proxy of
access to hospital care. Measuring
any other variable would not be relevant given the intrinsic
design and package of benefits of the CHI
schemes we investigated.
Admission rates vary from region to region depending on the
morbidity pattern, health-seeking
behaviour and the availability of health services. In India, the
average admission rate in 2004 was 23
per 1000 people in rural areas.14 There was considerable
interstate variation, ranging from 9 per 1000
people in Jharkhand to 101 per 1000 people in Kerala.
One important barrier to utilisation of health services is the
financial barrier. Utilising health care has
a cost. If the individual patient must bear this cost, then it
constitutes a significant barrier to accessing
health care.80 There is evidence that user fees and OOP payments
at the time of illness reduce access
to health services.81 Patients then either forego health care or
must cope with high medical bills. The
poor and vulnerable are usually excluded from health care
because of their inability to afford OOP
payments at the time of illness. To overcome this barrier,
policy-makers advocate pre-payment
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30
systems of financing health care.33;36;80;82 The objective of
pre-payment systems is to maximise the
temporal distance between contribution and utilisation.
There are three possible ways of collecting resources in a
prepaid system. One is through taxes, and
the other is through contributions to a health insurance fund. A
third mechanism is through personal
savings for medical contingencies.83 However, in the Indian
context, the first two are the predominant
mechanisms. In most low- and middle-income countries, the tax
base is narrow, and health budgets
are usually inadequate to finance the necessary health services.
Social and private health insurance
products are usually limited to the formal sector and the elite,
respectively.84;85 One option that
remains, especially for the informal sector and the poor, is
community financing through CHI.86 It is
hypothesised that CHI schemes enable their members to access
health care by removing part or all of
the financial barriers. Households make a prepayment at a point
in time when their members are
healthy and able to pay. So when any insured individual falls
sick, she has the possibility of accessing
care without worrying about organising funds to pay the
bills.
However, one must remember that financial barriers are just one
of the many obstacles to accessing
health care. Other barriers like social, cultural, geographical
and organisational may or may not be
addressed by a CHI scheme and remain as potential impediments to
receiving appropriate care.87
Evidence that health insurance reduces these financial barriers
and increases access to health care is
available in high income countries.79;88-90 However, such
evidence is limited in low income countries.
Most reviews of CHI schemes in the first half of the 21st
century studied various aspects like financial
protection, enrolment and resource mobilisation. These authors
rarely evaluated access to health
care.45;51;91-94 Prior to 2003, empirical evidence was provided
mainly by a couple of authors.95-98 In
India, Ransons studies did not provide clear evidence that the
CHI scheme had increased utilisation
of hospital services.69 Hence it was important to study the
effect of CHI on access to health care.
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31
Table 4: Demand and supply barriers to accessing health
care.
Demand-side barriers
Lack of information about health services Lack of education to
identify the illness or recognise its seriousness 99 Distance from
a hospital Low socioeconomic status 100 Lack of health insurance101
High opportunity cost Household/community beliefs about aetiology,
treatment and providers101;102 Complex decision-making process
within the family Availability of informal substitute services,
including home remedies
Demand- and supply-side interactions
High cost of services User fees 95;103 Informal fees Long
waiting time
Supply-side barriers
Lack of staff Poor staff attitudes towards patients100 Lack of
drugs and supplies Lack of technology
Adapted from Ensor et al. (2004).
2.4 FinancialprotectionIndian patients who receive health care
face the challenge of making OOP payments at the time of
service utilisation, especially in low- and middle-income
countries. Unlike their counterparts in most
high-income countries, these patients do not have the security
of a prepayment system to finance their
health care. Therefore, they face a double burden: that of the
illness itself and the need to find the
necessary funds to finance the treatment. While certain expenses
may be met by the household from
its current income and/or savings, there are situations where
the family has to mortgage or sell assets
to pay the patients medical bills. Such expenses can be
catastrophic for many families, especially if a
sizable proportion of their current or future income has to be
spent on health care.104 There is
increasing evidence that some families are impoverished or
pushed further into poverty because of
these expenses.105-107
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32
2.4.1 Thenotionofcatastrophichealthexpenditure(CHExp)There is
much debate on the definition of CHExp. One of the first
definitions was by Berki in 1986:
any medical expenditure that endangers the familys ability to
maintain its customary standard of
living should be considered catastrophic.108 Subsequently,
various authors have used different
measures to define CHExp. Some define an absolute amount and
consider total health expenditure
(THE) above this absolute amount to be catastrophic.109 Others
agree that if the THE of a family
exceeds a certain proportion of its annual income, it should be
considered catastrophic. However,
there is no unanimity about the value of this proportion. Some
authors have fixed the threshold at
more than 10% of the annual income,104;110 while others state
that if a family spends more than 40%
of their disposable expenditure on health care, the expense
should be considered catastrophic.31;111-114
Indeed, the World Health Organisation (WHO) recommends this last
definition.115 However, the
above definitions only measure CHExp among households that have
sought care. The households that
had no choice but to forego care because they could not afford
it (and then experienced a health shock
because of loss of productivity) are not captured by the above
definition. This inherent weakness can
be overcome by using panel surveys.
Yet another point of debate is whether such a threshold is
applicable to all income levels. Obviously, a
poor family would face a health shock even if they had to spend
a small proportion of their annual
income on health care. In contrast, a rich family may be
perfectly able to cope with a health shock that
drains more than 20% of its annual income. Hence, the relevance
of fixing thresholds on the basis of
income levels must be questioned.
There is also a need to consider the type of medical event. A
planned event, even if costly, may be
managed through savings and borrowings from family and friends.
The family may be able to smooth
out the consumption in spite of the high medical expenses.
Conversely, an emergency event, even if
less costly than the former, may make it necessary for a family
to sell their assets, thereby
compromising future income and consumption.112
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33
Moreover, many authors only focus on direct health expenditures
when measuring THEs. Indirect
expenses such as transportation, informal fees and loss of wages
are not included in the calculation.
However, these expenses can be sizable and can increase the
incidence and intensity of CHExp.116
Given the limitations of this economic measure, it may become
necessary to consider non-economic
measures, like borrowing from the market, selling an asset or
downgrading ones lifestyle. Of course,
this argument needs to be validated and is a topic for future
research.
2.4.2 MeasuringCHExpHow does one measure CHExp? Usually three
indicators are used: the incidence, intensity and
impoverishing effect of CHExp. The incidence of CHExp is the
fraction of households in a population
that experience CHExp (as defined above). The intensity of CHExp
is the average of the amount
above the threshold spent by those households that experience
CHExp. This provides an idea of the
size of the problem for those households that experience CHExp.
The impoverishing effect is
calculated as the fraction of households whose THE causes their
total consumption to fall below the
poverty line.116
2.4.3 DeterminantsofCHExpCHExp usually occurs in an environment
where the following three elements are present:117
1. Health services requiring OOP payments,
2. Lack of pre-payment mechanisms, and
3. Low capacity to pay
Health services requiring OOP payments
CHExp occurs when patients have to spend money while using
health services, i.e., in health systems
that depend mainly on OOP payments to finance health care. There
is an overall positive relation
between the incidence of CHExp and the share of OOP payments in
THE.30;117 In countries like India,
Vietnam and Brazil, where OOP payments are very high, the
incidence of CHExp is higher, even after
controlling for other possible determinants. A 1% increase in
the proportion of THE due to OOP
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34
payments is associated with an average increase of 2.2% in the
proportion of households facing
CHExp.
Lack of prepayment mechanisms
In health systems that provide financial protection through
pre-payment mechanisms, the likelihood of
CHExp is reduced unless the co-payments or indirect costs are
very high.113 Another important
element is the cost of medical care. Many authors have
documented hospital admission (especially
emergency hospitalisation) as the main cause of CHExp.25;118
However, there is increasing evidence
that even ambulatory care,119;120 treatment of chronic
ailments31;120;121 and maternal care can be
catastrophic.122
Low capacity to pay
The third element is poverty. Obviously, poor families will
experience CHExp with even small health
expenditures.31;113;121;123 Indeed, even in high-income
countries like the United States of America,
there is evidence of CHExp among the poor.109 There is also
evidence that better-off families may
experience CHExp, especially when the family is large,31;124
includes elderly members123 or has
household members with a chronic ailment125 or a disability. A
health shock compounded by other
shocks (e.g., a religious function in the family25 or a crop
failure28) can also lead to impoverishment.
Richer families, which tend to consume more health care from
costly private providers, can also
experience CHExp.124;126 An ailment that may not be very costly
to treat but that incapacitates the
earning member of the household may cause the family to
experience a health shock by virtue of
reduced income.127 These considerations notwithstanding, CHExp
is most likely to occur in
households with inadequate coping mechanisms. Such mechanisms
include restricted access to credit,
limited assets, no opportunity for labour substitution and a
negligible social solidarity network. Thus,
small (especially female-headed) households are more prone to
CHExp.
Catastrophic payments are the biggest issue when all three of
these factors are prominently present.
Therefore, we would expect to see high rates of CHExp in
countries with high rates of poverty, large
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35
groups of people excluded from financial risk protection
mechanisms such as social health insurance,
and moderate to high levels of health care access and use. India
is a classic example where more than
80% of the population uses OOP payments to meet their health
care needs, only about 3% of the
population is covered by any form of health insurance, and more
than 37% of the population is below
the poverty line.
2.4.4 TheeffectsofCHExponfamiliesThe effects of a health shock
can be divided into three broad categories. The immediate effect is
a
reduction in consumption, including of food. This change may or
may not be associated with labour
substitution. Children may be pulled out of school and asked to
look after their siblings while the
mother seeks work. Previously non-working members of the family
may also start working to
augment the family income. In a worst-case scenario, families
may be broken up because of migration
or suicide.28 If the shock is limited or if the family has
sufficient coping mechanisms, the family is
able to tide over this acute phase and bounce back to normalcy.
In contrast, if the shock results in
indebtedness or sale of an income-generating asset, then future
income is also compromised.
Consumption will be reduced in the medium to long term,
resulting in malnutrition, more frequent
illness episodes and further widening of the poverty gap.128 The
situation worsens if adults must work
and lack the time to care for their children. Finally, if the
children have been pulled out of school and
food consumption is compromised, the next generation will also
be affected as the family remains in
the trap of illiteracy and poverty. These possibilities are
depicted in Figure 2.
Sauerborn identified 11 coping strategies that households use to
mitigate the effects of CHExp.129
They include using current savings, selling or mortgaging
assets, borrowing from formal or informal
creditors, labour substitution (usually by including children in
the labour pool) or diversifying the
income sources by doing extra work to meet the burden of health
costs. The choice of a strategy
depends on the households economic and social standing prior to
incurring the medical expense.
Poorer households have fewer options available to cope with
CHExp. Evidence suggests that families
relying solely on informal mechanisms are not able to insure
consumption over periods of major
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36
illness. A study in China showed that people tapped their social
networks first and tended to protect
core assets, such as land and cattle. Those households that
ultimately had to sell these core assets
invariably found it difficult to recover from the
catastrophe.130 Results are similar in India, where the
National Sample Survey Organisations (NSSO) report showed that
among 12,497 hospitalisation
episodes, more than one third borrowed to meet the costs.
However, only 4-5% of the patients sold
assets to cope with the calamity. This pattern of results held
in both the upper and the lower
quartiles.131 A study using nationally representative survey
data shows that more than 6% of Indians
were impoverished because of medical expenses in 2004.13
Figure 2: Possible trajectories of a family that has faced a
health shock.
2.4.5 PreventingCHExpProtecting families from CHExp should be a
policy goal of every government.111 The ability to pay
should not matter while accessing care.32 The ethical position
is that no one should spend more than a
given fraction of his or her income on health care.132 There are
many ways of providing health
security, ranging from increasing income129 to increasing the
depth of the benefit package119 or
Family
income
Non poor family with good coping mechanism
Income
Non-poor family with good coping mechanism
Time
Non-poor family with average coping mechanism
Poverty line
Non-poor family with poor coping mechanism
Poor family with average coping
Poor family with poor coping mechanism
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37
controlling medical costs.29 However, most authors are unanimous
in recommending that the best way
to reduce the incidence and intensity of CHExp is by reducing
OOP payments. They recommend that
countries shift to prepayment as the predominant mechanism for
financing health care.31;111;113;115;116
Therefore, countries must either strengthen their tax-based
systems or introduce health insurance to
protect vulnerable households.
2.4.6 HealthinsuranceandCHExpConceptually, health insurance (by
its prepayment and pooling mechanism), should protect families
from unexpected health expenditures. Families are always exposed
to the possibility of illness and
subsequent health care expenditure. Health expenditure creates
uncertainty, both in its timing and its
magnitude. Health insurance can be an effective way to overcome
both these uncertainties. Pre-
payment mechanisms ensure that when a patient falls ill, the
insurance fund meets the cost of the
illness and protects the family from raising money at the time
of illness. Similarly, the pooling
mechanism ensures that the premiums are usually a small part of
the potential health expenditure;
thereby once again protecting the family from paying beyond
their means. These two steps help in
reducing OOP payments considerably, thereby protecting the
family from financial catastrophe. In this
section, we examine the evidence first from the international
scenario and then from the Indian
context.
Studies from Mexico provide strong evidence that health
insurance prevents CHExp.133;134 Using data
from nationally representative surveys, the authors show