Enrollment in community based health insurance schemes in rural Bihar and Uttar Pradesh, India

This paper assesses insurance uptake in three community based health insurance (CBHI) schemes located in rural parts of two of India’s poorest states and offered through women’s self-help groups (SHGs). We examine what drives uptake, the degree of inclusive practices of the schemes, and the influence of health status on enrollment. The most important finding is that a household’s socio-economic status does not appear to substantially inhibit uptake. In some cases Scheduled Caste/ Scheduled Tribe (SC/ST) households are more likely to enroll. Second, households with greater financial liabilities find insurance more attractive. Third, access to the hospital insurance scheme (RSBY) does not dampen CBHI uptake, suggesting that the potential for greater development of insurance markets and products beyond existing ones would respond to a need. Fourth, recent episodes of illness and selfassessed health status do not influence uptake. Fifth, insurance coverage is prioritized within households, with the household head, the spouse of the household head and both male and female children of the household head, more likely to be insured as compared to other relatives. Sixth, offering insurance through women’s SHGs appears to mitigate concerns about the inclusiveness and sustainability of CBHI schemes. Given the pan-Indian spread of SHGs, offering insurance through such groups offers the potential to scale-up CBHI

Implementing a participatory model of micro health insurance among rural poor with evidence from Nepal

This paper reports on two voluntary, contributory, contextualised, community-based health insurance (CBHI) schemes, launched in Dhading and Banke (Nepal) in 2011. The implementation followed a four-stage process: initiating (baseline survey), involving (awareness generation and engaging community in benefit-package-design), launch (enrolment and training of selected community members) and post-launch (viable claims ratio, settled within satisfactory time, sustainable affiliation). Both schemes were successful on four key parameters: effective planning; affiliation (grew from 0 to ∼10,000) and renewals (>65 per cent); claims ratio (∼50 per cent); and promptness of claim settlement (∼23 days). This model succeeded in implementing CBHI with zero premium subsidies or subsidised health-care costs. The successful operation relied in large part on the fact that members trust that they can enforce this contract. Considerable insurance education and capacity development is necessary before the launch of the CBHI, and for sustainable operations as well as for scaling

The effect of consensus on demand for voluntary micro health insurance in rural India

Introduction: This study deals with examining factors that catalyze demand for community-based micro health insurance (MHI) schemes. We hypothesize that demand for health insurance is a collective decision in the context of informality and poverty. Our hypothesis challenges the classical theory of demand which posits individual expected diminishing utility. We examine factors beyond the traditional exogenous variables. Methods: This study uses data collected through a household survey conducted among self-h

Healthcare Seeking Behavior among Self-help Group Households in Rural Bihar and Uttar Pradesh, India

In recent years, supported by non-governmental organizations (NGOs), a number of demand-driven community-based health insurance (CBHI) schemes have been functioning in rural India. These CBHI schemes may design their benefit packages according to local priorities. In this paper we examine healthcare seeking behavior among self-help group households, with a view to understanding the implications for benefit packages offered by such schemes. This study is based on data from rural locations in two of India’s poorest states.1 We find that the majority of respondents do access some form of care and that there is overwhelming use of private services. Within private services, non-degree allopathic providers (NDAP) also called rural medical practitioners account for a substantial share and the main reason to access such unqualified providers is their proximity. The direct cost of care does not appear to have a bearing on choice of provider. Given the importance of proximity in determining provider choices, several solutions could be foreseen, such as mobile medical tours to villages, and/or that insurance schemes consider coverage of transportation costs and reimbursement of foregone earnings

Healthcare seeking behavior among self-help group households in rural Bihar and Uttar Pradesh

Abstract Background: In recent years, supported by non-governmental organizations (NGOs), a number of communitybased health insurance (CBHI) schemes have been operating in rural India. Such schemes design their benefit packages according to local priorities. This paper examines healthcare seeking behaviour among self-help group households with a view to understanding the implications for the benefit packages offered by such schemes. Methods: We use cross-sectional data collected from two of India’s poorest states and estimate an alternativespecific conditional logit model to examine healthcare seeking behaviour. Results: We find that the majority of respondents do access some form of care and that there is overwhelming use of private providers. Non-degree allopathic providers (NDAP) also called rural medical practitioners are the most popular providers. In the case of acute illnesses, proximity plays an important role in determining provider choice. For chronic illnesses, cost of care influences provider choice. Conclusion: Given the importance of proximity in determining provider choice, benefit packages offered by CBHI schemes should consider coverage of transportation costs and reimbursement of foregone earnings

What factors affect voluntary uptake of community-based health insurance schemes in low- and middle-income countries? A systematic review and meta-analysis

Introduction: This research article reports on factors influencing initial voluntary uptake of community-based health insurance (CBHI) schemes in low- and middle-income countries (LMIC), and renewal decisions. Methods: Following PRISMA protocol, we conducted a comprehensive search of academic and gray literature, including academic databases in social science, economics and medical sciences (e.g., Econlit, Global health, Medline, Proquest) and other electronic resources (e.g., Eldis and Google scholar). Search strategies were developed using the thesaurus or index terms (e.g., MeSH) specific to the databases, combined with free text terms related to CBHI or health insurance. Searches were conducted from May 2013 to November 2013 in English, French, German, and Spanish. From the initial search yield of 15,770 hits, 54 relevant studies were retained for analysis of factors influencing enrolment and renewal decisions. The quantitative synthesis (informed by meta-analysis) and the qualitative analysis (informed by thematic synthesis) were compared to gain insight for an overall synthesis of findings/statements. Results: Meta-analysis suggests that enrolments in CBHI were positively associated with household income, education and age of the household head (HHH), household size, female-headed household, married HHH and chronic illness episodes in the household. The thematic synthesis suggests the following factors as enablers for enrolment: (a) knowledge and understanding of insurance and CBHI, (b) quality of healthcare, (c) trust in scheme management. Factors found to be barriers to enrolment include: (a) inappropriate benefits package, (b) cultural beliefs, (c) affordability, (d) distance to healthcare facility, (e) lack of adequate legal and policy frameworks to support CBHI, and (f) stringent rules of some CBHI schemes. HHH education, household size and trust in the scheme management were positively associated with member renewal decisions. Other motivators were: (a) knowledge and understanding of insurance and CBHI, (b) healthcare quality, (c) trust in scheme management, and (d) receipt of an insurance payout the previous year. The barriers to renewal decisions were: (a) stringent rules of some CBHI schemes, (b) inadequate legal and policy frameworks to support CBHI and (c) inappropriate benefits package. Conclusion and Policy Implications: The demand-side factors positively affecting enrolment in CBHI include education, age, female household heads, and the socioeconomic status of households. Moreover, when individuals understand how their CBHI functions they are more likely to enroll and when people have a positive claims experience, they are more likely to renew. A higher prevalence of chronic conditions or the perception that healthcare is of good quality and nearby act as factors enhancing enrolment. The perception that services are distant or deficient leads to lower enrolments. The second insight is that trust in the scheme enables enrolment. Thirdly, clarity about the legal or policy framework acts as a factor influencing enrolments. This is significant, as it points to hitherto unpublished evidence that governments can effectively broaden their outreach to grassroots groups that are excluded from social protection by formulating supportive regulatory and policy provisions even if they cannot fund such schemes in full, by leveraging people's willingness to exercise voluntary and contributory enrolment in a community-based health insurance

"One for all and all for one": Consensus-building within communities in rural India on their health microinsurance package

Introduction: This study deals with consensus by poor persons in the informal sector in rural India on the benefit-package of their community-based health insurance (CBHI). In this article we describe the process of involving rural poor in benefit-package design and assess the underlying reasons for choices they made and their ability to reach group consensus. Methods: The benefit-package selection process entailed four steps: narrowing down the options by community representatives, plus three Choosing Healthplans All Together (CHAT) rounds conducted among female members of self-help groups. We use mixed-methods and four sources of data: baseline study, CHAT exercises, in-depth interviews, and evaluation questionnaires. We define consensus as a community resolution reached by discussion, considering all opinions, and to which everyone agrees. We use the coefficient of unalikeability to express consensus quantitatively (as variability of categorical variables) rather than just categorically (as a binomial Yes/No). Findings: The coefficient of unalikeability decreased consistently over consecutive CHAT rounds, reaching zero (ie, 100% consensus) in two locations, and confirmed gradual adoption of consensus. Evaluation interviews revealed that the wish to be part of a consensus was dominant in all locations. The in-depth interviews indicated that people enjoyed the participatory deliberations, were satisfied with the selection, and that group decisions reflected a consensus rather than majority. Moreover, evidence suggests that pre-selectors and communities aimed to enhance the likelihood that many households would benefit from CBHI. Conclusion: The voluntary and contributory CBHI relies on an engaging experience with others to validate perceived priorities of the target group. The strongest motive for choice was the wish to join a consensus (more than price or package-composition) and the intention that many members should benefit. The degree of consensus improved with iterative CHAT rounds. Harnessing group consensus requires catalytic intervention, as the process is not spontaneous

"Climate Cost of Cultivation": A New Crop Index Method to Quantify Farmers' Cost of Climate Change Exemplified in Rural India

We model the impact of agricultural droughts with a new multi-parameter index (using both climatic and non-climatic parameters) and propose a new risk transfer solution for crop insurance, called Climate Cost of Cultivation (CCC). We used 1979/80 to 2012/13 data relevant for wheat in Bihar, India to test the variation in the CCC values. The variance (risk to farmer) increased significantly in the second half of the period (two-tailed F-test, p=0.00045). We examine the efficiency of CCC by comparing it to typical index insurance (TII), and both indices to wheat yield data (2000/01 to 2012/13). The correlation of CCC index payouts with actual yield losses is improved by a factor of ∼3.9 over TII results (76.0 per cent, compared with 19.6 per cent). The pure risk premium of the CCC index is lower by around 90 per cent than the premium of the TII. We also elaborate a method to quantify the premium's climate change cost component

Impact of community-based health insurance in rural India on self-medication & financial protection of the insured

Background & objectives: The evidence-base of the impact of community-based health insurance (CBHI) on access to healthcare and financial protection in India is weak. We investigated the impact of CBHI in rural Uttar Pradesh and Bihar States of India on insured households’ self-medication and financial position. Methods: Data originated from (i) household surveys, and (ii) the Management Information System of each CBHI. Study design was “staggered implementation” cluster randomized controlled trial with enrollment of one-third of the treatment group in each of the years 2011, 2012 and 2013. Around 40-50 per cent of the households that were offered to enroll joined. The benefits-packages covered outpatient care in all three locations and in-patient care in two locations. To overcome self-selection enrollment bias, we constructed comparable control and treatment groups using Kernel Propensity Score Matching (K-PSM). To quantify impact, both difference-in-difference (DiD), and conditional-DiD (combined K-PSM with DiD) were used to assess robustness of results. Results: Post-intervention (2013), self-medication was less practiced by insured HHs. Fewer insured households than uninsured households reported borrowing to finance care for non-hospitalization events. Being insured for two years also improved the HH’s location along the income distribution, namely insured HHs were more likely to experience income quintile-upgrade in one location, and less likely to experience a quintile-downgrade in two locations. Interpretation & conclusions: The realized benefits of insurance included better access to healthcare, reduced financial risks and improved economic mobility, suggesting that in our context health insurance creates welfare gains. These findings have implications for theoretical, ethical, policy and practice considerations

An Empirical Study for Responsibility Commitment of Japanese White-collar

Abstract Background: In recent years, supported by non-governmental organizations (NGOs), a number of communitybased health insurance (CBHI) schemes have been operating in rural India. Such schemes design their benefit packages according to local priorities. This paper examines healthcare seeking behaviour among self-help group households with a view to understanding the implications for the benefit packages offered by such schemes. Methods: We use cross-sectional data collected from two of India’s poorest states and estimate an alternativespecific conditional logit model to examine healthcare seeking behaviour. Results: We find that the majority of respondents do access some form of care and that there is overwhelming use of private providers. Non-degree allopathic providers (NDAP) also called rural medical practitioners are the most popular providers. In the case of acute illnesses, proximity plays an important role in determining provider choice. For chronic illnesses, cost of care influences provider choice. Conclusion: Given the importance of proximity in determining provider choice, benefit packages offered by CBHI schemes should consider coverage of transportation costs and reimbursement of foregone earnings