HEALTH INSURANCE PART 1
Item
- Title
-
HEALTH
INSURANCE PART 1 - extracted text
-
I /
' /
/
/
/
4___
MEDICAL INSURANCE SCHEME
RAHA’S SELF FINANCING MEDICAL
INSURANCE SCHEME (MIS)
• The Journey of Raighar Ambikapur Health
Association began with the organizing
committee meeting on June 8, 1969 in Holy
Cross Hospital, Kunkuri, Raigarh dist,
Chattishgarh State. The meeting was called
to discuss a proposal for a Health
Association. With the agreement of the
participants RAHA was born.
1
VISION
RAHA envisions a wholesome, sustainable, caring
and
transformed
community
of
people.
MISSION
1.
2.
3.
4.
5.
To build up local leadership through value - based
training.
To work in partnership with people through an integrated
and holistic approach.
To facilitate preventive, promotive, curative and
rehabilitative health care services.
To promote Alternative System of Medicine.
To collaborate with like-minded individuals, organisations
and government.
HEALTH CARE SERVICES THROUGH RURAL
HEALTH CENTRES
> The Rural Health Centres are established to provide
health care services in the most needy areas. The
services are provided with the understanding of
wholistic health care. The emphasis is on treating
the person as a whole and not only the disease.
> RHCs are managed by various church related NGOs.
There are certain agreements between RAHA and
RHC.
1
OBJECTIVES
“People’s Health in people’s Hand”
❖
To make medical facilities available in the community itself.
❖
To subsidise the medical care of the members at primary,
and tertiary level.
❖
To encourage people’s participation in health care services
❖
To encourage people to be a caring community and contribute towards
the medical care of their fellow beings through membership fee.
❖
To reduce exploitation from money lenders.
secondary
STRATEGY
A movement of people “I AM MY SISTERS/BROTHERS KEEPER”(Genus :4 .9
)
taking
responsibility
for
each
other.
WHO CAN BECOME A MEMBER
Any person (male orfemale) irrespective of age, caste, colour or creed.
THE MEMBERSHIP FEE
Any person desirous of becoming a member of the scheme shall pay
annually a membership fee in kind or in cash equivalent to 2 kg of rice.
DURATION OF MEMBERSHIP
One year.
1
PRIVILEGES OF MIS MEMBERS ENJOYS
a.
At the Village level: The VHW gives health education and free treatment on the
specified minor sicknesses.
For minor ailments they are advised to take home
remedies.
b.
At the Rural Health Centre level. A member enjoys the following privileges:
As Out-Patient Free consultation
Free medicine (pills) upto Rs. 100/- per year
As In-Patient•
Free consultation
•
Fifty percent rebate is given on the total bill
•
A pregnant mother, who is an MIS member if admitted for delivery at the Rural
Health Centre will be expected to pay only Rs.50/- towards the entire cost of
delivery charges.
c.
At the Hospital Level
A contribution to the extent of Rs. 1,250/- is given on the total treatment per year.
Patients contribution towards hospital services is fixed as per the distance.
MEDICAL INSURANCE SCHEME
(MIS)
Achievements:
No. of districts RAHA provides health care services:
4
No. of Rural Heath Centres coordinated by RAHA :
85
Medical insurance members benefited
77,604
No. of health workers trained and activated
2200
No. of TBS trained and activated
2500
No. of Traditional Practitioners trained and activated :
850
1
The trend of MIS Membership from its inception
90000
77604
75032
80000
Fb
70508
■
84311
70000
58816
56366
.9*
60000
51000
50000
45000
VJ 50000
<U
x»
37000
E 40000
o
2
’
I'
30000
n
n
S4243
n
50226
1
I-i
r
50000
53fl33J i
53598
61053
45677 F
I
n
J
n
:■
I
■
•
.
20000
10000
-
10000
2000
0
nr
56578
51496
-
I
1931 1S32 1983
h
i _..
H I - I -j [- 2001 2QC2
___________
__
B —._________________
a id
1984 1985 1986 1S871S88 1989 19901931 1992 19931994 1395 1996 1997 1398
iiii
13992000
Year
MEDICAL INSURANCE MANAGEMENT
COMMITTEE
The Medical Insurance Scheme is a people’s movement. From its inception
efforts were made to decentralize the scheme allowing greater participation for
the people. The emphasis is on the role of VHW/Dai at the village level and
the Rural Health Centre as a secondary level of treatment and support. Now it
is considered essential to formally establish Local Committee to administer
the scheme at the local level through Medical Insurance Management
Committee.
PURPOSE OF THE COMMITTEE
The committee is constituted with a purpose of administering the Medical
Insurance Scheme at the beneficiaries level. The committee is an expression
of RAHA’s purpose of empowering the people to manage their own affairs
1
(
IN’IliRNATIONAI. JOURNAL Ol- 111 Al TH PLANNING AND MANAGI MI N I
Ini. J. Health Plann. Mgmt. 13. 47 67 (|99X)
WILLINGNESS TO PAY FOR RURAL HEALTH
INSURANCE THROUGH COMMUNITY
PARTICIPATION IN INDIA
K. Mathiyazhagan
Quantilalh e Ana/ysis Unit. Institute for Social and Economic Change. Nagarhhavi.
Bangalore-72, India
SUMMARY
f
I
The main objective of this article is lo examine the willingness to pay for a viable rural
health insurance scheme through community -participation in India, and the policy
concerns it engenders. The willingness to pay for a rural health insurance scheme
through community participation is estimated through a contingent valuation approach
(logit model), by using the rural household survey on health from Karnataka State in
India. The results show that insurance/saving schemes are popular in rural areas. In
fact, people have relatively good knowledge of insurance schemes (especially life
insurance) rather than saving schemes. Most of the people staled they are willing to join
and pay for the proposed rural health insurance scheme. However, the probability of
willingness to join was found to be greater than the probability of willingness lo pay.
Indeed, socio-economic factors and physical accessibility to quality health services
appeared to be significant determinants of willingness to join and pay for such a scheme.
The main justification for the willingness lo pay for a proposed rural health insurance
scheme are attributed from household survey results: (a) the existing government health
care provider’s services is not quality oriented; (b) is not easily accessible; and, (c) is not
cost effective.
The discussion suggests that policy makers in India should take serious note of the
growing influence of the private sector and people’s willingness to pay for organizing a
rural health insurance scheme to provide quality and efficient health care in India. Policy
interventions in health should not ignore private sector existence and people’s willing
ness to pay for such a scheme and these two factors should be explicitly involved in the
health management process. It is also argued that regulatory and supportive policy
interventions are inevitable to promote this sector’s viable and appropriate development
in organizing a health insurance scheme. © 1998 by John Wiley & Sons, Ltd.
jness lo pay; viable health insurance scheme; community
KEY WORDS: willing!
participation; contingent valuation approach
INTRODUCTION
The World Bank’s agenda on Financing Health Services in Developing
Countries (1987), and the recent World Development Report (1993), emphasizes
the demand side — highlighting health insurance, user fees, and the private
sector for strengthening the health sector. This is a major departure from the
CCC 0749-6753/98/010047-21S17.50
© 1998 by John Wiley &. Sons, Lid.
48
K. MATHIYAZilAGAN
earlier approaeli which focused on the supply side- public sector spending,
costs, management and elliciency that has dominated the international
health finance agenda for many years (Griilin, 1989, 1990). The emphasis on
demand is quite understandable as even two decades after Health For AU by
2000 AD was launched, the non-availability of the necessary finances is a major
obstacle to further progress in many developing countries like India (AbelSmith and Dua, 1988; Abel-Smith, 1992).
In fact, there has been substantial increases in the total plan expenditure in
India for health and family welfare in nominal terms, but it has not increased in
real terms (Economic Survey. 1997). 1'or example, the total plan outlay for the
Sixth Five Year Plan (1980 85) was Rs.6.7 thousand crores, which accounted
for only 3.12 per cent of the total outlays of budget during this period. It
increased to Rs. 14.1 thousand crores; but in real terms it had increased only 0.12
per cent in the Eighth Five Year Plan (1992-97). Health expenditure in relation
to the gross national product (GNP) in India was about 0.98 per cent in the
Seventh Five Year Plan as compared to 0.91 per cent in the Sixth Five Year
Plan. Indeed, the anticipation that governments would increase expenditure on
health services to 5 per cent of the GNP was, in most cases, unlikely to be
realized. Yet, there is little evidence that donors will increase their aid to the
health sector, including in India. Ministries of health are being asked to find
their own solutions. This is an unfortunate scenario at the national level.
The situation at the stale level seems to be no better. For example, out of the
total plan allocation, only 3.30 per cent was the maximum proportion allocated
for the health and family welfare sector of the Karnataka stale during the last
15 years of planning. It accounted for only a maximum of 0.17 of net stale
domestic product for the same period. This has resulted in an under-funding
situation in the health sector at the stale level. This kind of concern has led to
substantial debate, in the national and international context about the range of
options for financing health care (de Ferranti, 1985; Hoare and Mills, 1986;
WHO, 1987; World Bank, 1987; Zschock, 1979). One central option is to intro
duce a health insurance scheme for improving quality health care services. Health
insurance is a risk-sharing approach whereby communities or individuals pool
their resources to cover uncertain cosily events, which would otherwise be difficult
or impossible for individuals to afford at their time of need.
There are several types of health insurance schemes operating in India,
through the General Insurance Corporation (GIC) and Life Insurance
Corporation (LIC). A central problem of these schemes is that they are biased
towards only the salaried class and better-off people, whose resulting distri
bution of services is often regressive, with middle-income and higher groups
benefiting disproportionately. Further, the doctors and hospitals in India are
concentrated mostly in the cities, where they are available to the urban middle
class but loo far away to benefit most of the rural poor.
In this context, it is realized that studying the potential for a viable rural
health insurance scheme, through community participation, is an appropriate
one. It is also considered as a way of realizing social justice, because it is based
on solidarity and cooperation between the well and the ill, the rich and the
«■» 1998 John Wiley & Sons. Ltd.
)
bit. J. Health Plann. Mftmt. 13. 47-67 (1998)
*
WILLINGNESS IO PAY I OR RURAL HEALTH INSURANCE
49
poor (Goinaa, 1986). Further, it is presumed that rural health insurance
through community participation could bring in more money to pay for better
use of health services by all. In the process, more people could possibly choose
the health services of the private sector through health insurance, leading to
shorter queues al government services and thereby fewer people having to
share the limited drugs and other supplies that can be afforded in the
government services. The viability of such policy and willingness to pay for it
can be justified, a priori, on the following grounds:
• it is evident that the rural poor are united by common concerns or events and
also represent their problems to administrative bodies through their leaders.
Does this mean that this kind of solidarity and cooperative effort of the rural
people could provide the basis for the viability of a scheme of rural health
insurance through community participation?
• it is also observed from the recent economic reform movement that
decentralization at the grass-roots level may increase efficiency in
government services (GOI, Eighth Five Year Plan Document, 1992). In
this context, would the existing Panchayati Raj System become an
instrument for eliciting community participation in the health programme,
and providing supervision and support to the primary health care
infrastructure?
• it is also evident from earlier studies that rural people bypass the supplyconstrained government health care services and seek care from the private
sector. Does this suggest that people are already paying out of their pockets
for health care? Does this give a basis for a scheme whereby private or non
governmental organizations could be the service provider, as these are
expanding in almost all parts of the country?
• while the experience of the Sevagram Rural Health Insurance Scheme of
Maharaslra in India shows the administration of the scheme to be feasible;
nonetheless, the question arises whether the existing village administrative
background (nearly 60 per cent of the total settlement of India) could
feasibly support the administration of the scheme?
Keeping in mind these questions and the importance of resource constraints
for financing quality health care services by the government, this study
considers whether rural health insurance through community participation in
India is a viable alternative policy: (a) to generate and increase financial
resources for national health development; (b) to foster efficiency in health care
provision; and, (c) to guarantee maximum access to health services for the rural
population, and rural poor, in particular. In this context, it is important to
observe that once the feasibility of a health insurance scheme is established, it is
necessary to then investigate whether the people are willing to accept such a
scheme and their willingness to pay for the same?
When economists attempt to infer values, they prefer evidence based on
actual market behaviour, whether directly or indirectly revealed. Thus, a
technique like the contingent valuation (CV) method — wherein values are
(f) 1998 John Wiley & Sons. Ltd.
hit. J. Health Plann. Mgmt. 13. 47-67 (1998)
50
K. MATHIYAZHAG/XN
inferred from individuals’ slated responses to hypothetical situations — could
readily be expected to stir lively debate in academic circles. However, a final set
of reasons for economists to care about the contingent valuation debate has
less to do with potentially important values. According to proponents of the
contingent valuation method, asking people directly has the potential to inform
about the nature, depth, and economic significance of these values. Based on
this rationale, during the last few years there has been an increased interest in
the CV method of measuring willingness to pay for health care technologies
(Appel el al., 1990; Donaldson, 1990; Johannesson and Jonsson, 1991;
Johannesson et al., 1991a,b, 1993; Johannesson, 1992; Johannesson and
Fagerberg, 1992). This study is not a strict replication of these specific studies,
since this study adopts a heuristic approach through informal observation and
discussion with rural people about their opinions on existing health care
services alongside a household survey. It is also important to note that this
study first investigates the viability of a rural health insurance scheme through
community participation, and finds out whether people are indeed willing to
pay for such a scheme.
To repeat: the main objective of this article is to examine the willingness to
pay for a viable rural health insurance scheme through community parti
cipation in India, and the policy concerns it engenders. The first section of this
article has discussed the resource constraint upon providing government health
care services and the role of alternative financing. The research approach and
data source of this article arc discussed in the next part. The third section
discusses the descriptive results of the household survey, and the empirical
analysis of willingness to pay for a viable health scheme. Finally, by using
empirical results, the policy implications are also discussed.
RESEARCH APPROACH
In order to answer the policy questions for organizing a viable rural health
insurance scheme through community participation in India, it is necessary to
investigate the acceptance of the people regarding such a scheme and the extent
to which they are willing to pay for the same. In this context, this study
combines two approaches: viz., survey research, and, heuristic/documentary
research. The survey research has been designed to analyse rural health care
services available through private and voluntary organizations, the cost of their
services, and opinions of people on a rural health insurance scheme through
community participation. The second approach of heuristic/documentary
research is used in order to obtain the opinions of rural people for organizing
rural health insurance through community participation. In analysing the
survey data and making a comparative study, inter-state experience has also
been examined. By comparing the results of the two approaches, it is possible
to judge: (a) the viability of a rural health insurance scheme; and (b) willingness
to pay for such a scheme. The viability of any programme may be defined as
© 1998 John Wiley & Sons, Ltd.
bit. J. Health Plann. Mgmt. 13, 47-67 (1998)
WILLINGNESS TO PAY I OR RURAL HEALTH INSURANCE
51
feasible or practicable in terms of the ways and means of the design. The ways
and means of rural health insurance through community participation are
determined by: the financial sustainability of the programme; the accessibility
of the programme to the rural poor; the referral behaviour of patients in the
rural area; and, its administrative feasibility.
Data sources
The study is confined to rural Karnataka State in India. There are 27 028
inhabited villages spread over 19 administrative districts and the total
population living in these villages is 26.41 million. The necessary data for
analysis were mainly drawn from the household survey in rural Karnataka.
The sampling was carried out in three stages. Since socio-economic
development is diverse among the districts, it was decided to use a stratified
random sample to ensure its representative nature. The districts were stratified
into three strata based on the development of districts (i.e. developed, middle
order, and backward). In the first stage, six districts were selected out of the
three strata (i.e. two districts from each stratum). Within a district, the
administrative subunits in the form of taluks exhibited dillerent levels ol
development. Hence, in the second stage, the taluks were stratified in each
district into two strata in terms of their accessibility to health care services, as
expressed in the form of hospital beds per thousand population, doctors per
thousand population etc., into high accessibility and low accessibility
categories. In each of the selected districts, one taluk was selected from each
of the two categories. Thus, a total of 12 taluks were selected. In the third stage,
one village having a primary health centre (PHC) and private/non-government
organization (NGO) hospital services was identified. This selection was
purposive in the sense that the village was selected to obtain a large
community. One or two more villages proximate to the selected village with
PHC only were included in the sample. Thus, a total of 36 villages were
selected. Taking into consideration the lime and resources, it was decided to
cover a total of 1000 households. These households were allocated in relation
to the number of households in each of the villages. In all, there were 18 298
households. After deciding the number of households for each village, the
specific households were selected in a systematic manner by listing them.
Depending on the number to be covered, every third or fourth house was
selected from a given sample village. It was felt that the female head of the
household would be more knowledgeable about the health-related aspects of
females and children. Hence, both male and female heads were present during
the interview.
FINDINGS
This part examines people's opinions and their validity, through empirical
assessment, to a proposed rural health insurance scheme through community
t£) 1998 John Wiley & Sons. Ltd.
hu. J. Health Plann. Mgmt. 13. 47-67 (1998)
52
K. MATHIYAZHAGAN
participation, and their willingness to join and pay for such a scheme. Il
includes the exposure to, and knowledge of, the rural population in the case of
insurance/saving schemes, willingness to join and pay, choice of health care
provider, and preferences for the components of the proposed rural health
insurance scheme.
Exposure and knowledge of rural population on insurance and savings
The survey allowed rural households to answer open-ended questions on
their knowledge about insurance and savings schemes. It was expected that the
exposure of rural people to insurance and savings schemes may have valid
implications for their willingness to join and pay for a rural health insurance
scheme. In this context, data on: (a) their exposure to a scheme; (2) whether
they have subscribed to a scheme; and, (3) their understanding of the objectives
of such schemes were collected. A person exposed to the scheme meant that he
has heard about the scheme. Subscribing to the scheme meant that he has
heard of, and subscribed to the scheme; and, an understanding of the objectives
of such schemes meant that he has heard of, and he has the knowledge of the
principles and objectives of lhe*schemc.
Insurance/saving schemes are popular in rural areas. People have relatively
better knowledge of insurance schemes (especially life insurance schemes) than
savings schemes. The findings (Table 1) reveal that nearly 64.4 per cent of the
total sample of households were exposed to life insurance schemes. Among
them, nearly 12.2 per cent of the people were subscribing to the scheme. It also
revealed that nearly 56.9 per cent of the people had understood the risk-sharing
concept of life insurance very well. Though saving schemes were as familiar as
life insurance schemes among the rural people, it was found that only 3.39 per
cent of the total sample population subscribed to savings schemes. -Though the
principles and objectives were well understood by the rural households, it was
not clear why rural people were not subscribing to the saving schemes. It was,
also clear from Table 1 that people had hardly heard about health insurance
schemes (2.6 per cent). Perhaps, health insurance schemes by the governmentowned (GI) and its subsidiaries (like National Insurance Corporation Limited,
the New India Assurance Corporation Limited, the Oriental Insurance
Corporation Limited and the United India Assurance Corporation Limited)
operating as commercial health insurance schemes in India did not reach the
Table 1. Exposure and knowledge of sample households on insurance/savings schemes
(%).
Particulars
Life insurance schemes
Saving schemes
Health insurance schemes
(C) 1998 John Wiley & Sons, Lid.
Exposed
Exposed and
subscribed
64.4
12.2
56.9
64.3
3.9
0.0
65.5
0.0
2.6
Exposed and
understood
Im. J. Ik-ahh Plann. Mgmi. 13, 47-67 (1998)
53
WILLINGNESS TO PAY FOR RURAL HEALTH INSURANCE
rural people. Il was also shown from the survey that most people saw health
insurance as part of a life insurance scheme.
Willingness to join a proposed rural health insurance scheme through community
participation
An understanding of the viability of rural health insurance requires detailed
information that can come from an investigation of the willingness to join a
rural health insurance scheme. Willingness to join such a scheme is discrete
willing or not willing. Therefore, a suitable estimator was used to explain the
qualitative response. The contingent valuation approach, or hypothetical
valuation method, was used to reveal rural households’ willingness to join and
pay a rural health insurance premium through community participation. This
technique involves a process of offering a set of hypothetical situations to the
respondents and determining how they would react to such situations. It means
that estimates are not based on observed or actual behaviour; but, instead, on
inferring what an individual’s behaviour would be from the answers he or she
provides in a survey framework. Although this kind of method may not always
provide accurate estimates, it docs provide an order-of-magnitude estimate
which could be valuable for planning purposes.
The survey results on households’ willingness to join the proposed rural
health insurance are presented in Table 2. Out of a total oi 1000 households,
nearly 91.8 per cent said they were willing to join the proposed health insurance
scheme, while 0.8 per cent said they were willing to join if most people in the
village joined the scheme, and nearly 7.4 per cent of the households said they
were not willing to join the proposed scheme. There were some differences
among regions regarding willingness to join the proposed scheme. In relative
terms, a higher percentage (97.6) of households from Belgaum District were
willing to join health insurance, and a higher percentage (19.1) of households
from Bangalore Rural District refused to join. However, the differences on
willingness to subscribe to health insurance did not vary much (91.5 to 97.6 per
cent) across different regions except Bangalore Rural District, where only 76.6
Table 2. Households’ willingness to join for proposed rural health insurance by region.
Dcode
Willing
Conditional willing
Not willing
Dcode 1 {n = 179)
Dcode 2 (n = 161)
Dcode 3 (n = 111)
Dcode 4 (n = 87)
Dcode 5 (n = 207)
Dcode 6 (h = 173)
76.6
91.5
97.4
92.6
97.6
96.6
1.3
1.1
0.0
1.1
0.5
0.6
19.1
7.4
2.6
6.4
1.9
2.8
N= 100
91.8
0.8
7.4
Dcode 1, Bangalore Rural District; Dcode 2. Mysore District; Dcode 3. Chikmangalore District;
Dcode 4, Uttarakannada District; Dcode 5, Belgaum District; Dcode 6, Gulburga District.
© 1998 John Wiley & Sons, Ltd.
Im. J. Health Plann. Mgmt. 13, 47-67 (1998)
54
K. MATH1YAZHAGAN
Tabic 3. Willingness to join a proposed rural health insurance by caste.
Caste
Willing
Conditional willing
Not willing
Brn & Ksha (n = 47)
Vai & Banaj (n = 15)
Linga (n = 163)
Okkali (//= 127)
KGBBAUDK (n
100)
SC/ST (n = 227)
Others (n = 321)
87.2
73.3
93.3
88.2
90.0
94.3
92.8
2.5
6.7
0.6
1.6
0.0
0.4
0.6
10.6
20.0
6.1
10.2
10.0
5.3
6.5
N
91.8
0.8
7.4
1000
Brn & Ksha, Brahmin and Kshatriya; Vai & Banaj, Vaishya and Banajiga; Linga, Lingayat;
Okkali, Okkaliga; KGBBAUDK. Kuruba,'Golla. Badagi, Besta. Akkasaliga, Uppara. Dcvanga.
Kammara; SC/ST, Scheduled castc/Scheduled tribe; others include Christians, Muslims, Jains and
Buddhists (religious category).
per cent of the households said they were willing to join the scheme. It was also
noted that the differences in willingness to join health insurance did not vary
among the different castes, except the Vaishya and Banajiga castes, which
reported a lower percentage of 73.3 (see Table 3). It is important to note that
the low castes (Scheduled caste (SC)/Scheduled tribe (ST)) recorded the highest
percentage (94.3) under the category of willingness to join the proposed
scheme.
Willingness to pay for the proposed rural health insurance scheme
The survey included direct questions on each rural household's willingness to
pay for health insurance. Households were asked to state the maximum
amount of money they could pay. The survey also included questions on
reasons for refusing to pay for the proposed scheme. Table 4 shows the survey
results of rural households' willingness to pay for health insurance. Out of the
total 918 households willing to join health insurance, 86.82 said they were
willing to pre-pay a health insurance premium for yearly medical services for
themselves or their families. Willingness to pay for the proposed rural health
insurance did not differ much among the six different regions’ households. It
varied between 80.46 and 92.79 per cent of the total households sampled.
Households were also willing to pay a maximum amount for the proposed
scheme which, on average, was nearly Rs. 163.48 per year. Il is also noticeable
(Table 4) that the average level of the maximum amount people were willing to
pay varied significantly from Rs. 148.05 to Rs. 187.85. It is also important to
note that most of the households (41.53 per cent) would pay between Rs. 121
and Rs.240. Nearly 32.62 per cent of the households would pay Rs. 120 or less,
which meant that they would pay Rs. 10 per month. A significant number of
households (7.90 per cent) were willing to pay between Rs.481 and Rs.600,
which amounted to nearly three to four times higher than the average
(maximum) amount (Rs. 163.48).
© 1998 John Wiley & Sons, Ltd.
bit. J. Health Plann. Mgmt. 13, 47-67 (1998)
WILLINGNESS TO PAY FOR RURAL HEALTH INSURANCE
55
Table 4. Willingness to pay for level of proposed rural health insurance scheme by
regions (%).
Region
Willing to
pay (Rs.)
Dcode I Dcode 2 Dcode 3 □code 4 Dcode 5 Dcodc 6 Total
(n = 179) (// = 161) (n HI) (Z/ = 87) (n = 207) (// 173) (N 918)
241-360
361-480
481-600
23.38
52.60
1 1.69
6.49
5.84
31.62
40.44
19.12
2.94
5.88
36.89
34.95
17.48
0.00
10.68
38.89
35.71
14.29
1.43
10.00
32.20
38.98
13.56
3.96
11.30
37.58
41.40
15.28
0.64
5.10
32.62
41.53
15.06
2.89
7.90
% of WP
86.03
84.47
92.79
80.46
85.51
90.75
86.82
Average
amount
willing
to pay
148.05
154.66
187.85
150.43
181.30
158.58
163.48
< 120
121 240
See Table 2 for Dcodes.
The results on willingness to pay in relation to castes are presented in Table
5. Nearly 84.14 per cent of the 227 SC/ST (low caste) households said that they
were willing to pay for a proposed health insurance scheme. Vyshyas and
Banajigas (high castes) accounted for the lowest percentage (66.67) under the
category willingness to pay for the proposed scheme. As already noted, on
average, the maximum amount people were willing to pay for health insurance
for all castes in the sample area was Rs. 163.48. In the case of the higher castes
such as Vaishya, Banajiga, Bhramin and Kshatriya it was, on average, between
Rs. 142.67 and Rs. 163.83. In comparative terms, the ‘backward’ castes like
Lingayat and Okkaliga were willing to pay a higher average amount, between
Rs. 172.60 and Rs. 173.35. The low castes like SC and ST were willing to pay
Rs. 162.18, which was higher than some of the high castes (Vaishya and
Banajiga).
Preference to pay for the proposed health insa rance scheme
Households' preference for the medical benefits plan was measured in terms
of types of illness; and hence, data were collected on medical services desired to
be covered by health insurance. Households were told that different types of
medical benefits had different costs. This was explained by using a hypothetical
method. Types of illnesses/medical care included: (1) hospitalized benefit; (2)
non-hospitalized benefit; (3) chronic illnesses benefit; (4) hospitalized and
chronic illness benefit; (5) hospitalized and non-hospitalized benefit; (6) chronic
illness and non-hospitalized benefit; and, (7) comprehensive medical care
benefit. The results are presented in Table 6.
Most households selected a comprehensive medical care benefit, followed by
hospitalized, and hospitalized and chronic illnesses care benefit. Out of the
<0 1998 John Wiley & Sons. Ltd.
bit. J. Health Plann. Mgmt. 13, 47-67 (1998)
©
I
t
I
Table 5. Willingness to pay for level of proposed health insurance scheme by castes (%).
Maximum amount
(Rs.)
o-'
Brn & Ksha
(n = 47)
Vai & Banaj
(n =15)
Linga
(n = 163)
Okkali
(n = 127)
KGBBAUDK
(n = 100)
SC/ST
(n = 227)
Others
(n = 321)
Total
(TV = 918)
<120
121-240
241-360
361-480
481-600
55.56
25.00
8.33
0.00
11.11
40.00
40.00
10.00
0.00
10.00
54.48
22.39
10.45
1.49
11.19
50.49
29.13
7.77
5.82
6.79
60.01
25.71
7.14
1.43
5.71
56.02
29.84
8.91
0.52
4.71
56.92
23.71
7.51
3.56
8.30
32.62
41.53
15.06
2.89
7.90
% of WP
76.60
66.67
82.21
81.10
70.00
84.14
78.82
86.82
Average amount
willing to pay
163.83
142.67
173.35
172.60
139.50
162.18
162.88
163.48
2
>
See Table 3 for castes.
£N
X
Table 6. Preference to pay for the different components of the proposed health insurance scheme (%).
Preference
I
a
£
£
Hospitalized benefits (n = 122)
Non-hospitalized benefits (n = 45)
Chronic illnesses benefits (n = 20)
Hospitalized + chronic (n — 99)
Hospitalized + non-hospitalized (n = 13)
Chronic + non-hospitalized (n = 76)
Comprehensive benefits (n = 422)
See Table 2 for Dcodes.
oc
Dcode 1
(n = 154)
Dcode 2
(n= 136)
Dcode 3
(n = 104)
□code 4
(n = 70)
Dcode 5
(n = 177)
Dcode 6
(n= 156)
Total
(N = 797)
12.99
1.30
9.74
13.64
6.49
1.39
54.55
11.03
1.47
10.29
14.71
7.35
3.68
51.47
12.50
1.92
9.62
16.35
4.81
2.88
51.92
12.85
1.43
10.00
15.71
2.86
1.43
55.71
12.43
2.26
8.47
15.82
5.08
2.26
53.67
11.54
1.28
9.62
17.31
5.77
3.21
51.28
15.31
5.64
2.51
12.42
1.63
9.54
52.95
>
o
>
z
WILLINGNESS TO PAY FOR RURAL HEALTH INSURANCE
57
total 797 households who preferred to pay, 52.9 per cent wanted a com
prehensive care benefit. This meant that they considered the combination of
hospitalized, non-hospitalized and chronic illnesses care benefits as necessary
to the entire household. About 15.31 percent of the total households preferred
only hospitalized care benefits and 12.42 per cent opted for hospitalized and
chronic illnesses benefits. The combination of other care benefits was reported
in only a small proportion of the total sample of households. When the results
were broken down by region, there was a similar pattern of preferences
emerging.
THE WILLINGNESS TO JOIN AND PAY FOR
RURAL HEALTH INSURANCE: FRAMEWORK
OF ANALYSIS
Evaluation of the viability and desirability of a rural health insurance scheme
through community participation and a population's willingness to pay for
such a scheme requires pre-evaluation of the consequences for health care
utilization of the rural households and their socio-economic characteristics.
Hence, in this context, the CV approach was used. In order to test the validity
of the CV method, i.e. whether the hypothesized theoretical relationships are
supported by the data (Mitchel and Carson, 1989), the validity was carried out
in this study by estimating the theoretically derived regression equations. In
this context, the logit estimator was used on the basis of computational
convenience. It has also been shown to be consistent with the theory of utility
maximization, under certain specifications of the utility function. The following
is a brief description.
The proposed logit model was expected to determine the willingness of
rural people to join a proposed health insurance scheme. It was presumed that:
(1) an individual must decide between some available options; and, (2) the
individual chooses one option above the rest if the utility of that option to the
individual is greater than the utility of any of the other options. The two
options considered in this particular context were willingness to pay and not
willingness to pay. It assumed a hypothetical rural health insurance scheme to
be available, the details of which were the subject of a briefing collectively in a
village gathering, a day before the investigation, and individually to the
concerned sample of households at the time of interview. It was assumed
that the private/NGO hospitals would be service providers, mainly because
the private provider emerged as the people’s choice in the rural area
(Mathiyazhagan, 1994). The administration and monitoring of the scheme
was to be done by the government and the community. In this context, it was
expected to test a hypothesis that there is a positive relationship between
people’s willingness to join and pay for rural health insurance and their socio
economic characteristics. The general framework of the logit model is
expressed as follows.
© 1998 John Wiley & Sons. Ltd.
hit. J. Health Plann. Mgmt. 13. 47-67 (1998)
58
K. MATH1YAZHAGAN
It was assumed that the utility of option i to the jlh individual may be
expressed by the following equation:
Uy =Vy + Ey
i.e. utility of the /th option to the jth individual is made up of a systematic
component or representative utility Vyy which was assumed to reflect the
individual tastes.
The systematic component Vy was assumed to be a linear function of the
characteristics of the individual and attributes of the different options available
to him.
K
Pik Sikj
ij =
k= \
The (3 values are the weights to each of the socio-economic characteristics of
the individual j and the attributes of the options i (Sjkj) in the probability of
choosing that option. These weights were assumed constant across individuals,
but not across alternatives.
It can be demonstrated that if the Ey values are distributed according to
the extreme value distribution, then the probability that the option i will be
selected from a set of m options, can be expressed by the logit model presented
in the following equation.
M
Preselection option i) = ExpeVy^/^^ Exp(Vy)
m=\
Description of variables
In the model, the response of people's willingness (or unwillingness) to join
and pay for rural health insurance in a hypothetical situation was considered as
a dependent variable. The explanatory variables were classified into four
categories. The first consists of the variables that proxy for the risk factors of
the decision-making unit. These include demographic characteristics (such as
age, size of the family, caste of the respondent) and health-related factors
towards physical accessibilities (such as travel time and wailing time). The
economic factors such as income, occupation, characteristics of income
sources, were also included.
For each categorical variable in the analysis, one category has been selected
as a reference category. An estimated coefficient for each of the remaining
categories of the variable, indicating the significance of the category’s
contribution to the probability of reporting that condition (i.e. willingness to
join and pay) has been made in the analysis. An odds ratio has been estimated
for each category of the factor, that expresses the magnitude of the increased
reporting in relation to the reference category. Interaction effects for variables
included in the analysis were tested for significance.
© 1998 John Wiley & Sons, Ltd,
Im. J. Health Plann. Mgml. 13, 47-67 (1998)
WILLINGNESS TO PAY FOR RURAL HEALTH INSURANCE
59
RESULTS
The results from the logistic regression analysis lend support to the hypothesis
that there is a significant relationship between willingness to join and pay for
proposed rural health insurance and social, demographic, economic and
physical accessibility of the households in the rural areas. The results are
presented in Table 7.
Socio-demographic characteristics
It was found that the family size of households strongly influenced the
decision-making process for willingness to join and pay for rural health
insurance. It means that larger family sizes have a 119 per cent higher
probability of joining and a 27 per cent higher chance of paying for the
proposed scheme as compared to small family sizes. However, the caste and
age of the respondents were not positive influencing factors in the decision.
In fact, in the case of age, it was found that the older people were lower (35
per cent) in their willingness to join and 64 per cent lower in their willingness to
pay for the proposed rural health insurance scheme as compared to younger
people. Thus, there is a negative relationship between age and willingness to
join and pay for the proposed scheme.
It was also found that there was an inverse relationship between caste
and willingness to join and pay for the proposed scheme, except for low caste
(SC/ST). The results show that the willingness to join the proposed scheme is
18 per cent lower for backward caste and 13 per cent lower for religious
minorities as compared to higher castes. It is important to note that the lower
caste (SC/ST) showed a positive attitude towards willingness to join and pay
for the proposed rural health insurance scheme. It was estimated that there was
nearly a 35 per cent higher chance as compared to the higher castes.
Health status variable
As a group, health status variables cannot be rejected as being insignificant
in the choice of health insurance. This is borne out by the likelihood ratio test
statistics. The results indicate that variables such as health condition, number
of hospital episodes, number of working days lost due to ill-health, are
significant determinants of willingness to join and pay for the proposed rural
health insurance scheme. In contrast, the variables like health-seeking behaviour
by households are not influencing factors upon households’ willingness to join
and pay for the proposed scheme. People who were sick have a 296 per cent
higher chance of willingness to join but only 172 per cent higher willingness to
pay for the proposed scheme as compared to people registering no illness at
that time. Thus, the probability of willingness to pay for a rural health
insurance scheme was found to be less than the probability of willingness to
join, which means there is significant difference between willingness to join and
to pay for the same.
© 1998 John Wiley & Sons. Ltd.
Im. J. Health Plann. Mgmt. 13, 47-67 (1998)
K. MATHIYAZHAGAN
60
Table 7. Logistic regression estimates for willingness to join and pay for the proposed
rural health insurance scheme.
Explanatory
variable
Reference
category
variable
I.
(a)
(1)
RISK FACTORS
Demographic characteristics
Age:
Middle age
Old age
(2)
Family size:
Medium
Large
Small size
(3)
Caste:
Backward
SC/ST
Religious
Higher caste
(b)
(1)
Health status variable
Health condition:
Illness
(2)
No. of hospital episodes:
Three or more times
One or two times
No. of working days lost due
to ill-health
More than a week
Less than a week
(4)
No. of times doctor consulted:
More than one time
One time
(5)
Source of health care service
utilized:
Private health care
Public health
care
II.
(1)
ECONOMIC ACCESSIBILITY
Annual income:
Middle income
High income
Low income
(2)
Income flow characteristics:
Daily or weekly
Irregular/others
Threee times in a year
Two times in a year
Once in a year
Monthly
Occupational status:
Business and allied activities
Labours
Agricultural and
allied activities
(3)
(3)
Willingness
to join
Odd ratios
[Exp(B)J
Willingness
to pay
Odd ratios
(Exp(B)l
Youthful
0.95
0.65
0.76
0.36
1.71**
2.19*
1.09**
1.27**
0.82
0.92
0.87
0.84
1.35**
0.84
3.96*
2.72*
0.79
I.32"
1.59**
1.36**
0.50
0.58
1.31**
1.22**
1.60**
2.15*
1.42**
2.13*
1.10**
0.45
0.63
1.58**
1.07**
1.15**
0.66
0.65
1.49**
1.43**
0.90
0.66
0.85
0.64*
No illness
(continued)
© 1998 John Wiley & Sons, Ltd.
r-
bit. J. Health Plann. Mgmt. 13, 47-67 (1998)
i.
61
WILLINGNESS TO PAY FOR RURAL HEALTH INSURANCE
Table 7. (continued)
Explanatory
variable
III. PHYSICAL ACCESSIBILITY
(1) Distance between hospital and
clients’ home
More than one kilometre
(2)
(3)
Reference
category
variable
Willingness
to pay
Odd ratios
[Exp(B)J
2.96*
2.45*
1.13**
1.09**
0.92
0.47
0.85
1.55*
1006.33
932.04
110.01
42
654.74
580.66
82.26
42
Less than one
kilometre
Travel time to obtain care services:
More than 0.5 h
Less than 0.5 h
Wailing time to obtain care services:
More than 0.5 h
Less than 0.5 h
IV. FAMILIARITY OF HEALTH SYSTEM
(1) Education:
Illiterate
Formal education
Ancillary statistic:
—2 Log likelihood (<5 = 0)
—2 Log likelihood (5=1)
Goodness fit (chi-squared test)
Degree of freedom
Willingness
to join
Odd ratios
[Exp(B)]
♦♦Significant at 5 per cent level of significance; •significant at I per cent level of significance.
The number of hospital episodes in the household may lead to higher risks in
the household. This is consistent with the hypothesis that households more
prone to ill-health are more likely to be insured, since they face the greater risk
of larger health care costs. It was expected that there would be a positive
significant coefficient on the number of hospital episodes. The results indicate
that, with the exception of willingness to join, willingness to pay has a positive
significant coefficient. It means that households who had three or more hospital
episodes in a month may have a higher probability of willingness to pay for the
proposed rural health insurance scheme as compared to those who had one or
two hospital episodes.
Not surprisingly, the higher the number of days lost to ill-health, the more
likely someone is to join and pay for the proposed health insurance scheme.
The results indicate that, people who lost more than a week of working days
due to ill-health in a month have a 59 per cent higher willingness to join and a
36 per cent higher willingness to pay for the proposed scheme as compared to
those who lost less than a week of working days.
The health care provider in the rural areas would play a significant role in the
decision to join or pay for any proposed health insurance scheme. It was
assumed that those who had a private health care provider were expected to
join and pay for a rural health insurance scheme. The estimated coefficients are
© 1998 John Wiley & Sons, Ltd.
hit. J. Health Plann. Mgmt. 13, 47-67 (1998)
62
K. MATH1YAZHAGAN
significant at the 5 per cent level. The results show that people who used private
sources of health care service have a 35 per cent higher chance of joining the
proposed health insurance scheme compared to people who only used
government sources of health care services. However, those who used private
sources of health care services have a 9 per cent lower probability of willingness
to pay for the proposed health insurance scheme as compared to a willingness
to join.
Economic accessibility
Ability to pay is undoubtedly a major consideration in the decision to insure
or not insure. Therefore, it was expected that there would be a positive co
efficient with the real income of households. The estimated coefficients are
positive and significant at the 5 per cent level in the case of all income
categories (i.e. low, middle and high income). The results indicate that the
higher income level households have a higher chance of willingness to join and
pay for the proposed scheme. In contrast, coefficients are negative in the case of
income flow characteristics such as irregular income. It is important to note
that households which receive a regular income daily or weekly have a 10 per
cent higher probability of willingness to join and a 15 per cent higher
willingness to pay for the proposed rural health insurance scheme as compared
to all other categories. This implies that most of the households of labourers
and allied agricultural activities have a higher willingness to join and pay for
the proposed scheme as compared to business and allied activities. The results
suggest that the occupational status of the households is not playing any
independent role in the decision-making process on willingness to join and pay
for the proposed scheme. The estimated coefficient is negative in the category
of occupational status (i.e. business and allied activities).
Physical accessibility
It was assumed that improved access to care was an important indicator for
health policy. Distance, travel and waiting time to obtain health care were used
as proxies for the physical accessibility of the respondents. It can be seen that
the estimated coefficients of physical accessibility are significantly positive in all
cases except one variable (i.e. waiting time). This suggests that the longer the
distance and travelling time to obtain health care, the greater the willingness to
join and pay for the proposed scheme. It is evident that distance between the
hospital and the clients’ home of more than one kilometre leads to a 196 per
cent higher chance of willingness to join and a 145 per cent higher chance of
willingness to pay for the proposed scheme as compared to less than one
kilometre distance. It also shows that there is a significant difference between
willingness to join and pay across these two categories. Those who travel more
than 0.5 h to obtain health care have a 13 per cent higher probability of joining
the scheme and a 9 per cent higher probability of willingness to pay. It implies
that people are willing to pay for health care services if they are brought close
© 1998 John Wiley & Sons, Ltd.
bit. J. Health Plann. Mgmt. 13, 47-67 (1998)
WILLINGNESS TO PAY FOR RURAL HEALTH INSURANCE
63
to their house. The waiting time in hospital to obtain care is seemingly not a
significant influence on the decision-making process of willingness to join and
pay for the proposed scheme.
Familiarity of health system
Educational status was used in the analysis as a proxy for familiarity with
the health system for rural people. It is quite reasonable to assume that
education may make a significant contribution in the decision-making process
on the proposed health insurance scheme. But the coefficient is not significant
in the case of willingness to join. It suggests that educated people have a 15 per
cent less chance of being willing to join the scheme as compared to illiterates.
However, the coefficient is significant in the case of willingness to pay for the
proposed scheme. The results indicate that educated people are 55 per cent
more likely to pay for the proposed scheme as compared to illiterates.
COMMUNITY PARTICIPATION IN HEALTH-RELATED SERVICES
The proponents of community participation have envisaged self-motivated,
rural communities working together with the State to design their own
programmes to improve health and development. This grand vision has proved
difficult to achieve in practice, particularly in countries and regions without an
existing tradition ofjoint community-government cooperation (Morgan, 1993).
However, rural communities in India do have a history of cooperating in social
events/common problems such as rural drinking water, street lighting etc. Thus,
organization of rural health insurance through community participation is
likely to be favoured. In this context, community participation and its role in
social services delivery has been conceptualized and stressed in some studies. A
United Nations report (1981) reviewed this subject as spontaneous voluntary
base-up participation, without external support. But, this type is referred to in
the literature as informal (Sherraden, 1991), bottom-up, community supportive
(Werner, 1976), social participation (Muller, 1983), or wide participation
(Rifkin et al., 1988). It is not isolated to one sector such as health or education,
but is part of a larger process of social development intended to foster social
equity.
Spontaneous participation may be a deliberate effort to protest at, or to
counteract. State policies. At the other end of the concept, induced
participation can be sponsored, mandated and officially endorsed. This type
is the most prevalent mode to be found in developing countries. Induced
participation is called formal, top-down, community oppressive (Werner,
1976), direct participation (Muller, 1983), or narrow participation (Rifkin et
al., 1988). Induced forms are not intended to be inter-sectoral, nor to affect the
basic character of state-citizen relations. This study however, favours the
spontaneous, bottom-up, view of participation. It implies that communities
voluntarily join together to pay and organize a rural health insurance scheme
© 1998 John Wiley & Sons, Ltd.
bit. J. Health Plann. Mgmt. 13, 47-47 (1998)
64
K. MATH1YAZHAGAN
that meets their particular needs. In addition, of course, it helps the
government to attain Health for All by 2000 AD without an undue financial
burden.
The proponents of community participation, as contained in this study,
visualized self-motivated rural communities working together with the State to
design their own programmes to improve health and development. It implies
that communities voluntarily join together to pay for and organize the rural
health insurance scheme (Tables 2 and 3). In this context, the study found that
most rural people were prepared to participate and contribute some amount to
such a scheme (Table 4). It is also important to note that most of the
households (41.53 per cent) would pay between Rs. 121 and Rs.240 (Table 4).
Nearly 32.62 per cent of the households would pay Rs. 120 or less, which meant
that they would pay only Rs. 10 per month. A significant number of households
(7.90 per cent) were willing to pay between Rs.481 and Rs.600, which
amounted to nearly three to four limes higher than the average maximum
amount (Rs.163.48).
It is interesting to note, moreover, that the Government of India spent about
only Rs.90 per capita in the year 1990-91 on state health services, the amount
just enough to develop primary health care service (Duggal, 1986b). But the
expenditure involved in providing quality health care services worked out to be
only Rs.76 per capita year year (Rs.71 for hospital and Rs.5 for door-step
services) in the Sevagram project. Hence, it could be justified that if the
Government joins forces with the people’s willingness to pay for a viable health
insurance scheme, it helps the government to provide a quality health care
service without an undue financial burden. This could provide a base for a
viable health insurance scheme through community participation in India. It
has also proved itself in the Sevagram Community Insurance Scheme operated
by a voluntary organization in Maharastra State in India (Jajoo, 1993; Deve,
1991; Jajoo et al., 1985).
The empirical evidence of other developing countries also shows that health
insurance through voluntary participation can be successful. Countries in this
context almost always have some form of voluntary health insurance for their
rural populations, while only a few countries have this option for urban
citizens. For instance, in China, the rural cooperative insurance approach,
based on a decentralized approach to health care, was put into action in 1968
on a voluntary basis. In 1973, this scheme covered approximately 70 per cent of
China's 50000 communes (Hu, 1981). A voluntary prepaid health insurance
scheme, called the health card, was introduced for the rural people in Thailand.
It was extended and adopted as a national rural health insurance system in
1988 (Hongvivatana and Manopimokc 1991). It is also evident that 60 per
cent of the rural population voluntarily nrolled in health insurance in Zaire s
Bwamanda health zone (Kutzin and Barnum, 1992). Recently, a voluntary
health insurance scheme for the urban population was set up in Indonesia: a
scheme for private employees and their dependants started as a pilot project in
1985 in Jakarta. By 1988, the scheme had been extended to 16 cities in eight
provinces (Ron et al., 1990).
© 1998 John Wiley & Sons, Ltd.
Im. J. Health Plann. Mgmt. 13, 47-67 (1998)
WILLINGNESS TO PAY I OR RURAL HEALTH INSURANCE
65
CONCLUSION
In a nutshell, the results show that insurancc/saving schemes can be popular in
rural areas. In fact, people have a relatively good knowledge of insurance schemes
(especially life insurance) compared with saving schemes. Most of the people
staled they were willing to join and pay for the proposed rural health insurance
scheme. However, the probability of willingness to join was found to be greater
than the probability of willingness (and ability, doubtless) to pay. Indeed, socio
economic factors and physical accessibility to quality health services appeared to
be significant determinants of willingness to join and pay for such a scheme. It is
also important to note that, by using the same survey data, it was found that
private health care providers emerged as the people’s choice. Choice of private
health care provider is significantly associated with the socio-economic status and
physical accessibility of the people (Malhiyazhagan, 1994). The main justification
for the choice of private health care provider and a willingness to pay for rural
health insurance can be attributed from the household survey results: the existing
government health care provider's services are not (a) perceived to be quality
oriented; (b) easily accessible; and, (c) cost effective.
The estimated results arc in accordance with the theoretical predictions, and
also support the validity of the CV method using the binary responses on
willingness to pay for rural health insurance schemes through community
participation. It is important that the findings are viewed in the context of
India's on-going economic reform and structural adjustment. The economic
reforms curtail government spending on social sectors including health, in
order to control and stabilize monetary factors. In the light of the findings of
the present study, the government may be able to redefine its role in providing
health care services and tap the potential of rural households in bearing health
care costs. It is also very important to promote the credit system among rural
people in villages. This could help to bring a sustainable income to support the
insurance scheme. In this context, the role of private organizations/NGOs
assumes importance as care providers.
The above findings also assume greater importance in the context of recent
constitutional provision for decentralized administration under the Panchayat
Raj System (PRS) in India. The local bodies under PRS have the potential for
participating in health insurance schemes. Such an arrangement has been
found to be effective in the Sevagram Community Health Insurance experience
as noted earlier. In this new context, the people will have a greater choice of
health care services. The government will be playing the role of monitor and
facilitator and not necessarily as financier and provider of health care services.
This could provide an alternative framework for designing a viable rural health
insurance scheme through community participation in India.
REFERENCES
Abel-Smith, B. (1992). Financing health for all. World Health Forum 12(2), 191-200.
© 1998 John Wiley & Sons, Ltd.
hit. J. Health Plann. Mgmt. 13, 47-hl (1998)
66
K. MATH1YAZHAGAN
Abel-Smith, B., Dua, A. (1988). Community-financing in developing countries: the
potential for the health sector. Health Policy and Planning 3(2), 95-108.
Appel, L. J., Steinberg, E. P., Power, N. R.. Anderson, G. F., Dwyer, S. A., Faden, R. R.
(1990). The reduction from low osmolality contrast media: what do patients think it is
worth? Medical Care 28, 324-337.
de Ferranti, D. (1985). Paying for health services in developing countries: an overview.
World Bank Staff Working Paper No. 721.
Deve, P. (1991). Community and self-financing in voluntary health programmes in
India. Health Policy and Planning 6(1).
Donaldson, C. (1990). Willingness to pay for publicly provided goods: a possible
measurement benefit? J. Health Economics 9, 103-118.
Duggal, R. (1986b). Health Expenditure in India. FRCH Newsletter, Vol. 1.
Economic Survey (1997). New Delhi: Government of India, Ministry of Finance,
Economic Division.
Gomaa, R. (1986). A matter for international community as a whole. World Health
Forum 1, 4.
Government of India (GOI) (1992). Eighth Five Year Plan Document. New Delhi:
Ministry of Finance, Economic Division.
Griffin, C. (1989). Strengthening Health Services in Developing Countries through the
Private Sector. Washington DC: World Bank.
Griffin, C. (1990). Health Sector Financing in Asia. World Bank, Internal Discussion
Paper, Asia Regional Scries.
Hoare, G., Mills, A. (1986). Paying for Health Sector. EPC Publication No. 12.
Evaluation and Planning Centre. London School of Hygiene and Tropical Medicine.
Hongvivatana, X, Manopimoke, T. S. (1991). A Baseline Survey of Preference for Rural
Health Insurance. Thailand: Mahidol University.
Hu, T. (1981). Issues of health care financing in the people’s Republic of China. Soc.
Sci. Med. 150(4), 233-237.
Jajoo, U. N. (1993). A decade of community based immunisation. World Health Forum
3,240-291.
Jajoo, U. N., Gupta, O. P., Jain, A. P. (1985). Rural health services: towards a new
strategy. World Health Forum 6, 150-152.
Johannesson, M., Fagerberg, B. (1992). A health economic comparison of diet and any
treatment in obese men with mild hypertension. J. Hypertension 1063-1070.
Johannesson, M., Jonsson, B. (1991). Economic evaluation in health care: is there a role
for cost-benefit analysis. Health Policy 17, 1-23.
Johannesson, M. (1992). Economic evaluation of lipid lowering: a feasibility test of the
contingent valuation approach. Health Policy 20, 309-320.
Johannesson, M., Aberg, H., Agreus, L., Borgquist, L., Jonsson, B. (1991b). Cost-benefit
analysis of non-pharmacological treatment of hypertension. J. Int. Med. 307-312.
Johannesson, M., Jonsson, B., Borgquist, L. (1991a). Willingness to pay for
antihypertensive therapy: results of Swedish pilot study. J. Health Economics 10,
461-474.
Johannesson, M., Johansson, O. P., Kristrom, B., Gerdlham, U. G. (1993). Willingness
to pay for anti-hypertensive therapy: further results. J. Health Economics 12, 95-108.
Kutzin, J., Barnum, H. (1992). Institutional features of health insurance programmes
and their effects on developing country health system. Health Planning and
Management 7(1).
Mathiyazghagan, K. (1994). The Viability of Rural Health Insurance Policy in India.
Second Phase Report submitted to the International Health Policy Program, USA.
Mimeo.
Mathiyazhagan, K. (1994). Rural health through community participation: a viable
policy option for India? Health Exchange, No. 3, Autumn.
Mitchell, R. C., Carson, R. T. (1989). Using Surveys to Value Public Goods: The
Contingent Valuation Method. Washington DC: Resources for the Future.
© 1998 John Wiley & Sons, Ltd.
hit. J. Health Plann. Mgmt. 13, 47-67 (1998)
J'1
WILLINGNESS TO PAY 1-OR RUrAl HEALTH INSURANCE
67
Muller, F. (1983). Contrasts in community participation: case studies from Peru. In:
Moriey, D., Rohde, J. E., Williams, G. (Eds). Practising Health for All. Oxford:
Oxford University Press, 190-207.
Rifkin, S. B., Muller, F., Bichmann, W. (1988); Primary health care: on measuring
participation. Soc. Sci. Med. 26(9), 931-940.
Ron, A., Abel-Smith, B., Tamburi, G. (1990). Health Insurance in Developing Countries.
Geneva: 1LO.
Sherraden, M. S. (1991). Policy impacts of community participation: health services in
rural Mexico. Human Organisation 50(3), 256-263.
United Nations Report (1981). Popular Participation as a Strategy for Promoting
Comtm - ity-level ‘action and National Development. New York: Department of
International Economic and Social Affairs.
Werner, D. (1976). Health care and human dignity. Contact (Special series) 3, 91-106.
WHO (1987). Economic Support for National Health for All Strategies, Background
Document. A40/Technical Discussions/2 for Fortieth World Health Assembly.
Geneva: World Health Organization.
World Bank (1987). Financing Health Services in Developing Countries: An Agenda Jor
Reform. Washington: World Bank.
World Bank (1993). World Development Report 1993: Investing in Health. New York:
Oxford University Press.
Zschock. D. (1979). Health Care Financing in Developing Countries. American Public
Health Association International Health Programmes, Monograph Sei s No. 1.
APHA, Washington DC.
« ' 1998 John Wiley & Sons. Ltd.
hit. J. Health Plana. M^tat. 13. 47 67 (1998)
1
Health Insurance Systems in
Developing Countries
Contents (1)
• Generalities on health care financing
- brief history of health care financing in the
developing world (focus on SSAfrica)
- notions of progressivity and regressivity in
financing
1
____
• Insurance and solidarity
- concepts
Bart Criel
Department Public Health
ITM Antwerp
13/2/2004
Contents (2)
History of health care financing (1)
• Mutual aid arrangements
- typology
- history and rationale of the development of
social health insurance in Western Europe
• In the 60’s: ‘free' health care as a
constitutional right
• In the 70’s and 80’s: economic crisis leads
to the progressive introduction of out-ofpocket payments (OOP) for health care
• Voluntary health care insurance
- models/terminology
- discussion of field experiences (DRCongo,
Guinea-Conakry)
• In the 90's: OOP virtually generalised
• Today: growing interest for health
insurance
• Remaining questions and issues...
13/2/2004
Misereoi/Aachen
13/2/2004
3
Misereoi Aacbern
—
1
)
Proportional financing
Regressive financing
Income 2
■
Income 2
Income I
Income I
12.5%
regressivity
proportioiuililx
Km
Miser eor/Aachen
13/2/2004
Progressive financing
I ncome 2
5
Miser enr/Aachen
13/2/2004
Out-of-pocket payments and (seasonal)
exclusion
S
temporary
exclusion
□
o
c
is
Income 1
ar
sE
HC
HC
Hospital
o
>
25"/..
progressivity
_ _
13/2/2004
permanent
exclusion
411"/..
Miser eor/Aachen
s
Time
13/2/2004
Mlsereor/Aachen
9
1I
Proportion of Households with Ciitnstrophic Expenditures x s. Shari' of
In 2001, the World spent lnt.S3.8 trillion on health care
Out-of-pocket Payment in Total Health Expenditures ((>OP"n fill i
(international dollars estimated at WHO - Timor Leste and Somalia are not included)
Same NabaiW Health Accamls. EIP/FER/FAR World Health Oigantation
Pn -ate insurance
AjC
04%
fl
Social insurance
23 9%
I
Out of Pocket'
Otlwr
I
13/2/2004
Misereor/Aachen
9
13/2/2004
Misereotc '-iKthen
OOP as % THE vs.GDP per capita
Insurance (1)
"the reduction or elimination of the uncertain risk of
loss for the individual or household by combining a
larger number of similarly exposed individuals or
households who are included in a common fund that
makes good the loss caused to any one member"
(ILO 1996)
13/2/2004
Misereor/Aachen
13/2/2004
Miseteot/Aachen
I .
Insurance (2)
• Insurance implies the possibility of an ‘unbalance’
between initial investment and eventual result
• From a purely financial perspective, insurance
implies the existence of ‘winners’ and ‘loosers’
• Insurance differs from reciprocity where ‘inputs’ +/equivalent to ’outputs’
• Insurance can be blended, to varying degrees, with
solidarity
_
13/2/2004
Misereor/Aachen
Insurance (3)
Insurance as a function versus insurance as
a particular institutional set-up
(Kutzin, WHO, 1998)
- saveguard access to heailh care when needed
- protect household's income and assets from the financial
cost of expensive medical care
13
13/2/2004
Miser eoi 'Aachen
‘Classical’ problems in health
Calculation of premiums
insurance
• Basic formula:
tl
• Adverse (or preferential) selection
- assumption of community rating (as opposed to risk rating)
- P = expected expenditure on benefits + administrative costs +
reserve
number insured
• Moral hazard
• Cost-explosion
Note: expected expenditure on benefits
= f (probability of event occurring under insurance) &
= f (cost of the event)
13/2/2004
Miser eor/Aachen
15
13/2/2004
Miser eor?A achen
4
I
1
Adverse selection: a problem in
voluntary insurance
Moral hazard (1)
• Definition: “the tendency of individuals, once insured,
to behave in such a way as to increase the likelihood
or the size of the risk against which they have insured
’’ (Mills 1983)
• Moral hazard in insurance creates both a financial
and public health problem
• Definition: "those who anticipate needing health care
choose to buy insurance more often than others"
• Adverse selection in health insurance creates a
financial problem
• How to manage adverse selection?
- mandatory membership
- careful design in voluntary schemes (HH membership, limit
period of enrolment, waiting period, threshold subscription
rate)
• The special case of ‘cream-skimming’
!
13/2/2004
Misereor.'Aachen
17
13/2/2004
Moral hazard (2)
Cost explosion
• Distinction between ‘patient moral hazard’ and
■provider moral hazard’
• How to manage moral hazard?
Rodwin (1981), in his analysis of the French
health care system, wrote that
" if one were to ask. as an intellectual exercise, how
to design a cost-maximising health care system, a
likely response might be to have a combination of
health insurance, fee-for-service remuneration of
providers, and minimal state intervention to regulate
fees and monitor the volume of services rendered
- demand-oriented measures: disincentives to reduce excess
demand (e.g, co-payments, fixed indemnity)
- provider-oriented measures: e.g. change provider
remuneration systems, reinforce gate-keeping by first line
health services
_
MiseiBoi/Aaphen
13/2/2004
Misoreor/Aachen
19
■
13/2/2004
Misereoi,mc:hen
Wl
S
I
Solidarity (1)
Solidarity (2)
the inputs
" the conscious acceptance of unity and the
willingness to accept its implications"
(Dunning, 1992)
• Income-solidarity :
- the rich contribute proportionally more than the
poor
- = vertical equity
• Risk-solidarity :
- the healthy contribute as much as the sick
- = horizontal equity
• In health insurance solidarity means that people accept - at
least implicitely - that the personal ‘return' will not necessarily
match the initial personal 'investmenr
• In the case of mandatory health insurance, the legislator
imposes this unequal relationship upon people: solidarity is
then institutionalised but nevertheless reversible
_
13/2/2004
Miseieor/Aachen
21
Solidarity (3)
I
13/2/2004
MiseieotiAachen
Insurance & Solidarity
the outputs
• Benefits allocated according to needs and not
to merits (i.e. not a function of the individual
inputs made into the system)
• Insurance is a technique
• Solidarity is a value that results from
a collective choice made by society
P
13-2/2004
Misereor/Aachen
23
13/2/2004
Miser eoi/Aachen
6
Collective arrangements to cope with
individual adversities: a typology of mutual
aid systems
Without insurance
- systems of family and
clan solidarity: moral
obligation to help
■
- informal mutual aid
systems (endogenous
assoc movements.
tontines or ROSCA's)
expectation of
reciprocity
- prepayment systems
without sharing (i e
'mutualisation') of the
risk
13/2/2004
I
Mutual aid arrangements in the
perspective in formal-formal
• With insurance
- mandatory insurance systems
managed by the State (the
Bismarckian social health
insurance model): insurance and
solidarity
- voluntary insurance systems
• private finality insurance without
solidarity
• public finality, insurance with
solidarity
niton nal
Ibnnal
hinnk- .uxii'l.ui
solnlinn
Wil unilux’
tbr-|wfii
insurance
MHOs | Eunyi )
/
\ nvAvimii'
tHHI'il . j.i:
ixypiiynuit
-RCT4 \-
Misereor/Aachen
25
1
I nxltj/fi> iis ;i>*< x.i,iri\k
13/2/2004
lieilrh iiwimxi
Miser edf.'ASchen
___
The case of social health insurance in
European society : a phased history (1)
The case of social health insurance in
• Second half of 19th century
• End of 19th - early 20th century
European society : a phased history (2)
- ‘traditional' mutual aid arrangements (kinship, guilds of 17th18th century) no longer adequate in rapidly changing
environment
- dynamic of Mutual Health Organisations (MHOs) among
workers in context of rapid industrialisation and class
• Compulsory system after World War II
- considerable management problems (lack of administrative
skills, no economies of scale, concentration of risks, etc.):
social homogeneity, but poor sustainability
Misereor/Aachen
- gradual take-over by nation-wide, state-controlled,
compulsory institutions of si cial security (see Bismarck
regime)
- increase in coverage and scale accompanied by growing
bureaucratisation and professionalisation and by qualitative
changes in social relationships
struggle
- benefits mainly of non-medical nature: no effective health
care delivery system available at that time
13/2/2004
- mutual aid dynamic coincided with trade union movement
- post-war momentum throughout the continent
27
13/2/2004
Misereor'A.when
I
The case of social health insurance in
European society : a phased history (3)
Why collective arrangements for
individual risks? (deSwaan 1988)
• Extension to non-wage earners in the ‘golden sixties'
• external effects: i.e indirect effects of one person's
deficiency or adversity for others not immediately
affected
- sometimes with opposition of workers...
I
• Recently, shrinkage of the benefit package
- growing OOP payments
- issue of choices in health care: what is to be funded
collectively9 And what is to be individually funded?
- cfr cholera epidemics fn Kith century cities
• extension and intensification of the "chains of human
interdependence"
- state formation led to new bureaucratic networks
- development ol capitalism led io new networks of prodiiction/consiinipiion
13/2/2004
Misereor/Aacben
29
13/2/2004
Misereoi'Aecnen
. .and today
100 years ago..
_ _
13/2/2004
Challenge for European social insurance
systems
Social health insurance in Europe
• low coverage
• limited Stale intervention
• benefit package no or little
health care
• small-scale initiatives of
relatively limited effectiveness
in terms of social protection
• 'overseeable' size and
important community control
• strong feeling of ownership by
community
L.
• high coverage
• important State intervention
• comprehensive package of
benefits
• nation-wide systems of high
effectiveness and with important
economies of scale
• huge managerial complexity
and little community
involvement
• weak feeling of ownership by
the community
Misereor/Aac hen
31
• Impressive achievements... but at a cost?
- increasing gap between people's contribution and actual use
Of that money
- at the expense of participation and ownership, with,
eventually, a gradual 'erosion' of solidarity 7
13/2/2004
Miserea'/AacKen
8
‘One hundred and eighteen years of the German
health insurance system: are there any lessons for
middle- and low-income countries?’
The German Social Health Insurance
System
• Barnighausen T & Sauerborn R (2002). Social
Science and Medicine. 54, 1559-1587.
Ratio cash benefits (sick pavi ovoi benefits in kino (health care,'
I
Misereor/Aachen
13/2/2004
I
The German Social Health Insurance
System
COOOO
1,5000
13/2/2004
I
o 1919
□ 1938
■ 1940
o 1948':
■ 1994
o 1998
[........1
Misereor/Aachen
Misereor/Aachen
Voluntary health insurance serving a
public purpose: different denominations
• Community based Health Insurance (CBHI) or
Community Health Insurance (CHI) or Mutual
Health Organisations (MHOs) or Micro
Insurance
Evolution over time of number of sickness funds
10000
13/2/2004
33
• In French: Mutuelles de Sante
• One possible further sub-distinction:
- Mutualistic or 'Participatory' model
- Provider-driven or Technocratic' model
1
35
13/2/2004
MisetncH Aachen
i1
9
■
■ The technocratic model: the
I
The mutualistic model:
a purchaser between payer and provider
X
Care
Households
$
Insurer or
Households
buyer
(source of
-►
funds)
f
’ Representntn’its' f
13/2/2004
provider also is the insurer
$
---------- ►
Contract
37
Main features of the two models (1)
13/2/2004
Provider-driven or
'technocratic' model
- relatively large scale
- less social selectivity
- predominantly top-down
planning
- management by health
services
- usually overlap with
functional entity of health
care delivery
Miser eor/Aachen
I
■ i. k r
$
r
Miser eor/Aachen
• Mutualistic or
participatory' model
- small scale
- selectivity target
population
- predominantly bottom-up
planning
- management by
community (member)
organisation
- not necessarily overlap
with functional entity of
health care delivery
◄
Provider
(destination oi
funds)
13/2'2004
Miser eor’Aachen
1 Main features of the two models (2)
• Mutualistic or
‘participatory’ model
• Provider-driven or
‘technocratic’ model
- intermediate structure
between payer and
provider
39
13/2/2004
- no such intermediate
structure the provider is
also the insurer
Miser erir/Aachen
10
I
u
■
■
I
s
I
■
Bwamanda (DRCongo) district:
an insurance for hospital care
Households
- Voluntary
- Individual pr<
remiums
- Yearly subsc
icription
■ 1 month per■ year
■Collected by healilth centre
District Health Team
A,
V
Bwamanda scheme subscription rales ("<>)
a huge interest from the population
no
to
Insurance
Fund
50
10
Those
requiring
inpatient car >
!0
0
20% co-paymtlent
if referred
1S86 1987 1988 1989
Misereor,'Aachen
■
■
I
■
AOOIHI
•0(11 HI
Bwamanda: spatial analysis of hospital
utilisation: all hospital admissions 1993
Admission rates (%o inh.)
45
40
35
30
20
15
10
5
0
I •Mo
I OST
Cl liih mill revenue
13/2/2004
1993 1994 1995 ; ■
Misereoi. Aachen
13/2/2004
Bwamanda: less dependency from
'external’ financing
J
IQt)
Hospital
year
13/2/2004
lomin
47
28
I‘MH
I 'M9
0
Distance froin h< spital (in Km)
lixivmul ic-wiun
Miser eor/Aachen
43
13/2/2004
Miser eor'Aachen
11
1
Overcome distance as a barrier to hospital use ?
Explanations of this succes story: the
crucial importance of context
Caesarean sections 1991-1995
C-section rate
• Reasonably well functioning district health system
(% oxpecied births)
2.5%
2,0%
1.5%
1.0%
0.5%
0.0%
• Substantial external support
LlLL
II
III
Access to Hospital
13/2/2004
• Monopoly position of the Bwamanda hospital
Insured
(a.o. remuneration MD's independent from the insurance)
• Monetarisation of the local economy
• Relationship of trust between population and CDI
project in general, and 'District Health Team’ in
particular
• Managerial creativity DHTeam
IV
Miser eon'Aachen
45
13/2/2004
Misereor.'Aachen
The context (1)
The Mutualistic model
- mid 80's : the Guinea health care delivery
system had virtually collapsed
- launching of centrally led policy of reform
• The PRIMA research project in GuineaConakry
13/2/2004
MisereoriAachen
• development of districts as basic functional units of the
(public) health care system
• user fees at all levels of the district system
• strong effort of standardisation of clinical decision
making at the level of the first line
• creation of health committees
■ strong external institutional suppoit (UNICEF)
47
13/2/2004
Misareor/Aachen
48
12
I
I
The context (2)
- 10 years later:
• people use the system, but...
• limited community participation in management decisions
• growing user dissatisfaction with quality of care supplied
in the government health care facilities (rigidity of
standardisation, poor staff attitudes)
- ... and also
• widespread practice of 'over-billings' in the public health
care facilities, up to 10 times official flat fee
• seasonal variation in income in rural Guinea: 50% of
households face (partial) financial exclusion from health
care
13/2/2004
Misereor/Aachen
■
■
49
The context (3)
• creation of Mutual Health Organisations (MHOs). a
solution?
- MHOs: non-for-profit, autonomous, member-based
organisations
- financing of health care through a risk-sharing arrangemem
(insurance)
• research project PRIMA (1996-2000)
- MOH Guinea, German & Belgian Aid, MMB. ITM
- test whether MHOs can
1) improve financial accessibility to health care
2) weigh on the quality of the supply of health care in the
contracted public health services
Miser eor/Aw hen
13/2/2004
■ ■
I
I
2
Cohorts of adherents 1998 & 1999
The MHO Maliando
• household as unit of subscription with individual
premiums (2SUS)
I
■■
• contract with health centre and hospital
- free access (except small co-payment) to all care at health
centre level
- free access to emergency obstetrical-surgical care and
paediatric care at hospital level
- free transport to hospital in case of emergency
Mrsereor/Aachen
1
IvorI. >
Cuhul iit liiiiKChiiklr llml
Kiiiieililk- wlk'iu .- in I "is
11 ’o hlillllh
|2'M l»IIIM.'ll>lkk lill.lllliu
I ''IK |vu|>le i
T
1 "hill -’I liorm'llirllk lllul
li’iik'r ilk •.Ir.iiK in I"1
lii<is'lii»W> Ini.illiii'.- I‘i?‘.i |vi>|i|i
Suh^>ii|iil;ili«i '
• coverage of the system
- 1998: 1400 / 17000 people (8%)
- 1999: 1000 / 17000 people (6%)
13/2/2004
i Hi* Unkdii'M- h'tallin-.
(I67linil«i.iinl<k
liilalline K4’ pcupk-i
51
13/2/2004
Miser eor'ArKhen
13
Research question
Hypotheses
Why do people behave as they behave?
(See: Criel B. and Waelkens M.P (2003) Declining subscriptions to the
Maliando Mutual Health Organisation in Guinea-Conakry (West Africa):
what is going wrong? Social Science & Medicine, Vol. 57, N0?, 12051219)
13/2/2004
Misereor/Aachen
■
53
13/2/2004
Miser eoi/Aachen
Results
Methods
• focus groups: 3 in each of the 4 sub-populations
- pop 1: year 1 + year 2+
- pop 2: year 1 + year 2 - pop 3: year 1 - year 2+
- pop 4: year 1 - year 2 -
I
Miser eor/Aachen
(1) The majority of people - adherents and non
adherents alike - understand and accept the
concepts and principles underlying the MHO
- + notion of prevention
- + redistributive effects of insurance
- + need to recruit a large number of people
- + mam motivation to join: improved access
- +/■ Maliando as body repre senting the membeis' interests
- - rationale of mandatory subscription of household (control of
adverse selection)
- - rationale of co-payments (control of moral hazard)
• in total 137 participants
• in total 383 interventions
• 4 validation focus groups
13/2/2004
• (perception of) poor quality of care
• lack of understanding/acceptance of
concepts/principles underlying health care insurance
• lack of confidence in the management of the system
• suspicion vis-a-vis 'external' associative movements
• lack of articulation of Maliando with existing
endogenous movements
• inability to pay the premium
55
13/2/2004
Miser eor/Aoohen
56
14
Results
Results
(2) The specificity of the MHO model, and its
complementary character to endogenous
associative movements is well recognised
(3) Suspicion because of previous bad experiences
with externally-driven (e.g. the State) and
institutionalised / formalised forms of associative
movements not an issue
- Maliando fills a gap
- Participants clearly identify the divergent purposes
between existing schemes and the MHO
- The MHO is perceived as exogenous but well accepted
because of its advantages
13'2'2004
Misereor/Aachen
57
Results
13/2/2004
Miser eof/Aachen
Results
(4) People believe in the integrity of the (financial)
management of Maliando. but are disappointed
because the organisation has not kept promises
made concerning the quality of care
(5) A lack of financial resources is a reason for not
joining
- for the very poor/ destitute
- but also for large households nobody considers as poor
- access has improved, but care for adherents is perceived as
inferior to (over-billed) non-adherents
- the MHO is not directly held responsible
but people reproach Maliando for not being able to meet
their expectations
13/2/2004
Misereor/Aachen
59
13/2/2004
Misereor'A .tc hen
60
15
Results
Main conclusions
(6) Better access to health centre care is in practice
not considered worth it: a striking conflict between
advantages of access and the disappointing quality
of the care offered (at the health centre)
;;i
..if we would receive good care, that is a friendly welcome,
good products and a fast recovery, I would be ready to join in
2000. If that does not happen, then I am sorry but I am not
going to join" (Pop 3)
" when you go sick to the health centre, you come back home
still sick. Neighbours who are not member laugh at you and you
feel ashamed. If we. the first members, are not satisfied, the
others will never join" (Pop 1)
13'2/2004
Misereor'Aachen
61
13/2/2004
ITM 2002-2003:
Desk-study of'CBHI in SSAfrica
13/2/2004
f lisereor'Aachen
Miser e o< /A achen
Two observations
- There is a real problem of access to quality health
care and Community Health Insurance (CHI) offers
opportunities for better financial access, for
promotion of quality of care and responsiveness to
the demand, yet subscription rates to CHI schemes
remain low
• Establish the ‘State of the Art’ of the
CBHI ‘movement’ in sub-Saharan
Africa
• Reflections on a possible research
agenda
,
• If efforts are made to explain, people can perfectly well
understand and appreciate health care insurance
• It is not necessary to design health care insurance schemes
that articulate with, or are integrated m existing traditional
systems of mutual aid
• The design of insurance schemes should be flexible enough to
take into account problems in ability to pay
• A truism: no interest if no value for money
• Hypothesis for further research: there may be rational reasons
for health workers not to support, even to oppose the
development of MHOs
- African communities have developed a variety of
associations that mobilise and pool individual
resources, yet few such initiatives pay for health care
and the promotion of CHI remains largely driven by
external organisations
63
!
13.-2/2004
Mlseieoi • Aachen
16
1
Two questions at the start of this
enquiry
In the literature: a profusion of
typologies
Why so (relatively) little interest for a health care
financing model that offers, in theory, a suitable
solution to a perceived problem?
Against a background of vibrant community
organisations and associative movements, which
are the obstacles to the development of CHI ?
>Why?
- A great variety of schemes
- Different disciplines involved and different
frameworks of analysis handled
- Two paradigms
• the Anglo-Saxon school
• the Continental European School
=
■
13/2/2004
65
Misereor/Aachen
■
■■
13/2/2004
66
Miser eoi .'Aachen
■ ■
■ Towards a single typology?
rRcgicui________
Preoilenl d.’-ir/iijii.in
Dominant reprcscniaiion
CluillCkTISIIO
I emphasised
Implcnienianon and
managemeiH
13/2/2004
The 'Ciinlincnial
Etini|iciuf school
i i,nih--peakin; Alina
\IiiIki //w <K' Sunlc
■linn association of
members l2l created Io pool
ic'Oiirccs foi health care I? I
and mandated lo discuss
nvgottatc "Uh providers__
Social component
Associative movement
Gains m <ocial capital
Hotlom-up by members of
the association
Misereor/Aachen
The 'Anelo-Saxun' tchmil
English-speaking Africa
Coinmunily-bascd Health
Insurance_____________
Ilian insurance mechanism
(2 l Io finance health care
sen ices
*
- Financml component
Micfo-I'inancc
- Resource mohilisalion
Top-down: by providers
and or MOH_______
I I
67
Mqnu}ier: Provide!
Membership:
Members
Separate insurer [ ( Mliei '
(ieoeraphical
Ethnic origin
Professional.
Formal sector
Professional:
Informal sectoi
Existing groups__
Other ?
13/2/2004
Misereor/Aachen
17
Evaluating the performance of CHI schemes:
the problematic case of voluntary
management
Causes of low subscription rales
The most important factors seem to be:
Demands an important investment in time
The quality of the health care delivery
The trust people have in the achievements of the
enterprise
The financial capacity of the target population
The administrative follow-up expected is that of a
computerised world
Certain tasks are too complex for volunteers
The number of members has to remain limited
- because of time constraints of managers
i |
- for ‘social control’ to be effective
=> small pool, small benefit package,
continuous concern of containing expenses
13/2/2004
Misereor/Aachen
69
....
Three hypotheses.
Quality of care may be improved through 3 levers
• a financial lever: a more regular and possibly a higher
flow of revenues for the provider
• a contractual lever conirac'ual arrangements established
between CHI and provider
• a socio-political lever the power of an organised group
of users to express their demand, to increase the
responsiveness of the providers, and eventually to weigh
on the quality of the care supplied
• Quality of care is a condition for the
success of the scheme
(Perceived quality rather than ‘objective’
quality)
• The scheme may contribute to the
improvement of the quality of care
13/2/2004
Misereor/Aachen
Miser eoi/Aachen
The scheme may contribute to the
improvement of the quality of care
Quality of health care delivery
_
13/2/2004
I
13/2/2004
MiserecH/Aacheh
18
Financial capacity: the difficult
question of subsidies
Trust
• Trust in the competence and integrity of the
managers of the scheme
• How best to organise subsidies
- Destination of subsidies9
■ Subsidise payments of subscriptions of pooi members
• Subsidise the investments costs of ttie launching of the scheme?
• Subsidise the functioning costs of the insurer'’
- Timing of subsidies9
• From the start on?
• Or at a later stage''
- Subsidies by whom9
(e g. greater distrust when government agents are
involved)
in the chances to achieve the promised
N • Trust
results
(e.g. continuous rotation of health personal
increases uncertainty for the future)
■
•
13/2/2004
Miser eor'Aachen
73
• CHI: a value-driven model of organisation of clients >
a mere financial arrangement
• CHI and Health Workers: the challenging need for
new partnerships that lead to win-win situations
• Need to systematically investigate the contexts in
which some CHIs perform well, and contexts in which
they don't
Misereor'Aachen
75
Linkages with systems of Social Assistance for Health Care
- See ITM Workshop 18/12/2003
13/2/2004
II
Final thoughts
13/2/2004
Government'' Central and/or local government?
• Donors?
II
Miser cor 'Aachen
CHI and context:
a tentative framework lor analysis (1)
Political dimension
• Social dimension
- Is the development o(
solidarity-based systems of
health care financing really
a societal priority?
Economic dimension.
- Is the local social fabric
sufficiently strong? And
is their enough trust in
local leaders, institutions
and structures?
- Is the purchasing power of
people sufficient to make
health insurance a feasible
option?
13/2/2004
Miserear
19
CHI and context:
a tentative framework for analysis (2)
• Technical dimension:
- The supply: is the quality of
the care supplied sufficient
to make health insurance
an attractive option to
people?
- The health workers: is
there a minimal openness
towards a different
relationship with the
users?
13/2/2004
• Management
dimension:
- Is there sufficient
knowledge and freedom
in the local health
systems to experiment
in an intelligent way
with such complex
social arrangements of
health care financing?
Miseretx/Aachen
77
20
t
Slide 1
COMMUNITY HEALTH INSURANCE
KARNATAKA EXPERIENCE
BY
UNDP, KARUNA TRUST, & CENTRE FOR POPULATION DYNAMICS
Slide 2
P 0 cv-
✓
Partner Organisations
United Nations Development Programme
Ministry of Health & Family Welfare, GOI
Directorate of Health & Family Welfare, GOK
Karuna Trust
National Insurance Co. Ltd.
Centre for Population Dynamics
Slide3
✓
tide 4
Models
Model!
In T. Narsipur, the scheme would be organized and managed by the
Karuna Trust, an NGO
Model II
In Bailhongal the official health personnel would organize and manage
the scheme under the supervision of the Chief Executive Officer of the Z.P.
Slide 5
Organization structure of project
Kara na Trust
GOK
T. Narsipur Taluk
n
Kara na Trust
&
District and Taluk
Level Committees
Taluk Level Hospital
______________ ..................
CPD
H
BailhongaHaluk
District and Taluk
Level Committees
Taluk Level Hospital
Primary Health Centre
Primary Health Centre
Health Committee &
Self Help Groups
Village Health Committee &
Seif Help Groups
Slide 6
Project Implementation Committees
i
District Level Committee
I Taluk level committee
i
I Chairman
i
__
Chief Executive Officer, Zilla Panchayat
| Executive Officer Taluka Panchayat
1. Deputy Secretary Administration of the
Z.P.
I 1. Administrative Medical Officer General
Hospital.
2. District Surgeon
j Members
2. Administrative Medical Officer, CHC
3. Executive Officer Taluk Panchayat.
j 3. Child Development Project Officer
4. Representative of the NIC
I 4. Representative of the NIC
| 5. Representative NGO-Karuna Trust
| 5. Project Officer, NGO- Karuna Trust
i
I
I
I
j Member Secretary
I| District Health & FW Officer.
Ii 1. Taluk Health Officer
Permanent Invitees | 2 Admimstratve Medical Officer, General
j Hospital.
| Taluk Health & FW Officer
1___________________
Slide 7
Salient features of the Scheme
• Oriented towards the poor.
• Community level and family is the unit of membership
•
Micro-credit financing for Out-patient care through SHGs
• The premium is Rs. 30 per person per annum for a health insurance cover of Rs. 2500/• The insurance would cover:
> Ail inpatient - hospitalization cases.
> At public health facilities
> Rs. 50 per day - given directly to the hospital for drugs
> Rs. 50. per day - given to patient for loss of wages
> Referred cases also
• The premium:
> subsidized fully for BPL SC/ST population
> Partially subsidized for BPL non-SC/ST population
> Not subsidized for APL population
Salient features of the Scheme (Cont.)
•
Revolving fund at health institution -to settle claims immediately.
• Active case finding by the social workers deputed at health centres and field staff.
• Referred cases to any public health institutions anywherel considered.
• Marketing the insurance and claim settlement, documentation etc. done by social workers.
• No exclusion of any diseases
• No waiting period.
Side 9
Premium Structure and Benefits
Annual Premium amount
Coverage & exclusions
Patient Hospital User
Subs id i Users Total
Sum
Beneficiaries sed by contrib Premium assured for loss for drug charges
charge
of
Project ution amount
wage
fund
A
BPL - SC &
ST
30
B
BPL Non SC
&ST
10
C
APL
30
2500
50
50
20
30
2500
50
50
30
30
2500
50
50
1. Only in
patient
Nil
expenditure
2.0nly
Government
Nil
institutions
3. No
Actuals exclusions of
any diseases
|
Side 12
Knowledge of the public regarding Health Insurance
(in Per cent)
Knowledge
28.28
Source of Knowledge
Print & electronic Media
24.70
Insurance Agents
20.22
Health Institutions
30.22
Friends/Relatives & Others
24.87
Total
100.00
Side 13
Perception of the public regarding Health Insurance
Reasons for not insuring
Reasons for insuring
(in Per cent)
Cheapest way to get health/medical care
56.42
Too expensive
18.59
Quality of care
20.31
High premium
13.31
Obligatory
23.27
Why pay before falling sick
16.25
Total
100.00
Low coverage of health services
10.89
Complicated Scheme
13.53
Better to pay for consultation
8.84
No trust in Insurance
14.15
Hassles of claim
4.44
Total
100.00
Side 14
Willingness to pay premium amount
Premium amount in Rupeess/per annum.
%
Less than 50
31.56
50-74
44.14
75-99
6.94
100-149
17.36
Total
100.00
Side 14
Progress
Date of commencement
BPL______________
SC&ST
Non SC & ST_______
Total
T. Narsipura
01.09.2002
Total
Urban
Rural
82546
5323
77223
2546
2546
85092
79769 5323
Rural
Bailhongal
01.10.2002
Urban
31204
1224
20322
51526
1224
T. Narsipura
Total
32428
20322
52750
Bailhongal
Amount fully subsidized @ (Rs. 30) per person
2476380
972840
Amount partially subsidized
25460
304830
Total amount subsidized from UNDP fund
2501840
1277670
Amount collected from BPL Non SC &ST
50920
304830
Total amount paid to NIC
25,66,900
15,82,500
4,43,800*
6,94,400
Amount claimed during one year
_________
Health Insurance claims-T.Narsipura & Bailhongal Taluks
100000 1
3M00
90000 -
10
0
100
80000 -
72300
|Q
7*
70000 .800
1!
60000 -
17400
3
§
50000 -
i
40000 -
19900
,2500
'500
33900
31000
30000 -
!770D
54500
'0000
20000 -
10000 -
2800
12500
5600
0
Sep-02
—
0 ct-02
Nov-02
Dec-02
Jan-03
Feb-03
Mar-03
month#
Apr-03
May-03
Jun-03
Jul-03
Aug-03
Sep-03
•
;Chechady Vally : Mahuadanr : Rat
Assessment format for Documentation: -
Health Insurance SchemeXHL
l.
II.
SI.
No
General Information :
Clinic/ Hospital
1.
Informant
3.
Working in the area since when ? :
5.
Inforamtion about people/ Villages:Total
Total
Name of Village
Population
No.of
(Appro
Families
ximate)
2. Area
4. Designation
6. Date
No. of | Total
Catholic Catholic
families population
(appro
ximate)
Dais
Health
Worker
Compounders
Others
(Specify)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10
11.
hr
hr
I
I
L
SI.
No
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
~29TT
Name of Village
Total
No.of
Families
Total
Population
(Appro
ximate)
No. of
Catholic
families
Total
Catholic
population
(appro
ximate)
Health
Worker
Name of the key personals in village
Dais
Compounders
Others
(Specify)
Information about the Scheme
Year
Total No. in the Scheme
ShNo?
Families Villages
Members
1.
1986
111.
2.
1987
3.
1988
4.
1989
5.
1990
6.
1991
7.
1992
8.
1993
9.
1994
10.
1995
11.
1996
12.
1997
13.
1998
14.
1999
2000
16.
2001
17.
' 2002
1 18.
2003
I
■
Total contribution from
people for the scheme
Total expenditure on patients
of the scheme
IV. Information about the Scheme
SI.No.
Total No. of patients
Year
seen in the clinic
1.
1986
2.
1987
3.
1988
4.
1989
5.
1990
6.
1991
7.
1992
8.
1993
9.
1994
10
1995
11.
1996
12.
1997
13.
1998
14.
1999
15.
2000
16.
floor
17.
i 2002
18.
| 2003
Total No. of Beneficiaries of Health Insurance Scheme
At village level
Clinic level
Hospital level
Total
I
k
7
District Health Accounts: Ah Empirical
Investigation
V B Annigeri
V i n c- cf
ao
O'h o
. C o vm
Reprinted from Economic and Political Weekly, Vol XXXVHI, No 20, May 17, 2003
Pagination as in Original
District Health Accounts: An Empirical
Investigation
f
7
Economic reforms combined with a resource crunch have compelled planners and. policymakers alike to constantly and frequently take stock of resources available to the vital health
sector. Estimations of health sector resources and financial flows accruing to this sector were
Joi a long while limited mainly to public sector alone. This paper attempts a micro-level
estimation of health accounts at a district level in the hope of evolving, in due course, a more
comprehensive methodology applicable to wider areas such as the state and the country.
N B Annigeri
I
Introduction
estimates may not be useful for health sector analysis. This may
be due to the fact that it is difficult to define what are the
constituents of the health sector.
In the present day context, health accounts are in the process
of development across the globe. The need for such an account
ing has risen due to increased complexity of health care systems
and the need to keep track , of the resources of the health
sector per se.
JFn the wake of economic reforms, countries across the globe
| are experiencing a severe resource crunch. This is very much
-JLtiue for the health sector as well as for other sectors. In view
of this, policy-makers and planners in the health sector are
'ntinuously taking stock of resources available to the health
sectoi and seeking ways and means of finding new resource
base for this vital sector. Attempts are also on to review allocation
II
patterns and to assess efficiency of prevailing resource use. In
Methodological
Issues
■ the past two decades there have been many attempts, which
. have tried to estimate health expenditures of an economy both
The conceptual framework for estimating the health accounts
from public as well as private sources. Efforts by Abel Smith
emanates fiom two major attempts namely, (i) one carried out
*^'h^.963,
Griffith and Mills (1982), and Mach and by the OECD group of countries; (ii) and the other one by the
, j Abel Smith (1983) are considered to be important milestones in
Harvard School of Public Health.
i j -this respect.
A careful understanding of financial flows to the health sector
OECD Methodology
seems to have emerged as an important policy tool in the recent
times. Earlier attempts in developing countries were restricted i
The OECD methodology (2000) broadly concentrates on the
to estimation of health expenditures from the public sector only. followingcomponents-healthfinansing; health providers; health
This was obviously due to data limitations experienced in such care function.
counit ics. In the background of limited availability of resources
In the financing component, various levels of government are
to the health sector, a judicious use of resources assumes utmost
taken separately as well as various other private sources of
significance. To have a comprehensive picture ah
health
financing and households. Health care providers include various
expenditure we must take into account not only public sector providers including drug production, hospitals and others. Func
spending but private sector contributions in this regard. A
tions of health care include preventive, promotive, curative and
'lysis of such expenditures with regard to the sources of funds
rehabilitative care. Thus the OECD methodology tries to evolve
on what uses the funds are made will gives us a form of health accounts in a tri-axial formal. The methodology seems
accounts for the health sector, which may be termed as National
to be quite exhaustive in its coverage. For a developing country
Health Accounts.
like India, the data to match those requirements may not be easily
Both national income accounts and national health accounts
available, but a beginning needs to be made so that in a years
are similar, in the sense that what national health accounts
to come wc may probably evolve the methodology, which suits
describe for the health sector is being done by national income
specific requirements of our own country.
, accounts for the economy as a whole. Both these estimates agree
to the fact that money payments or transfers should not be double
Harvard School Methodology
counted and a distinction to be maintained between capital and
current expenditures. With regard to (he health sector, the national
The methodology states (hat expenditures on health should be
health accounts is a recent addition and in most such developing
taken as ‘cxpcnditurconactiviiic.swho.se primary intention (regard
countries cllorts arc still in their imancy. Some studies have
less of effect) is to improve health”. It excludes large programmes
indicated that the methodology adopted for the estimation of
that have health effects, but whose primary goal is not health
national income accounts may not act as a useful tool for the
- fot example general food subsidies, housing improvement and
national health accounts [Foulon 1982, Petre 1983]. Il is argued
large in ban watci supply projects. Still the debate over what to
that the categories adopted in the estimation of national income
include in the domain of health expenditures is not conclusive and
, ;
Economic and Political Weekly
May 17, 2003
1989
I
Graph 1: Sources of Finance for Medical Care Costs Incurred
by Households (Outpatients)
Hl
District Health Accounts (DHA)
I
Running down the,
savings
16 per cent
y.
I
I
From out of
regular Income
41 per cent
Borrowing from
friends
10 per cent
Borrowing from
moneylenders
9 per cent
Distress sale
24 per cent
Graph 2: Sources of Finance for Medical Care Costs Incurred
by Households (Inpatients)
Borrowing from
friends
44 per cent
I
i
|||!ifewikr
■i
Distress sale
0 per cent
Borrowing from
moneylenders
30 per cent
Running down
the savings
22 per cent
■
1990
In the present study a modest attempt is made to estimate the
district health accounts in Karnataka. Ideally health accounts ati
such a micro level will prove to be more useful in evolving such
estimates and also help in strengthening the methodology for its!
replication at the state and finally for the nation as level. Few I
issues would assume importance in this regard.
(a) What should be the ideal scope of District Health Accounts
(DHA) to begin with?
(b) Should health care services produced in the district and used 1
by residents of other districts to be considered in this regard or ,
not?
(c) Should health care services produced in the areas outside
the district but used by the residents of the district be included
or not?
(d) What public expenditure items arc to be considered in esti
mating DHA? This is more significant in the background of
different approaches adopted by different researchers in the
Indian context, for estimating health expenditures.
(e) The same argument also holds good for expenditures made
by NGOs and private corporate bodies.
(f) How to reconcile expenditures made by other governmental
departments other than health?
From out of
regular income
4 per cent
consensus is likely to emerge once the developing countries start
estimating health accounts according to country specific needs.
This methodology considers the flow of funds in the health
sector from three angles - (1) source of funds; (2) financing
agents; and (3) uses of funds.
Fund sources refer to those entities that provide funds to
financing agents. Financing agents arc those entities that pay for
the purchase of health care services. They may own or operate
provider institutions, as (he ministry of health does or they may
finance services provided by others, as done by private health
insurance.
Il is important to note that entities can appear at more than
one level. For example households (a source) pay premium to
insurance companies (a financing agent). However households
also act directly as financing agents, purchasing health care
services directly from providers. Households can appear at both
levels in the flow of fund analysis since they play both roles.
The NHA considers this as if households pay part of their
expenditures to other financing agents and retain a certain part
with themselves as financing agents. This leads to a transfer
. between columns and rows in the matrices.
The final level of the flow of funds analysis can be categorisation
of a variety of ‘uses’: (i) providers and institutions; (ii) functions
or type of health care services; (iii) line items or economic
expenditure categories; (iv) regions or geographic, administrative
categories and (v) socio-economic categories.
Formulation of flow of funds analysis is complete when the
levels are clearly distinguished, all relevant levels and entities'
included in their appropriate place and well-defined categories
of uses have been agreed upon.
I
Methodology
In the background of these and other issues related to the
estimation of DHA, the present exercise has made a modest
beginning. The methodology adopted for the current exercise is
explained as below:
Public expenditure: Under this category we have considered ;
medical and public health (2210). Though ideally we must also ‘
consider expenditures on family welfare, nutrition, water supply
and sanitation, child health, and expenditures made by other
government departments, in view of resource and time constraints
we have restricted ourselves to medical and public health only.
Data on public expenditure was collected from different sources
in the district.
Private expenditure: In order to capture household expenditures
a household survey was conducted in both urban and rural centres.
Sample households were chosen in a way as to provide due
representation to different socio economic groups as well as
geographical regions within the district. Random circulatory
method was adopted to select the sample units. A total of 250
households were surveyed and based on the per household
expenditure on health (curative), (he total household expenditure
on health for the district was estimated.
Employees State Insurance (ESI) data regarding contributions
made by employers as well as employees was collected.
Table 1: Utilisation of Facilities
Facililios
Utilisation (Per Coni)
Public hospital
Public health clinic
Private hospital
Private doctor
Private nurse
Traditional healer
Others
~ 3’5729
4 04
13.97
38.24
0.74
1.10
1.84
Economic and Political Weekly
May 17, 2003
Spending on health by departments other than health are also
considered. For example, expenditure incurred by jails, police
department, railways, slate transport corporation, etc. The data
sources produced at the end-of the report gives in detail the
different sources from where the data was collected.
: blon-goveminental organisations: Two of the NGOs were con1 tacted in the district to‘gather expenditure data related to health
j activities.
IV
Results
At the outset we will take a look at the profile of households
surveyed. About 13 percent of households belonged to scheduled
caste (SC) and 5 per cent belonged to scheduled tribe (ST). Other
backward communities (OBC) constituted about 33 per cent,
majority of the households had very low income per month. For
example about 40 per cent of the households had income less
than Rs 1,400 per month and 28 per cent had income between
Rs 1,400 to 2, 500. Of the total households 7 per cent were huts
39 per cent were kutcha houses. Illiterates in the total sample
accounted for about 24 per cent and the share of those educated
till primary and upper primary levels were 23 per cent and 31
per cent respectively.
These sick people out of the sample, utilised the facilities as
given in Table 1.
The table clearly shows that the dependence of the community
on private facilities is more in comparison to public facilities.
Financing of Medical Expenditure
by Households
Many studies have shown that private resources arc quite
significant in total health expenditures. But it needs to be examined
Table 2: District Health Accounts of Dharwad (Rs Lakh) for the Year 1997-98
Total
Uses
3615.35
2620.24
1209.18
423.45
388.78
168.89
165.79
140.77
89.64
77.44
74.57
40.25
39.01
15.79
9.89
6.52
5.87
3.94
3.42
0.85
0.10
0.00
9099.74
Medicines
Salary
Medical and public health
Family welfare
Medical supplies (equipments)
Office exps
Construction and maintenance
RCH programme
Capital expenditure
ESI contributions
Logistics
Rehabilitation care
Diet
Leprosy treatment
Training
Research expenses
Blindness control
Malaria programme
Power and water
Aids control
Other
Transport
Total
All Private
Househould
Funds
3372.18
708.48
0.00
0.00
247.97
165.44
7.18
0.00
58.13
65.52
74.10
40.25
3.17
0.00
0.20
6.52
0.00
0.00
0.00
0.00
0.00
0.00
4749.14
Private
NGO
_____
Others
530.49
177.99
42.36
165.44
7.18
205.61
0.45
57.68
65.52
3372.18
73.77
0.33
40.25
3.17
0.20
6.52
3445.95
796.39
506.80
Government
State
Local
Total
_____
Government Union
243.17
1911.76
1209.18
423.45
140.81
3.45
158.61
140.77
31.51
11.92
0.47
0.00
35.84
15.79
9.69
0.00
5.87
3.94
3.42
0.85
0.10
0.00
4350.60
85.00
356.39
393.17
0.00
1.25
139.63
13.62
157.17
1468.64
1209.18
30.28
67 33
3.44
65.53
1.14
1.08
11.92
0.44
84.00
Foreign
1.00
2.73
73.48
0.00
0.01
91.83
7.12
9.69
0.03
28.84
15.79
9.69
7.00
5.87
3.94
3.42
0.85
0.10
996.06
3084.65
164.60
105.29
Table 3: District Health Accounts of Dharwad (Percentages) for the Year 1997-98
Uses
Medicines
Salary
Medical and public health
Family welfare
Medical supplies (equipments)
Office exps
Construction and maintenance
RCH programme
Capital expenditure
ESI contributions
Logistics
Rehabilitation care
Diet
Leprosy treatment
Training
Research expenses
Blindness control
Malaria programme
Power and water
Aids control
Other
Transport
Total
All Private
Funds
Total
39.73
28.79
13.29
4.65
4.27
1.86
1.82
1.55
0.99
0.85
0.82
0.44
0.43
0.17
0.11
0.07
0.06
0.04
0.04
0.01
0.00
0.00
100.00
Economic and Political Weekly
37.06
7.79
0.00
0.00
2.73
1.82
0.08
0.00
0.64
0.72
0.81
0.44
0.03
0.00
0.00
0.07
0.00
0.00
0.00
0.00
0.00
0.00
52.19
May 17, 2003
Household
All Private Funds
Total
NGO
Others Government
37.06
0.81
5.83
1.96
0.47
1.82
0.08
2.26
0.00
0.63
0.72
0.00
0.44
0.03
0.00
0.07
37.87
8.75
5.57
2.67
21.01
13.29
4.65
1.55
0.04
1.74
1.55
0.35
0.13
0.01
0.00
0.39
0.17
0.11
0.00
0.06
0.04
0.04
0.01
0.00
0.00
47.81
______ Total Government Funds
Foreign
Union
State
Local
0.93
3.92
4.32
0.00
0.01
1.53
0.15
0.08
1.73
16.14
13.29
0.33
0.74
0.04
0.72
0.01
0.01
0.13
0.00
0.92
0.01
0.03
0.81
0.00
0.00
1.01
0.08
0.11
0.00
0.32
0.17
0.11
0.06
0.04
0.04
0.01
0.00
10.95
33.90
1.81
1.16
1 99 I
I
how this expenditure is financed. In other words it is not
enough to say that private sector contributes the major share of
health expenditures, but it would be interesting to see how
actually households are drawing the money to fulfil their medical
needs,
Graphs 1 and 2 make it amply clear as to how the house
holds are able to spend money with help of different sources of
finances.
Foi outpatient care, 24 per cent of the expenditure comes
from the distress sale of household articles and 9 per cent
through borrowing from money lenders, 16 percent from dipping
into savings. This speaks about the kind of inconvenience
households face in meeting their simple outpatient heath care
needs.
Money made available for the inpatient care shows that 30 per
cent is through borrowing from moneylenders and 44 per cent I
out of borrowings from friends. Drawing from savings
finances 22 per cent of impatient care. These would certainly •
indicate that episodes of morbidity affect the economic position
of the households rather badly. Though households do '
finance their medical needs, it seems that they undergo a lot of
economic pressure to do so. In this background the question of
supporting public provisioning of medical care facilities seeks
I
support again.
Table 4: District Health Accounts of Dharwad
(Rs Lakh) for the Year 1997-98
Uses
Government
Salary
1911.76
Medical and public health
1209.18
Family welfare
423.45
Medicines
243.17
Construction and maintenance 158.61
Medical supplies (equipments) 140.81
RCH programmes
140.77
Diet
35.84
Capital expenditure
31.51
Leprosy treatment
15.79
ESI contributions
11.92
Training
9.69
Blindness control
5.87
Malaria programme
3.94
Office exps
3.45
Power and water
3.42
Aids control
0.85
Logistics
0.47
Other
0.10
Rehabilitation care
0.00
Transport
0.00
Research expenses
0.00
Total
4350.60
Total
Union
_____ __________
Government
State Local Foreign
356.39
1468.64
1209.18
30.28
157.17
65.53
67.33
1.14
28.84
1.08
15.79
11.92
9.69
5.87
3.94
3.44
3.42
0.85
0.44
0.10
393.17
85.00
1.25
0.00
139.63
7.00
13.62
996.06
84.00
2.73
73.48
1.00
91.83
0.00
7.12
9.69
Total
Government
Salary
43.94
Medical and public health
27.79
Family welfare
9.73
Medicines
5.59
Construction and maintenance 3.65
Medical supplies (equipments) 3.24
RCH programmes
3.24
Diet
0.82
Capital expenditure
0.72
Leprosy treatment
0.36
ESI contributions
0.27
Training
0.22
Blindness control
0.13
Malaria programme
0.09
Office exps
0.08
Power and water
0.08
Aids control
0.02
Logistics
0.01
Other
0.00
Rehabilitation care
0.00
Transport
0.00
Research expenses
0.00
Total
100.00
1992
Based on data collected from the district (both public and
private) an attempt was made to develop health accounts for the
district (Tables 2 and 3). The matrix of health accounts shows
different souiccs and uses of funds in the district. The government
Appendix A: Explanatory Note on Items of Uses in DMA
3084.65 164.60
Explanalions
Salary
Salary of officers, staff, DA, TA, interim
relief, other allowances, establishment
expenses. Accident relief fund. Salary of
social workers.
0.01
2
Medicines
Drugs and chemicals, medical
reimbursement, medicine to poor patient.
3
ROH programmes
0.03
4
Medical supplies (equipments)
Provision of contraceptive/vaccination.
X-ray. linen and bedding, instrument and
equipment,
Hospital equipment, surgical equipment,
uniform and shoes.
5
Transport
Expenditure on petrol/diesel.
6
Office expenses
7
Other
Expenditure on telephone, contingency/
stationery. Contingency.
Not defined
8
Diet
Expenditure on food/milk/lruils/eggs/
vegetables.
9
Family welfare
Expenditure on sterilisation/NSV (no
scalpel vasectomy).
Expenditure of TB clinics, other govt
hospitals, rural health services, school
health services.
105.29
Union
Government
State
Local Foreign
8.19
0.00
9.04
1.95
0.03
0.00
3.21
0.16
0.31
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
22.89
33.76
27.79
0.70
3.61
1.51
1.55
0.03
0.66
0.02
0.36
0.27
0.22
0.13
0.09
0.08
0.08
0.02
0.01
0.00
0.00
0.00
0.00
70.90
1.93
0.00
0.00
0.00
0.00
1.69
0.00
0.00
0.16
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
3.78
Particulars
1
Table 5: District Health Accounts of Dharwad
(Percentages) for the Year 1997-98
Uses
V
District Health Accounts
0.06
0.00
0.00
0.02
2.11
0.00
0.00
0.00
0.22
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00 !
0.00
0.00
0.00
0.00
2.42
10 Medical and public health
11
Construction and maintenance
Equipment maintenance, repair and
maintenance, improvement, moderni
sation, expenditure in respect ol pro
perties, addition and alteration.
12 Leprosy treatment
Prevention and control of diseases.
13 Malaria programme
Prevention of malaria disease/dislrlbulion ol medicines/drugs.
14
Logistics
Travelling expenditure.
15 Power and water
Expenditure on energy and water.
16 Capital expenditure
Purchases of vehicle, ambulance.
17 Training
ANM training/NGO training.
18 Blindness control
Prevention and control of blindness.
19 Aids control
National aids control programmes.
Awareness to public regarding AIDS.
20 Research expenditure
Expenditure on research.
21
Expenditure on patient rehabilitation.
Rehabilitation care
22 Other
Not defined.
Economic mid Polilicnl Weekly
Miiy 17, 2003
i
I-
funds have been classified into union, state, local and foreign exercise of evolving health accounts at the district level can be
depending on the flow of resources. In the same fashion, private considered as a beginning. They need to be looked from the point
' funds have been classified into, household, non-governmental of view of evolving a methodology of develop ir.g health accounts
organisations and others (small private firms spending an health at the sub-regional level. But a consensus needs to be arrived
care needs). The district health accounts in terms of percentages at to strengthen the methodology.
indicate that all private funds account for about 52 per cent of
the resources flowing into the district. Out of this, 37 per cent
Scope for Further Refinements
arc contributions by households, 8 per cent by NGOs and about
5 per cent by others/ Public resources account for about 47 per
In the present exercise a modest attempt has been made to
cent of which state government spends about 33 per cent, union present a sources and uses matrix of resources flowing into the
government spends about 10 per cent and local bodies contribute health sector at the district level. If this is considered as a
about 2 per cent. If one looks at the share of uses, it is interesting beginning, the refinements can be made in future attempts in the
to note that both slate and union governments arc spending less areas of (i) health financing component; (ii) expenditure on health
on medicines whereas salary assumes greater significance in their by source of funding; and (iii) expenditure on health by provider
spending patterns.
and souice of funding (this has been partly covered in the present
An attempt is also made to evolve the accounts matrix for public study).
iesources only (Tables 4 and 5), which show that salary consumes
Health provider component includes (i) expenditure on health
major chunk of resources. The major role in the provision of by provider and (ii) expenditure on health by function. In this
health services rests with the state government which accounts category different levels of health care institutions act as pro
for about 70 per cent of the total public resources.
viders. A careful examination of sources of funds and uses for
Though the DHA estimate has more scope for refinement the different levels of institutions would throw more light on the
present estimates nevertheless give a picture of flow of funds efficient use of resources. Under this category we also need to
within the health sector of the concerned district. The present consider pharmacy/biomcdical industries, medical equipment
and allied industries and other related industries.
In the context of analysis of health care functions, flow of
Appendix B: Data Sources
funds
to various functions like preventive, promotive, cura
I Government
tive and rehabilitate care, capital formation in health care
(D District Health Office (DHO), Dharwad
industries, education, research and training and so on could be
(a) Salary and non-salary
(b) Plan and non-plan expenditure
included.
(c) Expenditure on drugs
Future attempts in estimating health accounts especially in
(d) Reproduction and child health (RCH) programmes
the Indian context must cater to several resources flowing from
(e) Capital expenditure on hospital building
the non-formal sector where there are many players in the
(f) District leprosy office
provision of health care services. For example, services of herbal
(g) District malaria office
(2)
District Civil Hospital, Dharwad.
medicine providers, yoga and naturopathy establishments,
(a) Non-plan expenditure
household expenditure on medicines prepared within the house.
(b) Users money and vehicle cost
x
Only when such a holistic perspective is taken about health
(c) Nurse (ANM) training, (plan)
accounts, one can meaningfully evolve ‘health accounts’ in its
(d) Blindness control - plan and non-plan expenditure
true sense. TI71
(e) Blood bank — AIDS control, plan expenditure
(3)
(4)
(5)
(6)
(7)
(8)
(f) Post maternity care centre
(g) Leprosy unit.
Karnataka Institute of Medical Science (KIMS), Hubli
South Central Railway Hospital, Hubli
Leprosy Hospital and Rehabilitation Centre, Hubli
Karnataka Mental Hospital and Rehabilitation Centre, Dharwad.
District TB Centre, Hubli
Police Department (expenditure on reimbursement and health unit)
North-West Karnataka Road Transport Corporation
(expenditure on reimbursement and health unit)
Sub-Jail/Borstal School’s Health Unit
Employees Stale Insurance (ESI) Office
(Employees and employers contribution)
Address for correspondence:
ejiidi^is5n^TOr-neU.n-
References
Abel-Smilh, B (1963): ‘Paying for Health Services: A Study of the Costs
and Sources of Pi: -.ce in Six Countries', Public Health Papers No 17,
World Health Organisation, Geneva.
(10)
- (1967). An International Study of Health Expenditure and Its Relevance
(11)
for Health Planning’, Public Health Paper No 32, World Health
Organisation, Geneva.
ii Local Bodies
Foulon, A (1982): ‘Proposals for a Homogeneous Treatment of Health
(1)
Hubli Dharwad Municipal Corporation (HDMC)
Accounts , The Review of Income and Weall/i, 28.
Griffiths, A and A Mills (1982): Money for Health: A Manual for Survevs
III Private
in Developing Countries, Sandoz Institute for Health and Socio-Economic
(1)
Dental Hospital (SDM). Dharwad
Studics.andlheministryofHealthoflhc Republic of Botswana (Gaborone),
(2)
Karnataka Cancer Therapy and Research Institute, Hubli
Geneva.
IV Non-Governmental Organisation
Mach, E P and B Abel-Smith (1983): Planning the Finance of the Health
(1)
Karnataka integrated Development Services (KIDS), Dharwad
Sector: A Manualfor Developing Countries, World Health Organisation,
(2)
Institute for studies on agricultural and Rural Development (ISARD),
Geneva.
Dharwad
i OECD (2000): A System of Health Accounts for International Data Collection
V Foreign Funding Agency
Version 1.0, OECD Health Policy Unit.
(1)
Expenditure of Karnataka Health Systems Development Programmes
Petre, J (1983): 7he Treatment in the National Health Accounts of Foods
(KHSDP), Dharwad
and Services j ■ . ndividual Consumption, Produced, Distributed or Paid
for by Government, Eurostalc, Luxembourg.
O)
Economic and Political Weekly
May 17, 2003
1993
!
!
*<
-
Oiscussion
vthe Indian university system and the rela
tive lack of quality in scientific research
are strong negative factors. But it is pos
sible to overcome these problems pro
vided more people think along the lines
suggested below.
/
X
Some three or four years ago, I pub
Amrik Singh
and research had emerged as superior to
lished a piece on Science Journals in India.
what obtained in other countries. The
Amongst other things, I had made the
'T'hc basic thrust of Ramachandra Cuba’s
invention of the atom bomb was an extra
point that, despite all the negative factors
1 article ‘The Ones Who Stayed
ordinary feat of scientific research. Its use
al work, it is possible to plan (he publi
Behind’ (ETW, March 22, 2003) is that
over Japan in 1945 might have been a
cation of science journals in such a way
India, like US or even the UK can and
political decision but of this there can be
that about 50 ol them are straightaway
should in course of lime emerge as an
no doubt that both the invention and manu
accept ed a s i n le rn a t i on a 11 y co m pa ra bl e. I n
autonomous centre of thought and dis
facture of the bomb had been done only
about a year’s lime, this number can be
course. This formulation should be seen
in that country.
taken to 100 or so. In about five years, this
in a context which is somewhat wider
All these factors combined together to
number can be doubled, if not trebled.
than what Guha has presented. Something
put the US in the forefront. It is not only
What
is required is that a group of people
about the stae of Indian publishing and its
in the field of Indian studies that the US
connected
with policy-making come to
interaction with the emergence and con
is ahead of the rest of the world, it is ahead
gether and adopt a plan of action.
solidation of an intellectual community in
of everybody else in the different branches / This plan of action should survey the
India wotild in my opinion strengthen the
of regional studies. Guha has referred to
entire range of scientific research and
thrust of the argument.
thc/'field of south Asian history. But the ' identi fy those areas where Indian research
Till about a century ago, the centre of
same can be said in respect of scores of
ers arc doing well and arc currently pub
thought and discourse in the Englishseveral other fields of enquiry. No more
lished in foreign journals. Their numbers
speaking world was the UK. By the begin
heed be said about this issue for it'’is
might
have come down of late but with
ning of the last century, the centre had /obvious (hat, for almost half a century
a little effort the situation can be reversed.
started
starrea moving to the US. At the end
encl of / now, the US has been leading the world
During the last 10-15 years, China has
second world war, there was no doubt that/ in accumulating knowledge and nroducforged ahead rapidly. That is because some
the US had become its unquestioned loader/ ing research in every possible ^rea of
master minds are at work in that country
The decision to locate the United Nations
knowledge.
/
and there is a plan of action. What we lack
in New York was an implied recognition
Two corollaries of what has-been said
is such a plan.
of the fact that the US had emerged as a
above need to be^spelt out. One, though
While this proposal was by and large
world power and also graduated tb be
the UK was at one time the leading country
ignored, I tried to interest one of the key
come the leading intellectual centre'of the
in the field of knowledge in this era of
policy-makers to see some merit in this
world. The USSR was a formidable power
globalisation, it continues to be one of (he
approach. The response was not positive.
no doubt and there was confrontation
leading players even nov^. Several other
Most people seem to think (hat India
between these two countries for another
countries of the world a/e also beginning
emerging as a regional centre of original
few decades. But the US had^ne unmis
to emerge as regional Centres. Secondly,
research is not a feasible proposition. I do
takable advantage.
/
it has so happened that, largely because
not agree with that perception. So far al
By (hen, English had emerged as (he
of our population and partly because of
any
rale they have had the last word.
most important language in the world.
the study and dissemination of English
However powerful USSR might have been
for about (wo centuries in whatever
Social Science Journals
and however productive (hat country was
bumbling way it might have been done,
in a variety of ways, its international
India too has emerged as a significant
Unlike the field of science, something
acceptance did not measure up to a posi
regional power.
miraculous
happened in the case of the
tion of undoubted leadership. Some other
In terms of her publishing strength, the
social
sciences.
One of the leading pub
factors too were at work but, for obvious
UK is miles ahead of India but that is
lishers undertook to publish journals in
Reasons, they cannot be gone into here.
because of the historical legacy of what
the social sciences provided the promoters
A factor which reinforced the American
had obtained in that country before the
of these journals met two preconditions.
position of leadership was that, even before
second world war. Today India is not only
One was that they should appear on
second wofld war, there was a systematic
the third most important country as far as
schedule
- a professional obligation - as
attempt on her part to attract talent from
the publication of books in English is
laid down in the journal itself. Most of
all over the world. If there is one country
concerned, in a number of other ways
the journals published in India do not
in history which has built herself up on
India is doing well. This is despite all the
understand the importance of timely pub
the basis of the identification and pursuit
negative things that tare happening and
lication. On the contrary, they arc casual
of talent, it has been the US. No wonder
come in the way of India emerging as a
as
well as sloppy in their approach.
the American system of higher education
bigger regional power. The weakness of
Secondly, it goes without saying that
Towards an Intellectual
Community in India
1994
Economic and Political Weekly
May 17, 2003
!
I
1
H-
L Vk.w
MACROECONOIV^CS AMD HEALTH:
AM UPDATE
April 2004
World Health Organization
(*' v...!
J
MACROECONOMICS AND HEALTH
Introduction
Since the release of the Report of the Commission on Macroeconomics and Health (CMH) in 2001, several
countries have evaluated the recommendations in light of their unique country health and socioeconomic
contexts and have embarked on steps to implement policies that would secure health as an essential
component of development planning. Countries are approaching the work as a vehicle to assert national
health priorities and as another input into reaching the Millennium Development Goals through strategic
social sector and economic policy.
A central theme to the follow-up work to the CMH Report as coordinated by WHO is to maintain a countrydriven process, with countries assessing their individual situations in order to best develop and implement a
long-term Health Investment Plan. Since almost every country has ongoing programmes and mechanisms to
reach a variety of health and development goals, the approach taken by each country reflects the
programmatic and financial resources (both budgetary and extra-budgetary) at their disposal to integrate
development strategies with health priorities. This paper provides a summary of the achievements of
countries thus far as they have begun to implement the recommendations of the CMH and describes the
early processes and inputs into existing poverty reduction programmes and other national development
strategies. This will include a description of country priorities and mechanisms by which pro-poor public
policies have been developed, contributing to socioeconomic stability and economic growth.
Background
The necessity of integrating health across sectors to create a viable development strategy was established
by the findings of the CMH (December 2001). The Commission emphasised the central role of health in
securing economic development, identifying the poorest populations as disproportionately affected by
disease and the financial hardships caused by disease. The Report concluded that low- and middle-income
countries must increase resource allocations to health, and high-income countries must increase their
contribution to health in poor countries within a development framework. Equally important to increased
health expenditures, the Commission recommended that countries examine their health systems and
institutions to identify inefficiencies and limits to the capacity to absorb additional funds and to elucidate the
inequities of health provision to the poor.
In parallel, WHO has stressed that Health for All and Primary Health Care (PHC) strategies cannot be
successfully implemented without placing them within each country’s socioeconomic context The result is
the emergence of an international consensus: socioeconomic growth and development can be achieved only
by rigorously promoting the implementation of pro-poor health policies within a developmental framework
and financed through a massive scaling up of health investments.
Though health is accepted as an important goal of economic growth and development, economic
development alone has not brought about the achievement of national and global health goals. The World
Bank reports that though countries are spending one third of their budgets in the health and education
sectors, the benefits are primarily experienced by the rich, not the poor (World Development Report, 2004).
Several reasons are cited as to why public services are falling short, including the failure of funds to reach
the peripheral service delivery level, weak incentives at the local level, and also lack of demand by the poor
due to financial, logistical, cultural and educational barriers to access.
Over the last decade, several reports have supported a concerted international effort for scaling up essential
interventions for health promotion, disease prevention, treatment, and risk-factor reduction through a
coordinated sectorwide approach (World Development Report, 2003; World Health Report, 1999 and 2002).
It is widely accepted that a range of interventions exist that, if efficiently and systematically applied, could
reduce the burden of disease of the poor.
i
L1
The CMH Report called for health investments to be placed centrally in countries’ development agendas
through long-term macroeconomic policies, highlighting the links between health investment and poverty
reduction. CMH Working Group 1 states that this “new thinking - that health enhances economic growth supplements and, to a degree, realigns ideas of the justifications of spending on health, justifications that are
based on humanitarian and equity arguments”.
The work thus far
In June 2002, the 1st Consultation on National Responses to the Report of the Commission on
Macroeconomics and Health (CMH) was convened in Geneva. Representatives from ministries of health,
finance and planning from 20 countries came together to translate the recommendations of the CMH Report
into concrete actions at the country level towards achieving the Millennium Development Goals (MDGs). The
Consultation positioned WHO, inter alia, to support these efforts in countries and to provide opportunities for
periodic consultations on the impact of the Macroeconomics and Health (MH) process.
WHO has responded by establishing a Coordination of Macroeconomics and Health (CMH) Support Unit that
assists interested countries to analyse their health policies and create fiscally sound strategies. The Support
Unit works with WHO and its partners to:
1) help align macroeconomic growth goals towards reducing poverty and improving the health
outcomes of vulnerable groups; and
2) support the aims of sustainable growth and development by integrating MH into PRSPs,
achievement of MDGs and other national development agendas.
A series of Consultations at the regional level provided countries the forum to share approaches and
successes in the MH process. The 2nd Consultation on Macroeconomics and Health, "Increasing
Investments in Health Outcomes for the Poor" (October 2003, Geneva), furthered the momentum of the
countries. Discussion among ministers of health, planning, and finance, bilateral and multilateral partners,
and financing institutions contributed to further focus MH work on improving access to health care and on
innovative solutions to address the obstacles that hinder efficient use of financial resources. As expressed in
the meeting declaration (see Annex 2), countries identified resource mobilization options, human resource
constraints, and the harmonization of donor funding as key issues.
In the two years since the CMH Report was published, approximately 40 countries have taken steps to act
on its recommendations with ongoing support by all levels of WHO. The work has been driven by three
overarching themes:
•
Develop a multisectoral investment plan to improve health outcomes, especially among
poor people;
•
Strengthen commitments to increased financial investments in the health plan to
achieve MDGs and other national goals; and
•
Determine how to minimize non-financial constraints to the absorption of greater
investments by increasing efficiency and effectiveness.
Given the diversity of health, economic and social situations, efforts to place health in the macroeconomics
context must accommodate the health priorities, opportunities and obstacles unique to each country.
Specifically, governments are assessing their health priorities and evaluating the cost of providing necessary
interventions to the poor, in light of the financing mechanisms available internally and externally and the
constraints experienced within the system. Substantial progress is being achieved in many countries that
have initiated the CMH follow-up work, which includes advocating for the central role of health in sustainable
development, establishing alliances and developing focused economic analyses. The work has demanded a
multi-sectoral approach. Implementation must take into account the cross-sectoral interaction of risk factors
for disease. Without the complementary improvement of other sectors such as education, water and
sanitation, and environment, countries will be unable to optimize investments in health or achieve national
health objectives.
In summary, countries have built on existing mechanisms for health investment and policy and systems
reform and have used the macroeconomics process to make these activities more central to poverty
reduction and economic growth. During the process of developing a long-term Health Investment Plan,
several key opportunities and outcomes have emerged within the countries:
2
•
•
•
•
A process to identify and promote country health priorities and health-related MDGs
The establishment of a cross-sectoral mechanism to further promote priorities and to
negotiate and collaborate with bilateral and multilateral partners and donors
A move to directed evaluations of health financing and resource mobilization options specific
to the country social and economic context
A vehicle to insert health more strongly into PRSPs and other poverty reduction instruments.
HOW COUNTRIES ARE MOVING FORWARD
1.
Focus of WHO's Macroeconomics and Health support
Though cost-effective prevention and treatment tools are available for controlling major diseases (e.g. TB,
HIV/AIDS, and malaria), insufficient resources, coupled with a diverse range of systemic constraints,
continue to obstruct national efforts to reach the poor. WHO supports governments’ leading role in the
development of pro-poor investments and policies for health to help achieve national targets and the MDGs
using the findings of the CMH as a starting point. Substantial progress is occurring in those countries that
have initiated CMH follow-up work. This includes promotion of pro-poor strategies, expansion of
developmental alliances across sectors and instigation of new research and analysis.
The CMH Report highlights the destructive impact of HIV/AIDS as a unique challenge to growth and poverty
reduction. AIDS significantly lowers economic growth and drives more families into deepening poverty, whilst
causing great suffering and loss of life. There is a growing disruption to the economic and social fabric that
has increased the risk of political and community instability, particularly in low-income countries. The WHO
and UNAIDS global initiative ('3 by 5') seeks to provide life-long antiretroviral treatment to 3 million people
living with HIV/AIDS in poor countries by the end of 2005. Core principles include urgency, equity and
sustainability, and a concerted and sustained action by many partners. MH's integrative approach helps
place the response to such socially and economically devastating diseases into a broader context of pro
poor health policy and development. For example, HIV/AIDS initiatives and programmes need to be a part of
long-term government socioeconomic reforms, especially concerning the poor, and part of the government’s
overall health investment plan.
Leveraging the opportunities presented by other sustainable development mechanisms (e.g. Poverty
Reduction Strategy Papers and Medium Term Expenditure Frameworks), governments are assisted in
building domestic macroeconomic and public sector modelling capacity so they can implement an investment
plan for health. As countries attract additional sources of funds, the MH process builds institutional capacity
to effectively absorb increased funds and strengthen primary health care. The aim is to extensively increase
access by the poor and disadvantaged to essential and cost-effective health interventions, greatly improve
health outcomes and contribute to sustainable socioeconomic growth.
Over 40 countries have expressed interest in adapting the CMH Report's findings to their growth and
development agendas. The initial focus is to strengthen a country's ability to carry out sound
macroeconomic analysis so as to develop evidence-based and equitable health policies. Several
countries are designing national Health Investment Plans that scale up cost-effective interventions while
addressing the multi-sectoral determinants of health.
2.
Relationship to the Poverty Reduction Strategy Papers
The Poverty Reduction Strategy Papers (PRSPs) are broadly based upon the World Bank's Comprehensive
Development Framework (CDF) and the Monterrey Consensus1. PRSPs encompass five core principles:
1) country-driven, 2) pro-poor and results-oriented, 3) a multisectoral approach, 4) partnership-oriented, 5)
sustainable. These match the spirit and thrust of the MH process, which is country-initiated and -directed,
based on three themes arising from the CMH Report:
1. Give priority to multisectoral, pro-poor strategies that make health central to sustainable development
agendas;
2. Strengthen commitment of all partners to increase significantly the resources invested to improving health
outcomes;
1 The International Conference on Financing for Development, held 18-22 March 2002 in Monterrey, Mexico, formally
adopted the Outcome Document (the "Monterrey Consensus"). Developed, developing and transition economy countries
pledged to undertake important actions in domestic, international and systemic policy matters.
3
i
3. Progressively eliminate non-financial constraints by increasing equity, efficiency and effectiveness of
health-related interventions.
The MH approach augments PRSPs by placing health at the centre of development agendas and by
identifying and addressing constraints to equitable access. A unique feature of the multi-stakeholder national
MH mechanism is that it helps ensure increased investments are coupled with a pro-poor rationale to guide
resource allocation and priority setting. Momentum is sustained through regional and country CMH focal
points, utilizing a growing network of WHO partners including academia and civil society.
As the recent WHO survey on PRSPs has documented (WHO/HDP/PRSP/04.1), the health component of
national strategies to reduce poverty and catalyse sustainable development lack an explicit implementation
strategy that targets the poor. PRSP indicators are national aggregates and are often vaguely worded (e.g.
"strengthen the capacity of district health workers"). Moreover, PRSPs frequently are additive compilations of
sectoral plans, without any systematic way of rationalizing objectives, sequencing reformsand' ^™ng| for
financial sustainability. WHO adds value to the PRSP process, using the findmgs of the CMH Report, by
helping countries craft a health strategy that significantly improves health outcomes, especially for the poor
and marginalized segments of the population.
The CMH Report offers an analytical framework that, when used to assess the health components of the
PRSP can provide specific guidance on how to ensure the poor are clearly targeted and truly benefit from
the strategies proposed. First, it helps to make a convincing argument to donors and senior political eaders
for significantly increased funds for health (both through internal reallocations and by use of external grants).
Second the process uses a cross-sectoral approach to identify and progressively remove systemic barrier
to more effective and equitable delivery of health services. Third, by emphasizing that ^so“r“s^'d
allocated to preventive and primary health care before curative and tertiary strategies, the CMH Report helps
countries put in place concrete steps to achieve the health-related MDGs.
Sixteen countries (Table 1) have both the MH process and PRSPs. In these countries, a MH approach helps
focus^^artners on the need to place health centrally in development, operationalizing the hea th elements of
the PRSP. In addition, the national MH mechanism strengthens high-level dialogues via regular interministerial discussions that are inclusive of civil society and other stakeholders. Nine countnes and one sub
regional grouping (CARICOM) do not have a PRSP process. Here the MH process initiates a high-level
dialogue similar to that developed by the PRSP. The aim is to generate commitment to a sustainable
approach to growth and development, which holds that improved health outcomes are a prerequisite for
socioeconomic advancement.
4
7
Table 1: Annex: CMH countries with PRSP and HIPC
Region
Country
HIPC
V = Yes
AFRO
AFRO
AFRO
AFRO
AFRO
AFRO
AFRO
AFRO
AFRO
AMRO
AMRO
EMRO
EMRO
EMRO
EMRO"
EMRO
EMRO
EURO"
EURO
Congo, Rep of
SEARO
Bangladesh
SEARO
India
SEARO
Indonesia
SEARO
Nepal
SEARO
WPRO
VVPRO
WPRO
WPRO
WPRO
WPRO
WB Category2, ’ Indebtedness4
PRSP/
l-PRSP
Y = Yes
SI
LIC
LIC”
Y
Lie"
lie’
Tic'
Tic’
Tic
Tic
Tic
si"
Tii”
"mT
sT
TF
"sT
"sT
TT
Caribbean Community5
varies
varies
Mexico
UMC
LI
Ethiopia
Ghana
Kenya
Malawi
Mozambique
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Nigeria
Rwanda
Y
Y
Senegal
Y
Y
Y
Djibouti
Iran
LMC
LI
LMC
TT
si"
sT
si
LMC
Jordan
Tic”'
Y
Pakistan
Sudan
Y
Yemen
Y
Azerbaijan
LIC
Y
LIC
LI
V
LIC
TF
UMC
TF
LIC
LI
Estonia
Y
LIC
LI
"sT
TT
TT
Y
Tic
Lie
Sri Lanka
V
Y
Cambodia
Y
LIC
Ml
LMC
TF
sF
TF
TF
China
La'oPDR ”
Y
LMC
LI
Y
Y
Mongolia
LI
Papua NG
Ti
Philippines
LMI
TF
Abbreviations:
LIC
Low Income Country
LI
Less Indebted
LMC
Low Middle Income Country
Ml
Moderately Indebted
UMC
Upper Middle Income Country SI
Severely Indebted
2 Source: World Bank list of economies (July 2003).
... „
3 World Bank income group-. Economies are divided according to 2002 GNI per capita, calculated using| the Worid Bank Atla method.
The groups are: low income, $735 or less; lower middle income, $736 - $2,935; upper middle income, $2,936 - $9,075; and high
"Worid Bankfndebte^ess: Severely indebted means either of the two key ratios is above critical levels: present value of debt serv|ce
to GNI (80 %) and present value of debt service to exports (220 %). Moderately indebted means either of the two key rabos exceeds 60
% of but does not reach, the critical levels. For economies that do not report detailed debt statistics to the World Bank ^tor Reporting
System (DRS), present-value calculation is not possible. Instead, the following methodology is used to dassify 1the
Severely indebted means three of four key ratios (averaged over 1999-2001) are above cnt.cal levels: debt to GNI (50 /0). debt to
exports (275 %)• debt service to exports (30 %); and interest to exports (20 %). Moderately indebted means 3 of the 4 key ratios exceed
60 % of but do not reach, the critical levels. All other classified low- and middle-income economies are listed as less indebted.
5 Caribbean Community sub-region States comprise 15 members including the former Commonwealth Caribbean, Suriname and Haiti.
5
Relationship to the Millennium Development Goals (MDGs)
3.
The MDGs were endorsed by 147 heads of state in September 2001 at the UN Millennium Summit. At the
"High-level Forum on the Health Millennium Development Goals" (Jan 2004) held in Geneva by WHO and
the World Bank, it was stated that developing countries will not be able to achieve the health and nutrition
MDGs "unless extraordinary actions are taken to improve the coverage and quality of health and nutrition
services.” During the summit, the experiences of Uganda and Tanzania were reviewed. A key finding was
that the "lack of a holistic cross-sectoral view on priority interventions that improve health" significantly
weakens planning to achieve health MDGs. And while the PRSPs do address various sectors, the approach
is often more additive than integrative, with various sectoral activities lumped together without first
undertaking a holistic assessment of overall national priorities and the effectiveness of current expenditures.
The MH process encourages a cross-sectoral dialogue to increase governments’ and partners' awareness
that a multisectoral analysis is needed to develop a sustainable and comprehensive approach to growth and
poverty alleviation. MH research, analysing all factors influencing domestic health outcomes, can be used to
redefine narrow sectoral priorities and strategies within a true multisectoral framework. The participatory MH
process also helps garner the political commitment to institute an integrative approach to making resource
allocations, helping to ensure that primary health care interventions of proven value are adequately funded.
One Cambodian expert described the relationship in this manner: "While the MDG targets for international
development efforts over the next 15 or so years have been fixed, the CMH begins to construct the pathway
towards attaining these goals."
4.
Linkages and harmonization
Countries need regular and coherent dialogue with donors on what technical and financial support is
essential, and how to best match delivery of both to the real absorptive capacity of countries. The MH
process, by focusing on harmonization, creates a dialogue amongst major stakeholders as to how they can
move from earmarked funding and discrete projects to allocating funds against comprehensive planning and
expenditure frameworks, track progress against an agreed set of outcome indicators, and consolidate
implementation procedures.
Further, donors and external agents are encouraged to pay more attention to the recurrent costs of
investment programmes and to human resource needs. In several countries where the PRSP has been
assessed, it was found that too many capital investments are included without adequate sustainability
planning. Donor earmarking compounds the problem, since donor priorities end up determining distribution of
resources, staff priorities and management time, rather than PRSP implementation being based upon a
comprehensive and holistic method to reducing poverty.
To counter this fragmented approach, the MH process advocates for a national coordinating mechanism that
could convene high-level representatives from government, NGOs, bilaterals and civil society to assess
progress towards improved health outcomes for the poor. It would centre attention on the development of a
comprehensive framework
framework for
for planning
planning and
and for
for financing,
financing, one that spans the various sectoral plans
comprehensive
contained in national poverty reduction efforts, such as the PRSPs. Its purpose would be threefold:
To advocate for donors to move from earmarked funding of discrete projects and vertical
programmes to allocating funds against a comprehensive expenditure framework;
a)
b)
To reduce transaction and administrative costs by harmonizing and streamlining implementation
procedures;
c)
5.
To track and evaluate progress against a common set of process and outcome indicators.
The process of MH at the country level
Support from WHO/HQ
Macroeconomics and Health is a country-initiated and -directed process. After analysing its needs, the
government, with facilitation by WHO, compiles the necessary evidence base to mobilize partners and create
political support. The resulting high-level political commitment culminates in the development and full
implementation of a Health Investment Plan integral to ongoing poverty reduction strategies for sustainable
development.
6
Country requirements are being met by the WHO's mobilization of organizational and partner resources.
WHO helps countries access technical support so they can develop an evidence-based investment plan that
garners cross-sectoral backing. An important element is the national coordinating mechanism, whether new
or added to an existing high-level body, which encourages a pro-poor approach to health policy
development. WHO also has a unique integrative role, using its established country-level relationships with
partners, NGOs, and donors to place health investment plans within existing development agendas. The
outcome is to strengthen and sustain political support and commitment, improve the predictability of donor
financing, and develop and implement an investment plan to achieve national development goals.
Added value of regional support
The WHO regional offices leverage their close relationships with countries to disseminate the findings of the
CMH Report and catalyse a Macroeconomics and Health strategic planning process. Regions identify local
and international technical resources and collaborate with HQ to mobilize funds needed to sustain country
activities.
African Eastern Mediterranean and South-East Asian offices incorporated the CMH findings into their
regional developmental strategies. AFRO and EMRO have regional concept papers that outline the local
relevance and impact of MH and provide a framework for collaborative opportunities with HQ at the country
level. EMRO and AFRO operationalized the process via regional workplans containing specific targets for
advocacy, policy development and technical products as well as the necessary actions to reach these
objectives.
EMRO organized a successful regional consultation in June 2003, while AFRO held a similar meeting in
early August 2003. SEARO’s meeting occurred on 18-19 August 2003. These provided a venue for the
review of national actions and experiences to increase health investments. Countries discussed opportunities
and obstacles to Health Investment Plan development, debated options and then outlined individual
strategies to put in place a customized process for increased health investments.
Two unique features characterized these three regional intercountry meetings. First, the methodology was
innovative in that it brought together senior officials and operational-level directors from ministries of finance,
planning and health. The blend of viewpoints allowed a holistic assessment of the actual barriers to scaling
up investments in health. Such barriers include low political commitment, weak physical infrastructure,
inadequate monitoring and information systems, insufficient human resource capacity, and ineffective social
mobilization efforts. Second, the participants were able to outline practical ways to implement a crosssectoral strategy to addressing constraints, make better allocative decisions, collaborate to attract new
sources of funds (e.g. public-private partnerships) and explore innovative financing mechanisms.
6.
National Macroeconomics and Health process overview
Initiated and led by government, the MH process reflects the specific opportunities and constraints faced in
the domestic health, economic, social and political environments. Based on the experiences of countries that
were early adopters of MHS, three phases outline the main outputs and activities of a MHS and offer a
sequenced approach to achieving essential objectives. Of the roughly 40 countries in various stages of
planning and strategy development, over 30 are categorized as Phase 1 while seven are engaged in Phase
2 activities.
■
Phase I: Preparation
Activities: Disseminate CMH Report to important stakeholders to analyse its relevance to the current national
situation. Promote high-level commitment to the MH process. Identify resources required to embark on
planning activities. Define research and technical support needs.
Outcomes: 1) Attain high-level national political commitment to MHS, for example, the development of terms
of references (ToR) for a national MH coordinating mechanism. 2) Develop an outcome-oriented work plan
outlining activities, linked to a budget and timeline. 3) Develop ToRs for research studies and any technical
consultants needed.
Estimated time: 6 months
7
Phase II: Planning
Activities: Assess the health status of the poor. Determine effectiveness, efficiency and equity of current
health-delivery infrastructure. Identify health priorities, outcome gaps and limits in capacity. Evaluate health
intervention options based on cost/benefit and co st-effectiveness studies. Perform cost analyses of
investment package options.
Outcomes: 1) Sustain cross-sectoral commitment to increasing investments in health as part of the larger
development framework, for example, the integration of health outcomes into ongoing PRSP or MTEF
processes. 2) Develop long-term Health Investment Plan based on situational and costing assessments. 3)
Define an implementation strategy, identifying key stakeholders and how their support will be secured.
Estimated time: 18 months
Phase III: Implementation
Activities: Implement the Health Investment Plan. Ensure effectiveness of mechanisms to monitor the
implementation process as well as assess the long-term impact on health outcomes and economic growth.
Analyse impact and use this information to refine and optimize resource allocations. Gamer political support
for implementation and sustain cross-sectoral backing.
Outcomes: 1) Collect and track relevant health and economic indicators. 2) Secure an increase in internal
investments for health and (if required) supplemental funding by external donors.
Estimated time: Several years
7.
Tracking outcomes
There are two inter-related levels to tracking outcomes in countries employing a MH approach.
Administratively, budgets submitted for country and regional CMH-related activities are carefully assessed by
the Secretariat to ensure that expenditures are linked to specific outcomes and that outcomes are clearly on
the critical path to creating a national Health Investment Plan. WHO then responds to accepted country and
regional requests with technical products and financial support. As activities are undertaken, WHO regional
and country focal points oversee implementation and monitor achievements of funded workplans.
Achievements are conveyed to WHO/HQ using short technical progress reports at the end of each phase
(Annex 1).
At the country level, the MDGs and national targets provide broad benchmarks to assess progress of poverty
alleviation efforts. The country leads the process of developing domestic indicators, with technical support
provided by WHO and other development partners. Three complementary approaches help a country track
results. First, the CMH Report helps persuade senior decision-makers to support linking pro-poor health
policies to specific outcomes defined by the health-related MDGs. Second, workshops, seminars and other
mediums foster collaboration between all partners to implement national strategies in a unified manner,
agreeing upon a core set of national indicators. Third, provision of resources and products (e.g. end-of-phase
Technical Progress Reports) assists the country to use collected data to measure progress of its
implementation efforts as well as its advancement towards health-related MDGs. To avoid duplication and
needless paperwork, the Secretariat supports streamlined reporting processes and the improvement of
current information sources by strengthening existing monitoring systems.
8.
Achievements to date
1) Fostering high-level political support
Copies of the report and background papers, translated into multiple languages, have been widely
distributed for country review. Many countries (e.g. Ghana, India, and China) held national workshops with
essential stakeholders to assess how to incorporate CMH findings into national development strategies.
Several countries initiated the MH process through a national launch event, allowing important government
officials and other high-profile participants to express publicly their support of the MH process. For example,
in India, the Indian National CMH was launched in January 2003 with a keynote address by Dr Jeffrey Sachs
of Columbia University. In Sri Lanka, a Macroeconomics and Health event led by the National Health Council
and chaired by the Prime Minister resulted in the establishment of a National Commission on
Macroeconomics and Health (NCMH).
8
-t
WHO products
b
Technical support for advocacy tools, national workshops, and consultations to secure commitment
from politicians and policy-makers. IEC (Information, Education, Communication) products include an
"Investing In Health" information booklet, an electronic newsletter and the MH website
(http://www.who.int/macrohealth). These maintain support, help disseminate experiences to date and
inform additional stakeholders (e.g., development partners, donors, etc.) of progress.
B
Seed funds to catalyse and promote a national launch and other activities aimed at securing broad
based support and national commitment.
2) Establishment of high-level national MH mechanism
National cross-sectoral mechanisms support the MH process, usually by expanding the scope of existing
coordinating bodies. Occasionally, a national MH commission is established if no better mechanism exists
(e.g. Ghana, India and Nepal). Comprised of representatives from multiple ministries including health and
finance, the structure of the mechanism is country-dependant. For example, Sri Lanka’s NCMH includes
representatives from various ministries, the WHO Country Office, UNDP, the private sector and academia.
The Commission is co-chaired by the Minister of Health, Nutrition and Welfare and the Minister of Rural
Economy and Deputy Minister of Finance. A different structure exists in Ethiopia. Their MH coordination is
provided by a newly hired Macroeconomics and Health Country Coordinator (an Ethiopian economist) and by
a Technical Working Group operating under the Ministry of Health.
WHO products
■
Technical guidelines to design Terms of Reference (ToRs) for domestic MH coordinating
mechanisms, with provision of case examples of other countries' coordinating efforts.
Support to identify and place an in-country focal point, when requested by the country.
■
Seed funding to establish the national MH mechanism.
3) Development of outcome-oriented workplans
Linked to a budget and timeline, this plan outlines the activities, outputs, and objectives unique to a country’s
strategic plan. It includes the identification of resources and support needed to carry out the described
activities. Over 20 countries have submitted Phase 1 work plans, and a majority of these have received
partial funding. These preparatory workplans pave the way for development of the Health Investment Plan.
WHO products
c
Mobilize technical and financial resources necessary for the development and implementation of a
realistic and outcome-oriented work plan, budget and timeline.
E
Guidelines, templates and outlines to help countries assess gaps in technical expertise they will need
for policy development and planning.
■
WHO, especially regional focal points, identifies and places local experts by collaborating with
universities and regional and national NGOs, and by the selected use of international consultants.
Over 21 countries have participated in regional technical meetings, with many also receiving in
country follow-up visits by technical experts.
Regional workshops to assist country progression, share country experiences and lessons learnt, and
develop specific strategies to create and fully implement a plan for investing in health.
4) Assessment of health situation and analysis of health infrastructure
Several countries, including Indonesia and Sri Lanka, have produced country concept papers to adapt the
findings to local health, economic and political situations. These concept papers are an initial assessment of
the health and health delivery structures of the country.
Countries, in this phase, execute an in-depth epidemiological survey of the causes and risks associated with
9
r
morbidity and mortality, disaggregated by income level, ensuring that the conditions most impacting the poor
will be targeted. Also, an analysis of the capacity of current health systems to absorb additional funding and
assessment of funding gaps for scaling-up of the current health infrastructure and services to the poor is
finalized. This provides a basis for sequencing and prioritization of targeted health investments. Indonesia,
for example, received funds to prepare an assessment of public health expenditures aimed at assessing the
poverty reduction impact of current and proposed spending patterns. Eight countries have now entered this
phase of the MH process (Cambodia, China, Ghana, Ethiopia, Rwanda, Mexico, Indonesia, and Sri Lanka).
In this planning stage, countries are identifying the need for experts and institutional technical support to
perform such analyses. Technical experts are recruited to assist countries in planning and executing the
necessary assessments and analyses. Technical experts will also assist countries in developing important
linkages with local and regional partners, such as representatives from the World Bank and NGOs.
WHO products
e
Mobilise and coordinate technical support for environmental scanning and the identification of key
stakeholders and socioeconomic factors.
■
Fund selected research, as well as aid countries to create ToRs for technical and research groups.
■
Develop and maintain relationships with academic and development partners to assist in analyses
and evaluation at the countrylevel.
■
The Earth Institute at Columbia University and the Royal Tropical Institute (KIT) are supporting
specific assessment activities in several countries, as well as helping define ways countries can
strengthen institutional research and analytical capacity.
5) Development of a Health Investment Plan
Countries will develop investment strategies based on the assessment of options and determine a package
of high-priority, cost-effective interventions. A costing analysis of the selected interventions will ensure a
sound evidence base on which to develop a long-term Health Investment Plan. Governments are working to
foster and sustain cross-sectoral support for the Health Investment Plan. An important management element
will be putting into place an internal mechanism for tracking of key outcomes. We expect eight countries to
complete this phase by 2005.
WHO products
K
Continue to develop and access a pool of experts who can address countries’ research needs (e.g.,
economics, epidemiology, health services research, etc.)
■ Will collaborate with countries to identify key economic and health indicators, including health-related
MDGs and country-specific health goals (i.e. Healthy Indonesia 2010), by which to track the
effectiveness and impact of the investment plan.
■ Assist countries in building linkages with development partners, NGOs, donors, and academic
institutions to sustain support and integration with ongoing poverty reduction plans and public health
projects.
The next section will give some examples of the varied paths to the MDGs being built by countries employing
a Macroeconomics and Health Strategy.
10
Table 2: CMH 2004 Country Progress
14
Through end of Phase 2 (tracking MHS process)
WHO
Region
Country
I S
Initial
contact
Country
missions
and
=6 2 request for
U- Q info
or
regional
meetings
S 2
Angola
Aug 03
Botswana
Aug 03
Congo
Ethiopia
AMRO
EMRO
Aug 03
..l._. ..
Y
...2...........
Y
Jun 02
Jun 02
Mar 03
Malawi
Aug 03
Mozambique
Aug 03
Nigeria_____
Aug 03
Rwanda
1
2
Senegal
1
Caribbean
Community 11
1
El Salvador
Mexico12
2
Djibouti
„1___
Y
Y
May.03..... ........ Nov02_____
Nov 02
Aug 03
Y
Dec 02
May 03
May 03
Sep 03
Sep 03
Jul 02
Aug 02
Jul 03
Jun 03
Jul 03
Aug 03
Jun 03
Sep 03
.Sep_p3_____
Nov-03
Sep 03
Jun 02
Jan 04
Jun 03
Jun 03
Jun 03
Jun 03
Jun 03
Nov-03
Dec 02
Mar 03
Jun 02
Jun 02
Apr 03
Y
Apr 03
Y
Dec 02
Y
Apr 03
Azerbaijan__
1
0
Nov 03
Y
Bangladesh
_AprO3
Sep 03
Y
1
„SeP.P3____
Apr P.3____
National
mechan. in
action
Sep 03
Iran
Baltic States:
Estonia
National
mechan.
created7
Sep 03
Jordan
1
Mar 03
Aug 03
Sep 03
Sep 03
Mar 03
May 03
Sep 03
Aug 03
Sep 03
Aug 03
Plan,
budget
approved
Aug 03
Apr 03
1
Sep 03
plan,
budget
submitted6
10
Jul 03
Sudan
Jul03„_„..... Apr03.
,.Jy!P3
..§ep 03
Jul.03-------Sep 03
Mar 03
Y
Apr 02
Aug 03.
Nov 03
..feb_04_____
Jul 03
India
Y
Jun 02
Aug 03
Nov 02
„Decp2_____
JanQ3______
Indonesia
Y.
Dec 02
Aug 03
Sep 03
.M?.LQ3_____
SeptOS____
Sept 03
13
May 03
Aug 03
Oct-03
Mar 04
July-03
Aug-03
Y
Jun 02
Aug 02
Dec 02
Oct 02
Aug 03
Sep 03
Sep 03
Sep 03
Aug 03
Aug 03
Feb 03
Dec 02
Feb 03
Jan 04
May 03
Jan 04
Sep 03
Jan 04
Jan 04
Jan 04
Mar03______ Jul 02
Dec 02
SEARO
Nepal
1
Sri Lanka
2____
1
Thailand
Cambodia
China
i
Philippines
Lao PDR
Mongolia
Papua NG
□
Jan 03
Y
Yemen
WPRO
Oct 03
Kenya______
Pakistan
EURO
Aug 02
Apr 03
Ghaiia
AFRO
Sep 03
Follow-up
Y
Y
Y
AHaQ?.__________
.JU1P3____ ___De_c02
Jan 04
Included in a regional proposal
8 Only the latest date shown for missions, meetings and funds dispensed, e.g. a Phase 2 date will overwrite the Phase 1 date.
7 A few countries have developed a National Commission on Macroeconomics and Health as the mechanism for driving this process
(e.g. Mexico, Ghana, Sri Lanka, India). Several others are using or considering the use of existing multi-partner/trans-sectoral
commissions to manage the MHS process (e.g. Indonesia, Djibouti, Ethiopia, Argentina). In this case, they are rewriting existing ToRs to
look at health economics and financing issues within a cross-sectoral framework. In most cases they are also expanding the
membership of such committees to include civil society, private sector and other ministries (e.g. Defence & Agriculture in Djibouti).
6 AFRO worked with Ghana and Ethiopia to disseminate their experiences during the "2nd Consultation on Macroeconomics and
Health" (October 2003).
6 Ethiopia is hiring a CMH country coordinator to work with the Ministry of Health.
10 Funding provided for support from KIT: Royal Tropical Institute Amsterdam.
11 Caribbean Community sub-region States comprise 15 members including the former Commonwealth Caribbean, Suriname and Haiti.
12 Funded by non-WHO resources, primarily internal government resources.
13 Funding provided for support from KIT: Royal Tropical Institute Amsterdam.
14 This table only shows those countries that have expressed a strong interest in committing to Phase 1 activities, orthose countries already
actively pursuing Phase 1 or Phase 2 strategies.
11
ACHIEVEMENTS THROUGH MARCH 2004
In countries in which the process has moved past initial requests for information, a synopsis is provided of
how the Macroeconomics and Health process is catalysing some notable efforts to strengthen cross-sectoral
networks linking donors and national leaders.
1.
African Region (AFRO)
There is growing interest among WHO African Regional Office (AFRO) member states to implement the
CMH recommendations. For example, Ghana and Ethiopia are in the process of developing investment
plans for strengthening "close-to-client", or primary health care, systems and extending coverage of essential
health interventions. Angola, Botswana, Republic of Congo, Ethiopia, Ghana, Kenya, Malawi, Mozambique,
Nigeria, Rwanda, Senegal, Tanzania and Uganda requested support to engage in a cross-sectoral process
leading to multi-year Health Investment Plans.
To augment human resource capacity at the regional level, a regional CMH officer has been recruited. The
officer is working collaboratively with other regional CMH contacts and the CMH Secretariat at WHO
Headquarters to support local adaptation and ownership of the Macroeconomics and Health process. AFRO
has produced a wealth of practical guides and background documents to help countries implement the
Macroeconomics and Health (MH) process. Exchanging similar documents between regions has broadened
the range of products and resources available for all participating countries.
Fourteen countries attended a WHO AFRO workshop on 4-8 August 2003 in Addis Ababa, Ethiopia. The
workshop objective was to support countries in developing a process that will lead to investment plans for
expanding coverage of essential public health and health-related interventions that address the most
important causes of avoidable morbidity and mortality. Partidpants from each of the participating countries
included: (a) Director of Planning, Ministry of Health; (b) Director of Planning, Ministry of Finance; and (c)
WHO Country Office health economist (or National Management Professional). The role of the latter is to
ensure follow-up at the country level. The workshop has led to the development of draft Plans of Work for 12
countries, and dearly outlined the steps necessary to advance the CMH follow-up in these countries. By the
end of the workshop consensus was established on the importance of Macroeconomics and Health to the
countries. Countries developed draft Plans of Action to take the process forward.
A regional concept paper and country guidelines for incorporating MH into poverty reduction efforts have
been developed. The current focus of activities at regional level is on human resources and technical
support to countries. A critical milestone for regional advocacy efforts was the 53rd Regional Committee
(RC) meeting of ministers of health from the 46 countries, which took place 1-5 September 2003 in
Johannesburg, South Africa. During the RC meeting, the Ministers of Health and the Regional Director
endorsed the recommendations of the Report of the Commission on Macroeconomics and Health (CMH),
attaching great importance to the Report's findings. They also commended the AFRO CMH strategy paper
“Macroeconomics and Health: The way forward in the African Region" and the resolutions contained within.
On the last day of the meeting, the ministers adopted the resolution and paper on Macroeconomics and
Health.
Angola
The MH process is beginning to highlight the important links between health and economic development
among essential target audiences. A study on ‘Public Financing of the Social Sectors in Angola’ for the years
1999-2001 was jointly carried out in 2002 by WHO, UNICEF, UNDP and IOM in coordination with the
Government of Angola: Ministry of Finance, Ministry of Health, and the Ministry of Education. There exist
tangible entry points for implementing the MH process in Angola. Both the Poverty Reduction Strategy Paper
(PRSP) and the Medium Term Development Program (MTDP) are being drafted at this time, providing the
opportunity to analyse current objectives to see if they address key determinants of health and ensure health
12
7
is central to poverty reduction.
Following the AFRO CMH workshop in Addis Ababa, Angola plans to elaborate a structured framework
encompassing the CMH findings, key elements of the CMH workshop discussions, and an outline of existing
Angolan public expenditure mechanisms in health. This will aim to integrate the MH process into current
national development plans and initiatives.
The Republic of the Congo
Epidemiological data shows malaria to be the leading cause of morbidity and mortality among the poor, with
other infectious diseases having a large impact (e.g. HIV/AIDS, TB, and vaccine preventable diseases). 15
July 2003 saw the country’s draft l-PRSP well received, with World Bank (WB) and donors agreeing to
ensure quick access to debt relief through Heavily-lndebted Poor Countries (HIPC) Initiative.
The Republic of the Congo notes that it will require significant and effective international support, both
financial and technical, in order to reach the Millennium Development Goals (MDGs). National public sector
spending on health has only reached 4.35%, so more advocacy at the highest political levels is needed in
order to place health more centrally to the budgetary planning process. An important challenge to be faced,
despite new oil revenues forecasted, is the continued heavy scheduled external debt service obligations
(currently 46% of government revenue). The economy is poorly diversified and almost entirely export-based.
The goal is to increase public health spending to 20% by 2008, and this will be a major part of the Congolese
MH strategy.
Ethiopia
The MH process is generating awareness of the important links between health and economic development
among essential target audiences. The authorities welcomed a MH approach and the opportunity to
establish a Technical Working Group under the Ministry of Health and the country's Central Joint Steering
Committee of the Health Sector Development Programme.
A Macroeconomics and Health Country Co-ordinator (MHCC) was recruited in December 2003 to assist the
Technical Working Group. The MHCC and Technical Working Group, under the guidance of the Health
Minister, will direct research to evaluate the current health care frameworks and the costs of increased
health care expenditures. The MH Plan of Action received final approval and endorsement by the Ministry of
Health in May 2003. The Technical Working Group has started to assess how the MH process can integrate
into the established PRSP. An MH workshop was completed during the Annual Review Meeting of the
Health Sector Development Programme II (HSDP) in April 2003.
Ethiopia hosted the Intercountry workshop for CMH for AFRO states in August 2003, giving the government
an international platform to share its experiences, whilst exchanging ideas on developing a country-led MH
process with other countries. In addition, visits by the Columbia University team and by WHO HQ occurred
several times throughout 2003. International experts from Columbia University provided technical expertise
in economic and technical analysis to support Ethiopian efforts to carry out needed research and build an
effective evidence base for policy development.
Ghana
A high-profile launch of the Ghana Macroeconomics and Health Initiative (GMHI) was held in Accra in
November 2002. The Ghana Commission on Macroeconomics and Health (GCMH) is carrying forward the
GMHI, analysing the Ghanaian Poverty Reduction Strategy in light of the CMH Report's findings. Six
technical papers sponsored by the GCMH were reviewed, investigating cross-sectoral factors affecting
health (published in February 2003). Ghana is focusing on three main issues: health insurance, access to
water and sanitation, and human resources capacity at village level. A Technical Working Group has
investigated performance and outcome gaps in every area of the Ghana PRSP implementation, identifying
cross-sectoral causes of health system deficiencies. In one notable outcome of the MH process, analysis
has prompted new policies and strategies that aim to increase the capacity of human resources within the
health sector.
In Ghana, the MH strategy is positioned to heighten commitment of important ministries that influence the
allocation of resources through the national planning process. In addition, Regional Ministers, a potent
political force, are being sensitized to the necessity of reassessing current health investments. Moreover,
13
•?
such downstream political support is necessary to develop the capacity of district managers to design and
implement realistic district plans. The predicted increase in the capacity to deliver essential health
interventions ties in well with Ghana's establishment of sector-wide insurance schemes. Additionally, MH
work supports MDG achievement.
The GMHI has completed several early objectives. This is embodied in three groups of reports: 1) the
technical reports commissioned by the GCMH, 2) the consultant's report “Investments in Health to Reduce
Poverty and Stimulate Economic Development in Ghana: Findings and Recommendations of the Consultant,
December 2002", and 3) the report “Scaling -up Health Investments for Better Health, Economic Growth and
Accelerated Poverty Reduction, June 2003". These three documents will form the conceptual basis for the
Health Investment Plan, along with other background materials currently in preparation. Completion in early
2004 of this analytical work will allow it to influence the PRSP and budgetary review processes and to help
develop national policies optimizing the uptake of new resources and investments.
Kenya
In March 2003, the Columbia team met with the newly appointed Minister of Health, the head of the National
AIDS Control Council (NACC) and donor organizations in Nairobi to discuss the potential value of
implementing a cross-sectoral plan for increased health investments. The Minister of Health, the NACC and
donor groups requested technical assistance to evaluate the financial needs for scaling up health
expenditures in Kenya. The President is keenly interested in expanding health prevention and interventions
in the country, making this is a pertinent time to engage in a MH process. In July 2003, a Columbia team met
with senior health and finance policy makers to discuss options for commencing the MH process and
potential linkages between existing health frameworks and PRSPs.
Since the CMH workshop in Addis Ababa, the team led by Ministry of Health's health economists has
focused on consensus building among stakeholders. Toward this objective, briefings have been carried out
for: 1) The Permanent Secretary and Director of Medical Services in Ministry of Health, 2) Permanent
Secretary Ministry of Planning and Development, 3) the Minister for Health, and 4) Chief Executive for
National Hospital Insurance fund and senior management of the Ministry of Health.
The team has also finalized the Plan of Action for Phase 1 for the next 6 months. It aims to link the MH
process and subsequent health investments to: 1) the Economic Recovery Strategy (ERS) investment
programme; 2) the next National Development Plan (2006-15); 3) the national budgetary process; and 4)
and UN Development Assistance Framework Group (UNDAF) workplan.
The Republic of Malawi
Political and socio-economic development is constrained since Malawi is a landlocked, single cash crop
agricultural economy with concentrated ownership of assets, limited foreign and domestic investment and a
high population growth and density. Malawi participated in the CMH workshops in Addis Ababa, but is still in
the preliminary stages of deciding how best to use the findings of the CMH Report. As a Heavily Indebted
Poor Countries (HIPC)-I country, the delegation felt that a possible CMH entry point was the reallocation of
funds, previously tied to servicing external debt, into the PRSP-defined poverty reduction objectives. The MH
process will be located in Ministry of Economic Planning & Development (MOEPD). The MOEPD holds
cross-sectoral meetings once a month on development programmes and projects. The other opportunity is
that the MOEPD coordinates the activities of the PRSP jointly with Ministry of Finance.
Mozambique
"It is strong health and education services that give people the tools they need to take advantage of
expanding economic growth." - Dr. Humberto Cossa, Director, National Directorate of Planning, Ministry of
Health.
Mozambique has made significant progress in conceptualising various strategic options for investing in
health. In 1999 an Action Plan for the Reduction of Absolute Poverty (Plano de Ac^ao para a Redu^ao da
Pobreza Absoluta—PARPA) defined the actions and priorities to be implemented across sectors. PARPA
was taken as the basis for the design of the Interim Poverty Reduction Strategy Paper (PRSP). Linkages to
the Medium-Term Expenditure Framework (MTEF), giving emphasis to the objective of poverty reduction,
are being defined.
14
The goals of the MH process in Mozambique are to streamline the analysis and evidence of the CMH Report
into the national development agenda: Accelerated Economic Growth and Absolute Poverty Reduction.
Mozambique views the Minister of Health as the "pivot of the process", who will lead efforts to assess
studies, available data and policy documents so as to formulate a country-specific report on
Macroeconomics and Health. Important steps include assessing the interrelationships and the opportunities
presented by the "Health Expenditure Review" (PER), the "Expenditure Tracking and Service Delivery
Survey", and the "National and Sectoral Medium Term Financing and Expenditure Framework".
Phase 1 of MH work will concentrate on effective advocacy and social mobilization and the use of good
communication techniques. The overarching objective is to put into place a solid basis for the design of a
long-term investing in health strategy. Ownership building, particularly inclusion of bodies such as 2025
National Development Agenda Council, will be emphasised.
Nigeria
Nigeria accounts for 13% of sub-Saharan Africa's GDP and 55% of West Africa's GDP, so an enhancement
of Nigerian socio-economic progress could have tremendous spill-over effects for the continent. Oil and gas
account for 20% of GDP, 95% of foreign exchange earnings and up to two thirds of government revenue.15
A significant window of opportunity currently presents itself to initiate a multi-sectoral process that will
generate development of a Health Investment Plan integral to poverty reduction mechanisms. It is important
to note that Nigeria is a heavily indebted poor country with severe debt-servicing constraints, even with the
nonconcessional rescheduling of Paris Club debts (December 2000). Access to bilateral credits is virtually
non-existent, while commercial credit exists only at market rates.
Nigeria's Minister of Health chaired an important session which closed the 2nd Consultation on
Macroeconomics and Health, "Increasing Investments in Health Outcomes for the Poor” (28-30 October
2003), synthesizing the various themes of the meeting and helping push forward the draft Declaration from
the Consultation. Following this Consultation, the Minister of Finance from Nigeria chaired part of the
recently-completed High-level Forum on the Health MDGs, co-sponsored by WHO and the World Bank.
Nigeria also chaired a number of sessions at the 53rd Regional Committee which took place in September
2003 in South Africa. Present were 45 ministers of health from the AFRO region who unanimously endorsed
the CMH agenda and requested WHO to provide technical support to countries.
Nigeria's MH process is to be directed in the Department of Health Planning and Research of Federal
Ministry of Health. This department has a government mandate to coordinate the implementation of the
health components of ongoing initiatives such as NEPAD, PRSP, MDG, etc. Social mobilization will be
embarked upon concurrently, in partnership with other sectors such as Women Affairs, Water resources,
Environment, Agriculture and Education. Various partners (e.g. NGOs, civil society, donors, etc) will be
targeted for a comprehensive briefing on the relevance of CMH findings and recommendations to Nigeria.
This will spur national ownership of the process and gamer the support required to the implement the CMH
action agenda.
The Phase 1 objectives comprise two main prongs: 1) to build consensus on the relevance of the findings of
and recommendations of the CMH Report at federal, state and local levels, and 2) to set up an appropriate
institutional mechanism for moving forward the MH agenda in Nigeria. The latter includes defining linkages
to the PRSP efforts and support for establishing National Health Accounts to track the sources and flows of
funds to and within the health sector. This includes economic research studies, analysis of intervention
options and assessment of financing mechanisms. Once funding is secured, the government will inaugurate
a national mechanism to drive the MH process, create a concept paper on MH in Nigeria, and develop the
specific operational strategy to integrate relevant CMH findings into long-term health investment strategies.
Rwanda
In March 2003, a team from Columbia University visited Rwanda at the invitation of the President of
Rwanda, the Minister of State for HIV/AIDS, and the Executive Secretary of the National AIDS Commission
(CNLS). The purpose was to identify how the MH process could be adopted. A PRSP was completed in
June 2002, with a priority on rural development and agricultural transformation. The aim was to realize a real
annualised GDP growth rate of 6-7% and to reduce poverty from 60% in 2001 to 30% by 2015. The Minister
15 Source: Foreign Direct Investments December/January issue, 8 December 2003, Financial Times Business.
15
of Finance and Economic Planning and the Minister of Health both worked with WHO to develop a
Macroeconomics and Health Strategy. Initially, the plan will focus on four areas for analysis and research:
1.
2.
3.
4.
The potential contribution of community health insurance schemes (‘health mutuels') to finance health
service delivery and improve access to healthcare in Rwanda;
Strategies for enhancing the salary, professional development, and incentive packages of health
professionals in the public sector to enable the scale-up and sustainability of public health programmes;
An evaluation of spending on major health interventions, and the need to prioritize health care
expenditures;
The macroeconomic impact of healthcare spending in Rwanda.
Focal points are the Director of PRSP Planning and Monitoring in the Finance Ministry and the Director of
Planning for the Ministry of Health. Columbia University has placed an in-country adviser to support these
individuals as well as the Secretariat for the National Task Force.
Senegal
On 28 April 2003, the International Monetary Fund (IMF) approved a new 3-year agreement under the
Poverty Reduction and Growth Facility (PRGF) mechanism to support Senegal’s economic reform program
for 2003 to 2005, totalling about US$ 33 million. This is closely articulated with the Senegalese l-PRSP
framework and is heavily reliant on wide-ranging structural reforms. At this critical juncture, Senegal wishes
to ensure the centrality of essential health interventions, and that macroeconomic analysis carefully looks at
health outcomes when deciding upon the shape and nature of proposed structural reforms.
The Ministry of Finance has primary responsibility for defining a global public expenditure control policy. As
Senegal moves to full implementation of a MTEF through a PTIP (programme triennial d'investissement
public), capital budgetary expenditures will become more scrutinised, especially since they will be linked with
the performance based budgeting (PBB), introduced in 2002 to the health and education sectors. Of note,
Senegal has identified a reduction in HIV/AIDS growth as a high priority. This implies a substantial public
health component to ensure achievement of this objective.
The MH process can provide a strong analytical and evidence-based argument for significantly increased
health investments. Phase 1 objectives for Senegal revolved around two main thrusts: wide dissemination of
key messages from the CMH Report, and the development of a national and high profile mechanism to
manage and sustain the MH process. The country wishes to support the creation of an evidence base
showing the impact of various health investment scenarios upon health outcomes, especially for the poor.
United Republic of Tanzania
During the AFRO workshop in Ethiopia, participants from Tanzania and Zanzibar proposed a Framework for
CMH Plan of Action covering November 2003 to March 2004. Two principal objectives were identified: 1) to
build consensus on the relevance of the findings and recommendations of CMH, and 2) to establish
institutional arrangement for facilitating implementation of the CMH recommendations.
Good opportunities exist for sparking strong interest in the MH process. For example, Tanzania will place the
CMH Report's findings as an agenda item in the annual health sector review, as well as in the PRSP
reviews. Additionally, joint meetings of the Ministries of Health of the Tanzania Mainland and Zanzibar will
seek to best coordinate efforts and leverage their various experiences.
Uganda
Several entry points for commencing a MH process were identified by Uganda's participants to the CMH
workshop in Addis Ababa. Core on-going processes, for which the mechanism to manage the MH process
can be linked, include:
1.
2.
3.
4.
5.
6.
7.
Revision of the PRSP (PEAP)
Developing Health Sector Strategic Plan II
Studies to generate evidence for Health Sector Strategic Plan (HSSP) II, e.g. burden of disease studies
National Health Accounts
Health systems performance assessment and the Benefit Incidence Analysis
Inter-ministerial efforts to improve health and level of funding
Health sector working group
16
The principle outcome sought for the first six months is the forging of a consensus on carrying forward the
work on MH at the country level. The objectives are:
•
Define the framework and structure for articulating health and development.
•
Outline the advocacy package for investing in health.
The MH process will be located in the Prime Minister's (PM's) office, as the PM's mandate will be to
coordinate inter-ministerial health financing. The comprehensive approach to health and economic
development will be discussed during the upcoming scheduled PRSP review. This will also delineate
linkages and potential synergies with the revision of the Poverty Eradication Action Plan (PEAP) and the
Health Sector Strategic Plan (HSSP) II development process.
2.
The Americas Region (PAHO/AMRO)
PAHO/WHO has suggested opening a dialogue on the implications of the CMH Report for the Americas,
initially with a few key regional stakeholders such as the Central American Integration System (SICA), the
Andean Health Agency (ORAS), and MERCOSUR.
PAHO's success in the HIV/AIDS strategy to mobilize health investments for anti-retroviral packages has
been noted. The importance of having a macroeconomic foundation for managing the health sector has
been stressed. At the country level, PAHO/WHO is interested in incorporating National Health Accounts into
the local MH process as basic tools. They also feel that the MH-triggered research will contribute to the
epidemiological database to assess the burden of disease of the poor and options for cost-effective
interventions.
The regional office participated in the 2nd Macroeconomics and Health Consultation, "Increasing
Investments in Health Outcomes for the Poor", 28-30 October 2003.
Caribbean Community
The 15 member states that make up the Caribbean Community (CARICOM) have set up a Caribbean
Commission for Health and Development. CARICOM includes Antigua and Barbuda, The Bahamas,
Barbados, Belize, Dominica, Grenada, Guyana, Haiti, Jamaica, Montserrat, St. Kitts and Nevis, Saint Lucia,
St. Vincent and the Grenadines, Suriname, and Trinidad and Tobago. On 22 September 2003, the official
launch of the CARICOM CHD announced the plan of action and objectives for the Commission. Chaired by
the former head of PAHO/WHO, Sir George A. O. Alleyne, this Commission is patterned after the WHO
CMH, and is charged with the responsibility of providing guidelines for action to the 15 member states. The
overall goal is to "give substance to the Nassau declaration that the health of the region is the wealth of the
region and respond to Millennium Development Goals in which health and development are priorities."
A policy framework is being developed to assist the CARICOM member countries in structuring their health
and development agendas. This will be accomplished by a clear assessment of all determinants of health,
coupled with selected studies on burden of disease and cost-effectiveness analysis. A macroeconomic
framework will assess the aggregate returns for areas such as direct foreign investment, tourism and trade
that can be expected by a coherent long-term strategy towards investments in health. Research proposed
includes papers on the labour market returns to health and inequalities in health and income. Such research
will convince senior government leaders of the necessity for increased health investments that are pro-poor.
An 18-month timeline guides the creation of a framework establishing priorities for health financing, including
public/private partnerships and the sharing of services. The framework, plus locally developed evidence, will
help member states structure their health and development agendas in an interrelated manner, while
focusing on provision of pro-poor health services. An important outcome for the Community is partnership
building, catalysed by multi-sectoral workshops to be sponsored in the various member states.
The Caribbean Community has obtained donor support for a significant part of their work plan, showing the
value of engaging all local stakeholders into the earliest stages of developing a work plan for implementing a
MH strategy. PAHO/WHO will be the executing agency and will provided needed technical support in concert
with WHO-HQ, using local and regional technical experts when possible.
17
El Salvador
The Ministry of Health of El Salvador organized the first of a series of three seminars on Macroeconomics
and Health in cooperation with PAHO/WHO. Held in May 2003, the first seminar included a presentation of
the recommendations of the CMH Report, a presentation on National Health Expenditures in countries of the
Latin American and Caribbean (LAC) region and the presentation of detailed studies on Health Accounts
from El Salvador. The second seminar (September 2003) focused on health, equity and poverty issues.
The first and second activities are preparatory activities to launch the national MH Commission, which will be
the third activity to take place in 2004. El Salvadorian officials are working through the local PAHO office to
initiate the mechanisms to get WHO support to:
•
sponsor participation of a high-visibility participant at the El Salvador CMH launch; and
•
develop a long term MH strategy, using focused technical support and experts working
collaboratively with a high-level national mechanism.
Mexico
The Mexican Commission of Macroeconomics and Health (CMMS) was inaugurated in July 2002. Since
then, the Commission has scheduled periodic meetings, set up a web site to disseminate the Report findings
widely, and outlined plans for forward movement of the process. The WHO/PAHO representative is
coordinating the preparation of the proposal. Based on the consensus reached on the priorities and activities
for the joint work plan, WHO/PAHO will also work with the Secretariat to assess funding sources. The CMMS
continues moving forward towards the completion of a report on the different aspects of the relationship
between health and economics in Mexico.
In order to better organize this challenging research project the CMMS was divided into five working groups,
each of them coordinated by one of its members. The groups were established based on a careful process in
which policy needs were prioritized. Each group will generate a report that would feed the CMMS's final
product. The five working groups are the following: (1) Diagnosis of the health status of the Mexican
population and of the public health system vis- a-vis the achievement of the MDGs, (2) Health, economic
development and poverty reduction, (3) Intra and inter sectoral health related public policies, (4) Health
insurance and social protection and (5) .Global and regional public goods for health in Mexico.
3.
The Eastern Mediterranean Region (EMRO)
In WHO's Eastern Mediterranean Region, the Commission on Macroeconomics & Health (CMH) Report was
discussed at the 18th Meeting of the Regional Director with WHO Representatives and Regional Office staff
in October 2002, with the participation of the CMH Secretariat. Further, EMRO's 26th Regional Consultative
Committee (RCC 2002) commissioned work to assess the "impact of economic trends on health care
delivery with special emphasis on deprived populations." The 27th RCC meeting (July 2003) noted that an
EMRO task force on Macroeconomics and Health was formed and discussions with Headquarters
colleagues culminated in a proposal and a plan of action to support poor countries in the region. Moreover,
they placed on the 28th RCC agenda (July 2004) another issue relevant to macroeconomics and health:
mechanism for prioritization of public health problems in the region and health research priorities.
On 9 June 2003, representatives of the CMH Secretariat participated in an "Experts Consultation to Discuss
the Regional Strategy on Sustainable Health Development and Poverty Reduction" in Fez, Morocco. Along
with World Bank representatives and other partners, CMH joined a roundtable discussion on strengthening
the mechanisms for collaborative vision and integrated work within and outside WHO.
Linked to the Expert's Consultation, the WHO/HQ and EMRO hosted a Meeting to Facilitate the
Implementation of CMH in the Eastern Mediterranean Region, 13-14 June 2003 in Fez. Themes from the
Expert's Consultation fed into the CMH workshop, particularly the drive to build upon Community-Based
Initiatives (CBI) and incorporate lessons learnt following the World Bank Development Report (1993) into
current efforts for long-term investments in health. Country, Regional and the CMH Support Unit staff came
together to draft CMH national plans and a regional MH strategy.
Main themes from workshop discussions stressed that operationalizing MH work requires a solid
government commitment to reallocate national budgets and seek additional internal resources for health.
18
The success of Health Investment Plans will also rely on clear outcome tracking, strong supervision and
addressing known constraints realistically by offering practical steps to remove barriers. EMRO supports
country strategies that link MH work to WHO initiatives (e.g. Community Based Initiatives, "3 by 5"), as well
as with existing national mechanisms such as PRSPs and Sector Wide Approaches (SWAps). Finally,
participants agreed that investment plans should show a coherent path towards achievement of the MDGs.
The Regional Concept paper on sustainable development was presented at the Regional Committee (RC)
for the Eastern Mediterranean (29 September - 2 October 2003, Cairo). Ministers of Health, other RC
delegates and the Regional Secretariat approved the paper, entitled "Investing in Health of the Poor:
Regional Strategy for Sustainable Health Development and Poverty Reduction".
In March 2004, a joint WHO mission from CMH and the MDG/PRSP team met with EMRO focal points for
sustainable development, Basic Development Needs (BDN) and CMH follow-up. EMRO staff requested that
WHO/HQ work with them to develop a more coherent range of analytical and technical tools, which could be
made available to WHO country offices. Such tools would help national ministers and WHO representatives
(WRs) clarify the strategic linkages needed among various initiatives (such as PRSP, Heavily Indebted Poor
Countries (HIPC) Initiative, Global Alliance for Vaccines and Immunizations (GAVI), Global Fund for AIDS,
TB and Malaria (GFATM), etc.) and national policies.
Djibouti
The Minister of Health gave a presentation at the 2nd Consultation on Macroeconomics and Health,
"Increasing Investments in Health Outcomes for the Poor", 28-30 October 2003. Describing efforts to
implement a Macroeconomics and Health strategy, he noted that Djibouti has a poor physical and human
resource base. Furthermore, Djibouti has some of the highest rates of poverty, illiteracy, morbidity, and
maternal and infant mortality in the world. As the Ministry of Health's allocation has dropped from 5.7% to
4.2% of the total government budget, the Minister places a priority on raising awareness among senior
government leaders of the centrality of health to developmental strategies. The country has just commenced
the first stage of a multi-year programme to reduce poverty, improve health and other social sector outcomes
and spur economic growth and development. The World Bank and USAID have recently agreed to fund
health and educational interventions in Djibouti with a total of approximately US$ 50 million over the next
three years.
Initial MH efforts aim to insert a strong health component into the World Bank and USAID programmes for
restructuring and reform, which accompany the national development plan. Currently, the national
macroeconomics steering committee and CMH technical group are being put in place, to be directed by the
Health Ministry. As over 50% of the health budget is funded externally, Djibouti finds its national priorities
dictated by external donors. Cooperation between the Ministries of Health and Finance is increasing, but the
health sector is allotted a very small portion of internally-generated resources.
In October 2003, a member of the Secretariat spent nine days in discussions with the Secretary General for
the Ministry of Health and the Director of Budgets for the Ministry of Financing and Planning. This led to
revision of the Djibouti work plan and a preliminary situation analysis in which epidemiological and economic
data was collected and collated. Additionally, Djibouti was assisted in preparing for their participation at the
2nd Consultation on Macroeconomics and Health in Geneva (28-30 October 2003), where they gave a wellreceived country presentation on their perceptions of the MH process.
A follow-up visit by a member of the CMH Secretariat as well as by a consultant health economist from
EMRO took place in January 2004. The objective was development of a concrete plan of work to draw up a
national Health Investment Plan by October 2004.
The Islamic Republic of Iran
The highest levels of the Ministries of Health, Planning and Budget have debated the CMH
recommendations. The Deputy Minister for Social Affairs felt that the provision of technical support to
analyse existing data, which could then be used to develop an evidence base for pro-poor policies, would be
critical for success.
Medical education is integrated under the Ministry of Health, with provincial health ministers also filling the
role of medical school deans. Iran is building upon the success of recent poverty alleviation initiatives to
increase community involvement in health. One important gap they have identified is the weakness of current
19
information management systems, which are inadequate for generating an analysis useful to decision
makers. WHO is being requested to aid in identifying IT tools, and the Regional Office and HQ will work with
Iran to explore various options to remove this constraint to progress.
In assessing the macroeconomic and political constraints to increasing pro-poor health services, the Deputy
Minister for Social Affairs noted that Iran and many other countries are facing opposing inputs: on one side
are "neo-classical inputs pushing privatisation and downsizing of public sector services" while on the other
side are calls for "increasing investments in health services to the poor, which can only be delivered by the
public sector". The resolution of this "political question" needs the involvement of WHO in its role as global
advocate for equitable health services.
In June 2003 Iran sent a team to the EMRO CMH meeting that included the Deputy Minister for Social
Affairs. Iran notes that a 5-year health & development plan is being finalized now, creating a window of
opportunity for ensuring the centrality of health to poverty reduction and sustainable development strategies.
The country feels that the basis of such multi-sectoral planning should be reliance on Iran's internal
resources, with reallocation based on evidence. These comprise two prime objectives of Iran's Phase 1 work
plan for Macroeconomics and Health.
Jordan
The government of Jordan is embarking on a social and economic transformation program of which health is
a prominent component. Intersectoral collaboration is also evident in the establishment of the National
Committee on CMH with representatives from the Ministry of Planning, Ministry of Finance, and other
concerned parties. Health problems such as malnutrition, diarrhoea, infant and maternal mortality, clean
water and sanitation and access to a functional referral system and quality care are considered to be
impacting the poor disproportionately. Basic essential interventions that have greatest impact on the poor are
needed, and this requires a planned intersectoral effort (clean water, adequate sanitation, primary education)
with appropriate policies and mobilization of resources to respond adequately and equitably to the health
needs of the poor.
The government of Jordan is highly committed to advancing the CMH model by expanding evidence-based
essential interventions to all people, including the poor and disadvantaged. Therefore, in December 2002,
the Prime Minister has established a high-level National Committee to respond to the CMH initiative, chaired
by the Health Minister and including the Minister of Planning and the Secretary General of the High Health
Council. A technical committee has emerged and is charged with developing a strategy and plan for health
services consistent with the CMH model.
Currently, the High Health Council (HHC) is leading the effort to develop a pro-poor Health Investment Plan
in cooperation with a local consultant and the Technical Committee on CMH. The HHC's efforts are directed
at the policy and strategy level and aim to improve health system performance and to achieve effectiveness,
efficiency and equity in health services in Jordan. A Jordanian team from the HHC, Ministry of Health,
Ministry of Planning, and Ministry of Finance, attended all the regional and international meetings on CMH
organized by the WHO.
There are plans to establish a country-wide health information system. This will facilitate decision-making
and foster cooperation between the different health sub-sectors. The Healthy Villages Program is considered
to be one of the successful experiences that can be built upon, because it can effectively meet the needs of
the poor in Jordan. Expansion of this program to include more villages is under consideration. The Healthy
Village Program is an example of what an intersectoral approach can achieve.
Human resources development is one of the top priorities in Jordan. Two studies to assess the dental and
nursing workforce situation in Jordan are underway. These studies are being conducted by the High Health
Council in cooperation with consultants from local universities. Another response to the health needs of the
poor is development of a universal health insurance program, a topic currently under study in Jordan.
Next steps to implement a National Health Plan:
1.
The CMH concepts are rarely disagreed upon and therefore advocacy in this regard is not difficult.
However, a national body with a full mandate is needed to maintain momentum and enthusiasm for the
MH process.
20
2.
Effort is needed to identify the poor so as to reach them with well-targeted interventions.
3.
In order to reach a consensus on a list of essential evidence-based, feasible interventions, technical
assistance will be needed during the process.
In Jordan, work to develop a national Health Investment Plan has already started and is expected to be
finalized in a few months.
Pakistan
Pakistan has a multi-pronged approach to reducing poverty, based on the Poverty Reduction Strategy Paper
(PRSP) and incorporating 1) acceleration of economic growth, 2) governance reforms, 3) expanding social
safety nets, and 4) investing in human resources. Health sector investments are viewed as part of the
Poverty Reduction Plan, with attention shifting to the provision of primary care and community-based
initiatives. The foundation of the current health sector reform process is felt to be improved governance. As
the PRSP is already finalized, the objective for Pakistan will be to disseminate the major findings of the CMH
Report, translate them into the local macroeconomic context, and use them to define research to construct
an evidence base for integrating health into the PRSP. While reaching the MDGs is a high priority, the
pressing need is to reach the 45% of the population that currently does not have access to essential health
services.
At the EMRO CMH workshop, the WHO Representative (WR) stressed that technical support was more
urgently needed than financial support and that increasing local institutional capacity was critical. He felt the
entry point for implementing CMH-related findings will be the augmentation of the capacity of countries to
carry out strategic thinking and policy analysis that can support a multi-partner, multi-sectoral strategy for
health and poverty reduction.
The Secretary of the Ministry of Health made the case that the MH process provides an opportunity to re
examine health strategies from a macroeconomic perspective. He strongly suggested to EMRO colleagues
that each health ministry form a distinct "policy development" unit that has high political clout, adequate
resources to "conduct macroeconomic analysis for strategic planning", and includes at least one health
economist and one political strategist. This will aid in devising policies and strategies that will win support
from the most senior levels of government. He also stressed that the chair be the prime minister or
president, someone who could break down sectoral walls and foster bold initiatives to strengthen all the
determinants of health. The NCMH should also have technical working groups dealing with research,
analysis, policy development and implementation. These would be chaired by influential political leaders,
respected for their technical ability, and able to take concrete steps to achieve desired outcomes.
Sudan
Sudan is a large country of nearly 32 million inhabitants that must cope with almost 1 million internally
displaced people and a rural population of about 10 million. Within the context of severe civil strife and a
large trans-national migrant population, long-term strategic health planning must rely on coordinating a
diverse network of internal and external partners, aid agencies and other agents. Since the push for primary
health care, there has been a marked inability to foster intersectoral collaboration or achieve coordination of
various plans even within one public sector. The PRSP is merely one of many UN initiatives, and the
government feels some integrated framework to rationalize all these initiatives is needed. They expressed
the hope that the CMH focus on building up existing networks and strengthening partner networks will lead
to a real cross-sectoral dialogue and participation in poverty reduction efforts.
The WR has pointed out that there is a window of opportunity presented by HIPC funds since the
International Monetary Fund has agreed that 100% of these released obligations will be applied to the
PRSP. The National Plan for Health Investments will aim to take advantage of this. Senior Ministry officials in
delegation (Finance, Health, Social Welfare) discussed and revised the MH workplan.
A joint WHO CMH/PRSP mission visited Sudan in March 2004. Based on feedback from the Ministries of
Health and Finance, the team suggested that the government use the momentum provided by the MH
process to build upon increased inter-ministerial dialogue and seize the opportunity for more holistic
approaches for health sector planning. Furthermore, it could employ a health systems framework to restate
key health policy issues, allowing strategic options to be addressed effectively, while reconciling immediate
post-conflict activities with broader, more comprehensive development of the health sector.
21
Yemen
Yemen's Coordinator for the Macroeconomics and Health Program (MHP) attended the EMRO CMH
workshop accompanied by the Assistant Deputy Minister for Foreign Affairs from the Finance Ministry and
the Director General of Projects from the Ministry of Planning. The team identified the following priority areas
for work: 1) the determination of burden of disease of the poor and vulnerable, 2) advocacy, and 3) the
creation of a consensus among stakeholders. The health sector reform initiative was identified as an entry
point for the MH process. The PRSP process will be the vehicle for operationalizing the MH process, with the
Yemen MHP Coordinator maintaining momentum and developing buy-in from influential stakeholders.
The Coordinator of the MHP is located within the Ministry of Public Health and Population. The Ministry has
set up an inter-sectoral National Commission on Macroeconomics and Health to adapt the CMH Report to its
national strategic priorities.
At the request of the Ministry of Health of Yemen and the WHO Resident Representative of Yemen, a joint
PRSP and CMH mission from WHO Geneva visited Sana’a from 9 to 12 March. The objectives of the
mission were to assist the Ministry of Health in strengthening its health sector strategy, which will then feed
into the PRSP, and to assess the role of the Macroeconomics and Health initiative in supporting this process,
as well as identifying areas in which WHO-HQ could provide further support.
The main findings of the mission were that the Health Investment Strategy being developed by the MH
process can be an effective tool in linking goals, health systems function strategies and health expenditure
plans as well as a tool for advocacy. The team recommended that the MH work focus on:
1) Analysis: Using the three themes of the CMH Report to assess the evolving health sector strategy.
a)
Pro-poor strategies: assess if current and proposed strategies specifically target interventions to
improve the health status of the poor (e.g. primary health care (PHC) over tertiary care, and
preventive over curative interventions, etc.). Then, assess if the implementation strategy includes a
data collection strategy that allows monitoring and evaluation of outcomes and impact on the poor
(e.g. are epidemiological data, household health spending surveys and assessment of health facility
usage being disaggregated by household income quintiles, etc.)
b)
Greater financing for health. Assessment of the financing gap to look at both options for internal
reallocations of funds to health and how external funds can predictably fill gaps. Includes commission
of studies to develop a localised impact analysis of the socio-economic benefits of significantly greater
investments in health, especially PHC and improving access to essential health interventions among
the poor and rural populations.
c)
Removal of system barriers to access by the poor. The primary focus is to stimulate a dialogue on
how the various health and health-related sectoral strategies (e.g. education, water, and sanitation
strategies) can be harmonized, how local evidence can be used to set priorities, and how the various
strategies can be correctly sequenced to sustain achievements. Strategies should explicitly consider
how to progressively build up institutional and human resource capacity, using progress towards the
MDGs as one way of tracking success.
2)
Planning: The MH process works within the Ministry of Health to assess the quality of the evidence base,
commission research to fill gaps (two papers are being completed to address these first two points), cost
various health strategies, and then determine priorities and sequencing of strategies. This well-costed
and evidence-based strategy will be the basis for requests for increased internal allocations and donor
support.
3)
Implementation: The national CMH team has drafted a Terms of Reference fora coordinating body that
can provide input into health sector strategy, advocate for greater public expenditure on health and track
the impact over time of the pro-poor elements of health plans. Two short-term objectives, incorporated in
the PRSP, are to:
a)
b)
Support National Policy on Essential Drugs and Logistics, including the review and approval of the
Essential Drug List and National Treatment Guidelines
Encourage NGOs to participate in provision of health services (e.g. Yemen Family Health Association).
22
4.
The European Region (EURO)
Following the release of the CMH Report, the Regional Director of the WHO European Region decided to set
up a special Task Force to assess the relevance of the Report's findings to the Region and propose specific
interventions. The Task Force work plan is in line with the implementation of RC52 Resolution on Poverty
and Health (EUR/RC52/R7). The first meeting of the EURO Task Force was held at the end of January
2003, in videoconference link with WHO Geneva and the European Observatory on Health Care Systems in
Brussels. A strategy was outlined for follow-up and for the assessment of available resources.
Preliminary analytical work of the Task Force has highlighted that:
1) EURO countries, even at the lowest income level, have a health system in place, a tradition of public
health, a work force with a higher level of skills and a better developed infrastructure than countries at a
comparable level of economic attainment elsewhere;
2) Health data show relatively lower levels of infant, child and maternal mortality and high levels of adult
mortality;
3) Predominant health challenges are more complex than in developing countries from other Regions, and
include chronic non-communicable diseases, such as cardiovascular disease and injuries, or more difficult
infectious diseases, such as multi-drug resistant tuberculosis.
EURO participated in the 2nd Macroeconomics and Health Consultation, "Increasing Investments in the
Health Outcomes of the Poor", 28-30 October 2003, in Geneva.
Azerbaijan
A Country-Wide National Workshop on "Poverty and Health" was held in Baku on 19-21 November 2003.
The workshop was a joint collaboration between the Ministry of Health of Azerbaijan, the European Regional
Office of the World Health Organization (EURO) and WHO Headquarters. The objectives were to:
•
•
•
•
Familiarise participants with the notions of investing in health for development;
Provide an overview of the challenges and successes of integrating health in the PRSP;
Provide an overview of how different health system functions and technical programmes are changing
to better tackle the problems of the poor in Azerbaijan;
Explore concrete examples of integrating social and economic determinants of population health into
policy development.
The workshop blended theoretical and scientific input with practical tools useful for participants involved in
decision-making at different levels of policy development in Azerbaijan. Practical experiences and case
studies were utilized.
This occurred within the context of the new Biennial Collaborative Agreement between the Ministry of Health
of Azerbaijan and EURO for 2004 to 2005. One priority element of this agreement is the participation of a
country representative in a "knowledge forum on pro-poor health action", with the purpose of supporting
policy-makers to exchange experience on managing progress towards placing health in the context of
poverty reduction strategies and MDGs.
At this time (January 2004) WHO/HQ are collaborating with the WHO country office and Ministry of Health of
Azerbaijan to determine the best ways to move forward. One possibility, dependant on funding, is the
placement of a short term consultant in Azerbaijan to help with efforts to integrate health into the broader
development agenda.
Baltic States sub-regional initiative: Estonia
Estonia is a middle-income country in transition, a new member of the World Trade Organization steadily
moving toward a market economy with increasing ties to the West, including the pegging of its currency to
the euro. A major goal is accession to the EU, possibly by 2004. The overall health status of the Estonian
population has been found to be poor as compared to EU and Nordic countries, for some problems lower
than the reference countries of Central Europe. Infant mortality rate is 12.32 deaths/1,000 live births. Among
the main health problems affecting Estonia are cardiovascular diseases, chronic liver disease and cirrhosis,
alcohol abuse, occupational health and violence-related problems. Tuberculosis and HIV/AIDS are raising
particular concern and have contributed to most of the 50% increase in infectious disease mortality since the
late 1980s. Lack of estimates of poverty (as well as homelessness) is an obstacle to in-depth analysis of the
23
links between poverty and health problems, but a 2002 study commissioned by the World Bank and Ministry
of Social Affairs of Estonia reached the conclusion that wide inequalities exist and are worsening.
In March 2003, WHO presented its work on the MH approach to a group of decision-makers and officials
from the Estonian Ministries of Social Affairs, Foreign Affairs and Finance, academic representatives and
international agencies. The Government has expressed an interest in the CMH approach, and a member of
the Secretariat gave a presentation on MH strategies entitled, "Investing in Health to Reduce Poverty and
Spur Development." Good interactions and dialogue followed the meeting, and Estonia is considering ways
to follow up.
5.
The South East Asian Region (SEARO)
The Regional Office in South East Asia has been active in communicating to countries the relevance of the
CMH Report. SEARO has established a dedicated Working Group to engage in disseminating the Report's
findings, making policy decisions regarding implementing its framework in the countries, and providing
support to countries in this effort. Inter-ministerial and intersectoral meetings involving donors, development
agencies, NGOs, media, and academia, for disseminating the core messages of the CMH Report, preceded
the work. A Regional Conference of Parliamentarians on the CMH Report was held in December 2002. The
Report was also on the agenda of the recent meeting of the Regional Director with WHO Country
Representatives, in April 2003. Earlier, the meetings of Health Secretaries and Health Ministers, held in April
and September 2002, had the CMH Report on their agendas.
In conjunction with the above meetings, the Regional Office finalized the Country Guidelines for CMH
Follow-up and a related document, Outline for a Strategic Framework and Investment Plan.
In response to country interest and need for support, SEARO organized the Regional Consultation on
Macroeconomics and Health for the South-East Asian Region (SEAR). This meeting was held at the World
Health House in New Delhi on 18-19 August 2003. The meeting brought together representatives from the
Ministries of Health, Finance and Planning from 9 SEAR countries, including Bangladesh, Bhutan, India,
Indonesia, Maldives, Myanmar, Nepal, Sri Lanka, and Thailand. Also, East Timor-Leste was represented by
the head of the WHO office in that country. Other participants included WHO representatives from HQ,
Region and Country level and representatives from the World Bank, Columbia University, and USAID.
The meeting provided the countries a venue to discuss and share experiences and challenges in this
process. Also, the countries had an opportunity to work with the WHO offices at all levels to discuss the
support needed in terms of advocacy, technical work and building alliances with donor and development
partners. Out of deliberations among countries, country status presentations, and outcomes of working
groups, several considerations and challenges associated with planning and implementing a MH strategy
were identified by the SEAR countries. These issues are the foundation of future coordination of efforts
among countries, WHO offices, funding entities, and other partners.
Bangladesh
Bangladesh has made significant strides in improving the health of its citizens over the last two decades,
including increasing life expectancy from 48 years to 61 years and decreasing total fertility rate from 6.3 to
3.3. Significant income-based inequality in health and in the provision of health services, however, continues
to be an important issue. Bangladesh is currently participating in various poverty reduction and health
promotion strategies in partnership with bilaterals, including developing a i-PRSP and receiving funding from
the Global Fund for AIDS, TB and Malaria.
In this setting, Bangladesh plans to build on the available data and analyses done in conjunction with these
initiatives and to supplement this information with further work on pro-poor planning and policy formation.
The government is committed to a pro-poor health strategy that targets resources for priority health
objectives and the Essential Services Package (ESP) within its new Health, Nutrition and Population Sector
Programme (HNPSP, 2003-2006).
A successful advocacy workshop held by the Ministry of Health and Family Welfare and the WHO-Dhaka
office in May 2002 and Ministerial representation at the Regional Conference on Macroeconomics and
Health in August 2003 initiated the Bangladesh MH work. Currently, the Ministry of Health and Family
Welfare is in the process of establishing a NCMH equivalent - the National Commission on MacroHealth and
Poverty Strategy - with the Health Economics Unit of the acting as the secretariat.
24
7
A work plan has been developed for the Commission which emphasizes continued advocacy activities
linking poverty and health, evaluation of the evidence available for a situational assessment and costing
identified essential health interventions.
India
India is spending less than 1 % of its gross national product on its health care budget, and private health
spending, mostly in the form of out-of-pocket expenditures by families and individuals, accounts for 82.2% of
total health expenditures. The 2002 Indian national health policy strongly advocates increased spending by
the central government. The policy envisages raising health expenditures from 5.2% of GDP in 2001 to 6%
of GDP by 2010, with government health spending increasing from 0.9% of GDP to 2% of GDP.
A well-received presentation on the CMH Report during the 2002 meeting of Health Secretaries and Health
Ministers led the Government of India, in January 2003, to establish a National Commission for
Macroeconomics and Health (NCMH), co-chaired by the Health and Family Welfare Minister and the
Finance Minister. The objectives of the NCMH are to evaluate the impact of increased investments in health
on poverty reduction and economic development and to formulate a long-term strategy for scaling-up
essential health interventions, with a focus on the poor.
A sub-commission will function as the technical and operational arm of the NCMH, with the chair and
Member Secretary already selected and the remaining spots to be filled by 1-2 economists and 1-2 public
health specialists. The sub-commission will conduct meetings and hire consultants and experts as
necessary.
The work of the NCMH has been slow to commence, but building on the momentum from the 2nd
Consultation on Macroeconomics and Health in October, the NCMH technical sub-commission is developing
a detailed work plan and budget for 2004, identifying the key issues for India and the resources that will be
needed to adequately analyse these issues. The main areas of analyses that will go into the development of
a Health Investment Plan include an assessment of the current health financing mechanisms and options for
mobilizing additional resources, costing of an essential health services package, the role of the public and
private sector in delivery of this package, and the implications of the HIV/AIDS epidemic. Overarching issues
include monitoring and accountability, decentralization, inter-sectoral coordination, ensuring equity and
economic development.
In coordination with the country, regional and HQ WHO offices, necessary linkages with technical groups
and expertise from WHO and other institutions are being made to assist the NCMH in the identified analyses
and assessments. The end product of the work of the NCMH sub-commission will be a report by October
2004 that will be the foundation of a Health Investment Plan, and further work will be undertaken to best
ensure implementation and long-lasting effects of these recommendations.
Indonesia
In 2000, total spending on health amounted to 1.6% of GDP in Indonesia, or about US$ 8 per person.
Additionally, overseas development assistance (ODA) to Indonesia averages US$ 2.3 billion annually, of
which only 6% is dedicated to the health sector. Many of Indonesia’s most significant health problems tuberculosis, malaria, infant and maternal mortality, and malnutrition - are problems from which the poor
suffer disproportionately. Indonesian children from the poorest families are nearly four times more likely than
children from the richest families to die before their fifth birthday.
The government of Indonesia will integrate its health and development initiatives under an overall
macroeconomics and health policy framework. The objectives of this framework are to 1) accelerate existing
initiatives for pro-poor policy and funding commitments: CGI (Consultative Group of Indonesia, chaired jointly
by the Coordinating Minister for Economic Affairs and World Bank), PRSP, etc.; 2) provide focused technical
assistance to address systemic issues and integrate pro-poor priorities into policy processes; and 3)
increase political commitment for health as a means of poverty reduction and economic development.
Within this framework and in the setting of fiscal decentralization and decreased economic growth, Indonesia
aims to improve overall health status through policy development and corresponding financial commitments.
To fulfil the health outcomes outlined within Healthy Indonesia 2010 and the MDGs, the Consultative Group
on Indonesia Health Working Group, the Government of Indonesia and the donor community have agreed
on a shared plan of work consisting of 6 objectives:
25
1
1.
2.
3.
4.
5.
6.
Reduce financial vulnerability to major medical expenses
Optimize the participation of private and NGO health providers in increasing coverage
Ensure pro-poor institutional environment under decentralization
Ensure sufficient resources to priority health programs (financial)
Ensure access for the poor (non-financial constraints), and
Ensure accountability by local government.
Indonesia, as part of its MH work, is in the process of completing several important areas of focused
research including the completion of a book that conceptualises health and poverty and describes the place
of health priorities within the PRSP, a report on costing essential health services, and an assessment of
human resource distribution of health care workers. Additionally, studies have been contracted to review
decision-making process for sectoral allocation and absorption issues and a review of public health
expenditures.
Nepal
Nepal’s public expenditure on health as percentage of GDP per capita is approximately 1.06%. The trend
has been a slight decrease in health sector allocations as compared to those in other sectors. By contrast,
the allocations to the education and water sectors have increased. Investment in health has increased during
the last 10 years from 2.1% to 5.2% of the overall government budget. Recent political instability, however,
has slowed this trend.
Nepal has improved many national health outcomes, with expansion of Essential Health Care to about 70%
of the population. Access to health care facilities and workers in its rural communities has significantly
improved. However, geographical variations among other health indicators persist, with rural populations
having poorer health outcomes. According to a recent situational analysis prepared by the Royal Tropical
Institute (KIT) of Amsterdam, health financing stems mainly from taxes and users fees, with the poor bearing
the brunt of these fees. There are significant resource gaps on the road to achieving MDGs.
In response to the CMH recommendations, a Sub-Commission on Macroeconomics and Health (SCMH),
part of a National Commission on Sustainable Development, has been formed. The Sub-Commission is
chaired by the Ministers of Health and Finance and is comprised of representatives from most of the
ministries, the National Planning Commission and the private sector. The WHO Representative to Nepal and
the WHO Health Planner have been in close contact with the Sub-Commission. The Sub-Commission has
identified key activities and areas of research (including advocacy workshops, epidemiological profile of
disease among specific populations, a study on private health expenditures, and developing a coordinated
effort for health sector reform and poverty alleviation) needed to move forward the MH process. Some
studies that are relevant to the work of the SCMH are being carried out by the Health Economics and
Finance Unit of the Planning Division of the Ministry of Health, including pilot projects with Social and
Community Health Insurance schemes and studies of private health expenditures.
Nepal has developed a work plan for the SCMH for 2004 and is collaborating with the Royal Tropical
Institute (KIT) of Amsterdam to carry forward the initial situational analysis and other technical assistance
relevant to the Macroeconomics and Health work.
Thailand
Many in the government of Thailand believe that to achieve better health, a holistic approach, demanding
strong support from non-health sectors, is crucial in overcoming health-related problems. The increasing
roles of development banks in various structural adjustment programmes, including health, are evident in
Thailand. Examples include the trend toward hospital autonomy and the public sector reform initiative.
In response to the CMH Report, the Ministry of Public Health of Thailand has set up a Working Group on
Macroeconomics and Health, co-chaired by the Senior Advisor to the Ministry in Health Economics and
comprised of 15 experts from the health, economic, and financing sectors. The Working Group has
developed a proposal to set up a National Commission on Macroeconomics and Health (NCMH). It has been
proposed that the NCMH be jointly chaired by the Health and Finance Ministers. A joint secretariat will be
set up comprised of representatives from National Economic and Social Development Board (NESDB) and
the Bureau of Policy and Strategy to develop a strategic framework for an investment plan targeting the
MDGs.
26
The MH process for Thailand as defined by the Working Group consists of five steps: 1) Analysis of current
situations and trends focusing on the poor and marginalized, 2) Diagnosis and prioritization of the main
health problems, 3) Examination and evaluation of selected health interventions for cost-effectiveness and
feasibility, 4) Development of a Strategic Framework and Investment Plan; and 5) Advocacy for mobilizing
political support for integration of health into poverty reduction strategies. The Working Group has identified
study on cost-effectiveness of interventions in the Thailand context in 15 diseases as a priority area of
further study.
Sri Lanka
Sri Lanka has had well known and significant successes in the public health arena, including decreasing
birth rates and death rates, increasing life expectancy to levels of developed countries and low infant
mortality rates and maternal mortality rates. However, there are still significant disease challenges for Sri
Lanka. Malaria, TB, and mental illness are on the rise and malnutrition is not under control. Sri Lanka is also
addressing current human resources issues, such as a shortage of nurses and paramedics as well as the
commitment by the government to absorb all graduating doctors through 2009.
In light of the existing health issues, Sri Lanka is assessing whether it is investing enough in health.
Compared to other countries in the region and globally, Sri Lanka’s national health expenditure as a
percentage of GDP (3.2%) is low. Sri Lanka is currently evaluating various strategies to mobilize funding for
health, including the feasibility of private insurance, community financing, ear-marked taxes, and cost
containment strategies.
Sri Lanka formed a National Commission on Macroeconomics and Health (NCMH) in early 2003 to address
health sector priorities, including mobilizing funding for health and the shortage of health care workers. The
NCMH is co-chaired by the Minister of Health, Nutrition and Welfare and the Minister of Rural Economy and
Deputy Minister of Finance and includes representatives from various ministries, the WHO Country Office,
UNDP, the private sector and academia. The work of the NCMH is synergistic with Sri Lanka’s Poverty
Reduction Strategy Paper (PRSP) and Vision 2010 -which formulated an economic development strategy calling
for sustained 7 to 9 % annual GDP growth - in developing a long-term policy that highlights pro-poor health and
development issues and achievement of the MDGs.
The NCMH is commissioning health financing studies on designing and costing a basic health care package for
the poor, human resource planning and issues of decentralization. The NCMH has also commissioned a report
entitled “Macroeconomics and Health Initiatives in Sri Lanka”.
The NCMH has developed a work plan for 2004, which will culminate in a needs-based ten-year investment
plan and report of the NCMH, based on the studies summarised above and others looking at the economic
implications of disease and scaling up interventions. Additionally, the Commission will focus on building the
capacity for MH work at the central and provincial levels, including a potential National Centre in
Macroeconomics and Health.
6.
The Western Pacific Region (WPRO)
The recent outbreak of Severe Acute Respiratory Syndrome (SARS) led the Western Pacific Regional Office
to devote scarce resources to confronting this grave event. In spite of this, they continue to support strongly
the further dissemination of the CMH Report's findings. They are working with member states to increase the
uptake of this evidence base into national health policy development and the design of poverty reduction
mechanisms. Despite the challenges posed by the SARS outbreak, two states, China and Cambodia, have
moved forward substantively with instituting a Macroeconomics and Health process.
In addition, a regional proposal outlining the MH activities and outcomes for governments of Papua New
Guinea, Philippines, Lao PDR, and Mongolia has been developed by the country and regional offices.
People's Republic of China
Sparked by a strong expression of interest by the Government for information about MH strategies and the
findings of the CMH, the Commission's Report was translated into Chinese in November 2002. Follow-up
discussions stimulated authorities to integrate health investment into reform agendas and new
developmental policies. Recently, the urgency of investing in health was heightened by the media attention
surrounding SARS.
27
China has made considerable progress in the past 20 years towards improving living standards, including
health, as well as reducing poverty and achieving strong macroeconomic growth. Large-scale poverty
reduction has been one of China’s greatest accomplishments during its economic reform period. Since the
early 1980s, GDP growth has averaged 10 % per annum, life expectancy and mortality rates have continued
to improve markedly, while some 400 million people have been lifted out of poverty.
In the aggregate, China has made considerable progress in improving its key health indicators in the last 50
years mainly because of the public health emphasis of government spending prior to 1980. For the most
part, these gains have been maintained or slightly improved with the early market economy reforms which
emphasized provision of fee-for-service rural care and rapid adoption of higher technologies. The
improvements, however, mask sharp underlying disparities. Inadequate financing of health services in poor
areas and limited access in remote areas, particularly in western China, have resulted in widening disparities
in health conditions. Since 1980, the share of villages with Rural Cooperative Medical Systems (RCMS) has
declined from about 90% to just 14-15%. Even in urban areas, community health services are under
supplied, while there has been a proliferation of high-cost hospital services.
China’s public health spending shrank as a share of GDP (to 1.3%). During the same period patient fees and
insurance payments, mainly for non-public health services, rose sharply in both absolute value and their
relative importance. External funding by the foreign assistance community remained an important stimulus
and source of finance, helping central and local authorities attend to immunization, nutrition, tuberculosis and
other infectious diseases, and to emphasize the needs of the poor and creation of public goods in health.
A key constraint to effective delivery of health services includes a decentralized system of inter
governmental finances, exacerbating regional inequalities and the effective delivery of health services. Local
governments bear heavy expenditure responsibilities, including for providing health services, which are not
matched by adequate own-revenue sources or sufficient government transfers.
Strategic, targeted increases in government spending on the health of the poor will build their capacity for
production and increase their ability to contribute to the rural economy. This will help ensure overall
socioeconomic stability and create options for sustainable health insurance systems. Health investments can
be an important development objective, as it will improve rural health conditions, decrease regional health
disparities and, by improving the health of the local workforce, augment the output of the rural economy.
Along with Health Partners in China, the Ministry of Health has set forth an outcome-oriented follow-up to the
CMH Report. Chinese authorities are building a local evidence base to systematically link poverty alleviation
and health reforms to the UN Development Assistance Framework, especially in conjunction with the UN
Theme Group on Health. The CMH process has built momentum among China's policy makers to use the
Report's evidence to design national policies that integrate health and economic development. The
challenge is to better integrate individual initiatives within an overall policy framework to provide common
direction based on the nature of poverty and health in China. The initial analyses undertaken that placed the
CMH recommendations in the China context included a study on the sub-provincial linkages on health and
local economic growth, a analysis of China’s macroeconomic policies (in conjunction with DFID), a study
describing the economics of rural health, and an analysis of the effect of migration patterns on health care.
In April 2003, the Ministry of Health and the Chinese Health Economics Institute held a work session to
review follow-up activities, strengthening their conviction to develop a Macroeconomics and Health strategy.
China participated in the 2nd Consultation on Macroeconomics and Health (October 2003, Geneva) where
they presented their overall strategy through a China State Council-backed document entitled
“Macroeconomics and Health in China” and led a meeting which enabled Consultation participants to
discuss China’s experiences and progress made on public health issues. This document identified three
main issues: 1) Inadequate health service capacity, 2) Inadequate health services for disease control and
prevention; and 3) Incompatibilities between the health management system and the new economic system
of the socialist market economy.
China’s activities during the 2nd phase have focused on continuing the work already begun, including
expansion of the sub-national National Health Accounts analysis and a new studies that will potentially
analyse the options for rural health scale-up under the New Cooperative Medical Schemes and analyse
community-based social insurance for health. Other work includes the analysis of the effect of SARS-related
investments on pro-poor health investments and health system development and the development of the
overall MH strategy.
28
The planned work for China in 2004 will centre on the integration of the studies commenced, the review of
the various epidemiological profiles in China and finally to incorporate the evidence collected into a medium
term investment plan. This work will be carried out in cooperation with high-level government participation,
WHO offices, local academics and experts and in integration with existing bilateral and multilateral initiatives
and projects.
Cambodia
Cambodia has strong interest in implementing the findings of the CMH Report, especially in light of the
desire to move purposefully towards the achievement of the MDGs. The Health Strategic Plan of 2002
provides a framework for cohesion among three other important efforts: a medium-term expenditure
framework; a monitoring and evaluation framework for analysing cross-sectoral performance; and guidelines
for developing annual operational plans for Health Ministry departments. This is enhanced by the Health
Sector Support Project, funded by a broad coalition of donors, instrumental in the government's adoption of a
long-term Poverty Reduction Strategy for 2003-2005.
Within this dynamic context, the WHO country office built commitment and support for the first health sector
review. This led to the Finance, Planning and Health Ministries to debate how to introduce the MH process
and ascertain entry points into health policy issues. In February of 2003, Dr. Jeffrey Sachs visited Cambodia
and discussed with senior government leaders how the evidence provided by the CMH Report could be
localised to achieve substantive outcomes.
On 22 May 2003, the Royal Government of Cambodia and the WHO Country Office jointly drafted the
"Proposal on Macro-Economics, Poverty and Health". Government authorities are ready to scale up access
of the poor to essential health interventions as defined by epidemiological evidence on Cambodia's burden
of disease, especially among the poor and disadvantaged.
With government support strong, the Proposal requested that a National CMH (NCMH) be established, firmly
integrated into the overall PRSP process. Chaired by both the Ministers of Health and Finance, and involving
influential stakeholders from society, donors and other partners, the Commission will serve to implement a
long-term strategy for increased health investments.
29
/
't
^YOrr*
at-- aalaW- „
.
H'
DH.Ccns03042
Medical insurance, right to water, and illness prevention.
World Consumers Day This month brought a gift for citizens, especially for those having
(or contemplating) health insurance. The Gujar at High Court has given a judgment
directing insurance companies io renew Mediclaim policies on existing terms and
conditions, without imposing arbitrary’ exclusion clauses (which is what insurers wore
doing, without informing the policy holders who were opting for renewals.)
Fakirbhai Shah’s case (described in Insight magazine, published by CERS of
Ahmedabad which fought against such exclusion clauses and obtained this judgment ) is
lypical.He had had a health insurance policy for 12 years before he developed kidney
failure in 2002, which required him to undergo dialysis four times a day. The insurance
company renewed his policy but raised the premium by 300 per cent and also excluded
five major diseases including kidney failure. (If whatever illness you are likely to claim
for. is excluded, there seems no point in having insurance anyway.) Tn other cases, the
insurance companies refused to renew the policy after the policy holder developed health
problems, lhe Consumer Education and Research Society (CERS) challenged this
practice and obtained this judgment forbiding arbitrary and unilateral exclusions of
diseases already covered under the existing policy (even if the disease was contracted
during the policy period) and also forbiding refusal to renew. The judgment, Insight
points out, oilers relief io lakhs of policy holders and marks a “turning point for
Mediclaim policies”. U P. has also ruled against claim rejections.
Insight advises that consumers having health insurance policies should not accept
exclusions at renewal, and fresh policy takers should ask for the licence number and ID
of the agent before signing policy documents . There have been instances where the
intermediary' or agent has failed to forward the documents to lhe company in lime (or
messed up the procedures, or suppressed details) resulting in repudiation of claims later
on) Several other suggestions are also listed in Insight (issues dated Jan-Feb 2004 and
March-April 2003 - the latter carries an in-depth examination of mediclaim as its cover
story').
No one makes a medical claim after undergoing illness and hospitalisation merely to
collect money. The average policy holder opts for health insurance only to safeguard
himseif/herself against unforeseen (and burdensome) expenses related to illness.
Prevention of illness has therefore been the focus of two other initiatives launched this
month. CERC took up “ water as a basic right” as its theme for its consumers day
celebrations, focusing on howr the provision of clean and safe water must be made a basic
entitlement for all of us. T hose of us who can afford to buy water (bottled and branded, or
from tankers) do not give it much thought but for millions of urban as well as rural
dwellers, finding the daily potful of w'atcr is a major hassle, and this causes preventable
illnesses that take the lives of thousands of children as well as adults. As summer draws
near, already there are lell-lale rows of empty pels lined up al public waler laps, wailing
for a few precious drops. V/hile CERC is focusing on municipalities’ obligation to
organise safe water supply, some urban NGOs are trying to sensitise city dwellers to the
need to conserve water as a priority. The Centre for Science and Environment (CSE of
Delhi, which hit the headlines last year with its expose on pesticide residues in soft
drinks, and has succeeded in forcing the government to look into safety norms) has
prepared a short ad spot (shown on TV) which shows citizens collecting rain water in
whatever container they find handy, from up-ended umbrellas to pot and pans, so that
the precious liquid may not run waste into gutters. Just watch the difference in our water
use when the household pump motor bums out and there is no water in the house -- we
manage to wash our faces with jus I a mugful of waler, whereas at other times we let the
tap flow merrily while we soap ourselves at leisure). Consumers have not only rights and
entitlements, but also obligations and duties - in this case, to conserve water . If we made
it go round better, there would be less illness in the country.
In a related initiative, the global People’s Health Movement (PHA) launched this week a
worldwide campaign on citizens’ “right to health”. Saturday March 20 was designated
World Day of Pretest against the apathy of governments that spend billions on defence
arsenal and exports but neglect basic health and simple, ^inexpensive outlays that could
save lives. Bangalore is one of the hubs of this global campaign to protest against the
' blatant violation of international humanitarian laws on people’s basic rights”. Dr. Ravi
Narayan, general secretary’ of the international People’s Health Movement, says that the
“World I rade Organisation (WTO) is ... a great threat to health in the world today”,
because under liberalised trade rules, the rich are getting richer while the poor are getting
poorer (with less access to basic health care which is becoming privatised and thereby
going beyond the reach of the economically weaker sections ).
The three items - PHM, CER.C and the Mediclaim judgment - together highlight what
should be a top priority in any governance for and by the people - health, and prevention
of illnesses
*
*
t
t
The pinch of salt this time is required to be taken with ads of multinational company LG
which has got rapped twice for misleading consumer. Once, by CERC which tested LG
refrigerators and found that the capacity fell short of the capacity claimed by the
manufacturer for various models (by 11 per cent). CERC went to court asking that Rs 11
crores , the amount by which the company has enriched itself at the cost of the buyers,
should be refunded to the customers. The second rapping was from the Advertising
Standards Council of India (ASCI) which ruled last month that LG’s ad for air
conditioners (promising the “Healthiest air in the world”) amounts to misleading the
public since it cannot be substantiated. I he ad has been ordered withdrawn.
Sakuntala Narasimhan
(iGOG words)
i
Ce>
-
>
ASHWINI’s Health Care System and
the Composite Health Insurance Programme for Adivasis
January 2004
1.0 Introduction
Group Insurance is not a new thing to the Adivasis I Even now in many adivasi villages, whenever
somebody becomes seriously ill and needs to be taken to a hospital, there is a “collection” among all
the houses in that village. With this money, they hire a vehicle and come to the hospital in a group. This
kind of ‘sharing the risk’, which is fundamental to any group insurance scheme, had been practiced by
the tribals for ages I However, the modern economic systems and lifestyles made it necessary to fine
tune these traditional practices. This is the basis of the Composite Tribal Insurance Scheme of
ASHWINI.
2.0 Genesis of ASHWINI
Though ASHWINI as an independent organisation was started only in 1990, its genesis dates back to
1986 when Stan Thekaekara and his wife, Mane started ACCORD, a Non-Governmental Organisation
in Gudalur. Their main objective was to to fight the unjust alienation of the adivasi lands and other
human rights violations by organising them as a strong group.
They facilitated the formation of village level sangams and these sangams enabled the adivasi families
to prevent any of their land getting encroached by powerful non-tribals of that area or by the
Government authorities. More than 200 such village sangams had been formed within two years. These
sangams were federated at the taluk level into "Adivasi Munnetra Sangam" which till today remains
the representative organisation of the adivasis, fighting for their just rights and striving for the socio
economic development of the adivasi community.
But, it was not only the problem of land. The village sangams again and again brought up the issue of
health care. Women were dying during childbirth. Children were suffering from easily preventable
diseases. Some intervention was urgently required. But, Stan and Marie were not doctors. They started
looking out for some doctors through their contacts. Fortunately, they met two young doctors,
Dr.Devadasan and his wife, Dr. Roopa, quite eager to take up the challenge.
3.0 Community Health Programme
Deva and Roopa joined ACCORD in 1987 just after their graduation from the Christian Medical College,
Vellore and launched a community health programme in the adivasi villages. The main focus was to
train village level Health Workers (HW) selected from the community itself, to identify and prevent
illnesses like diarrhoea, to provide immunisation and nutrition to the pregnant women and young
children, and generally to improve health awareness among the adivasi community. The team went
from village to village, participated in the sangam meetings and regularly monitored the progress of the
pregnant women and children.
Within a few years, the preventable deaths among the adivasis (like due to diarrhoea or during
childbirth) were more-or-less eliminated. The HWs did a tremendous job in the programme, kept
highlighting the health issues in the villages and closely followed-up the individual cases. The
immunisation status of the children & pregnant mothers dramatically improved with the launch of
Page I of 6
<
the community health programme. Issues like growth monitoring and nutrition were constantly brought
to the notice of the parents by the health workers. Thus far, the health programme consisted entirely of
these field activities. In spite of the successful community health programme, there were inevitable
cases needing hospitalisation, there were high-risk pregnancies which required the women to deliver in
a hospital, and acute cases of diarrhoea and fever among children too needed hospitalisation. Deva
and Roopa used to refer such patients to the local Government hospital or to the private clinics.
But the experience with these hospitals was not very encouraging since the care and treatment given to
these patients was not satisfactory, the doctors weren't there many times in the Government hospitals,
the costs of treatment in private clinics were high (ACCORD subsidised these costs). Deva and Roopa
were torn between following a few cases in these hospitals and visiting the villages all over the taluk.
Quite encouraged by the success of the community health programme and the role played by the
adivasi health workers, the adivasi community felt that the next logical step would be to start a hospital
of our own. There was a heavy demand from the village sangams to start a hospital. But the doctors
were reluctant, saying that Hospital is a permanent institution which needs to be run 24 hours a day, all
through the year - and for many years. The health team at that time was not equipped to handle such
an institution. Moreover, the ACCORD team strongly felt that their intervention had to be time-bound
and they will withdraw after a few years when the AMS can take over the initiative of protecting the
rights of the adivasis. But, hospital is a permanent form of intervention which cannot be withdrawn. And,
in any case, where are the nurses in the adivasi community (another basic philosophy of ACCORD was
to identify youth from the community itself to deliver al! the services to the people and to train them I) ?
And, Doctors ??
4.0 Gudalur Adivasi Hospit?!
However, the community was strong in its demand and felt that the community health programme
needed a hospital of its own to make it much more effective and acceptable to the people. So, they
started a search for suitable people. Again as a curious coincidence, there landed up a doctor couple,
Shyla and Nandakumar, willing to be part of the health programme. Having the idea! combination of
skills as Gynaecologist and Surgeon, they were what the "doctor ordered" and the people were looking
for I Young adivasi girls were identified by the sangams and the new doctors started training them as
nurses. Thus was born the "Gudalur Adivasi Hospital" [GAH]. In 1990.
With the establishment of the Hospital, we realised that this, intervention is going to continue for a many
years, and structurally it has to be different from that of ACCORD or AMS. So, the health programme,
activities and the staff were hived off from ACCORD and a separate legal entity called ASHWINI was
registered. From then onwards, Ashwini took care of the health issues concerning the adivasis and poor
people of this area. While Deva and Roopa continued their focus on the community health programme,
Shyla and Nandakumar started training tribal girls as Nurses. It was a major cultural change for the girls
- from innocent village life to a three-shifts-a-day routine in the hospital. Training had to start from
elementary Maths and English.
These adivasi nurses have come a long way in the next 10 years. They have become experts in
conducting deliveries, in assisting the doctors in surgeries, in the general administration of the hospital,
in ordering and managing the drug stocks, in designing systems to monitor the performance of the
hospital (All the patient details have been computerised after 1996) and in analysing the financial
aspects of the hospital management. They are constantly trained and their skills are upgraded to keep
up with the growth of the programme.
Page 2 of 6
Today, the Adivasi Hospital is one of the most sought after hospital in the Gudalur valley, not only by
the tribals but also by the non-tribals of the local area. Patients are brought from distant villages by
ambulance and good quality care is given. As all the staff are from the community and can talk the tribal
languages, the tribal patients feel at home. Efforts were constantly made to keep the place culturally
acceptable to them and the community gradually adjusted to the change. Today, there are cots in the
hospital, they come forward for surgeries and many of them regularly show up for antenatal checkups
etc. Some more young doctors came and worked in the hospital for brief periods - the health team
getting enriched by the interaction with each of these doctors.
5.0 Sub-Centres
Til! 1994, the health programme consisted of preventive care given by the HWs at the villages and
curative care provided at the GAH. However, during many interactions with the sangam members, a
need was felt to have another intermediate level comprising of a group of villages. The AMS had
already divided the sangam villages into eight administrative zones called "Areas" and an Area Centre
was coordinating the sangam activities of that particular Area. From 1995 onwards, a health Sub
Centre was started in each of these Area Centres.
These Sub-Centres coordinate the community health programme in the villages of that Area, provide
first aid and primary level curative care by dispensing medicines, Screen patients regularly, refer those
needing doctor's intervention to Gudalur Adivasi Hospital and follow-up the patients discharged from
the Hospital. Initially the senior nurses and health staff took responsibility to manage these sub-centres.
Later, a few more adivasi girls were trained specifically to run these sub-centres - They are called
"Health Animators". As per the need, they keep shifting between the hospital and the sub-centres, so as
to strike a balance between the curative and preventive programmes and to keep their skills sharpened
and updated.
6.0 Management
Monitoring and review of the activities, both in the villages and in the hospital are done by the staff
themselves in the monthly meetings. Besides, a Working Committee comprising of a few senior nurses
and health animators has been constituted. This group looks ahead, takes care of the long term
planning, budgeting and other policy issues.
ASHWINI is registered as a Charitable Society under the Tamilnadu State Societies Registration Act.
The General Body of the Society is constituted from the senior AMS activists, the adivasi nurses /
health animators and the doctors. Al! the members of the Executive Committee are adivasis. Thus,
though ASHWINI is legally an independent identity, it continues to function under the umbrella of the
AMS as an institution owned and managed by the adivasis themselves for their own development.
7.0 Breaking the Financial Barrier - The Insurance Scheme
The main objective of the insurance scheme is to break the financial barrier of the adivasi families at the
time of illness. We have noticed that lack of liquid cash at the time of illness is one of the most serious
barriers to the adivasis, preventing them from getting safe medical care and accessing hospitals. Our
challenge was to encourage them to plan ahead and save something for the possible event of sickness
in the future. For a community, eking out a day-to-day existence, this was a radical change. Saving for
Page 3 of 6
the future itself was a new thing - leave alone for their health needs. But, we were convinced that this
had to be done and hence, pursued our idea with the people relentlessly.
When Gudalur Adivasi Hospital was started in 1990, we discussed with the village sangams about the
financial aspects. On the one hand, none of us wanted the hospital treatment to be totally free as this
would not be sustainable in the long run. However, on the other hand, it would be difficult for the adivasi
patients to pay the entire costs of hospitalisation. Combining this need for resources with the adivasi
tradition of sharing, we arrived at the concept of group insurance. Though providing health care through
insurance coverage is a very modern idea, we hit upon the same solution, but through a very different
route and rationale.
We approached various agencies including some insurance companies. However, the insurance
policies existing at that time were targeting primarily middle and high-income people living in the cities.
The premiums were high as the claims ran into Lakhs to cover "costly" diseases like heart attacks and
bypass surgeries. These policies would be totally inappropriate for the adivasi community where
anaemia, malnutrition, safe delivery and care of young children were the major problems.
So, we needed a simple package covering these illnesses. Fortunately, following a long search, we met
some enterprising officers of the New India Assurance Company who were willing to design a special
package for the adivasis of Gudalur. After more than two years of discussions and negotiations, we
were able to design a scheme, which would address the specific health needs of our people. We finally
launched the composite tribal group insurance scheme in 1992.
According to this policy, for a premium of Rs. 15 per person per year, hospitalisation expenses up to
Rs. 1500 would be reimbursed by the insurance company. The Adivasi Munnetra Sangam decided to
insure all its members. We started by insuring 5000 adivasis in 1992 and the number has risen to
13000 by 2002, as new villages and members join the AMS.
8.0 Policy Details
To avail of the Group Discount and Long Term Discount offered by the insurance company, ASHWINI
insured all the members of the AMS for five years by paying the premium en bloc. In turn, the activists
of AMS, including the Health Animators of ASHWINI collect the premium from the members every year.
So, in essence, ASHWINI has taken a Policy with the Insurance Company for five years, whereas the
AMS takes a policy for its members with ASHWINI every year.
This arrangement made sense, considering the many
restrictions imposed by the insurance company on the
diseases covered under the policy, the Rs. 1500 ceiling
and the delay in the reimbursements. To encourage the
tribal patients to seek health care at the earliest and to
make the health system more effective, our health care
system has to be comprehensive and should provide for
all the health needs of the community.
Policy Highlights (1992-2002)
Started : in 1992
Membership : About 12000
Agency : New India Assurance
Company
Annual Premium : Rs. 15
Claims : Up to Rs. 1500 of
hospitalisation expenses
For example, pregnancy related admissions were not covered under the policy during the first seven
years. But, one of our major aims was to reduce the maternal mortality and to encourage the tribal
women to choose safe confinement. So, even while the insurance company was not reimbursing the
expenses of pregnancy related admissions, we continued to provide free treatment to the insured tribal
Page 4 of 6
women who get admitted for pregnancy related causes. However, due to our persistent efforts and
representations to various authorities including the Finance Minister of Government of India, the policy
was subsequently modified in 1997 to include pregnancy related admissions for the 1st and 2nd
deliveries I The table below gives the differences between the policy offered by the company and the
scheme offered by ASHWINI for the comprehensive health care of the AMS members.
Details of the Health Insurance Policy
_____ Particulars
Expenses covered under
the policy
Ceiling on the amount
reimbursable______
Diseases which are not
covered__________
Time taken to reimburse
claims
ASHWINI
~
Insurance Company*
Only hospitalisation expenses [Apart from hospitalisation costs,
includes OP treatment in the
hospital and in Sub-Centres
Rs. 1500 per year
No limit on expenses.
Chronic illnesses like
All illnesses are treated free of cost.
diabetes, TB, etc._______
From 3 to 9 months from the Patients do not pay any amount on
date of sending claims.
discharge, and hence claims are
instantaneous._____________
* Details of the policy with New India Insurance Company between 1992 and March 2002.
Summary of the Financial Details of the Insurance Programme from 1992-1997
___________ Description
Total Premium paid to the insurance company
Amount reimbursed by the company
1992-1997
Rs.4,35,722.25
Rs.5,94,566.00
1997-2002
Rs.5,94,566.00
Rs.12,68,051.00
9.0 Premium Collection
Insurance collection is a major annual event! The collection season commences with a meeting of the
tribal staff of ASHWINI and the field activists of AMS to decide the premium to be collected from the
members that year. Apart from the financial status of ASHWINI, issues like the income levels of Adivasi
families and the general economic situation of the Society are considered while deciding the premium.
Year
Premium
per
person
1993
1994
1995
1996
1997
1998
_1_999
2000'
2001
2002
2003
Rs. 4
Rs. 6
Rs. 8
Rs.10
Rs.12
Rs.12
RsJS
Rs. 17
Rs. 17
Rs.20
Rs.22
No. of
people who
paid
premium
3726
2744
3624
4125
3812
4899
_4768_
4619
4464
4291
4268
We started with Rs.2 per person per year in 1992, gradually
increasing it every year. We are collecting Rs. 22 per person for
the year 2003. The collection period commences on December
5th, a special day celebrated as Adivasi Day by the AMS and
goes on till April 14th, another special festival, “Vishu” [New
Year]. Depending on the situation each year, the collection
period may get extended. In the earlier years, the sangam
activists used to go from house to house, from village to village
explaining the insurance scheme and collecting the premium.
Now, as people are aware of the scheme, they come to the
sub-centres to pay the premium.
The exercise of insurance collection is an important aspect of
ASHWINI’s health programme, as it keeps the focus
continuously on the community. Instead of interacting only with
the patients in the hospital, the insurance scheme gives an
Page 5 of 6
opportunity for the field workers and sangam activists to interact with all the sangam members, to
explain the health programme and to get a true feedback from them.
The percentage of AMS members who pay the premium to ASHWINI has been hovering between 35%
and 50%. A survey done among the AMS members revealed that one of the main reasons for non
payment of premium was the lack of ready cash during the collection period. At present, we are trying
to evolve different methods to improve the premium collection from the sangam members and to
increase the awareness about the scheme in the villages.
10.0 Current Status
When the policy expired in March 2002, the New India Assurance Company informed us that they were
considering a steep increase in the premium from Rs.15 to about Rs.40 per person per year. ASHWINI
was not prepared for this precipitous hike, as it was using all its resources to meet the operational costs
of the health programme. Subsequently Sir Ratan Tata Trust, Mumbai was approached for
financial assistance to pay the insurance premium and we were extremely happy to get a positive
response from them in July 2002.
With the help of Tata Trust and some experts, we had undertaken a comprehensive review of our 10
year experience with the insurance scheme. The conclusions of this study have given us some direction
and guidelines to take forward our health care programme. Based on these findings, Tata Trust has
extended funding towards paying the premium for about 12000 adivasi members and for some
administrative costs in January 2003.
Based on the findings, we approached various insurance companies to restart our insurance scheme.
Our negotiations with the Royal Sundaram Insurance Company Limited were successful and we
designed a new insurance policy called ‘Tribal Health Shield’. This scheme came into existence from
May 19, 2003 and will be in operation for a period of one year. The major highlights of this policy are
given in the table below :
Tribal Health Shield
About 12200 members of the Adivasi Munnetra Sangam are insured
under this health insurance policy.
• Coverage of all illnesses including common illnesses.
• Coverage for Pregnancy related admissions for first 3 pregnancies.
• Maximum coverage limit is Rs. 1000 per year (Rs. 500 for pregnancy
related admissions).
• Annual Premium is Rs. 20 per person.
•
We are also working to create an awareness about this model of providing health care to other NGOs
and disadvantaged groups also by networking with them.
11.9 Future Plans
During the next five years, our efforts will not only be to consolidate our insurance programme in the
sangam villages, but also to share our experience with other charitable organisations working with
underprivileged people, so that a larger insurance scheme involving them could be created. Thus our
successful experiment with group insurance could spread to other people who wish to address their
own health needs effectively.
Page 6 of 6
NATIONAL CONFERENCE
ON
COMMUNITY HEALTH
INSURANCE
At Mysore, on 30th & 31st October, 2003
0
r
Organised by
Karuna Trust, UNDP & Ministry Of Health, GOI
A REPORT
National Conference on Community- Health Insurance
1
INDEX
Preface
Inaugural Function
Proceedings of the Conference
Presentations
1. Karuna Trust, Karnataka
2. Sri Mayapur Vikas Sangha, West Bengal
3. Family Health Plan Ltd., Karnataka
4. SEWA, Gujarat
5. National Insurance Company, Karnataka.
6. SHEPHERD, Tamil Nadu
7. Dr. Devadasan, Tamil Nadu
8. Sri. Rajeev Ahuja, New Delhi
9. Voluntary Health Services
Plenary Session
Panel Discussion
List of Participants
National Conference on Community Health Insurance
2
National Conference on
Community Health Insurance
A report
Preface
The persistent poverty and diseases have pushed the families of the
unorganised sector in the process of de-capitalisation and indebtedness to
meet their day-to day contingencies. Both macro and micro studies on the
use of healthcare services show that the poor and other disadvantaged
sections such as scheduled castes and tribes are forced to spend a higher
proportion of their income on healthcare than the better off. A majority of the
poor households, especially the rural ones, reside in backward, hilly and
remote regions where neither government facilities nor private medical
practitioners are available. They have to depend on poor quality services
provided by local, often unqualified practitioners and faith healers. Further,
wherever accessibility is not a problem, the primary health centres are either
dysfunctional or provide low quality services.
The burden of treatment is particularly high on them when seeking inpatient
care. The high incidence of morbidity cuts their household budget both ways,
i.e., not only do they have to spend a large amount of money and resources
on medical care but are also they are unable to earn during the period of
illness. Very often they have to borrow funds at very high interest rates to
meet both medical expenditure and other household consumption needs,
pushing these families into a zone of permanent poverty.
The gender bias with men having better access to healthcare when compared
to women due to various socio-economic and cultural reasons has also made
the health care out of reach of the poor women. The poor women who are
most vulnerable to diseases and ill-health due to unhygienic living conditions,
heavy burden of child bearing, low emphasis on their own healthcare needs
and severe constraints in seeking healthcare for themselves.
An UNDP sponsored pilot project on the development of a possible and
replicable model for community health insurance has been taken up in
Karnataka state. This project is being implemented in T.Narsipura taluk of
Mysore district and Bailhongal taluk of Belgaum district with w.e.f. September
2002. •
National Conference on Community Health Insurance
3
Why the National Conference?
national
A
conference
was
organised from 30th
31st
to
October
2003 at ANSSIRD
(Abdul Nazeeb Sab
State
Institute for
Rural Development)
at Mysore. Around
50
representatives
from Govt, of India and
Karnataka, World
Bank,
UNDP,
Insurance
Companies, NGOs associated with Community Health Insurance Schemes
attended the conference on 30th October 03. The next day on 31st October 03
a field visit was organised to review the project implementation and to interact
with various stake holders associated with the project, viz., beneficiaries,
members of the medical fraternity, officials from Government departments
and National Insurance Company, social workers and rural community based
organisation.
The main objectives behind organising the National Conference are to:
•
Have an in-depth discussion on the UNDP sponsored pilot project
being implemented in two talukas in Karnataka
•
Exchange notes on the various community based insurance schemes
implemented by other agencies
•
Explore the possibilities of development of a possible and replicable
model for Community Health Insurance Financing
•
Explore the possibilities of up-scaling the scheme in other parts of
Karnataka and India •
National Conference on Community' Health Insurance
4
National Conference on Community Health Insurance
30th to 31st October 2003 at Mysore
PROGRAMME
Details
Events
Date 30 Oct 03
Inaugural Function (1000 - 1045 hrs)
Dr. Paolo Carlo Belli, Economist, World
Lighting the lamp
•
Bank, Washington
Dr. H. Sudarshan, Hon. President, Karuna
Welcome address
Trust
•
Opening
remarks
by
Dr. Paolo Carlo Belli
the Chief Guest
Presidential address
K.H.
Sri.
Gopal
Krishna
Gowda,
IAS,
Chairman of the Karnataka Government
Health System, who presided over the
inaugural
Session II (1100 hrs - 1315 hrs)
Chairman
Ms. Alka Narang, In-charge, UNDP
Co-chairman
Sri. K.H. Gopal Krishna Gowda, IAS
Presentation of Models
•
Karuna Trust, Karnataka
•
Sri Mayapur Vikas Sangha,
W. Bengal
•
Summing up
•
Family Health Plan Ltd., Karnataka
•
SEWA, Gujarat
Ms. Alka Narang
Sri. Gopal Krishna Gowda, IAS
National Conference on Community Health Insurance
5
Session III (1400 hrs - 1530 Hrs)
Chairman
Dr. Pradeep Panda, Economist, New Delhi
Co-chairman
Sri. Rajeev Ahuja, Fellow ICRIER, New
Delhi
Presentation of models
National
Insurance,
Company,
Bangalore
•
Summing up
•
SHEPHERD, Tamil Nadu
•
Dr, N. Devadasan, Tamil Nadu
•
Sri. Rajeev Ahuja, New Delhi
Dr. Pradeep Panda
Sri. Rajeev Ahuja
Plenary Session (1545 TO 1700 hrs)
Panel Discussion:
“How Health Insurance can be spread in Karnataka and India”
•
Chairperson
Dr. Indrani Gupta, Economist, New Delhi
Panellists
Dr. Paolo Carlo Belli, USA
Prof. Muraleedharan, Dept, of Humanities
& Social Science, I IT, Chennai
Sri. Rajeev Ahuja, ICRIER, New Delhi
Vote of Thanks
Date 31.10.2003
• Field Visits
Dr. H. Sudarshan
General Hospital - Bannur & T.
Narsipura________________________
General Hospital-T. Narsipura
SHGs, Herbal Gardens, Kitchen
Gardens, Seed banks etc.,_________
PHC - Gumballi__________________
VGKK Hospital B.R, Hills.
National Conference on Community Health Insurance
6
Inaugural Session I (1000 hrs to 1045 hours)
two-day
The
National
Conference on Community
Health Insurance organised
by Govt, of India, Govt of
Karnataka,
UNDP
Karuna
Trust
inaugurated
by
and
was
Dr.
Palo
I ’ganispd®»
n
SO
I
II
Carlo Belli, Economist from III
J
World
Bank,
Washington,
. 1 fit
:'i -
I® -Si
h
.l
USA by lighting the lamp on
The conference started with an invocation by two local
October 30, 2003.
singers.
Welcome address:
In his welcome address, Dr. H. Sudarshan, Hon. President of Karuna Trust
expressed immense happiness in having delegates from different voluntary
organisations, National Insurance Company, representatives of Central and
State Government who were actively involved with the implementation of
various types of Community Health Insurance schemes in the country.
I KRimi c^ferem^oH/
IHSlWtCh 0^
I COWMY HEALTH IliSUWO
;
' •
SO'erSroCTOBER 20C&
30\<5|"OCTOBER
2003 ’
YEHUE: ANSSIRD. MYSORE
UNDP * Karuna Trust
■
L-
E
the
chief
Guest,
Palo
Carlo
J
Dr.
Belli of World Bank, Dr.
Sudarshan remarked that
Dr.
T
A '
‘
Welcoming
Palo
Belli
had
volunteered to come from
Washington
notice,
about
at a
having
the
short
learnt
conference
from the media.
National Conference on Community Health Insurance
7
Talking about the pilot project, Community Health Insurance sponsored by the
India,
of
Government
Government
of
Karnataka
and
United
Nation
Development Programme (UNDP) being implemented at T. Narsipura taluk in
Mysore
district
and
Yelandur taluk
in
Chamarajanagar district since
September 2002, Dr. Sudarshan said that Centre’s health insurance schemes
and private health insurance schemes, had not received the expected
response from the people.
He said that many insurance companies were
making efforts to take health insurance schemes to the rural areas. Though
many MNCs are also trying to foray into the villages with health insurance
schemes, they are a bit hesitant. He expressed the hope that people living
below the poverty line in the state would have access to medical care under
community health insurance schemes in the next five years.
“Successful
implementation of the programme in four taluks made out a case for the
scheme’s extension to the entire state" said Dr. H. Sudarshan.
Address of the Chief Guest:
Dr. Paolo Carlo Belli, Economist from World Bank, Washington, in his
inaugural address said that the benefits of health insurance schemes should
reach the backward classes to ensure their health needs.
Quoting a NSS
survey (1995-96) he said that in rural areas of Karnataka nearly 23% have
cited financial reasons for
not
availing
from
treatment
Government
“For
institutions.
sector
private
the
the
percentage is likely to be
even
higher",
Dr.
Belli
remarked.
National Conference on Community Health Insurance
t (I
8
Justifying the need of health insurance for the poor, Dr. Belli said that out of
pocket payments (OPP) constituted a severe barrier to access the health
system.
As per WHO, 2001, in India about 80% of the total financial
resources for health are harnessed on OPP basis. This is made up by selling
their assets to face health costs, particularly during catastrophic events like
accidents, chronic conditions etc., Accordingly to data by Peters (2002) more
than 20 percent of hospitalised patients in Karnataka fall into poverty due to
high medical costs.
Dr. Belli who remarked that hospital care is relatively pro-rich in public sector,
only 17.2 percent of inpatient bed days in the public sector (9.4 for rural
populations) are by people living below the poverty line out of the 36.6
percent of the below the poverty line people in Karnataka.
Health insurance is a mechanism by which health risks are spread across a
number of individuals thus protecting each of them from the loss associated
with negative events, said Dr. Belli.
Improved accessibility and quality of
services
IITYHEi
and
additional
source
of financing for
health
are the benefits
brought
by
sound
insurance schemes. Any
scheme, which provides
the maximum benefits at
the minimal costs, must
guarantee
financial
equilibrium, at least in long term, remarked Dr. Belli.
National Conference on Community Health Insurance
9
Presidential address:
Sri. K.H. Gopal Krishna Gowda, IAS, Chairman of the Karnataka Government
Health System, who presided over the inaugural session, said that illness is a
universal phenomenon. Urging that everyone should be covered under the
health insurance scheme, Sri. Gowda said that it would help people falling
victim to the disease. Lamenting the poor utilization of the hospital services,
Sri. Gowda observed that though infrastructure is good in the government
hospitals; people are still not using them. Urging the insurance companies to
include private hospitals also for treatment under medical insurance cover, he
said that it would alone help to popularise the scheme among all sections of
the people.
National Conference on Community Health Insurance
10
Session II (1100 to 1315 hrs
Ms. Alka Narang, (In charge, UNDP, New Delhi) - Chairman
Sri. Gopal Krishna Gowda, IAS - Co-Chairman
Presentations of experiences:
1.
Karuna Trust - Karnataka
2.
Sri Mayapur Vikas Sangha- West Bengal
3.
Yeshasvini - Karnataka
4.
SEWA - Gujarat
Synopsis of the presentations:
Karuna Trust, Karnataka
•
KarunaTrust, established in 1987 as an affiliate of Vivekananda Girijana
Kalyana Kendra, B.R. Hills to undertake rural health services programmes in
Yelandur Taluk, has its mission the integrated development of people and
improving quality of life.
Leprosy eradication was the first programme taken up due to the large
j prevalence of cases at
r^TwlTEREHCEON
LTH
Poca——
that
time.
In
gradual
stages,
other neglected
areas
of
health
were
taken up. Karuna Trust
has
•I
^3.r
J
got
tremendous
experiences in the course
of implementing various
programmes such as:
National Conference on Community Health Insurance
11
•
1
Leprosy, Epilepsy & Tuberculosis Control Programme
2
Community Mental Health
3
Community based Rehabilitation Programme
4
Community based Eye care
5
Cancer Detection Programme & Community dental health
6
Prevention and Treatment of Anaemia & Asthma Care
7
AIDS/HIV Awareness Programmes
8
Diabetes and hypertension programme
9
Tribal ANM Programme
10
Community Health Insurance Scheme
11
Empowerment of Rural Poor for better Health
12
Rajeev Gandhi National Drinking Water Mission Project
13
Home Hygiene and water Security Project
14
Total Sanitation Campaign
15
Tribal education & Integrated development
Currently Karuna Trust is working for the development of the rural poor and
needy in different parts of Chamarajanagara, Mysore, Mandya, Tumkur and
Bangalore districts of Karnataka state in health, education and integrated
rural development.
•
The Trust is implementing a UNDP, GOI and GOK sponsored pilot project on
community Health Insurance in Karnataka.
•
After taking over the government run PHC at Gumballi in 1996, the trust has
successfully made it a model PHC integrating conventional medical systems
with Indian system of medicine.
National Conference on Community Health Insurance
12
Pleased with the performance of the PHC run by the Trust, the Karnataka
•
Government has handed over six more PHCs to the Trust recently.
The Trust is running a Herbal Medicine processing Unit at Gumballi, which
•
has been started in 1995. Funded initially by Foundation for Revitalisation of
Local health Traditions (FRLHT), Bio-Conservation Network (BCN), then by
Ashoka Trust for Research in Ecology and Environment (ATREE) and from
internal resources.
•
The Trust has been implementing an integrated literacy project in Yelandur
Taluk to take care of Pre School, school education and adult literacy needs of
the people.
The UNDP sponsored pilot project on the development of a possible and
•
replicable model for Community Health Insurance Financing, taken up in
Karnataka State, is being implemented in T. Narsipura taluk of Mysore district
and Bailhongal taluk of Belagaum district of Karnataka.
Partner organisations for the UNDP sponsored pilot project on
Community Health Insurance Financing programme:
•
United Nations Development Programme
•
Ministry of Health & Family Welfare, GOI
•
Directorate of Health & Family Welfare, GOK
Karuna Trust
National Insurance Co. Ltd.
•
Centre for Population Dynamics
Objectives:
•
Developing and testing a model of Community Health Financing
•
Suited to the rural community
•
Exposing communities to the scope of health insurance
National Conference on Community Health Insurance
13
•
Developing a system for the interface with the organized Insurance sector
•
Increasing access to public medical care by rural poor and lower income
groups
•
Ensuring equitable through prepaid insurance
•
Enhancing use of primary healthcare facilities
•
Enhancing awareness of the need for preventive health care
•
Involving area specific community bases organizations such as SHGs, VDCs,
AWWs, PRIs, Co-operative societies
MODELS
•
The pilot project is organised and managed at two different places by two
agencies, one by a non-governmental organisation and the other by
government machinery, to study the impact of the implementation.
Model -1
In T. Narsipura, the scheme would be organized and managed by the Karuna
Trust, an NGO
Model - II
In Bailhongal the official health personnel would organize and manage the
scheme under the supervision of the Chief Executive Officer of the Z.P
Salient features:
•
Oriented towards the poor
•
Community level and family is the unit of membership
National Conference on Community Health Insurance
14
•
Micro-credit financing for Out-patient care through SHGs
•
The premium is Rs. 30 per person per annum for a health insurance cover of
Rs. 2500/The insurance policy covers:
•
All inpatient - hospitalisation cases.
•
At public health facilities
•
Rs. 50/- per Hospital for drugs
•
Rs. 50/- per day - given to patient for loss of wages
Referred cases also
The premium:
•
Subsidized fully for BPL SC/ST population
•
Partially subsidized for BPL non-SC/ST population
•
Not subsidized for APL population
•
Revolving fund at health institution -to settle claims immediately
•
Active case finding by the social workers deputed at health centres and field
staff.
•
Referred cases to any public health institutions anywhere considered.
•
Marketing the insurance and claim settlement, documentation etc. done by
social workers
•
No exclusion of any diseases
•
No waiting period.
•
Preventive & Traditional Health care: Promotion of herbal garden
•
Outpatient Care and Financing: Facilitating SHGs to set aside certain fund for
outpatient financing.
•
Inpatient Insurance: Exposing community to health insurance
National Conference on Community Health Insurance
15
Coverage:
Bailhonga
T. Narsipura
Details
Rural
Urban
Rural
Total
1.10.02
1.9.02
Started
BPL-SC & ST
Non- SC & ST
TOTAL
77223
2546
79769
Total
Urban
5323
82546
0
2546
5323
85092
1224
31204
20322
51526
1224
32428
20322
52750
Bailhongal
T. Narsipura
Rs. 24,76,380
Rs. 9,72,840
Rs. 25,460
Rs. 3,04,830
Total amount subsidized from UNDP fund
Rs. 25,01,840
Rs. 12,77,670
Amount collected from BPL Non SC& St
Rs. 50,920
Rs. 3,04,830
Total amount paid to NIC_______________
Rs. 25,66,900
Rs. 15,82,500
Amount claimed till 30.9.03
Rs. 4,57,400
Rs. 8,52,700
540
1,237
Amount fully subsidized @ Rs. 30 per
person_______________________________
Amount partially subsidized
Total No. of beneficiaries
Analysis of data:
•
Max. 45% patients in the age group of 15-35 years, followed by 40% in
the age group of 36-60 years age group
•
Wage loss compensation helping working age group.
•
Male inpatient - 54% & Female inpatient 46% in T. Narsipura
•
Inpatient rate: 6.5 per 1000 per annum in T.Narsipura while in
Bailhongal it is 25 per 1000 per annum
•
Claim ratio: about 23% of premium paid in T.Narsipura while in
Bailhongal it is 55%
Extension of the Project to other areas
In the pilot project, under both the models, the service providers are
government hospitals only.
In order to study the implications with private
sector hospitals as service providers, operation area of the T. Narsipura
Model was extended to tribal areas of Yelandur, Kollegala, Chamrajnagara
and B.R. Hills w.e.f. 1.4.2003. Under the Bailhongal model, the project was
extended to Belagaum Taluk from 16th June 03 to cover more beneficiaries.
National Conference on Communit}' Health Insurance
16
The extension figures till 30 September 2003 are:
Yelandur, Kollegala,
Details
Chamrajnagara and
Belagaum Taluk
B.R. Hills
Total
Rural Urban
Total
Rural
Urban
Started_________
16.6.03
1.4.03
'
____
0
59,494
_____
0_
59,494
33,716
BPL-SC & ST
33,716
__ 0
Non - SC & ST
0 ____ 0 _____ 0_
0
____ 0
" TOTAL
59,494
59,494
0
33,716
33,716
Details
No. of people covered till 30 Sep.03
Amount fully subsidized @ Rs. 30 per
person (Rs)______________________
Total amount subsidized from UNDP
fund (Rs).________________________
Total amount paid to NIC___________
Amount claimed upto 30 Sep. 2003
No. of beneficiaries
Yelandur,
Kollegala,
Chamrajnagara
and B.R. Hills
Belagaum
Taluk
33,716
59,494
93,210
10,11,480
17,80,358
27,91,838
10,11,480
10,11,480
1,42,700
297
17,80,358
17,80,358
81,700
27,91,838
27,91,838
2,24,400
Total
Preventive health care
•
•
•
•
•
•
•
•
As a part of the community initiatives for health care, Karuna Trust has
taken up promotion of Herbal Garden concept through SHGs.
To start with we have taken up 89 SHGs for its propagation
The interested SHG members grow the plants in their homesteads to
promote preventive and traditional herbal treatment.
Once the group members are aware of the utility of the plants, they are
exposed to the 2nd phase of the project namely HERBAL PRODUCTS
FOR HEALTH PURPOSES.
The SHG members grow the different plants for the use of their own
family and community.
Under the 2nd phase of project resource persons explain the
composition of the preparation of the medicine. The idea is to prepare
the medicines at the village itself.
So far 625 people were trained under four herbal medicine preparation
workshops.
8000 herbal saplings distributed to the interested individuals
National Conference on Community Health Insurance
17
Premium for III Phase:
National Insurance Company has agreed to bring down the premium from
Rs. 30 to Rs. 20.50 per person per year.
Measures for sustaining the project
•
In order to make the project sustainable, different community organisations
such as SHGs, VDCs, Co-operative societies, Gram Panchayats have been
involved for the awareness generation, survey of SC/ST population, identity
slip distribution and premium collection.
•
In Bailhongal, the patients who avail of the hospitalisation benefits are
motivated to pay Rs. 50/- out of the cash benefit they receive, towards the
premium charges for the next year’s policy.
Strengths
First time wage loss compensation by an Insurance Company
Working age group is the major beneficiary - 85%
Utilisation of public health services has increased
By involving the Non-Profit Organisations claim has increased
There is no exclusions of diseases
Fast claim settlement and re-imbursement
Low moral hazard
Good Community participation
Women access to Health centre has increased
Involvement of Health Insurance Companies
Outpatient care thru SHGs and Traditional Medicines
Replicability of the pilot project- Bailhongal model
Weakness:
•
Fewer claims may be because of in-adequate public health services
•
Service tax problem
•
Service commission not enough
•
I.D. slips in English
•
Private (for profit) health institutions not involved
•
No incentives to health staff
•
Problems in sustainability
National Conference on Community Health Insurance
18
Sri Mayapur Vikas Sangha, West Bengal
Sri Mayapur Vikas Sangha, established 1998, is a secular, non-government
development
organisation operating in
the area of Sri Mayapur,
Nadia
District,
West
India.
The
Bengal,
objectives are for broad
and holistic sustainable
human
I
II
1
J
—
-
H
I1
I
i
resource
development in the region of Sri Mayapur.
The Community Health Care Financing Project implemented since April 2001
under the UNDP, MOHFW, GOI & GOWB aims at convergence of microcredit, micro-enterprise and local self-governance initiatives in the health
sector covering 4 Grama panchayats and 6000 poor and marginalized
families.
Objectives:
To empower communities to better manage their health care
Establishing partnerships with the health service providers
Reduce burden of expenses on health care.
Strategy:
•
SMVS village health programme
•
Micro-credit programme
Health Services
National Conference on Community Health Insurance
19
•
Capacity building of community health workers
•
RCH package
•
Paramedical roles
•
Act as bridge between health service providers and receivers
•
Curative services and community financing
•
Integrating and capacity building of traditional birth attendant for safe home
delivery
•
Integrating and capacity building of local private health practioners on
•
Rational therapeutics and diagnosis
Essential drugs
•
Counselling skills for preventive and promotive health care
•
Proper referral
•
SHG operated Drug banks and referral transport
•
Linkage with health centres, consultant doctors, hospital for referral services
•
Community centred diagnostic facility
Salient features of the policy
•
Reimbursement for hospitalisation due to covered diseases/surgery limited to
Rs.5000
•
Reimbursement
for
domiciliary
hospitalisation
expenses
in
lieu
of
hospitalisation (subject to certain condition and exclusions)
•
Pre-hospitalisation expenses upto 30 days
•
Post Hospitalisation expenses upto 60 days
•
Age limit - 5 years to 70 years. Children between the ages of 3 months to 5
years can be covered provided one or both parents are covered concurrently.
Treatment covered:
•
Expenses on hospitalisation for a minimum period of 24 hours
•
In case of treatments like dialysis, chemotherapy, lithotripsy, radio therapy,
eye surgery, dental surgery, tonsillectomy, DNC taken in hospital/nursing
home, the time limit of 24 hours is not applicable.
National Conference on Communitj Health Insurance
20
Major exclusion under the policy
•
Any pre existing disease
•
Naturopathy treatment
•
Routine eye examinations, cost of spectacles and contact lenses and hearing
aids
•
Dental treatment of surgery unless requiring hospitalisation
•
Any injury or disease arising out of war invasion, act of foreign enemy
•
Convalescence, general debility, congenital external disease
•
Expenses on vitamins and tonics unless forming part of treatment for injury or
disease
•
Expenses directly or indirectly caused by or associated with HTLB-III or LAV
or condition of a similar kind commonly referred to as AIDS.
Present status
.
409 members of 77 SHGs (1022 family members) i.e. 25.33% SHGs are
covered under Jana Arogya Policy
•
Total Rs. 61600 was paid for their annual premium
•
In monthly instalment they are repaying the amount for the next year
.
Rs. 10225.50 they repaid to NMCHF for their next year’s premium
•
Till now 2 persons (1 male and 1 female) were benefited under this scheme.
National Conference on Community Health Insurance
21
Family Health Plan Ltd., Karnataka
Yeshasvini is an innovative scheme conceptualised by Dr. Devi Shetty,
Chairman, Narayana Hrudayalaya, Bangalore. Launched on 14th November
2002, the scheme is approved by the Government of Karnataka and
implemented
and
administered by Family
Health Plan Limited for the
farming
community.
Objective of the scheme is
to
provide
healthcare
services at the doorsteps
of the farming community
of Karnataka and make
available and accessible
even to the poor, the best
treatment in the best hospitals.
f
•
•
•
•
•
•
COHFEREHdE
fcr SIOCTOSWi
Y
'3
'• IIJ
■' I
!i
•__
a
Salient features:
A self funded scheme catering to the surgical need of the farmer community.
Farmer and his family member registered with the Karnataka State Co
operative society for a period of minimum 6 months can become beneficiary
under this scheme by making a payment of Rs. 60/- per annum per person.
Corpus generated out of the member’s contribution and Govt, contribution of
Rs. 30/- per person per annum is placed with the Yeshasvini Trust for
disbursing the payment towards entitled services as per the scheme.
Beneficiary avails cashless treatment at 80 recognised hospitals across the
State.
Beneficiary entitled for 1600 surgical procedures with an annual coverage of
Rs. 2 lakh with capping of Rs. 1 lakh per procedure.
Beneficiary also entitled to free outpatient consultation by a physician at the
identified network hospital and greatly discounted rates for out patient
investigation and specialist consultations.
Detailed project map
•
Only those who have been the members of co-operative society for the last 6
months are entitled to avail the benefits of the scheme
National Conference on Community' Health Insurance
22
•
Upper age limit to avail of the benefit of scheme is 75 years
•
Over 17 lakh farmers contributed to the fund so far
•
Total fund collected is over Rs.14 crores
•
Scheme operated by the Yeshasvini co-operative Trust
Contributions
•
Member contribution is Rs. 60 per annum (Rs. 5 per Month)
•
State Government of Karnataka contribution is Rs.30 per annum (Rs. 2.50
per month) per member
I
Collection of fund through:
•
The local District Co-operative Credit Societies
•
Milk Marketing Federations
•
Other recognized societies under the Ministry of Co-operatives, Govt, of
Karnataka
•
Collections will be deposited with DCC Banks and the same will be
transferred periodically to the Karnataka State Co-operative Apex Bank
Limited, Bangalore
Scope of Coverage
• Surgeries covered: Over 1600 surgical procedures have been identified and
covered at a pre-negotiated tariff
• Each member can get a coverage of Rs. 1 lakh per procedure and the upper
limit is Rs. 2 lakh per annum
• Free out-patient service to all farmers enrolled in the scheme at any of the
hospitals
National Conference on Community Health Insurance
23
Identified Network Hospitals
• 74 hospitals across Karnataka offer service as per the pre-negotiated tariff
hospitals extend services on credit and the amount is reimbursed by the
Trust.
• Stringent admission protocols are followed to avoid mis-utilisation of the
scheme.
Milestones
•
Launched the scheme on 14th November 2002
•
Till 31st May 2003-nearly 17 lakh farmers enrolled
•
1st June 2003 performed the first surgery
•
1639 surgeries performed till 30th August 2003
Forces Behind
Government of Karnataka
•
Karnataka State Co-Operative society
•
Family Health Plan Limited
•
Network hospitals.
National Conference on Community Health Insurance
24
SEWA, Gujarat
The women are not covered by basic social protection measures, yet
ie
J nOHisickness is a maj°r cr|sis
I IIand
economic leakage.
Self-Employed Women’s
1
Association (SEWA) is a
■
,
labour union of 7,00,000
informal women workers
in Gujarat, India. In the
\
J
■
absence
of
state-
sponsored or other social
insurance, SEWA
SEWA developed
developed its
its own
own and
and now
now reaches almost 103,000
insured persons. Operating for the last ten years, the SEWA plan is an
integrated insurance package with health insurance as a major component.
Main features:
•
Started in 1992 to cover Life insurance, medical insurance and asset
•
insurance
Targeted at SEWA Union members in 11 of Gujarat’s 25 districts, and their
•
husbands and children
Age restriction for adults: 18 to 60 years of age for life, upto 70 for health and
assets
•
Minimum hospitalization for 24 hours
•
First year exclusions: hysterectomy, piles, cataract, hernia etc
•
Conditions for reimbursement of treatment of pre-existing diseases
•
Currently three packages are offered with insurance premium varying
between 85 to 400 per annum
•
•
Strengths
Nesting within a larger, member-based organization
Rational, data-based setting of premiums and benefits packages (due to
associations with “formal” insurance companies)
National Conference on Community Health Insurance
25
8
•
•
•
•
•
•
Technical and financial support from external partners/donors
Dynamic management that has not hesitated to make changes
Generating understanding about insurance
Maintaining regular contact with members
Reaching the poorest
Targeting a widely dispersed population, thus increasing transaction costs
•
Lack of knowledge about health and health care among members
Concluding remarks:
Ms.
Alka
Narang,
pre-
summing
up
lunch
presentations,
the
-ill
.w
remarked that it was a
I®
difficult job to summarise
the
different
presentations,
as each
J
-
one was unique in its
characteristics of health seeking behaviour and claims. Observing the
statistics of SEWA where insurance claims in the first year were high and the
subsequent years saw it coming down, Ms. Narang wanted to know whether it
was due to steps taken for preventive care through local health traditions.
Urging for sustainability of the schemes, Ms. Narang wondered whether
surgeries like cataract etc, which were free under Government medical
schemes, were also being brought under the health insurance cover.
Sri. Gopal Krishna Gowda IAS, in his remarks noted that focus was different
in each of the presentations. He also urged for evolving a common scheme
for all.
National Conference on Community7 Health Insurance
26
Session III (1400 hrs - 1530 hrs)
Dr. Pradeep Panda, Economist, New Delhi- Chairman
Dr. Rajeev Ahuja (Fellow at Indian Council for Research on International
Economic Relations, New Delhi) - Co- Chairman
Presentation of Models
1. National Insurance Company, Bangalore
2. SHEPHERD, Tamil Nadu
3. Dr. N. Devadasan, Tamil Nadu
4. Sri. Rajeev Ahuja, New Delhi
5. Voluntary Health Services (presented in absentia)
Synopsis:
National Insurance Company, Bangalore
Insurance scenario
•
Coverage of the
population under
private, social or
other types of Health
Insurance is limited
•
.. ,
.
ESIS : about 3.4
crores
CGHS : about 40
lakhs
•
Railways: about 12 lakhs
•
Medi-claim Policy: 80 lakhs
National Conference on Community Health Insurance
27
Need for Insurance
• At any given point around 40 to 50 million people are under medical
supervision for major ailments
•
Financial burden arising out of serious ailments can seriously drain
the resources of any given individual
•
Health insurance for Hospitalisation is more relevant in this context
Universal Health Insurance Scheme
Unique Health Insurance Scheme launched by the central Government
•
aimed at providing Health Cover for all
•
Particularly the poorer sections of society
•
Premium Rs 1/- per day
•
Premium Subsidy for Below Poverty Line Families
•
Provision for loss of earning
•
The Reimbursement of medical expenses upto a total of Rs.30000/which can be utilised by one or all members of the Family
Coverage:
•
The Reimbursement of medical expenses upto a total of Rs.30000/-,
which can be utilised by one or all members of the Family
•
Coverage for death of earning head due to accident Rs. 25,000
•
Daily compensation of Rs.50/- towards loss of wages to earning Head
during hospitalisation upto 15 days.
Age limits
•
Between 3 months to 65 years
•
Family would include head, spouse, 3 dependant children and
dependant parents
National Conference on Community Health Insurance
28
Sum insured on floater basis
•
The reimbursement of medical expenses will be a total of Rs.30000,
which can be utilised by one or all members of the family.
Premium:
Details
Premium
For an individual
Rs.1.00 per day Rs.365/- per annum
Medi-claim premium for similar
Rs.637/- + tax
cover
For a family upto 5 (including
Rs.1.50 per day
the first 3 Children)________
Rs.548/- per annum
Medi-claim
Rs 637 x 5 = Rs.3185/-
For a family upto 7 including the
Rs. 2 per day Rs. 730/- per annum
first 3 Children and dependent parents
Medi-claim
Rs. 637 x 7 = 4459/For families below the poverty line the Govt. Will provide
a premium subsidy of Rs.100/ per Family
Policy exempt from Service Tax
Benefits:
Reimbursement of Hospitalisation expenses up to Rs.30, 000/- to an
individual/family subject to certain sub limits.
Personal accident cover for death of the earning head Rs.25, 000/Wage compensation @ Rs.50/- per day of hospitalisation of the
earning head of the family, up to a maximum of 15 days.
National Conference on Community Health Insurance
29
•
Major Healthcare needs of the most needy section of our society taken
care of - Fulfilment of one of the foremost social obligations of the
State.
Optimum use of the vast healthcare infrastructure of the State, hitherto
under utilised due to increased affordability by way of having insurance
coverage
Exclusions:
•
All pre-existing diseases
•
And diseases contracted within 30 days of coverage
•
Primary diagnostic expenses
•
Treatment for pregnancy, childbirth etc.,
•
Congenital diseases that the insurer is aware of
Administration:
Third party administrators are networking with low cost hospitals to
provide facility of cash less access to policyholders
Government and trust hospitals can also be used by policyholders
Constraints:
Collection of small premiums from large interior areas
Lack of awareness of the product
But steps taken to overcome these constraints
National Conference on Community Health Insurance
30
SHEPHERD, Tamil Nadu
Self Help Promotion for Health and Rural Development (SHEPHERD) based
at Trichy, is a professional development financial institute working with 7,500
rural families occupying the
'■
core community of central
Tamil Nadu.
Started in the year 1995,
under
the
Registration
Act
Society’s
1995
I
ft
■
y
Ij
ii
I
IP
by
Mr.Peter Palaniswamy and
eminent
other
person
L'S1.:
____
belonging to various fields of
_____ - * _
/'I
L/y
profession, its operations have now expanded over three districts of Tamil
Nadu namely Trichy, Perambalur and Salem which are identified as backward
and drought prone districts.
Processes and fruition of insurance
•
Major products on insurance are FOOD security, INCOME security
HEALTH security and ASSET security.
A. FOOD SECURITY
•
Operational activity in which the members save fistful rice each time
they gather for meeting.
•
Pooled rice is donated to the needy and old aged poor
B. INCOME SECURITY
1.LIFE
i) Scheme Coverage: 2000 to 2003
National Conference on Community Health Insurance
31
•
Covered 2,212 members and their spouse in the year 2000,
•
Covered 8,365 members in 2003.
•
The ratio of men and women were nearly 50%.
II) Life Insurance Scheme
•
Three schemes with premium varying between Rs.35 to Rs. 100/-
•
Coverage of natural death, accidental death, hospitalisation and
permanent disability.
Claims
Total claims till 2003 are 102
•
Current rate of claims per insured is 6/1000 member per year i.e. of the
total of 7167 life insured during the year 2003,45 were the claimants.
•
Of the total 7167 insured members, those covered under GSS are
6500, OGI-744 UNMIS-550.JBY-891.
•
The cause of death is often due to liquor habits of men
Cardio attack seems to the next common cause.
•
100% settlement was assured during last year on account of prompt
submission of relevant documents.
2. NON-LIFE
SHEPHERD has entered in to partnership with UIIC for providing Health,
Asset and livestock insurance.
(a) Livestock Insurance
The stress is on the three attributes viz. PREVENTION, PROTECTION and
PROMOTION.
National Conference on Community Health Insurance
32
(b) Livestock Coverage
The Livestock-diary was initiated in 2000 with coverage of 126 cattle,
.
350 in 2001,302 in 2002, and 85 in 2003.
Goats are not covered due to high rate of claims.
•
C. HEALTH SECURITY
This scheme aims at indemnifying the related expenses of the women
•
if they are hospitalised for at least 24 hrs in a hospital having a
minimum of six beds.
•
This scheme has been from May 2003
•
Covered 550 members, constituting 100% women coverage.
Sugam Fund:
•
Financial assistance to pregnant women for safe delivery
•
Soft loan of Rs.2, 000 to 3,000/-
•
Matching contribution from FWWB.
•
Fund is kept at each Block level federation for its operation.
D. ASSET SECURITY
•
Covers hut against damage by fire.
•
The scheme is linked with UIIC for coverage of Rs.5000/- by paying a
premium of Rs.45/-.
•
47 members enrolled
National Conference on Community Health Insurance
33
Dr. N. Devadasan, SCTIMST-Trivandrum & ITM, Antwerp.
•
A review of 10 Community Based Health Insurance Programmes in
India initiated by NGOs, with varying levels of community involvement.
•
Only one has
involved the
Government.
Six of them have
used existing
CBOs e.g. SHGs,
fl
Unions to develop
the insurance
programmes.
•
All target the poor - ranging from SC / ST to poor women in SHGs
•
The target population ranges from 1500 to ~ 5 million.
•
Eligibility criteria = Geographic limits, member of CBO, poor, in SHGs
usually adult women
Premium details:
•
Mostly voluntary. Only 2 have mandatory premiums
•
Unit for enrolment is the individual (7/10)
•
Premium per individual ranges from Rs 4 per year to Rs 250 per
year. 6/10 charge around Rs 20 to Rs 40.
•
8/9 has a definite collection period and 6 / 9 have a waiting period.
•
Collection usually done by the CBOs, NGOs
Benefits:
•
All cover hospitalisation benefits. Upper limit ranges from Rs 1250 per
patient per year to no limits (Direct model).
National Conference on Community Health Insurance
34
•
Some include other benefits, e g. cover for loss of wages, ambulance
fees
•
Providers are either NGO or Private providers.
•
Only one has Government provider.
•
Co-payments in almost all the schemes
•
Exclusions in many of the schemes e.g. chronic illnesses, deliveries,
TB, etc.
•
Almost all the NGOs also provide primary care through other resources
Output
•
Subscription rates vary from 10% to 60%. Most are in the range of 20 -
40%.
•
Not clear who are enrolling - the top half among the poor? Those near
the health facility? Those with risk of illness?
•
Hospitalisation rates - mostly (5/ 8) in the range of 1 - 10 admissions
per 1000 insured.
•
Again not clear who are using the benefits
•
Not enough information about the impact in terms of catastrophic
health expenditure.
Conclusions
•
CBHIs can be effective in protecting the poor - ? The poorest?
•
Can be financially sustainable.
•
Scaling up
•
One has to be careful about the design
•
Quality of care needs to be ensured
®
Management of Health Insurance is a complex task
National Conference on Community Health Insurance
35
Dr. Rajeev Ahuja, Fellow at Indian Council for Research On International
Economics Relations, New Delhi.
•
Health care financing in India unique in several respects
•
The share of public financing in total health care financing in the
country is just around 1% of GDP
•
This considerably low compared to the average share of 2.8% in low
and middle income countries
•
The beneficiaries are not only the poor but also the well-off sections of
the society.
•
Over 80% of the total health financing is private financing
•
Much of which takes the form of out of pocket payments and not any
prepayment schemes.
•
One quarter of all Indians falls into poverty as a direct result of medical
expenses in the event of hospitalisation (World Bank)
•
How to convert private out of pocket spending into health insurance
premium and how to provide health insurance to the people who
cannot afford to pay full premium-The twin challenges facing the Indian
health policy experts
•
Country may chose between public or private financing of health
services
•
But that choice is hardly available to countries like India because of its
limited ability to marshal sufficient resources, nature of employment of
the workers (most of them are self-employed)
•
Policy of the state is to provide free universal health care to the entire
population.
•
Insurance through prepaid schemes has a number of advantages more equitable, drivers of improvement in health care by encouraging
investment and innovation.
National Conference on Community Health Insurance
36
•
But private insurance leave out the low-income individuals who can’t
afford premium and limit the coverage for high-cost conditions or
services.
•
Private Health Insurance in India is a supplementary services - it is
limited
•
Most of them are mandatory, voluntary, employer based and schemes
in the NGO sector.
•
All these schemes together covers about 110 million or about 11
percent of the population (Garg 2000)
•
This is far short of the private health insurance potential which is
anywhere between 400 to 500 million people.
•
Even with development of private insurance only half of the country’s
population will have access to health insurance.
•
The low-income population (50% of the population) will be outside the
ambit of private health insurance.
•
After liberalisation of insurance market in 2000 no significant change in
the products or volume of business.
•
Medi-claim or Jan Arogya for the poor have not shown any growth
•
The reasons? Lack of marketing and not coverage of primary health
care costs
•
Why health insurance remained under developed in India? -Govt
policies, absence of data base on diseases, treatment and health
profile
•
Creation of standards for diseases and treatment procedures,
introducing
rating, credentialing of the providers to encourage
standardisation of services, creation of centralised database, billing,
claims and proposal forms is a must for entry into health insurance
business attractive.
•
Impact on the poor - they stand to benefit though private insurance
company may not cover them. But the likely impact of it far from clear.
National Conference on Community Health Insurance
37
Voluntary Health Services, Tamil Nadu
•
The Voluntary Health Services, a
non-profit charitable society
registered in 1958 is running a Medical Centre (Hospital) for catering to
the medical needs of poor and middle-income group of the community
in and around South Chennai. The Medical Centre consists of 405
beds with almost all the specialities. Nearly 70% of the patients
admitted are given free treatment including drugs and diet.
•
The Medical Aid Plan formulated by Dr.K.S.Sanjivi, founder of VH8,
being implemented by VHS, for the benefit of the general public
(mainly focusing on lower and
middle income groups of the
community) envisages covering the family as a unit of Health Care and
focuses on community participation, in its Scheme.
Family membership:
•
On payment of the Annual subscription, as noted below, the head of the
family is enrolled as a member and his dependant members are
included
•
The Card is valid for one year from the date of enrolment
Income group:
Members with monthly income below Rs.750/- p.m. are given free treatment.
Subscription:
•
Varies between Rs. 80 to Rs. 350/- per annum per family based on
income group
•
Those who do not opt for the family membership can be treated as
individual members.
Higher income group:
Members get 20% concession on the charges payable
National Conference on Community Health Insurance
38
Special features:
VH8 Hospital itself is implementing the scheme and there is no third
•
party involved.
Beneficiaries get their benefit under a single roof.
•
Outreach programme:
•
VHS is running 14 Mini Health Centres each covering a population of
5000, having a part time Doctor, male and a female multipurpose health
worker. There is also a Lay First aider, almost a lady of the area.
•
The mini Health Centres are placed in rural and semi-urban location
•
Special
nutritive
unit
where
there
is
Nutrition
Demonstration
periodically.
•
The Government of India have formulated the Primary Health Centre
concept following this pattern.
Learning
.•
The Medical Aid Plan envisages coverage and participation by the
general population
•
In spite of our social workers addressing the patient in VHS Hospital and
also Multipurpose Health Workers, in the village level in the 14 Mini
Health Centres run by us, the programme has not been very successful.
•
The family based programme has not become very successful on
account of defaulters’ rate being high and patients want to come to the
hospital, only when they are sick, though the family programme provides
Health Check up for all the members on getting enrolled.
•
This made us go in for an individual membership scheme and any body
who wants to get treated can avail the services from VHS.
•
Marketing need to be done vigorously.
©
National Conference on Community Health Insurance
39
Summing up:
Complimenting the participants for the excellent presentations, Dr. Pradeep
Panda, the chairman of the session, remarked that Community Based
Insurance is an innovation and emerging field. Referring to low participation
of the poor people in these schemes, he urged the service providers to
extend the coverage to the poor. Dr. Panda wondered whether the deterrents
were taken care while designing of the scheme.
Sri. Rajeev Ahuja, the co-chairman of the session observed that while the
scheme of National Insurance Company took care of the supply side, in
SHEPHERD the stress was on the demand side. Referring to the poor
statistics of claims, he strongly urged for reducing the premium charged on
the various Health Insurance Schemes by the service providers. “Insurance
players like NIC shall strive to increase the basket of different types of policies
to break-even rather than trying to achieve it on one type. Steps like this
alone will enable poor people to have access to Health Insurance cover.” said
Sri. Ahuja.
q
National Conference on Community Health Insurance
40
Plenary Session IV (1545 to 1700 hrs)
Panel discussion on
“How Health Insurance Can be spread in Karnataka and India”
Chairperson Dr. Indrani Gupta, Economist, JNU, New Delhi.
Panellists
Dr. Paolo Carlo Belli, Economist, World Bank, Washington, USA
Prof. Muraleedharan, Professor, Dept, of Humanities & Social Science, IIT, Chennai
Sri. Rajeev Ahuja, Fellow, ICRIER, New Delhi.
Prof. V.R. Muraleedharan
Initiating the discussion on the topic, Prof. Muraleedharan mentioned the
following as the basic issues involved.
©
It shall be health care system and not health insurance system
®
Revenue raising potential of the scheme is very limited
•
It shall not be treated as a source of finance
•
It shall be for organising health system
Dwelling on the challenges for spreading of the health insurance system,
Prof. Muraleedharan remarked that the stress of the schemes should be to
develop the consumer as an active purchaser of the scheme by making him
well informed. Advocating for developing a strong drug policy, he urged the
government to lay down clear-cut guidelines for referral cases. Pointing to the
routine marketing techniques used by the players to canvass for the scheme
Prof. Muraleedharan said that attempt must be to know how responsive the
consumers were by initiating a consultation process prior to start of the
scheme. Mutual trust between various stakeholders should be an essential
part.
National Conference on Community Health Insurance
41
Dr. Indrani Gupta
Complimenting the various stakeholders for initiating the community health
insurance, Dr. Indrani Gupta remarked that in India despite privatisation,
people do not come forward for health insurance under the feeling that it is
unlikely to happen to them. Referring to the scheme, Dr. Indrani remarked
that the beneficiary is getting the benefits at a cheap rate without knowing that
some body is bearing the actual costs.
While trying for replicability of the
scheme, this fact should be borne in mind, as public finance could not be
subsidized.
Asking the stakeholders for maintaining good data of the
scheme,
Indrani
Dr.
remarked that
most of the
schemes were for
hospitalisation. “It shall be a good idea to expand the coverage beyond
hospitalisation, which shall induce more people to join the scheme”, said Dr.
Indrani Gupta.
Referring to the target community of the scheme, she said that the scheme
need not be only for the poor. “If the community scheme works why not for
others?” Dr. Indrani Gupta asked.
Dr. Paolo Carlo Belli
Referring to the various sessions, Dr. Paolo Carlo Belli remarked that all of
them were highly interesting. Making a strong case for targeting the poor, Dr.
Belli remarked that insurance is not a panacea but had other important role to
play like public care and health promotion. “But management of the scheme
is one of the key limitations", said Dr. Carlo Belli.
Sri. Rajeev Ahuja
Sri. Rajeev Ahuja remarked that as a part of social security, Government
policies take care of the Finance, Health and Labour. There is a genuine case
of selling insurance as in house but government policy does not allow it.
Urging the NGOs, researchers to influence the government policies, he said
that health care system in the country is in chaos.
National Conference on Community Health Insurance
42
Talking about up-scaling the system, Sri. Ahuja remarked that the health
insurance market is un-tapped in the country. But the Public insurance
companies, which are becoming commercial, might not go for coverage of the
poor, as they do not identify for that cause. The Private insurance should do it
as their social responsibility.
Ms. Alka Narang
Ms. Alka Narang who anchored the discussion, referred to the rapid economic
progress made by China. In 1947 both India and China were on equal footing
but since then China’s economy has made rapid stride as they focussed on
poor section of the society. Since 80% of the health problem is rooted in
poverty. “Why we could not turn to our panchayats to start the process in
India?”
she asked.
Ms. Alka Narang made a strong plea for inclusion of
diseases like HIV also under the schemes apart from pooling the risks.
Dr. H. Sudarshan
Referring to presentations and discussions between the representatives of
World
Bank,
Central
and
State Government,
UNDP,
various service
providers, economists and voluntary agencies, Dr. H. Sudarshan who gave
vote of thanks, made a strong plea for up-scaling the community health
Insurance System throughout the state of Karnataka. “With all the key players
who took part in the National Conference positively inclined for it, it is for the
World Bank, UNDP, Government of India and Karnataka to take a decision in
this regard”, said Dr. H. Sudarshan.
National Conference on Community Health Insurance
43
LIST OF PARTICIPANTS
SL
1
_____Name
Dr. Paolo Carlo
Belli
Designation
Economist
2
3
Ms Alka Narang
Sri.
K.H.Gopalakrish
na Gowda, IAS,
In charge
Project
Administrator
4
Sri. Rajeev Ahuja
Senior Fellow
5
Ms I nd rani Gupta
Economist
6
Dr. Pradeep
Panda
Economist
7
Dr. H. Sudarshan
8
Ms.Tara Sinha
9
Sri.Amitava
Chakravarty
9
Sri.C.Chandrashe
kar
10
Sri.
Aswathanarayana
Organization address
World Bank
1338, 29 street
Washington DC 20007
USA.______________
UNDP, NEW DELHI
Karnataka Health
Systems Development
Project 1st Floor PHI
Building Sheshadri
Road, Bangalore560001____________
ICRIER
Core 6A, 6'h Floor
India Habitat Center,
Lodhi Road
Delhi- 110003_______
Institute of Eco.
Growth, Delhi
Telephone No
(R)4580020
(O) 2277391
(R) 6490918
(O) 24645218
rajeev@icrier.in
(R)
9818472833
27667107,288,365,4
24_______
1 A, Pocket A, Gate
R)26931004
Number 1, DDA Flats, 98170714685
Sukhdev Vihar,
New Delhi 110 025.
Hon. President Karuna Trust,
080-2257487
B.R. Hills, Yelandur,
Karnataka 571 441
Consultant
SEWA
(O) 079701, Sakar IV'1’
6580530
Ashram Road
(R) 079Ahmedabad-3 80009
6301591
’ (0)034722452
Office
Sri. Mayapur Vikas
Manager
Sangha
32
P.O. Sri. Mayapura,
Dist Nadia 741 313,
W. Bengal__________
Vice President Family Health Plan
(O)23556464
Ltd.
(R)24066077
3rd Floor Adityatr
Towers Road No-2
Banjara Hills
Hyderabad-500034
Andrapradesh_______
Manager-in
National Insurance
(O)5582379
Charge
Co. Ltd
144.M.G.Road
Bangalore-560001
National Conference on Community' Health Insurance
_______ E mail_______
Pbelli I @worldbank.org
vgkk@vsnl.com
sinhatara@hotmail.com
sewass@icenet.net
smvs@vsnl.com
Chandra@thpl.net
nicbro@vsnl.com
44
Sri.
W.K.Vijayaragha
van
Sr.Divisioal
Manager
National Insurance
Co. Ltd.
371,Prestige Shopping
Arcode
Ramaswamy Circle
Mysore- 570024_____
Divisional Officer,
PBNO.212
Prestige Shopping
Arcode 3rd Floor,
Ramaswamy Circle
Mysore-570024_____
Family Health Plan
Ltd
No.23/02,CPS House
1st Floor Ulsoor Road
Bangalore-560042
T.N.Pura Hospital
My sore Dist._______
Health & F.W
Services
Govt. Of Karnataka
17 Vaibhav Nagar
Belgaum-590010
General Hospital
T.Narasipura
(O)2422657
(R) 2476839
Dept- of Health &
Family Welfare
Services
TB Control Center
B.N. Street
Mysore-570021
Project Officer BAIF Institute For
Rural Development
Syrashettikoppa581212
Kalahatri Taluk
Dharawad Dist.____
Extension
I.H.D.U.A
Officer
Begur Gundulpet
Rural Community
Project Co
Ord inatar
Health &
Development Project
P.B.NO. 38
Mission Hospital
Mysore-570011
(O)2529205
12
Sri.
H.K.Ravikumar
Asst.Administ
-rative Officer
13
Sri.Prasant
Mallar
Assistant
Manager
14
Dr. K. Devendra
15
Dr. Narayana
V. Honnungar
Taluk Medical
Officer
Dist. RCH
Officer
Belgaum
16
Dr. Murthy
17
Dr. S. Jay Kumar
18
Sri. Deepak
Ksheerasagar
19
Sri. Il.C.Papanna
20
Sri. Santhosh
Kumar
Administrativ
e Medical
Officer
Dist. TB
Control
Officer
National Conference on Community Health Insurance
(O)2426339
(R)2427529
(0)56619001
mallar@fhpl.net
(O)262248
(O)2484983
(R)247180
honnungarnv@yahoo.c
om.
(O)261483
(R)2472252
(O)08370723441
(R) 723812
(O)631385
(O)2446644
45
21
Dr. D.N.
Devadasan
Doctoral
Student
22
Sri. Prabhakar
Shetty
Branch
Manager
23
Sri.K.S.Nanjappa
Project Co
Ord in atar
24
Dr.R.
Subbakrishna
Reader and
Research
Officer
25
Sri.N.R.
Lakshmi
Narayana
Branch
Manager
26
Ms. S.Akila
Capacity
Building Co
Ord inatar
27
Ms.K.N.
Tamilselvi
Block CoOrdinatar
28
Mrs. Sheela
Khare
Programme
Officer
29
B.S. Ajaikumar
Chairman
deva@devadasan .com
(R)080I.T.M Antwerp
8435151
Belgium c/o The
Valley School
Thatguni Post
Bangalore-560062
(O)24228053
National Insurance
(R)2361470
Co. Ltd.
Direct agents Branch
3rd Floor Prestige
Shopping Arcode
Ramaswamy Circle
My sore.___________
sdrangnathan@vsnl.co
(O)2302045
International Human
m
Deve. & upliftment
Academy
18-19,Hebbal
Industrial Area
Metagal ly Post
My sore-570016_____
rsubbakrishna@yahoo.
(O)2411996
Central Institute &
(R)2518878
com
Indian Languages
Manasagangothri
Mysore-16__________
Qicblrl402@vsnl.net
The Oriental Insurance (O)
6563144/6567
Co. Ltd
City Branch Office
506
(R)5719397
Lalbagh Hosur Road
Opp.9,h Cross
Bangalore-570006
shepherddevorg@sify.c
SHEPHERD
(O) 04312780648
om
Thiruchanapalli620102
Tamilnadu__________
shepherddevorg@sify.c
SHEPHERD
(O)431om
30/37, Renganagar
2780648
Vyyakondanthirumalai
Trichy
Tamilnadu__________
(O)222705
sheelakhare@yahoo.co
Jana Shikshana
Samsthan
(R)2560921
NO. K.T413
OPP. Chamundeswari
Temple Bannur Road
Mandya___________
IHDUA
bcchi@vsnl.com
(O)2302045
18-19 Hebbal
(R)
Industrial Area
9845381383
Metagally post
My sore-570016
National Conference on Community Health Insurance
46
30
Sri.
V.R.Muraleedhra
n
Professor
31
Sri. S.Anand
Insurance
Officer
32
Dr. Y.S. Gopal
Consultant
33
Mrs. Kripa
Keshav
Sr.
Programme
Officer
IIT
Dept, of Humanities &
social Sciences
Chennai - 650036
Activitistforcial
Alternatives (ASA)
3-A, Alli Street
Annamalai Nagar
Trichy-620017
Tamilnadu_________
Centre for Population
Dynamics,
312, Cauvery Block
A4
National Games
Complex
Koramangala
Banglore-560047
-do-
O) 04312750959
R)04312482614
-do-
asadev@eth.net
kripakeshav@vahoo.^
in
cfpd@vsnl.net
Director
Finance &
Administrativ
e__________
Medical Co
Ord in atar
Sri Mayapura Vikas
Sangha. Sri Mayapura
Nadia, West Bengal
Dr.Krishnedu
Sekhar
Chowdhary
Medical
Consultant
37
Sri. A.S
Rajagopalan
Micro Credit
Manager
38
Dr.Sujay Mitra
39
Dr. Prabas
Chaudhuri
34
Bijoy Kumar Roy
35
Dr.Kabita Maiti
36
(O)
03472/245232
(R)
03472/245226
(O)
03472/245235
(R) 245443
smvs@vsnl.com
Sri Mayapur Vikas
Sangha 12/2 Kutul
Sahi Road P.O Barasat
D/24 Paggnas(North)
West Bengal._______
Sri Mayapur Vikas
Sangha, Sri Mayapura
Iskon Nadia Dist
West Bengal-741313
(O)03472248107
smvs@vsnl.com
(O)
03472/245370
(R)
03472/245061
Rajagopl an@yahoo.co
111
Project Officer
-do-
m i t ra_sujay@redttmail.
com
Chief Medical
Officer of
Health Nadia
Govt, of West Bengal
Dept, of H&F.W
Chowdhary Bagan
BidhanPalli
P.O. Madhya gram
(O)
03472/245370
(O)
03472/252306
(R)
03472/252346
Sri Mayapur Vikas
Sangha, Sri Mayapura
Nadia, West Bengal
National Conference on Community Health Insurance
smvs@vsnl.coin
(R) 033-25526559
47
40
Dr. Raju V.
Deputy
Director
41
Dr. V.D. Dhanuj
Taluk Health
Officer
42
Dr. S.C.Dharwad
Di st Health &
F& W Officer
43
Dr.N. Karunakara
(O)2277390
(R)
9845583547
(O)2482886
(R) 2453716
Co-ordinator
Deputy Director
KHSDP
Bangalore-560001
Dist Health & Family
Welfare Officer
Belagum-590005
Dist Health & Family
Welfare Office
M.Vadagam
Belagaum-590005
Community Health
Center. Talakadu
T.Narasipura Taluk
Karuna Trust
12575,12"'Main E.
Block Rajajinagar
2nd Stage Ban galore.
Karuna Trust,
B.R. Hills, Yelandur,
Karnataka 571 441
-do-______________
-do-
Co-ordinator
-do-
Medical
Officer
44
Dr. T.K.Deb
Health Co
ordinator
45
Sri. Malleshappa
G
Secretary
46
Sri. Viswanath
Sri. Govind
Madhav______
Sri. G. Achutha
Rao
Treasurer
47
48
National Conference on Community Health Insurance
(O)2481952
(R) 2422506
Fax-NO: 242745
Fax:242745
(0)0821-
273365
(R) 3328464
0821-744025,
744018
vgkkbrh@sancharnet.in
-do-do-
-do-do-
-do-
-do-
48
LOO 099 - cpsr^vio^z ‘^p ^osu^eseqa ‘ppi. *o^
g^ga'is®
•Q ^0^
Ps-\4<r'-'
°\
T\
^\ojy
e Wes sr^ W?- jsb e
■■■HHHIIIMHi
djarteo
5,000/- sSdrt
46-55 ^o±>2jj
oSsSdri
56-65d q3o&&)
cSsSdri
66-70d
FSsSdri
70
100
120
140
70
100
120
140
50
50
50
50
^?zydo s^do t-odo-xw^.d sdrb ^dod dos^d
190
250
290
330
^w.do
dodo
£>ddo w^,d
dod.^dod
dOsssd
i4
-0
->
o
240
300
300
380
45
asSdrisk
r*
gjOsrodai
<=l
skrio 25 ^rzd^drt
jJ
_o
•
saoaSX)
g^de^ de?eo,
cto. 144,
d3>»
- 560 001
ssfS wdjseri.6 azlro
• wg wdaserij adja cXddedo ?
«d ^daaeri^ aadja 35a©^dx adaausadd wdj^cdo d^aeodo dd^ddo4 ssa&rd ao3 daa. 5000/- ddri S^tfod dad) ddaaari,
doxje^ daa&^dod 3ua©2j, 1)
BaoOodrt^od 2) edsjyadd dad)Ks?od 3) £daa ed^oio©^ dd&d 5ao&drtC>ri xJoz^oddqj
dadjrt^od.
1. £;dori u^dUj 5aoOodrt^ri wdjdjOk©, ao&do, cOde^K^rtdoxjadaaan d^aeofc / d^ dad, ddaaart fodori drio©d £)drd^ daa.
5000/- rte* ddri koacbfijtorbdjdo.
2. wdjd^ dedod dxd* 30 adrte* dod^ w^d, asaxJd doddd 60 adrts?ri xlododdiSj dad^oio dd^dd^ z^Ddcjariod^d.
3. do&^jd aoa : 5 ood 70 ddr, 3 3orts?od 5 ddrd dod^aa dd ddo6 dod sjartaa /
.':
wdjd^ edaoa d&ron* daaeorte©,
e. woioa d^dfdd©^ daaonaoOo&dod
erc)xJo,33aoofc©ddetfo.
W.
sao^ooio ddjri £doa ddoiotododo.
. . .
......
saoOodritfri dad) ddoari : (S^od £ddd©, dodo - e/w)
^^a d&ron* daaeo wn daaodrf ddd aoartaa e?drd daaoSdod d^d6d
■
/<’<
r-z^: >'>.’:■ :•
.<.4 .>
-- '
-■''
zPo^^dosi xJosS odjaAdde?b.
e^ssdaddefc. (Sj-^rird eruadoris^
10 m? djaeft aro&ri xPo^^ddf^o).
2. d^ tsadj djados^csadd, xbriz^d d^ tadsSjTOd^dde^.
3. 24 rtodo&ja s&arar edq^pdod dadj^d djadod rododdd^ de^^dde^o.
4. 24 riodok/a a^prar edr^dad d^da wd^sssOodoc^dde^.
1. tfde 3j?^ 15 utf djaefirisPri
B10 'Illi
77a)©^cd«o cdX’d
^e^o^odod^d.
1. oiradjde
sao^dri*
djd^oio©^
24 dod dad^ ddcsari doad,.
2. d^cdaa©^, aedaaeddi, de^oSaae dd&,
dad,, dod d^ dad) doaasa^doioEOod teo, drtoiood d^ dad), tja^ej^
dricdoodjdo, a dodo^ h
saoEodriCrt ej^odo©, dad, ddnari, 24 rio&Sri^
dad, aoiodo e^oOodos^ae^.
II
>
.! II I
I
3530^0, &&od ^odrWri do^ad dusd^a^.
1. ^do djsadad s^adrd^ ^dododd oijadjde eao^dri^ dddjri dja^d dd^.
2. adaodo e>d§o& djadode ddrdC^ S^od saoxdrt^ d^d, djaad ddu ■
a&ad, dq^oira, dojso^a, rt^rdja^d©,
d^ dadj - dxdjd do^odssad arorLa Q^d^daoSjaedo, dd^ 353(dJeU5*‘ d^du* dj^e&, d^dja/Aje^,
duaerirtsk,
- dado, wddA dotoo^ad^ saoSodrt^ri djsdod dd^d©,,
BsoSodri^d^ £dja d/sdrd©,
^d^odo ade^bs^©,.
3. d^^a das^caoiort^©, taadjri djaad ddj.
4. dr^d dJe>d3J3©d doe^ ddu aasrtjs dd^ris?, djdro xroddrt^ri dod^, saes^^dRFjriert daaad ddu.
5. ddrc^drs / doriri doz^oa&d zaad^oio <003, dd^rt^o.
6. dodrte5 d^/dadj- ^djd; dedodedd^cS©^doad,.
7. o&od^ ecto ade& w^dorsSod voolsad Baotodrfefc/naofcri^.
8. c&Ddjde dodj^d dd^, xradjad^ Stored, wasd^ daad saraod daaeKrfcb.
9. zaadjri d^dsafi ataaoes6, aortas
doe©d dt^.
10. £cr^ dddd zracoodo^od e&dcsafi aaarias ddasf^ssafi wriod dd^.
S: • aiossd sddoi»si at?s>a!
dad^rrcfi wdjd; deod 7 Eiddaa^rrafi daadt; xiaadeSdod^ ©.sod daaa^tf tfod^ri daadd^d^. wd^otood zodortdoiisd 30
Sdritfaa^ri £daa na^Ddodod^ w^d^ dd^d
d&e^rteb dod^ xfo^oddiSj d^aeofc dd>d daadri Nodari aedd^d^.
Community Health Insurance in India
An Overview
Community health insurance is an important intermediate step in the evolution of an equitable
health financing mechanism such as social health insurance in Europe and Japan. Social
health insurance in these countries, in fact, evolved from a conglomeration of
small community' health insurance schemes. Historically, during the peak of the industrial
revolution workers ’ unions developed insurance mechanisms which were eventually
transformed. Community health insurance programmes in India offer valuable lessons for
policy-makers. Documented here are 12 schemes where health insurance has been
operationalised. The two following articles describe in some detail two successful
community health projects.
N Devadasan, Kent Ranson, Wim Van Damme, Bart Criel
A
1° I d Heal‘\Organif
than
ZA 80 per
per cent
cent of
of total
total expenditure
expenditure on
on health
health inin India
India isis
Tntun '7 (1/gure f'or l 999’2()01 [World Health Organisation
2004])
nrivn e and
f"' most
"“r of this
hk flows
fl°WS directly
d’reCt y from
frOm households
households to
t0 the
the
private-for-profit health care sector. Most studies of health care
spending have found that out-of-pocket spending in India is
actually progressive,
progressive or equity neutral; as a proportion of nonnon
food expenditure, richer Indians
Ind.ans spend marginally more than
poorer Indians on health care. However, because the poor lack
the resources to pay for health care, they are far more likely to
They are generally targeted at low-income populations, and the
nature of the ‘communities’ around which they have evolved is
quite diverse: from people living in the same^own or district
t° members of a work cooperative or micro-finance groups Often’
the schemes are initiated by a hospital, and targeted Presidents
of the surrounding area. As opposed to social health insurance
membership is almost alwaysvoluntary rather than mandatory’
Internationally, there is a shortage of empirical ev“7o
assess whether or not CHI schemes have improved access and
financial protection among the poor. Enthusiasm for such schemes
is 2.6 times more likely than the richest to forgo medical treatment
when ill [Peters, Yazbeck et al 2002]. Aside from cases where
people believed that their illness was not serious, the main reason
for not seeking care was cost. The richest quintile of the popu
lation is six times more likely than the poorest quintile to have
been hospitalised in either the public or private sector [Mahal,
Singh et al 2000]. Peters et al (2002) estimated that at least 24
aians nospitahsed tall below the poverty line
per cent of all Indians hospitalised fall below the poverty line
because they are k
•••••«-
i
in utilisation among the poorest with the implementation of
insurance [Yip and Berman 2001] or mandatory prepayment
schemes [Diop, Yazbeck et al 1995] in developing countries. But
studies of voluntary CHI schemes have yielded less promising
results. The studies and reviews that have been undertaken
suggest that many schemes are short-lived and fail even to meet
the goals they set for themselves [Bennett, Creese et al 1998].
people
SZs'hmiting
?.001ing and_reso^ce transfers (International Labour Office
to exclude the poorest among their target populations, in part
mis context, health insurance appears to be an equitable alter because they generally charge a flat (or uniform) premium that
native to out of pocket payments.
is unaffordable to the poorest. Under the three schemes reviewed
In recent years, community health insurance (CHI) has emerged
by Preker et al [Preker, Carrin et al 2001] in Rawanda, Senegal
as a possible means of: (1) improving access to health care among and India, even among the insured, low income remained a
the poor; and (2) protecting the poor from indebtedness and
significant constraint to health care utilisation.
impoverishment resulting from medical expenditures. The World
The purpose of this paper is to describe Indian CHI schemes,
Health Report 2000, for example, noted that prepayment schemes
and where data are available, their impact - it is intended to serve
represent the most effective way to protect people from the costs
as an update on earlier work by one of the authors [Ranson 2003],
ofhealth care, and called for investigation into mechanisms to bring
In India, community health insurance has a long history. The
the poor into such schemes (World Health Organisation 2000).
earliest such scheme was started in Kolkata in 1952 as part of
Various other terms are used in reference to community health
a student’s movement. The Student’s Health Home (SHH) caters
insurance, including: ‘micro health insurance’ [Droretal 1999],
.
t0 the students in the schools and universities of West Bengal,
‘local health insurance’ [Criel 2000] and ‘mutuelles
tuelles ’ [Atim
[Atim C
C Currently there are more than 20 documented CHI programmes
2001]. We define CHI (along the same lines as
as [Atim 1998]) of which five were initiated in the past three years. Based on
as “any not-for-profit insurance scheme that is l
a"
V1SltS t0 twe,ve of the schemes, the authors describe the context
at the informal sector and formed on the basis of a collective
in which they are operational, their design and management, the
pooling of health risks, and in which the members participate
administrative challenges faced by them, and their impact. The
in its management.” CHI schemes involve prepayment and the
names and locations of the programmes included in this summary
pooling of resources to cover the costs of health-related events.
are given in the accompanying table.
Economic and Political Weekly
July 10, 2004
t
3179
Underlying Objectives
Most of the insurance programmes have been started as a
reaction to the high health care costs and the failure of the
government machinery to provide good quality care. The objec
tives range from “providing low cost health care” to “protecting
the households from high hospitalisation costs.” BAIF, DHAN,
Navsaijan Trust and RAHA explicitly state that the health in
surance scheme was developed to prevent the individual member
from bearing the financial burden of hospitalisation. Health
insurance was also seen by some organisations as a method of
encouraging participation by the community in their own health
care. And finally, especially the more activist organisations
(ACCORD, RAHA) used community health insurance as a measure
to increase solidarity among its members - “one for all and all
for one.”
Context
Almost all the 12 CHIs are based in rural or semi urban areas,
working among the poor. This ranges from tribal populations
(ACCORD, Karuna Trust, RAHA), dalits (Navsarjan Trust),
farmers (MGIMS, Yeshasvini, Buldhana, VHS), women from
self help groups (BAIF, DHAN) and poor self-employed women
(SEWA). The size of the target population (i e, the population
from which they aim to draw members) ranges from a few
thousands to 25 lakh (Yeshasvini trust). Most of them (eight
of the twelve) use existing community based organisations to
piggyback the health insurance programme. While in some it is
the existing self help groups (SHGs), e g, DHAN, BAIF; in others
it is a union (SEWA, ACCORD and Navsarjan). In two others
it is the cooperative movement (Yeshasvini and Buldhana). These
community-based organisations have been a useful platform to
explain the principles of health insurance to the community, for
collecting premium and for managing claims and reimburse
ments. And most important, they have instilled a sense ofownership
of the insurance programme among the community.
In India, there appears to be three basic designs, depending
on who is the insurer (see the Figure). In Type I (or HMO design),
the hospital plays the dual role of providing health care and
running the insurance programme. There are five programmes
under this type. In Type II (or Insurer design), the voluntary
organisation is the insurer, while purchasing care from indepen
dent providers. There are two programmes under this type. And
Table 1:12 CHI Schemes In India
Name and Location of the CHI
As Well As Year of Initiation
Target Population
Type
Remarks
ACCORD
Gudalur, Nilgiris, Tamil Nadu
1992
Scheduled tribes of Gudalur taluk who are members of
the Adivasi Munnetra Sangam (AMS) - the tribal union.
(N = 13,070 individuals)
Type I
Linked with the New India Assurance
Company
BAIF
Uruli Kanchan, Pune, Maharashtra
2001
Poor women members of the community banking
scheme and living in the 22 villages around Uruli
Kanchan town.
(N= 1,500 women)
Type III
Linked with United India Insurance
Company
BULDHANA Urban Cooperative and
Credit society. Buldhana, Maharashtra
Farmers living in Buldhana District
(N = 175,000)
Type III
DHAN Foundation
Kadamalai block, Theni district,
Tamil Nadu
2000
Linked with United India Insurance
Company
Poor women members of the community banking scheme
and living in the villages of Mayiladumparia block. Total
of 4,514 members and their families.
(N = 19,049 individuals).
Type II
No linkages. The women operate the
scheme by themselves
Karuna Trust
T Narsipur Block, Mysore District,
Karnataka
2002
Total population of T Narsipur block and Bailhongal block,
with a focus on scheduled tribes and scheduled caste
populations.
(N=634,581 individuals)
Type III
Linkage with National Insurance
company
MGIMS Hospital
Wardha, Maharashtra
1981
The small farmers and landless labourers living in the
40 villages around Kasturba Hospital.
(N = 30,000 individuals)
Type I
No linkages. The organisation operates
the scheme.
Navsarjan Trust
Pathan District, Gujarat
1999 (discontinued in 2000)
Select scheduled caste individuals in two blocks of
Patan district, north Gujarat
(N= ?)
Type III
Linkage with New India Assurance
Company
RAHA
Raigarh, Ambikapur, Jashpurand
Korba districts of Chhattisgarh
1980
Poor people living in the catchment area of the 92 rural
health centres and hostel students.
(N = 92,000 individuals).
Type I
Have their own providers
SEWA
11 districts of Gujarat
1992
534,674 SEWA Union women members (urban and rural),
plus their husbands living in 11 districts
(N = 1,067,348 individuals).
Type III
Linkage with National Insurance
Company
Student’s Health Home
Kolkata, West Bengal
1952
Full-time student in West Bengal state, from Class 5 to
university level.
(N=5.6 million students)
Type I
Have their own health facilities
Voluntary Health Services
centre.
Chennai, Tamil Nadu
1972
Total population of the catchment area of 14 mini-health
Type I
Have their own hospital and health
Type II
Operate their own programme
Yeshasvini Trust
Bangalore, Karnataka
2003
3180
centres in the suburbs of Chennai.
(N= 104,247 individuals in two blocks)
Members of the cooperative societies in Karnataka
(N = 25 lakhs)
Economic and Political Weekly
July 10,2004
Figure: Types of Community Health Insurance schemes in India
Type I
Type II
Provider + Insurer
E
i
Insurer (NGO)
2
o
Insurance
Company
S'
Provider
E
.2
E
NGO
O
Provider
I
V
CT
2
Q.
Type III
a.
CD
3
CD
Community
Community
Community
Type I: ACCORD, MGIMS, RAHA, SHH, VMS
Type II: DHAN, Yeshasvini
Type III: BAIF, Buldhana, Karuna Trust, Navsarjan
SEWA
finally in Type III (or Intermediate design), the voluntary scheme covered only surgeries, all other medical conditions
organisation plays the role of an agent, purchasing care from being excluded. While most of the schemes reimbursed direct
providers and insurance from insurance companies. This seems costs of treatment (consultation, medicines and diagnostics), one
to be a popular design, especially among the recent CHIs, with scheme (Karuna Trust) also reimbursed loss of wages for the
five of the 12 adopting this. The insurance companies are mostly patient. Some CHIs had also added other benefits, e g, life
the GIC subsidiaries, e g, National Insurance Company, the New insurance, insurance against personal accident and/or asset
India Assurance Company, the United India Insurance Company, insurance into the package to make it more attractive to the
etc. Of late private insurance companies like the Royal Sundaram,’ community.
and ICICI Lombard have been involved with CHI programmes.
In the Type I CHIs, there is a cashless system of reimbursement.
As most of these programmes serve the rural poor, the pre However, in the other two types, usually it is a fixed indemnity
miums also have been low; in the range of Rs 20 to Rs 60 per with patients having to settle bills and then getting it reimbursed
person per year. Only three programmes had premiums higher 2-6 months later from the NGO. The exception was the Yeshasvini
than Rs 100 per person. The premium is usually paid as a cash scheme, which, though a Type III scheme, had managed to
contribution once a year during a definite collection period. Two negotiate a cashless system with the private sector by using the
schemes (RAHA and MGIMS) allowed the community to pay services of a Third Party Administrator (TPA). Most of the CHIs
equivalents in kind. The community and their representatives as have a fixed upper limit, ranging from Rs 1,250 to Rs 1,00,000
well as the staff of the voluntary organisation helped with the per patient per year.
collection of the premium, e g, at Yeshasvini, the premium
Most of the providers are from the private sector - either for
collection is organised through the existing cooperative infra profit or not-for-profit hospitals. Only one CHI (the Karuna Trust)
structure. Enrolment to the insurance programme ranged from had a public sector provider. In the Type I schemes, where the
a thousand to seventeen lakhs (Yeshasvini).
insurer is also the provider, there is an attempt to maintain quality
At most of the schemes, the unit of enrolment is the individual and keep costs down. For example at ACCORD, the hospital
and membership is voluntary. While some of the schemes en largely uses only essential and generic drugs. However, in the
courage family membership by providing a family package/rate Type II and Type III schemes, where the provider is mostly the
ze g, DHAN, Vimo SEWA and VHS), none requires enrolment private sector, we did not find any evidence of cost containment
>f the whole household. However, several of the schemes do or quality checks. Yeshasvini was the exception, where they have
enrol groups rather than individuals — enrolment in these same managed to negotiate capitation fees for each surgery. At SEWA,
schemes is to some extent mandatory’, and they come to re there is an ongoing initiative to empanel select hospitals (pri
semble social insurance schemes as a result. At Karuna Trust, marily government and trust hospitals) judged to be providing
for example, the cost of the premium is entirely subsidised for a high standard of care.
the poorest among the target population - the BPL-SC/ST - who
As stated earlier, most of the schemes are administered by the
are automatically enrolled in the scheme. Some of the self-help community, their representatives or by the voluntary organisation
groups at DHAN purchase insurance for all SHG members staff. This helps keep costs down. Usually they handle the
(generally 15 to 20) out of profits earned by the SHG (i e, certain following activities:
SHGs have chosen to make the scheme mandatory). At SHH, Creating awareness aulullg
among ulc
the communitycommunity; coitectms
collecting oremium
premium
foran theltaT'to S tl'pmmmm" “
<at ACC°^’coHect the premium and hand
it over to the NGO); monitoring for fraud (DHAN has an in
As stated earlier, while some of the CHI schemes limited the surance committee comprising of SHG members who scrutinise
benefit package to only ambulatory care, the twelve studied by
every sing,e c,aim)’ submitting claims; and channelling the
the authors all provided inpatient care.I?°i^
"Q
*,
^\C!'ed °.Ut reimbursements (at BAIF, the reimbursements are sent to the local
patient care as well as outreach services. It is observed that the SHG who while handing over the amount to the patient, reinforces
community prefers to have both outpatient and inpatient care. the benefit of insurance). All these activities help in increasing
Most schemes had important exclusions like pre-existing ill the efficiency of the scheme. Also it helps build a sense of
nesses, self-inflicted injuries, chronic ailments, TB, HIV, etc. One ownership among the community and increases accountability.
Economic and Political Weekly
July 10, 2004
3181
One of the weaknesses of the CH Is is the lack of techno and Yeshasvini) are run purely on funds raised from the
managerial expertise. This is reflected in the fact that most of community. All the Type 1 schemes have supplemented the
them do not have inbuilt mechanisms to prevent adverse selection locally raised resources with external resources (either from the
or moral hazard. Due to the asymmetry of information, it is government or donors). These external resources range from
possible that only the sick enrol in these schemes (adverse 20-40 per cent of the total reimbursements. Only two have relied
selection). Simple measures like a larger enrolment unit, a exclusively on external resources. Unfortunately, it was difficult
mandatory enrolment, a definite collection and waiting period to get accurate financial estimates of the administrative costs,
are measures to prevent this. While all (except VHS) have a especially since a lot of this is subsidised by the community.
definite collection period, other measures are usually not used.
Financing health care has always been a very difficult exercise.
SHH to a certain extent overcomes adverse selection by using Even in rich countries like the US, there does not seem to be
the institution as an enrolment unit.
enough for all. It becomes all the more challenging in a lowSimilarly, because of the insurance programme, the behaviour income country like India. While the Constitution ofIndia promises
ofthe patient or the provider may change (moral hazard). Capitation to provide adequate health care to the population, successive
fee structures, standard treatment guidelines and copayments are governments both at the state and the centre have failed in many
some strategies to prevent this. The only measure consistently ways to do so. This is probably one ofthe reasons why the majority
used by most CHIs to reduce the patient induced moral hazard ofthe public turns to the private sector fortheir health care needs.
is co-payments and deductibles.
Another equitable method of health financing is the social
The absolute number of enrolees varies tremendously, from health insurance - seen in most European countries. Given the
only 909 at BAIF (scheme is only in its second year) to as many low percentage of workers in the formal sector, this appears to be
as seventeen lakhs at the Yeshasvini programme. The average a distant dream. However, these European (and Japanese) social
subscription rate varies from 10 to 50 per cent of the target health insurances have actually evolved from a conglomeration
population. Except at Vimo SEWA, there has been no study as of small ‘community health insurance schemes’. Historically,
to why the rest of the target population are not subscribing, but during the peak of the industrial revolution, worker’s unions
during the interviews, some of the reasons for not paying were developed health insurance mechanisms to protect their mem
elicited. These included:
bers. This gradually developed into today’s social health insur
(1) No immediate benefit; (2) premium too high; (3) “we are well, ance [Ogawa et al 2003; Bamighausen T et al 2002]. Thus
why should we pay in advance? When we fall sick, we shall pay”; community health insurance can be seen as an important inter
(4) large families - this is specially since most of the CBHI’s mediate step in the evolution towards an equitable health financ
unit of membership is the individual; (5) “(Insurance scheme) ing mechanism.
Hospitals are far away and so we have to pay a lot to access
The community health insurance programmes in India offer
hospitalisation. Better use the premium money to go to a nearby valuable lessons for the policy-makers and the practitioners of
doctor”; and (6) “we pay every year, but do not get any benefit health care. While many state that the poor in India cannot
out of it. So we have decided not to pay anymore”.
understand the complexities of health insurance and will not
There is tremendous variation in terms of claims submitted accept any insurance product, we hereby document 12 schemes
annually for inpatient care, ranging from only 1.4/1,000 insured where health insurance has been operationalised. It is clear that
per annum to more than 240/1,000 insured per annum. Among what is required is a good product. Some ofthe conditions that
schemes with the highest rates of utilisation, adverse selection have allowed these schemes to succeed are:
appears to be responsible for the high rates.
— An effective and credible community based organisation (or
Among schemes with low rates of utilisation, it appeared that NGO). This is absolutely necessary as it is the foundation on
not enough had been done to address non-financial barriers to which health insurance can be built. The CBO helps in dissemi
accessing health care. The indirect costs of health care are not nating information about health insurance and more importantly
addressed by the schemes (Karuna Trust being an exception), helps in implementing the programme with minimum costs.
and in many of the schemes, the direct costs are only covered - An affordable premium - this is very important. While most
up to a ‘cap’ or ‘ceiling’ (as at DHAN, RAHA and SEWA). Even health insurance products (even for the poor) have premiums in
at those schemes that do not have a cap (e g, SHH), non-financial the range of Rs 100 plus per member per year, we find that people
barriers may prevent people from utilising the scheme (e g, are willing to pay only in the range of Rs 20 to 60 per person
distance, lack of knowledge about the scheme, limited awareness per year. This is significant, and needs to be taken into account
of health/illness, etc.)
by the insurers if they want their products to penetrate the
In terms of their ability to protect individuals and households rural market.
against the catastrophic costs of health care, the schemes again — A comprehensive
w benefit
uviivm package iisS iiccessarv
necessary to
to rnnvmrp
convince the
seem to vary considerably Those that provide the greatest degree community of the benefits of health insurance Most of the CHIs
of protection have the following characteristics: (1) Cover 100 d
Most ot the CHIs
documented, especially the Type I schemes have provided a
per cent of the direct costs; (2) cover all (or at least some) of comprehensive package and thisj is one of the main reasons why
the indirect costs; (3) cover all kinds of illness (e g, all non- lpeople
' ’have enrolled
" ’ in their schemes. Unfortunately, most of
4-1. « 'T'T1
z
z..__
J
of bospiWi,.,,™.
delivery, chronic illnesses); and (4) provide benefit right at the t ’ ' ’
CCd
to introduce exclusions by the insurance companies. While most
source of health care, i e, with no per.od during which the patient insurance
,’ based on economic
has to cope with the costs of care. Thus, it was generally the reasons, one has to look at ------------------health insurance within
a public health
Type I schemes,.. which
provide
health
care directly, and usually context. Diseases like TB, HIV and mental illnesses have sin.
,
„
.
,
with no ]■
““— of DJotectio^3"013 benefltS’ that Provided the
degree
^ificant public health importance and should be covered. Simi
greatest degree of protection.
larly it is ironic that while the country has invested tremendously
An important question is about the financial viability of these in safe deliveries, most health insurance products do not cover
‘small’ schemes. Ofthe 12 studied, four (BAIF, DHAN, Buldhanha it. And finally as India enters an epidemiological transition and
------------------
■'
~
____________________ __________________________________________ ___________
IT
3182
Economic and Political Weekly
July 10,2004
will have to encounter chronic diseases like diabetes and hyper be instituted to protect the poor. We suggest that community
tension, it becomes imperative that these diseases are included health insurance could be an interim strategy to finance the health
in the benefit package.
care of the people; till a more formal social health insurance is
- A credible insurer is imperative for people to have faith in the in place. We also suggest that this is a feasible alternative given
product. This is where the NGOs and the CBOs score as they that community based organisations and movements exist in
have a relationship with the community and so the people are
India. What is required is to regulate the providers and to legislate
willing to trust them with their money. Insurance companies need
so that the community health insurance programmes find a space
to learn from this important lesson and would need to approach within the Indian insurance context. SZJ
the rural sector keeping this in mind.
- And last but not the least, the administration load of the scheme Address for correspondence:
on the community should be minimal. Unnecessary documen deva@devadasan.com
tation lead to frustration. In one of the schemes a community
member mentioned that she had to pay more to get the certificates [The authors would like to thank the World Bank, Washington for funding
than she got in reimbursement. This is where the Type I and the fieldwork. We also would like to express our gratitude to the managers,
staff and community representatives of the 10 CBHI schemes who shared
Type II schemes score over the others.
Many would dismiss community health insurance as a drop their experiences and valuable time with us. This work was possible thanks
to a grant from the Belgian Directorate General of Development Cooperation/
in an ocean. It may appear insignificant, given the scale of the Framework Agreement with the Institute of Tropical Medicine, Antwerp.]
problem in India. But, one needs to look at it in context. One
of the main lessons from these case studies is the fact that a good
References
community based organisation can help develop an effective
community health insurance programme. And India is teeming Atim, C (1998): Contribution of Mutual Health Organisations to Financing,
with such organisations — be it the trade movement, or the
Delivery, and Access to Health care: Synthesis of Research in Nine West
and Central African Countries’, Bethesda, Maryland, Abt Associates Inccooperative movement. So upscaling should not present a prob
p 82.
lem if one uses these existing institutions. Already there are
- (2001): Contribution of Mutual Health Organisations to Financing,
examples of community health insurance being introduced in the
Delivery, and Access to Health care: Nigeria Case Study, ILO, Geneva’.
dairy cooperative sector (Mallur, Karnataka and Anand, Gujarat); Bamighausen, T and R Sauerbom (2002): ‘One Hundred and Eighteen Years
the head loaders union (Mathadi trust in Mumbai), shop owner’s
of the German Health Insurance System: Are There Any Lessons for
Middle- and Low-Income Countries?’, Soc Sci Med, 54, pp 1559-87.
union (Palakad, Kerala). The possibilities are endless, if ap
Bennett, S, A Creese et al (1998): Health Insurance Schemes for People
proached properly.
Outside Formal Sector Employment, Division of Analysis, Research and
However, one needs to mention a word of caution. The main
Assessment, World Health Organisation, Geneva.
pitfall in developing community health insurance is to find an Bhat, Ramesh (1999): ‘Characterisitics of Private Medical Practice in India:
A Provider Perspective’, Health Policy and Planning, 14 (1), pp 26-37.
appropriate provider. The Indian private health sector is un
regulated and unaccountable [Bhat 1999], In this context, intro Criel, Bart (2000): Local Health Insurance Systems in Developing Countries:
A Policy Research Paper, ITM, Antwerp.
ducing health insurance can lead to uncontrolled cost escalation
Diop, F, A Yazbeck et al (1995): ‘The Impact of Alternative Cost Recovery
without the promise of quality [Ranson and John 2001], So it
To(y>m<2S23n4O^CCeSS and EqUity Niger’’ Health Policy <*nd Planning,
becomes imperative that while considering community health
insurance, one should seriously consider mechanisms to intro Dror, D and C Jacquier (1999): ‘ Micro-Insurance: Extending Health Insurance
to the Excluded’, International Social Security Review, 52 (1), p 71.
duce measures for cost containment, assuring quality and ensur
ing standard treatment practices. And this is where the CBO (or International Labour Office (Universitas Programme) (2002): ‘Extending
Social Protection in Health through Community Based Health
NGO) can play a crucial role, by countering the power of the
Organisations: Evidence and Challenges’, ILO, Geneva, 79.
providers. The CBO could negotiate with the providers and Mahal, A, J Singh et al (2000): Who Benefits from Public Health Spending
in India?, The World Bank, New Delhi.
develop a package that is conducive for the patients and the CHI.”
Yet another issue is the legality of these schemes, given the Naylor, C D, P Jha et al (1999): A Fine Balance: Some Options for Private
and Public Health Care in Urban India, The World Bank (Human
new Insurance act (IRDA Act 1999). Currently
the act does not
- ------------------------Development Network), Washington, DC.
.CKDOwledge the presence of these schemes and their role in the Ogawa, S, T Hasegawa, G Carrin and Kei Kawabata (2003): ‘Scaling Up
larger
This could
ar<T«i- insurance market. -ru:
i j also be the reason why
. many
Community Health Insurance: Japan’s Experience with the 19th Century
Jyorei scheme”. Health Policy and Planning, 18 (3), pp 270-78.
of the newer schemes have linked up with the formal insurance
companies - to legitimise their activity. But in the process, they Peters, D, A Yazbeck et al (2001): ‘Raising the Sights: Better Health Systems
for Indians Poor , The World Bank (Health, Nutrition, Population Sector
may have lost on the flexibility and innovations necessary for
a successful CHI.
Peters, D H, A S Yazbeck et al (2002): Better Health Systems for India's
The other issue that needs to be addressed is that of financial
Poor: Findings, Analysis, and Options, The World Bank, Washington, DC.
sustainability. The very fact that many of them have been op Preker, A, G Carrin et al (2001): A Synthesis Report on the Role of
Communities in Resource Mobilisation and Risk Sharing, Geneva, WG3,
erational for more than a decade, itself is proof that it may be
CMH, World Health Organisation, p 41.
a sustainable form of health financing. While accurate financial Ranson, M K (2003): ‘Community-Based Health Insurance Schemes in India:
data about the schemes were not available easily, rough estimates
A Review’, National Medical Journal of India, 16(2):79-89.
show that they are able to raise about 60 to 100 per cent of their Ranson, M K and K R John (2001): ‘Quality of Hysterectomy Care in Rural
Gujarat: The Role ofCommunity-Based Health Insurance’, Health Policy
resources. This has important policy implications, as it gives an
and Planning, 16(4):395-403.
indication towards the amount subsidy required to make these
World Health Organisation (2000): The World Health Report 2000: Health
schemes viable. And given the fact that most of these schemes
Systems: Improving Performance, WHO, Geneva.
target the poor, it is important that the government comes forward - (2004): The World Health Report 2004: Changing History, World Health
Organisation, Geneva.
to subsidise this equitable health financing mechanism.
In a country with one of the highest out of pocket health care Yip, W and P Bennan (2001): ‘Targeted Health Insurance in a Low Income
Country and Its Impact on Access and Equity in Access: Egypt’s School
expenditure in the world, it is imperative that some measures
Health Insurance’, Health Economics, 10:207-20.
Economic and Political Weekly
July 10, 2004
3183
Page 1 of 4
Welcome to Microinsurance India-Publications
Publications
Author
Year
Aggarwal A
2002
Ahuja R, Jutting J
2004
Ahuja, R
2004
Ananth B
2003
BanerjeeTK
2001
Cain M
1981
Churchill, Liber,
McCord, Roth
2003
Dandekar V.
1985
Desai A , Akshay D 2000
Economic Times
India
2003
I*
CM
Action
Theme
Title
Type
A new approach and model for
weather derivative instrument
Crop Insurance Link Page View
based on water table for floods,
droughts and rainfall
Are the poor too poor to
Demand
Link Page View
demand health insurance?
Assessment
Health Insurance For The Poor
Health Insurance pdf File Download
In India
Maximising Access to
Insurance for the Poor : A
General
ppt File Download
Presentation by Ms. Bindu
Background
Ananth, Manager, ICICI Bank.
Emerging Horizons in the
General
ppt File Download
Indian Insurance Industry
Background
Risk and Insurance Perspectives on Fertility and
General
Link Page View
Agrarian Change in India and Background
Bangladesh
Making Insurance Work for
Microfinance Institutions, A
General
Link Page View
technical guide to developing Background
and delivering microinsurance
Crop Insurance in India - a
Crop Insurance Link Page View
Review, 1976-77 to 1984-85
Deregulation of the Indian
General
Link Page View
Insurance Industry
Background
News Private insurers churn out
Microinsurance Link Page View
advisors to take on LIC agents
India
Economic Times of
2002 False Alarm
India
Economic Times of
2002 False Alarm
India
Ellis R, Alam M,
Gupta I
FFWB in India
FWWB India
.
^105
Health insurance in India 2000
Prognosis and prospectus
Regulation
Link Page View
Regulation
Link Page View
General
Background
(Health
Insurance)
Link Page View
Orientation manual on micro
General
insurance for microfinance
Background
institutions
Compilation of insurance
schemes available with the four
General
2002 nationalized insurance
Background
companies in India suitable to
poor families
2002
http://www.microinsurance-india.org/publications.asp
doc File
Download
doc File
Download
06-Jan-05
Welcome to Microinsurance India-Publications
Page 2 of 4
Hedging the health of the poor:
Community
Link Page View
2001 The case for community
health insurance
financing in India
Health insurance for the
Community
Link Page View
2002 informal sector: problems and
Gumber Anil
health insurance
prospects
Innovative Financial Services
for Rural India: MonsoonCrop Insurance pdf File Download
2003
HessU
Indexed Lending and Insurance
for Smallholders
The Self-employed Womens
Full Provider
pdf File Download
ILO STEP, SEWA 2001 Association's Integrated
Model
Insurance Scheme,India
Overview of General Insurance General
Indialnfoline.com 2004
Link Page View
Market in India
Background
Obligations of Insurers to Rural
IRDA
2002
Download
Regulation
rtf File
Social Sectors 2002
General
IRDA
2004 Indian Insurance History
Link Page View
Background
2qq4 IRDA Journal - Health
IRDA W VW"
Health insurance pdf File Download
insurance
An evaluation of the insurance
Joseph T, Tharian
1999 scheme for rubber plantations in Crop Insurance Link Page View
G, Chandy B
the context of natural damage
Community
Mutual insurance schemes and
Jutting J, Ziemek S 2000
Based Health
Link Page View
social protection
Insurance
Nationalization of LifeGeneral
Kabra K
1986
Link Page View
Insurance in India
Background
General
Private entry into health
Background
Mahal A
2000 insurance: What does it mean
Link Page View
(Health
for India?
Insurance)
Is consumption smooth at the
General
Maitra P
2001 cost of volatile leisure? An
Link Page View
Background
investigation of rural India
Manojkumar K,
Crop Insurance Scheme: A case
Sreekumar B.,
2003 study of banana farmers in
Crop Insurance pdf File Download
Ajithku
Wayanad district
Willingness to pay for rural
health insurance through
Demand
Mathiyazhagan K 1998
Link Page View
community participation in
Assessment
India
Health care microinsurance—
Full Provider
McCord M
2001 case studies from Uganda,
doc File Download
Model
Tanzania, India and Cambodia
Microinsurance: A Case Study
Of An Example Of The Full
McCord M, Isern J,
Service Model Of
Full Provider
doc File Download
2001
Hashemi S
Microinsurance Provision Model
Self-Employed Women’s
Association (SEWA - India)
Gumber Anil
http://www.microinsurance-india.org/publications.asp
06-Jan-05
Welcome to Microinsurance India-Publications
Mishra P
1994
Mishra P,
Copestake J
1997
Mosley P
2001
Mosley P,
Krishnamurthy R
N Devadasan
ACCORD
ASHWINI AMS
1993
2004
PantN
1999
Parekh A
2003
Prabhu S
1990
Prasad K
1996
Ranade A, Ahuja R 1999
Ranson M
2003
Ranson M, John K 2002
Ranson MK
Devadasan N
2003
Rao D
1999
Rao D
2000
Ravallion M,
Chaudhuri S
1997
Rengarajan V
2001
Rosenzweig M
1993
Page 3 of 4
Crop insurance and crop credit:
Impact of the Comprehensive
Crop Insurance Link Page View
Crop Insurance Scheme on co
operative credit in Gujarat
Agricultural risk, insurance and
income: a study of the impact
Crop Insurance Link Page View
and design of India’s
comprehensive crop insurance
scheme [review]
Insurance against poverty? The
'new generation' agricultural
Crop Insurance Link Page View
microinsurance schemes
Can crop insurance work?: the
Crop Insurance Link Page View
case of India
Community
The ACCORD Community
Based Health
pdf File Download
Health Insurance Scheme
Insurance
Insurance regulation and
Link Page View
Regulation
development bill - An appraisal
Appropriate Model for Health General
Background
Link Page View
Insurance in India: A
Presentation by Ashvin Parekh (Health Insurance
Crop Insurance in India - an
Crop Insurance Link Page View
Analysis
Community
Health insurance for tribals: a
Link Page View
Based Health
case study
Insurance
General
Life insurance in India Link Page View
Emerging issues
Background
Community-based health
Community
insurance schemes in India: A Based Health
Link Page View
Insurance
review
Ensuring the quality of
hysterectomy care in rural
Community
Link Page View
Gujarat: what can a community- Based Health
based health insurance scheme Insurance
do?
How to design a community
Community
based health insurance scheme:
Based Health
Link Page View
lessons learned from a review
Insurance
of Indian schemes
Life insurance business in India General
Link Page View
- Analysis of performance
Background
Privatisation and foreign
General
participation in (life) insurance
Link Page View
Background
sector
Risk and insurance in village
General
Link Page View
India: comment
Background
General
MFIs foray into microinsurance
doc File Download
Background
Women, Insurance Capital, and
Link Page View
Economic-Development in
General
http://www.microinsurance-india.org/publications.asp
06-Jan-05
Page 4 of 4
Welcome to Microinsurance India-Publications
Sinha S, Patole M
2002
Srinivasan G,
Castro R
2001
Subhedar S
2003
The Hindu Business
2003
Line
Townsend, R
1994
USAID
2003
Wadhawan S
1987
WHO
2003
Rural India
Background
Microfinance and the Poverty
of Financial Services: How the General
Background
poor in India could be better
served
India: Sustainable Microfinance General
Background
in the Informal Sector
Training and Education of
Consumers - Company
Consumer
Perspective: A Presentation S.
Education
P. Subhedar, Sr. Advisor,
Prudential Corporation Asia
NewsAviva Life Insurance policy for
Microinsurance
SHGs
India
Risk and Insurance in Village General
India
Background
US Provides $ 10 Million for News Development of India's
Microinsurance
Insurance Sector
India
Health-Insurance in India - the
Regulation
Case for Reform
Community Based Health
CBHI
Insurance
Link Page View
pdf File
Download
ppt File
Download
Link Page View
Link Page View
Link Page View
Link Page View
doc File
Download
Note: View Documents can be downloaded from the corresponding web site through the links
provided.
Horne | IndjmiMicroinsuran^ capacity-building project | SociaLSecuritydVIicro Insurance | Micro health insurances |
Useful Links
http://www.microinsurance-india.org/publications.asp
06-Jan-05
•J
Draft Copy
( For Private Circulation )
Health Insurance Scheme ( HIS h
Chechady Valley
A Study
( 11.12.03-30.12.03 )
by
Dr. Mathew P. Abraham, C.Ss.R- MD ( Community Medicine )
Sr. Prabha, HC - Director CHABI
Mahuadanr
10.01.04
COWENTS
i.
Introduction
Justification and background of the study
II.
Aims & Objectives of the study
III.
Methodology
IV.
Results of the study
1. About the Project
History - Its inception & development
Terms & Conditions
2.
Membership pattern over the years
r- Salae
r- Carmel
3.
Issues that came up during the interviews / discussions
> Director
Sisters of the Clinic / Hospital
Health Workers
Village Beneficiaries
4.
Stake holders suggestions
V.
Discussion & Recommendation
VI
Limitations
VII
Conclusion
VIII
Acknowledgement
I
INTRODUCTION
In this 3rd
ld Millennium, with all the modern technology, knowledge and so many health
professionals, why should people die prematurely of malaria, diarrhoea and other preventable diseases
? This is the reality of many of the villages in Jharkhand even today ! what is wrong with the current
medical profession ? Commercialization ? profit motives ? Alma ala declaration ( 1978 )
recommended primary health care as a means to achieve health for all. All over the world, we still
have health professionals committed to Primary Health Care. The health network of Chechady \ al ley (
Jharkhand ) remains as a beacon of hope to this commitment.
What is impressive about the Chechady valley is the marvelous work done by the Missionaries over a
century. The pioneering work of the Jesuits, the building up of tribal communities, the establishment
of strong infrastructure in the form of parishes, health centres and schools covering about 120 villages
in the Valley need to be definitely appreciated. Another inspiring fact of the Valley is the work of the
sisters of various congregations who silently make a difference in the lives of the people. They save
the lives of thousands of people who are brought to them with very little trace of life left in them.
They are brought with cerebral malaria, tetanus, typhoid complicated abortions, and so on. More over
they make a difference in the lives of many more through health promotion and prevention with the
help of the health workers and dais.
Health Insurance Scheme ( HIS ) of Chechady : A matter of pride
Today there are many agencies who try to build up self financing schemes for health care. They have
various intentions ; some are profit oriented and some are people oriented. About 15 years ago
inspired by RAHA model, Fr. Peter Jones and Fr. Ignatius initiated the HIS of Mahuadanr. This was
done in the context of many poor people dying without accessing even the available medical care
facility due to poverty and ignorance. The acceptance of HIS by the people was overwhelming and il
flourished with great enthusiasm. People’s contribution was given in kind ( rice ). A year ago. the
premium was changed from kind to cash. This and some other factors weakened the scheme.
CHABI’s interaction with the health worker’s lead to the realization that a scientific study need io be
undertaken about the HIS, as early as possible.
II.
AIM :
•
To study and Document the Health Insurance Scheme ( HIS ) olThe Chechady Vally.
OBJECTIVES :
1. To study the History especially the background and the process of evolution of the HIS
from its inception till now.
2. To critically evaluate the strengths and the weaknesses of the HIS.
3. To document the experiences and opinions of the people involved in the HIS al various
levels.
Ill
METHODOLOGY:
•
•
•
In depth interviews
Group discussions
Studying relevant documents
Table I : In depth Interviews
SI.
Date of Name
No. visit
Desig
nation
Congregation
Place
Pakripat
I No. of HIS
villages
Yes
covered No
Mahuadanr
Yes
01
13.12.03
Mr. Fulgence
Health
worker
Carmel
Hospital
02
13.12.03
Sr. Philo
Nurse
(ANM)
St. Joseph of
Taubs
03
15.12.03
Sr. Sushma
Nurse
Srs.
Charity
Nazareth
04
15.12.03
Sr. Pyari Assa
Nurse
(ANM)
05
17.12.03
Sr.Rithamma
Nurse
06
18.12.03
Sr. Assumta Nurse
Toppo
Hand Maids Ch at ma
of Mary
07
19.12.03
Ms. Suchita Nurse
(ANM)
Tigga
Holy Cross
Gothgav
08
20.12.03
Fr. Ignatius
S.J
Mahuadanr
09
22.12.03
Sr.
Prema Nurse
Xalxo
10
23.12.03
Sr. Rosalind
HIS
Director &
Parish Priest
Administrat
or Camel
Hospital
15
Yes
I 19
Yes
Srs.
of Tundtoli
St.Joseph of
the Aparision
11
Yes
St.Joseph
Taubs
35
Yes
of Salae
of
of Mayapur
Disciples of Dhawna
Don Bosco
CMC
15
10
No
Mahuadanr
■>
Table II : Group Discussion1
SI.
No.
oT“
OF
03
Date
Name of village
Clinic Area
23.12.03
29.12.03
29.12.03
Rega - Tonkatoli
Parhi - Kenatoli
Carmel Hospital
Cannel Hospital
Carmel Hospital
IV.
Results of the Study
1.
Terms & Conditions of the health insurance scheme ( HIS )
Participants
( Number )
Villagers (13)
Villagers ( 30 )
Health Workers (14)
1.
2.
A minimum of 20 families are required to start the scheme in any particular village.
Each member deposit 5 Kg. Rice or equivalent Money to the church authority.
3.
One leader is chosen from each village for voluntary service, she or he gets trained and
receives a medical kit with emergency medicines.
4.
Each member goes to this Health Worker ( H.W ) at the beginning of illness for treatment.
H.W keeps a register and enter the name and treatment given. Reports are submitted lo the
centre during monthly meetings of all the health workers in the centre.
5.
When H.W. fails to manage the case, patient is referred lo the dispensary or the hospital
with a letter and the scheme number. Treatment given should be mentioned in the referral
letter.
6.
Total cost benefit for the year is Rs.750/- for each member.
7.
To continue membership, each member should attend the monthly meeting held in the
villages by the respective staff.
8.
Pregnant women ought to go for antenatal care at least thrice during pregnancy to benefit
from the scheme incase of complications.
9.
Any self induced illness ( such as complications of induced abortion ) will not benefit from
the scheme.
10.
Members are taught about the mutual benefit of the scheme and the value of helping one
another.
1 1.
Members are advised to complete all vaccinations available for adults and children
12.
If a pregnant woman is a member, her child at birth is also eligible for scheme benefit for
that year.
Members are paying about 25% of the total cost and the Jesuit Society covers the balance amount.
There are seven dispensaries in the insurance scheme area. HIS members, go to the dispensaries for
the initial treatment-referred by the health workers from the villages. Carmel Hospital functions as a
secondary care centre Hospital and the dispensaries send timely bills to the church authority and gel il
paid from them. Monitoring and evaluation is done by the community health staff.
Rega Tonkatoli was chosen because out of 30 families there, 24 were part of the HIS for
the past few years.
Parhi Kenatoli was chosen because out of 50 families none of them were part of the HIS.
14 health workers were those who came for the meeting in Carmel Hospital. The total no.
of health workers of Cannel are 24.
4
Table - III
2.
Membership Pattern over the years
Year
Total
Members
Total
families
1996
369“
1997
444
1998
473
2000
858
2001
2002
694
766
707“
2003
277
76
85
106
160
184
158
166
63
1999
Graph - I
HIS - Salae Clinic
tn
CD
E
CD
"E
o
H
1000
800
600
400
200
0
,.858
€
,6^4
707
73
Line
277
1996 1997 1998 1999 2000 2001 2002 2003
Years
Graph - II
HIS Salae Clinic
200 n
</)
(D
E
45
"E
o
♦J 84
166
150
06
100
—♦“-Line
63
50
H
0
1996
1997
1998
1999
2000
Year
2001
2002
2003
Table - IV
HIS Mahuadanr
Year
Total
Members
Total families
1989
533”
2000
T758
2001
1691
2002
W2
2003
T278
111
N.A
402
433
289
Graphs - III
HIS - Mahuadanr
2000
(Z)
CD
_Q
E
1758.
1500
1691
1692
1278
CD
1000
"E
o
500
-- Line
33
0
1989
2001
2000
2002
2003
Year
Graphs - IV
HIS Mahuadanr
500 n
o>
400
E
300
433
402
289
line
200
o
100
0
1989
2001
2002
2003
Year
()
3.
Issues that came up during the interviews/Discussions:-
r- Director of HIS (Fr. Ignatius )
•
•
•
He feels that the scheme is in a declining phase and fears that it might die out eventually
The expense every year is about Rs.5 lakhs and the income is very low ( Rs. 2 Lakhs
1 Lakh as interest on capital and 1 lakh as collection from people )
According to him, reasons to change from kind ( Rice ) to cash were these:Rice collected were of mixed variety
- In the previous years selling of this rice was easy. People used to bu\.
Now people buy from market and can afford to buy better quality rice.
Many people in the scheme were selling their good quality rice in the
market, buying the cheapest quality from market and was giving it for
the scheme.
Sr. Nurses of the peripheral clinics:
Of the 8 clinics in Chechadi valley, 6 of them were very much aware of the HIS. Two of them
( Dhawna and Chatma ) were not aware of the scheme. They too have been going regularly for
the bimonthly gathering of the nurses of the Chechdi area. According to Dhawana & Chatma
nurses these was no HIS for the people of those areas.
Rest of the 6 clinics ( Mahuadanar, Pakripat, Sale, Tundtoli, Gotgav and Mayapur ) have HIS
running quite active. All of them were of very high opinion about the scheme. All of them
said that this scheme is of a great help for the people especially the poor.
All the 5 clinics felt that in the past 2 years the scheme is loosing popularity among people and
is slowly facing a decline. ( some even expressed the anxiety that the scheme might die out
eventually ). This was evident from the statistics of the past years from what ever limited
documents which were available ( Ref. Table III & IV and graphs )
Some of the reasons that were mentioned for this decline were these:1. Lack of proper communication between the centre ( Mahuadanr ), the peripheral units (clinics )
and people.
2. The centralized decision making without involving the peripheral units ( Sr. Nurses ) or the
people’s representatives ( VHWs / Ranches )
3. Lack of sense of belongingness of the peripheral units to the scheme - Almost all of them
felt that the HIS was a Jesuit’s scheme not the people’s scheme. “ Mahuadanr ka scheme
he na ? “. Hence many of the sisters as well as health workers are slowly loosing their
enthusiasm to work towards the progress of the scheme.
4. Shift of premium from kind (rice) to money ( Rs.60/- ) and again raising it to Rupees 80/- in the
immediate next year.
5. Some peripheral clinics even felt that there is too much of formalities and difficulty to gel the
expenses reimbursed from the centre. ( Availability of the Director )
6. False Propaganda against the HIS by some people with vested interests
Eg. a) The money lenders - village compounders etc.
These people propagate that :• Fathers are enjoying with the money collected from people.
• Those who are in the HIS are given second grade medication
• They will be converted into Christianity.
r- Health Workers meeting:HIS is a good scheme for the poor. They can access health care any time of the
year even when they do not have money with them.
For serious cases they can access to transportation ( ambulance ) too.
HIS protects the poor from exploiters like - Compounders and money lenders
If the HIS dies, diseases ( esp. Malaria ) still continue and poor people have to
generate money by :o borrowing from money lenders
o selling animals, field or other possessions
o getting into bonded labour for 3-4 yrs for just Rs. 1000, where they will be
given only food as wages.
HIS Motivates people to attend monthly village meetings and thus gel more
informed about health and diseases.
People want to continue in the HIS, but the increase in premium to Rs.80/- is affecting
them, especially the big families. In spite of the increase in premium, even now many
people are motivated to continue in HIS. “ Its difficult for us, but some how we will
raise Rs.80/- per head ” was their response.
Fr. Director meets health workers only once a year, ( during the 3 day health convention
) but has never spoken to them about the HIS.
Meeting with Beneficiaries
a)
^ga Tonl^gtoCi
All of them expressed that it is a very good scheme. Il is of great help for the people.
They found it difficult when the premium was shifted from kind ( rice ) to money.
They were not even aware about the rise in premium from Rs.60/- to Rs.80/-. Not even
the health workers or the panch were aware of it.
According to them health is still a priority ; but health is the last issue discussed in the
village as well as the parish meetings. Hence health issues receive only little lime for
discussion and also by that time half of the crowed would have dispersed. (Am Sabha )
When asked, “ if the scheme dies ? ” this was their response
“ Those who have
money will go to the hospital. Poor will remain in the village and die ”
(parlii T^enatofi:In 1990 20 families were members of the HIS
1991 17 families were members of the HIS
They too feel that it’s a good scheme
During 1990, ’91 some were benefited from the HIS, but not all those who were
members. Those who were not benefited from HIS got discouraged and dropped out.
Still some wanted to join the HIS but could not because of the ‘20 familes norm ’ in the
rule.
When asked how many familes might join if the 20 family norms is relaxed they
said that 10 -15 families might join the HIS.
s
4.
Suggestions that came from the stake holders:-
Director meeting the above mentioned stake holders on a regular basis to exchange
ideas and suggestions
Collective decision making, by involving the peripheral clinics, health workers, peoples
representatives and Director
Flexibility in rules, terms and conditions according to the situation of the particular
villages
The HIS should be extended to more people
More awareness creation about HIS should be done through
o SHGs
o Parish Priest’s of the Chechadi Valley parishes announcing after mass
o Gram Sabha, Catholic Sabha, Am Sabha etc.
It is not just lack of awareness : generating so much money immediately is a problem.
Hence people should be allowed to pay premium as installments.
By reviving and propagating the founding philosophy “ I am the Caretaker of my
Brothers / Sisters too.”
Parish Priests of the peripheral clinic areas also assisting the Sisters in motivating
people to join the HIS
Some fund should be allowed to be handled at the peripheral clinics too.
Poor harijans and non catholic tribals also should be included in the scheme.
Reducing expenses by avoiding Medical representatives ( Middle men ). CHABI or
some other common body acting as the agent to bring low cost generic drugs.
Allow the scheme to die for 1 - 2 years, then people might realize its worth and then
request to restart.
V
DISCUSSION & RECOMMENDATIONS:-
On the whole stakeholders at all levels feel that the HIS is a very good scheme and it is of great
help for the poor. All were worried about the declining trend of HIS especially in the past
years.
All of them expressed their anxiety about its too much of centralization especially in
decision making, bypassing the stakeholders at the health centres and villages. However all
of them feel that HIS should be continued and expanded to more people. The Director seemed
to be burdened with too many responsibilities, being the Parish Priest and the rector of the S..I.
Community. HIS seemed to be very low in the Director’s priorities, as he seemed to be
struggling for enough time. Documentation at the centre seemed to be grossly inadequate.
This was true at the peripheral clinics too.
Hence we suggest the following recommendations for the revival of the HIS.
1.
2.
Since the backbone of the HIS is the health personals at the village level ( VHVV) and
Health centre level ( Nurses & Doctors), it should be built upon their strength.
The HIS needed to be decentralized especially regarding
■ Decision making
■ Collection of funds at the periphery ( health centres )
■ In addition to the central fund, it is good to have a health centre fund to cover
some of the medical expenses at the health centre and village level.
9
3. Directorship need to be taken up by somebody for whom HIS is a priority and have enough
time to work towards its progress.
4. The communitarian bond, the strong infrastructure, the wealth & resources available in the
communities of Chechady Valley has to be mobilized to its maximum potential. This
includes generation of some funds for HIS at the local level too, through various income
generation projects.
5. A system for documentation need to be developed and proper documents need to be
maintained at all levels. These documents can be used for regular evaluation and
monitoring of the HIS. This will also help others to learn from its experiences.
VI
LIMITATIONS
1. Because it was Festival ( Christmas ) season. The availability of the Director was limited
2. Since this study was done over a span of just 20 days the researcher could not organize more
group meetings with the people at the village level.
3. Since there was limited knowledge of the local language, researcher could not go for 1
focus group discussions ‘ but had to depend on ‘ group meetings ’ with the help of a translator.
4. Lack of availability of sufficient documents, at the centre as well as in the peripheral clinics.
5. One of the peripheral Clinics, Cheropat was left out from the study due to lack of time.
VII
CONCLUSION:-
The people of Chechady Valley have decided to walk on a less trodden path by accepting HIS.
They are experiencing the positive effect of that decision. At this point of time dark clouds seems to
be interfering the growth process of the HIS. When the present health care system prefers to walk
through the path of expensive medical care for the rich minority, the great initiative taken in Chechady
Valley towards a poor oriented health insurance is a matter of pride. Inorder to sustain the process of
growth of HIS a timely intervention is obligatory. Let the poor and the abandoned receive our
primary attention.
VIII
ACKNOWLEDGEMENT
We express our heartfelt gratitude to the following people for their co-operation and support during
this study.
Fr. Ignatius - SJ, Parish Priest, Mahuadanr
The Jesuit Community of Mahuadanr
Dr. Romeo, CMC and the Cannel Hospital team
The Carmel Sisters Community of Mahuadanr
Mr. Fulgence and the other health workers of Mahuadanr
The sisters of the health centers of Chachady Valley
The people of Rega Tonkatoli and Parhi Kenatoli
lb
’So,
'( ("U to
Yeshasvini Cooperative Farmers Health Care Scheme
G..®
H
• -
Introduction
A novel Health Care Scheme exclusive for the Cooperative farmers, first of
its kind in the country is implemented by the Government of Karnataka.
The scheme was inaugurated by Honourable Chief Minister of Karnataka on
14/11/2002 and launched on 1/6/2003.
Eligibility for membership
------ --■. i>u
A farmer shall be a member of any of the followwg cooperative societies for
a minimum period of six months. He/she shall contribute a sum of Rs. 60/per annum at the rate of Rs. 5/- per month. Government of Karnataka
contributes Rs. 30/- per annum towards its share to each farmer. Thus the
total contribution is Rs. 90/- per member.
Benefits
Benefit is available to a member for in-patient hospitalisation including the
related surgeries can be availed by the members subject to maximum upto
Rs. 1 lakh in case of single surgery and upto Rs. 2 lakh in case of multiple
surgery. 1600 different types of surgeries related to heart, brain, chest, ear,
nose, throat and bones are identified and included in the scheme.
The benefit of the scheme is available to a member upto the age of 75
years. Apart from the member the other members of his/her family are also
covered under this scheme subject to payment of Rs. 60/- per annum.
Progress
Preliminary it was. targeted to enroll 25 lakh farmers, for effective
implementation of the scheme it was confined to 15 lakh members. As on
31/5/2003, 16.01 lakh farmer members are enrolled and Rs. 9.60 crores is
collected towards their contribution.
Government of Karnataka have sanctioned Rs. 4.50 crores towards its share.
pujKkrixIl-
■f
1/ z-
Cv-vVOM/ M
^CO C-Axn^eJ
^i3\^r3
fl
r
77 Private Hospitals and Nursing Homes have been identified throughout the
State in all the Districts in which the farmer member can avail the benefits
under this Scheme. Photo Identity Cards have been issued to all the farmer
members and the data of membership is computerised at District level.
Yeshasvini counters are opened in all the identified Hospitals.
AD
Monitoring Committees
I
A monitoring committee in each District is set up under the Chairmanship of
the Deputy Commissioner of the Districts,
with the District Surgeon,
District Health Officer as its members among others. Deputy Registrar of
the District is the member Secretary. This committee meets every Monday.
Yeshasvini Cell is setup at O/o Registrar of Cooperative Societies. The
Additional Registrar (C&M) as its Chairman, Chief Coordinator of the scheme
and representative of the implementing agency as its members.
A State Level Monitoring Committee is setup with the Principal Secretary,
Department of Cooperation, Government of Karnataka as its Chairman and
Registrar of Cooperative Societies, Managing Directors of the Karnataka
State Cooperative Apex Bank and Karnataka Milk Federation as its members
among others.
Achievement
As on 4th October 2003, 2728 surgeries are performed on the farmer
members and 12,745 members are treated as out patients. In all 15,473
farmer members have availed benefit under this scheme.
The following surgeries are done under the scheme Gaenocology, Cardiology, Artho, E.N.T., Urology, Gastro, Enthrology,
’Endoconoiogy, Vaginal Hystrectomy, Repair of Arms, Cyoscopy, CABG, AVR,
!
MVR and General Surgery.
2
Trust and Third Party Authority
Yeshasvini Cooperative Farmers Health Care Trust is being setup which
consists of the following members -
Honourable Chief Minister of Karnataka as Chief Patron.
Honourable Minister of Cooperation as Patron.
Principal Secretary, Department of Cooperation, Trustee
Registrar of Cooperative Societies, Trustee
Managing Director, Apex Bank, Trustee
Dr Devi Shetty, Chairman, Narayana Hrudalaya, Trustee
Dr Alexander Kuruvila, Medical Superintendent, Narayana Hrudalaya, Trustee
Mr A Shankar, Trustee
Dr M D Dixit, Trustee
Dr Guru Dev, Trustee
Director of Sugar, Trustee
Managing Director, KMF, Trustee
$^amily Health Plan Ltd.,/company incorporated under the Companies Act is
Administrator licensed by Insurance
being appointed as Third party
of India (IRDA) to implement the
Regulatory and Development Authority
scheme-
' Chairman
13
\j
Vethatvini Cell and
Additional Registrar of CS(CAM)
3
-7
V
medico
278 friend
279 circle bulletin
Nov-Dec 2000
Editorial
Can Health Care Insurance Ensure Right to Health
for AU?
Issues for Discussion at the January 2001 Annual
Meet
Barring the Annual-Meet in Mumbai (1992), the MFC has
not conducted systematic discussion on the health care
financing in India. The Annual-Meet in Calcutta (1993) that
followed Mumbai-Meet, had potential to take up such issue,
but it was poorly attended and the issue got lost in debating
the stratified system (government funded system for the
poor and market based for the rich) proposed by one of the
background papers. Even the Mumbai-Meet which did raise
some serious issues for reforms in health financing and
discussed some of the international experiences, eventually
focused more on the problems in private sector and means
t egulate it than on the appropriate mechanism for
1. ncing universal access health care service system in
India. This does not mean that financing issues have not
been raised and debated from time to time, but they have
been largely discussed within a limited framework.
In what sense, then, the next meet will recognise health
financing as the central strategic issue for achieving Health
For All? There are three important reasons for this optimism.
First, health insurance is not new for India, though we did
not consider it important enough for discussion except
under a few Primary Health Care (PHC) experiments.
Employees State Insurance (ESIS) has been in existence
almost since independence. Public sector insurance
companies have been selling few health insurance plans for
some decades now. Many unions have won reimbursement
packets for health care, thus making employers to partially
self-insure such employees. Hopefully, this meet would
force us to look at all such things and their lessons, and
broaden our perspective. Second, insurance is essentially a
specific method for financing in a market system.
Permission to allow private health insurance and
expectations of its wider acceptance suggest that the paying
consumers are dissatisfied with fee-for-service system. The
government is looking at it as a policy instrument to expand
health care market and the business people see an
opportunity for profit. Thus, the Meet will have to evaluate
the place of market determined financing system in the
strategy for achieving universal access. This has a direct
relevance for much talked about public-private partnership,
and the time has come to face the issue at the level of
financing. And third, by linking the issue of financing with
universal access, we are recognising that right to health care
is not a negative demand for regulating or restraining the
state from interfering with citizens’ rights, but a positive
demand on the state to intervene for the beneficence or
welfare of citizens. In other words, grand, national plans for
PHC need to be backed by a national strategy for financing
them.
Insurance has an attraction not only for those who consider
the health care market a panacea but also for many of those
who believe in right to health care. In both cases, the strategy
necessitates that people pool their resources to prevent those
who happen to fall ill from suffering serious financial
difficulties while availing of necessary health care. Secondly,
once the group is insured for particular services, it is
assumed that the individuals from the group falling sick have
guaranteed access to such services. That is, insurance
necessarily increases access to health care included in
insurance package by the individuals subscribing to it. This
commonality is at the base of interest in micro experiments
in methods of financing through different types of insurance
package by health activists and NGOs. The insurance
principle allows pooling of resources for possible risks.
This is because insurance is a technique of underwriting
risks and providing protection to acceptable risks by insurer.
The technique of underwriting classifies and provides rating
to each risk based on the information on the occurrence of
risk, attaches a specific price for providing specific
protection to risk(s), and, on each risk group creates a
surplus for profit. Thus, in a classical scenario, the insurer
would allow only the group having similar expected and
I
/
2
g
acceptable risks to pool resources through premium. But at
the same time, it ensures that those at higher risk and thus,
in greater need of service are kept in separate groups from
those who are less at risk and need less service.
Correspondingly, the groups at greater risk pay higher
premium than groups at lesser risk. Therefore, the market
place inequity existing in direct fee-for-service is brought
back. If our objective is to have a system where all have
universal access to a defined quantity and quality of health
care without financial and social barriers, then this scenario
of insurance does not bring us any closer to that objective.
At best, it facilitates pooling of resources within the social
and health-risk related classes and provides protection with
wide variation in quantity and quality of care to each class.
This would again reproduce the inequity we are trying to
overcome.
There is no space here to explain how insurance actually
functions and the plethora of terminologies it uses. It is
sufficient to note here that in actual practice, private
insurance uses numerous permutation and combinations in
order to expand its market, put restrictions on claims,
exclude risk-prone individuals and groups, exclude or
restrict use of expensive treatment methods, co-finance the
risks it insures, and so on. Here, it is sufficient to know that
all such permutations and combinations are ultimately based
on the above-mentioned principle of classifying, rating and
underwriting risks and making profit. For, eventually the
market principle asserts, that those who cannot buy health
care do not get insured for the health care. Well researched
material on insurance show that insurance increases use of
unnecessary health care, increases cost of health care at
much faster rate, promotes significant wastage of resources
in promotion and advertisement of insurance plans (e.g. US
health insurance companies spend one third amount of
insurance claims paid on administration and promotion), and
so on.
This does not mean that progressive group insurance plans
are not possible within the market system. In fact, the rise
of health insurance in USA was triggered off by such
progressive group insurance plans won through struggles
by some Trade Unions (TUs) in 1930s and 1940s. During
the Depression, hospitals faced with loss of revenue due to
the inability of the poor and the old to buy health care on feefor-service basis, were more amenable to link up with
employers for insurance coverage. They were progressive
in the sense that those plans provided uniform coverage to
employees irrespective of the wage levels and were paid for
by the employers. The basic difference in this rise of initial
progressive insurance in the US and the social insurance in
many European countries was that the former was
dispersed and market determined while the latter was
universal for a set of population and was through state
intervention with public funding. Thus, despite its
progressiveness, the insurance won as fringe benefits by
TUs in the US fuelled private insurance market while the
social insurance in Europe gave impetus to universal access
health care.
There are two lessons to be learnt from such history. Firstly,
we must remember that all market based financing methods
could be experimented in a micro situation on no-profit basis
mfc buiieiin / nov-dec 2GG0
in a progressive manner. Numerous community health
NGOs in India have even used the fee-for-service (the most
regressive market based financing system) methods in a
controlled and sensitive environment for a defined
population very progressively. The experiments in insurance
are no different. Secondly, the use of insurance as a strategy
for market augmentation and privatisation is considered
politically less controversial and consistent with the
changing role of state from provider (and controller) of
health services to regulator. This is to be achieved by
separating provision (production) from purchasing
(financing) in the government sector. This gives flexibility
to the government to work on independent financing
strategies in which the participation of private sector and
contribution of community financing through appropriate
insurance (particularly group insurance for the poor
communities) could be promoted. This could “decentralise”
the government health care institutions (hospitals, PHCs.
etc.) by making them compete in the market for insured
clients. In fact, the possibilities in such strategies for m;
penetration in health care, for strengthening private
providers and changing values and environment of public
providers, are immense. And that is what attracts a State
committed to the market values and the financial sharks
towards insurance. While this may be exciting for
researchers and policy makers, the end result is not difficult
to envisage. For, despite excessive innovativeness, high
expenditure, much higher state financial support and less
proponion of indigent poor in the population than in India,
the insurance based health care system of US has found it
impossible to provide universal coverage. If we do not learn
from that experience, then we are undoubtedly condemned
to repeat all the negative consequences.
Re-emphasising the importance of health financing, the
critique of insurance as a financing mechanism, in no way
means that there are no progressive methods ensuring
universal coverage, transcending insurance principle. In a
sense, the way out is commonsensical. though it is less
commonly accepted. We all know that different groups of
people are at different levels of risk for illness, and ’’ t
population is stratified in different socio-economic clat
So it is irrational and illogical to have an equal insurance
premium for all, this is recognised by insurance. However,
the need is to put it upside down by introducing the solidarity
principle, that is, the principle of cross-subsidy. This ensures
fair financing in the sense that those who earn more, pay
more while those earn less, pay less. And still, this would
ensure that all earning individuals are paying only a
reasonable and acceptable proportion of their income.
Secondly, the multiple layered financing through private
insurance is both expensive and prone to wastage. The
countries providing universal access have solved this
problem by replacing premiums with progressive taxation
systems, by public management of finances and by having
single payer health financing mechanisms. Moreover, this
system allow us to progress from universal coverage of the
insured group to the universal coverage for all.
Thus, while there is much to learn from insurance, there is
more to gain by going beyond it.
- Amar Jesani
mfc bulletin / nov-dec 2000
3
Two Community-Based Pre-Payment Schemes in Kheda, Gujarat
M. Kent Ranson
Health insurance is the pooling of resources to cover the
costs of future, unpredictable health-related events.
According to the health economics and policy literature,
health insurance can be used to: mobilise revenue for the
health sector; protect individuals and households from the
risk of medical expenses; and promote efficiency, quality
and equity of health-care services. On the other hand, there
is ample evidence to suggest that health insurance can
worsen existing inequalities and inefficiencies.
Proponents of health insurance argue that it can be used to
address specific deficiencies in India's health sector, in
rticular: high out-of-pocket spending, inefficiency, poor
ality and inequity. At present, health insurance coverage
in India is extremely limited, especially outside the formal
sector1. Non-governmental, non-profit organisations
provide health-care to approximately 5% of the Indian
population (Hsiao and Dave Sen 1995). Some of these
NGOs have implemented prepayment health insurance
schemes. There are a number of reasons as to why NGOs
should make good insurers for poor populations (adapted
from van Ginneken 1998):
They know the needs of their client groups so they
can develop appropriate strategies to assist them;
They typically involve beneficiaries in the design and
implementation of programs;
Effectiveness of health insurance schemes may be
enhanced by other aspects of the NGOs’ work, for
example, in the fields of employment and education;
Because they are non-profit, they can provide health
insurance at lower cost than for-profit insurers.
As part of my doctoral research, I conducted case-studies
of the prepayment schemes run by the Tribhuvandas
Foundation (TF) and the Self-Employed Women’s
Association (SEWA) in Kheda District, Gujarat. The
primary objective of my research was to identify, and where
possible quantify, the impact of these prepayment schemes
on rural households, looking at a variety of outcomes. These
outcomes include: medical indebtedness, access to
outpatient and inpatient medical care, preference of
allopathic versus traditional health care proriders, and the
empowerment of women to make medical decisions. Data
collection for this project was recently completed, and
analysis of the data is currendy underway. The purpose of
this paper is to provide a brief description of the two
schemes and the extent to which they have been utilised.
Section 1 describes Tribhuvandas Foundation’s medical
referral services, and Section 2 describes SEWA’s Medical
Insurance Fund. Section 3, the discussion, draws attention
to important differences in the design and utilisation of these
schemes.
Section 1
Tribhuvandas Foundation’s Medical Referral
Services
The Tribhuvandas Foundation was established in 1975.
Seed money in the amount of 650,000 rupees was provided
by Shri Tribhuvandas Patel, the founding chairman of Amui
Dairy, “to initiate a project for improving the health of
women and children in Kheda (and Anand) District” ( TF
Annual Report 1998-99). The Foundation became functional
in 1980, servicing some 53 villages during its first two years.
Today, the Foundation provides a broad variety of health and
related services, focusing on primary and preventive care,
in some 644 villages. The Foundation has its head office in
Anand, with sub-centres in Kapadwanj, Balasinor, Kheda and
Tarapur.
Membership & Coverage
Officially, households pay a total of 10 rupees per annum in
order to become members of the Tribhuvandas Foundation
(as is discussed below, many exceptions are made).
Membership is most often voluntary and open to all residents
of a village. The TF village health worker (VHW) normally
enrols families at the office of the village dairy co-operative
at the time of the annual bonus distribution. However,
membership fees can be paid at any time throughout the
year. In some villages, based on a decision made in the Daily'
Co-operative Society general body meeting, the membership
fee is automatically deducted from the bonus as it is
distributed. After paying the membership fee, there is no
waiting period before members may avail of TF’s referral
services.
Estimates of the number of TF member households are
derived indirectly2. TF calculates its membership bv
assuming that half of the total fees collected are from
households paying 10 rupees, and half are collected from
households paying 5 rupees, as many households are
allowed membership in TF at some reduced rate. Estimated
current membership is 1.7 lakh households in 644 villages.
Services
The current activities of the Tribhuvandas Foundation are
many and varied (see Box 1). Village-level health services
are provided by female TF Village Health Workers (VHWs),
M Kent Ranson is a Ph. D. Student at the London School of
Hygiene and Tropical Medicine
4
uifc bulletin / uuv-utx 2GG0
one per village. VHWs are supervised by some 70 field
workers who visit each village once every fortnight.
Generally, there is no discrimination between members and
non-members in terms of the village-level services. That is
to say, members and non-members alike receive free
Until late 1999, TF members would receive a concession for
inpatient services at the Shri Krishna Hospital. TF members
generally received a 50% concession on the total hospital bill,
but this was to vary according to level of need (for example,
very poor families
would receive a 100%
Box 1. Services Offered by the Tribhuv£ndas Foundation, 1997 to Present
1/
concession while
Pregnant and Nursing mothers are provided treatment.
wealthier families
2/
Malnourished children are provided treatment at home as well as at the Child Care
would receive no
Centre (Nutrition Rehabilitation Centre) run by the organisation.
concession),
TF
3/
Children are provided vaccines (DPT, Polio, BCG, Measles, etc.)
members are no
4/
TB patients are provided treatment at home at free cost.
longer
receiving
Pregnant mothers at risk are hospitalised at the organisation and provided treatment.
1 5/
special benefits at Shri
' 6/
As part of temporary methods of Family Planning, Nirodh, Copper T and Birth Control
Krishna Hospital.
pills are provided in the villages.
7/
Every week Family Planning Operation camps are organised at the main centre as well as
Finances
the sub-centres in which laparascopic and open surgeries are done.
8/
Pregnant women who want delivery at home are provided with a safe delivery kit.
As mentioned abov
9/
Gynecologic problems are treated by Shri Krishna Hospital’s Gynecologists and
the Tribhuvanda.
Obstetricians at the TF sub-centre?
Foundation
was
10/
For advice of specialists and for fu. ther treatment, patients are either hospitalised at the
started with money
Shri Krishna Hospital at Karamsad or seen by specialist in the sub-centre’s out-patient
provided by Shri
department.
Tribhuvandas Patel.
11/
A Nursery programme is run in the villages for children below five years of age.
As well, several
12/
Women are provided training free of cost, and supplementary income in handicrafts
domestic
and
(patchwork) so that they can generate income while sitting at home.
international funding
13/
agencies (including
V. omen who work in their free time are provided additional income for their femilies
UNICEF and the
through the Patchwork Programme.
Overseas
14/
L nder the Environmental Sanitation Programme, low cost toilets and cooking stoves are
Development
constructed.
Administration,
UK)
15/
i he organisation prepares and shows health-related video films to bring awareness
contributed
to
the
amongst rural people.
Foundation in its early
16/
Vr ith the help of the Blood bank of Shri Krishna Hospital Karamsad. blood donation
years. Today, the
camps are organised in the villages.
Foundation’s main
17/
Nutritious food is distributed in the villages at nominal cost.
sources of income
include: Amul Dairy
Source: Derived from TF brochure, ’Health And Rural Development Programme'
through the National
Federation of Rural
Development (NFRE
Delhi), bank interest
on funds, user-fees
community health services and subsidised medications.
charged for medicines, membership fees, and Dairy
Cooperati ve Society contributions.
TF’s health care referral services are the focus of this
document. Individuals who are identified as being
Since the inception of the referral system, the concessions
particularly ill or malnourished are referred to Anand or one
provided to TF patients at Shri Krishna Hospital have been
of TF’s four sub-centres. TF patients who require
offset by a donation from Kaira Can, a sister concern of
specialised care are referred to the Shri Krishna Hospital
Amul Dairy. The amount of the payment, however, has
“where specialists and modern diagnostic facilities are
been fixed at 500.000 per annum. At least during the last five
available” /Annual Report 1998-99). A TF worker is
years, no additional payment has been made by TF to the
available full-time at the hospital to assist TF members
Shri Krishna Hospital. In recent years the Shri Krishna
coming from the different villages. In the most recent fiscal
Hospital has incurred considerable financial loss in providins
years, roughly 2.000 patients have been referred. Relative
reduced-cost care to TF patients (Table 1). Thus, the Shri
to TF’s membership, the total number of patients admitted
Krishna Hospital has recently discontinued concessions to
has changed little over the years (for example, the number
TF’s members (although children under 5 continue to
admitted in 1982/83. 2,320, is almost the same as in 1997/
receive free care, there is a special scheme for women, and
98 at 2,360). The number of admissions per 100 TF
the poor may be provided with concession on a case-bv-case
households has dropped more than tenfold from 14.5 in
basis).
1982/83 to 1.4 in 1998/99.
5
mfc bulletin / nov-dec 2000
I Table 1. Annual debt incurred by Shri Krishna
I Hospital in providing concessions to TF patients,
■ 1996/97 to 1998/99 (actual Indian rupee values)______
| Fiscal Year Shri Krishna Donation by Debt Incurred
I____________ Referral Costs
Kaira Can by Shri Krishna
fRs)
(Rs)
(Rs)
1.771.707
500,000
1996/97
1,271,707
1997/98
1.458.624
500.000
958,624
1998/99
1.312,886
500,000
812,886
admitted to Shri Krishna Hospital has been decreasing over
the last four fiscal years (keeping in mind that the data for
1999/2000 is incomplete). Roughly 25% of TF admissions
at Shri Krishna Hospital during the last four fiscal years have
been in the Nutritional Resource Centre (NRC). All children
younger than 5 years of age (the threshold seems to be
slightly flexible) are kept in the NRC. NRC admissions as
' a percentage of total are increasing, from 18% to 40% in
only four years.
Table 2. Hospitalizations of TF members at Shri
Krishna Hospital______________________________
Adult
NRC
Year
Total
NRC as % I
of Total
History of the Referral Services
he system for referrals has evolved gradually since 1980.
Referral services were not included in the original plan for
TF. However, soon after commencement of TF’s activities,
it was found that there was a need for referral services
among the membership. Initially, many of the cases detected
by TF were taken to government or trust (charitable)
hospitals in Anand.
When Shri Krishna Hospital was under construction, its
director suggested that the two organisations work in co
operation. This was to be a mutually beneficial arrangement.
It was agreed informally that Shri Krishna Hospital would
provide care free of charge to TF members. Kaira Can
committed to donating 500,000 rupees per year to cover the
costs of concessions to TF members. This has continued
to this day. Due to the debt it incurs in caring for TF
members, Shri Krishna Hospital is no longer offering
concessions to TF members.
Preliminary Analysis of Hospital Utilisation Data
ihis analysis is based on the bills provided to the
Tribhuvandas Foundation by the Shri Krishna Hospital for
the fiscal years 1996/97 to 1999/00 (each fiscal year is from
1st April through 31“ March). These bills provide some basic
demographic information for each patient (for example,
gender, and village of residence), dates of hospital admission
and discharge, total cost of the hospitalisation, the amount
paid out-of-pocket by the patient, and the amount owed by
the Tribhuvandas Foundation.
At present, there are 8,465 records in the database3. The
records for fiscal year 1999/00 remain incomplete as not all
of the bills have been submitted to TE Overall, for this
four-year period, the average duration of hospital stay was
just over eight days, the average total costs was Rs 1,500,
the average out-of-pocket payment by patients Rs 824 (55%
of the average total cost), and the concession per TF patient
Rs 677 (45% of the average total cost).
As shown in Table 2, the total number of TF members
96/97
2913
2391
522
18%
97/98
2225
1711
514
23%
98/99
2071
1455
616
30%
99/00
1254
749
505
40%
Total
8,463
6,306
2,157
% of Total
100%
75%
25%
■i
Table 3 shows the breakup of admissions by gender for each
year (and by adult versus NRC). Overall, 45% of TF
admissions have been female. Very interestingly, the
proportion of female admissions to the NRC (35 to 38%) is
consistently lower than for adults (47 to 50%).
Table 3. Gender of TF patients hospitalised at Shri
Krishna Hospital_____________________________
Year
Adult/
Total
Female
%
Male i
Female
NRC
1,134
1.257j
96/96
Adult
2,391
47%
336|
522
186
36%
96/97
NRC
807
97/98
Adult
1,711
47%
90-11
514
NRC
195
38%
3191
97/98
1,455
98/99
Adult
729
50%
723!
616
216
4001
98/99
NRC
35%
362
749
99/00
Adult
48%
387|
505
187
99/00
NRC
37%
317
Total
8,463
3,816
4,643|
55%|
% Total
100%
45%
Average duration of hospitalisation varies little from one year
to the next at approximately eight days (Table 4). For each
year there are hospitalisations of less than one day’s duration
(generally ‘day surgeries’ and procedures). The median
duration of stay was 6 for each year, suggesting that (for all
years) the distribution is skewed right by a relatively small
1
6
mfc bulletin / nov-dec 2000
number of lengthy hospitalisations.
Table 4. Duration of hospitalization of TF members at Shri
Krishna Hospital____
Year
Total records Duration
Avg
Median
available
Duration duration
96/97
2,913
2,909
8.36
6
97/98
2,225
2222
8.27
6
~ 2,071
98'99
2,071
752
6
e
99/00
1,254
1252
7.66
6
Total
8,463
8,454
8.02 [
6
a maximum of 1,200 rupees yearly in case of hospitalisation.
Women also have the option of becoming lifetime members
of the Social Security Scheme by making a fixed deposit of
700 rupees4. Special benefits to which only the lifetime
members are entitled include: maternity benefit of 300
rupees with the birth of each child; reimbursement for
cataract surgery up to 1,200 rupees; reimbursement for a
hearing aid up to 1,200 rupees; and, reimbursement for
dentures up to 600 rupees. Exempted from coverage are
certain^chronic diseases (for example, chronic tuberculosis,
certain cancers, diabetes, hypertension, piles) and “disease
caused by addiction” (SEWA brochures, 2000).
Annual members pay their premium in cash. Voluntary
lifetime members usually pay their membership fee in cash,
but they may occasionally pay by a cheque from their SEWA
Bank account. Women who take a loan of more than 10,000
rupees from SEWA Bank are automatically enrolled in the
Integrated Social Security Scheme as lifetime members, an ’
the fixed deposit i
deducted directly from
Tables. C
Costs of hospitalisation of TF members at Shri Krishna Hospital
their loan.
(actual Indian rupee values)
Year Number Avg total Median Avg out- Median Avg TF Median
Annual membership fees
% TF
cost
of-pocket
concession
Concession are collected only from
April 1st to June 30th, and
96/97
2,913
1,094
715
485
300
608
371
56%
annual members are
97/98
2,225
1.701
1,062
1,044
500
657
389
39%
eligible for medical
98/99
2,071
1,601
1.060
967
600
634
404
40%
insurance starting on July
99/00
1,254
1st. The lifetime fixed
1,918
1,202
983
350
935
548
49%
deposit
can be paid
Total
8,463
1,500
1,094
824
400
676
404
45%
anytime throughout the
year. After paying the
fixed deposit, women are
eligible for benefits on whichever of the following dates
comes first: July 1st, October Is5, January 1st, or April 1st.
The number of members cited by SEWA refers to the
Section 2
number who on July 1st, the Is' day of the fiscal year, have
paid their annual membership fee or lifetime fixed deposit
SEWA’s Medical Insurance Fund
within the preceding twelve months.
average total cost of hospitalisation varies from 1,094 rupees
to 1,918 rupees over the last four years (Table 5). On
average, patients paid 55% of this amount, and TF 45%.
However, the average TF concession has varied
considerably, from only 39% in 1997/98 to 56% in 1996/97.
The Self-Employed Women’s Association, SEWA, is an
organisation of poor, self-employed women workers. The
organization’s main goals are to “organise women workers
for full employment and self reliance” (SEWA 1999). SEWA
currently has more than 200.000 members, approximately
148.000 of whom reside in Gujarat State.
SEWA’s Integrated Social Security Scheme was initiated in
1992. This Scheme provides life insurance, medical
insurance and asset insurance (against the loss of house or
working capital in case of flood? fire or communal riots).
This document deals exclusively with the Medical Insurance
Fund.
SEWA fully manages the Medical Insurance Fund (unlike the
life insurance and asset insurance components, which are
run in cooperation with government insurance companies).
In order to join the Fund, women must be between 18 and
58 years of age. Those who pay the annual Social Securitv
Scheme membership fee of 72.5 rupees (30 rupees of
which is earmarked for medical insurance) are covered to
The choice of provider is left entirely to the discretion of the
SEWA member. They are eligible for reimbursement
whether they use private-for-profit, private-non-profit or
public facilities. After discharge from hospital, the Fund
member is required to submit the following documents
within a three month period: a doctor’s certificate stating the
reason for hospitalisation and the dates of admission~and
discharge; doctors’ prescriptions and bills for medicines
purchased; and, reports of laboratory tests done during the
hospital stay. After submission of these documents, the
member is usually visited by a SEWA employee who verifies
the authenticity of the claim. All documentation is reviewed
by a consultant physician, and a final decision on the claim
is then made by an insurance panel (the panel consists of
eight people, a combination of SEWA Leaders and
Organisers). Finally, the Fund Member is notified of the
panel's decision, and when applicable, is paid by cheque.
The design and management of the Medical Insurance Fund
have evolved considerably since-1992. Initially, the Fund
was administered jointly by SEWA and the United India
mfc bulletin / nov-dec 2000
Insurance Company (UIIC). At that time, coverage only
included allopathic, inpatient care, not including
gynecological illnesses. The maximum amount of
reimbursement was 1,000 rupees. In 1994 SEWA assumed
complete control of the medical insurance component. In
1995, coverage was expanded to include treatment from
traditional bone-setters, occupational diseases, obstetric and
gynecological problems, and in exceptional cases,
homeopathic or traditional medical care (still to a maximum
of 1,000 rupees). In 1998, the maximum coverage was
increased to 1,200 rupees. In July of 1998, administration
of the Medical Insurance Fund for Kheda District was
decentralised, shifting from Ahmedabad to the district office
in Anand.
Throughout the ten districts of Gujarat where it operates, the
Medical Insurance Fund had approximately 18,700 lifetime
members (63% of total) and 11,100 annual members (37%
of total) in 1999-2000. In Kheda District, enrollment was
5,672, consisting of 1,548 lifetime members (27% of total)
d 4,124 annual members (73% of total)5. State-wide,
coverage by the Medical Insurance Fund is 20% (29,800
insured among 147,600 SEWA members) and 16% in Kheda
District (5,672 insured among 36,500 SEWA members).
Medical Insurance Fund members in Kheda represent
approximately 19% of Members state-wide.
Finances
Since the Fund’s inception, the premiums paid by annual
members plus the interest paid from the fixed deposits of
lifetime members have always exceeded medical claim
payments. Table 6 shows that cost-recovery (excluding
administrative costs, which are discussed in the next
paragraph) has varied from 119 to 309 percent (data not
available for 1992-94 and 1993-94).
It is very difficult to estimate the costs of administering the
Medical Insurance Fund; many of the administrative
functions are shared with the life and asset insurance
mponents as well as with other activities of SEWA. A
,ent study by the International Labour Organization found
that basic administration costs accounted for 9.3 to 19.7
percent of Integrated Social Security Scheme expenses
annually (personal communication with Michaela Balke,
ILO). Interest from a German Development Cooperation
grant (100 million rupees given in 1993) is used to cover all
administrative costs and to provide the maternity benefit of
300 rupees.
7
Preliminary analysis of Scheme utilisation data for
Kheda District
A total of 439 claims were submitted between July 1st 1994
•and September, 2000 in Kheda District6. There was a
gradual increase in the number of claims submitted to, and
reviewed by, the insurance panel each year. The rate of
claim submission during the two fiscal years 1997-99 was
20 per 1,000 insured women per year (in 97-98 there were
92 claims and 5,200 insured and in 98-99 there were 120
claims and 5,477 insured)7. Thirty-one percent of claims
were submitted by women with lifetime insurance policies,
and 69% by women with annual policies (N = 439). The rate
of claim submission was 17 per 1,000 per year amon2
annual Members and 30 per 1,000 per year among lifetime
Members during the two years 1997-99. Ninety-six percent
of claims submitted were approved for reimbursement (N
= 438). Of the 16 claims that were rejected, 11 were rejected
as the disease responsible for admission was judged to be
“chronic” or “pre-existing” and three were rejected as
documents submitted by the claimant were incomplete (data
not shown).
The mean age of claimants was 39.7 years (N = 439. SD =
9.7 years, CV = 24.4%) and the median 40 years. The age
distribution of claimants shows a peak between 35 and 49
years.
Interestingly, three claimants received
reimbursement despite age older than 58 years (theoretically,
the maximum age allowed for participation in the scheme).
The mean length of admission was 6.7 days (N = 439, SE
= 8.6, CV = 128%) and the median 5. The mean duration
of admission was fairly consistent from one year to the next,
the notable exception being 1994/95 when the mean
admission was 9.2 days, but the median only 6.
The mean cost of a hospitalisation (both reimbursed and
rejected claims) was 2,341 1999/2000 Rupees (N = 438, SE
= 2,117, CV = 90%) or 54 USD. The median cost was 1,629
1999/2000 Rupees or 37 USD. It was difficult to break this
overall value down into component costs, as many hospital
receipts reported only the aggregate cost (which may
include doctors fees, bed fees, medications and tests all
lumped together). In the 254 records for which the costs
could be disaggregated, medicine fees were the largest
component of the total cost (51%), followed by bed fees
(23%), doctor fees (12%), lab and x-ray fees (7%), and
other fees (7%). This breakdown varied markedly
according to the type of
hospital. For example,
Table 6. Contributions to, and payments by, SEWA’s Medical Insurance Fund
medicines accounted for
________ (actual Indian rupee values)
______
48% of costs at private_________Year_______
1994
for-profit hospitals,
1995
1996
1997
1998
1999
62% at private-nonMembers' Contributions
150,000
383,520
450,000
600,000 780,000 696,420
profit hospitals, and
Medical Claim Payments
125,659
124,203
78% at government
258,884
266,118
392,864
386,563
hospitals (data not
i Operating Balance
24,341
259,317
191,116
333,882 387,136 309,857
shown). Seventy-three
percent of claimants
Cost Recovery
119%
309%
174%
225%
199%
180%
used private-for-profit
8
hospitals, 20% private-non-profit (or charitable) hospitals,
and 6% government hospitals. The duration of
hospiialisation was longest for government hospitals (mean
= 9.1 days, median = 7.0 days) and shortest for private-non
profit hospitals (mean = 5.8 days, median = 4.0 days). The
total hospitalisation costs were much higher for a stay in a
pri vane-for-profit hospital (mean = 2,664 Rupees, median =
1.878 Rupees) than in a private-non-profit hospital (mean =
1.627 Rupees, median = 1,123 Rupees) or a government
hospital (mean = 880 Rupees, median = 623 Rupees).
Reimbursement on average was 75% for hospitalisation in
government facilities, 61% for private-non-profit hospitals,
and omly 46% for private-for-profit hospitals.
mfc bulletin / nov-dec 2000
the claim to SEWA, 46 days from submission of the claims
to the date of the panel’s decision, and 37 days between the
panel’s decision and receipt of payment by the claimant.
Discussion
These two prepayment schemes differ tremendously in
terms of design (Table 9). In both cases, the premium is
paid voluntarily and is collected annually. The TF scheme
covers entire households (including children) whereas the
SEWA scheme covers only female members of SEWA
between the ages of 18 and 58. SEWA specifically excludes
certain chronic diseases from coverage, which is not the
case
with TF. Under the TF scheme, members receive
The mean total cost of the 422 reimbursed hospitalisations
concession only if they seek care at the Shri Krishna Hospital,
was 2.332 1999/2000 Rupees (N = 422, SD = 2,091, CV =
while members of the SEWA may receive reimbursement
90%) or 54 USD. The median total cost was 1,629 Rupees
for care at any public, private or trust hospital. The
or 37 USD (Table 8). Over the six years, the standardised
concession provided under the TF scheme variable,
median total cost was between 1,466 and 1,776 Rupees,
depending on total cost of the hospitalisation and level r except in 1996/97 when it was 2,416 Rupees. The mean
financial need. Under the SEWA scheme, the insured ai
reimbursement was 1,148 1999/2000 Rupees (N = 422, SD
reimbursed to the full cost of hospitalisation, up to a
= 307, CV = 27%) or 26 USD (Table 7). The median
maximum of 1,200 rupees. The concession provided by TF
reimbursement was 1,211 Rupees. In general, the
is paid directly to Shri Krishna Hospital on a fee for service
standardized (or real) mean and median reimbursements
basis. The insured effectively receives this benefit at the
provided by SEWA have fallen through time. Of the 422
time of hospitalisation when the bill is paid. Under the
cases reimbursed, only 21% were reimbursed in full (90 of
SEWA scheme, the insured must first pay the full cost of
422), and 28% were reimbursed to less than one-half of total
hospitalisation out-of-pocket, and then seek reimbursement
costs (117 of 422, data not shown).
from SEWA by submitting bills and receipts. Thus,
members of TF enjoy the benefits immediately at the time
On average over the last six years, it took 161 days between
of discharge, while members of SEWA receive the
benefits only months later after their claims have been
processed and approved.
Tabbe 7. Total hospitalisation costs expressed in 1999'2000 Indian
_______ Rupees (for reimbursed claims only, N = 422)
Without assessing impact of these schemes on
Yecsr
SD
CV
Median
Year
N j Mean
households, it is impossible to conclude that one
2d62
101.2%
1,776
94/95
39
2332
94/95
design is superior to the other. Certainly the
differences do highlight the conflict of freedom of
95AX)
1,574
1.706
1,189
69.7%
95/96
62
choice versus ease and speed of reimbursement.
96'97
96'97
"tT 33232 2,460 76.1% 2,416
Under the SEWA scheme, women may attend a health
1,592
97/98
97/98
2,176
2055
103.6%
92
care provider of their choice, in a town or village that
is close to their home. Members of TF who wish 1
■117
1,777
9S'99
81.8%
1,497
98/99
2,173
benefit from the referral services have no choice as
1,944
86.8%
1,466
99/00
j 99/00
37
2,240
to where they will be treated, and the location of Shri
89.7%
Overall
422
2332
2,091
1,629
Overall
Krishna Hospital may be inconvenient to them.
However, by dealing with only a single hospital, TF
Table 8. Reimbursement paid by SEWA as expressed in
has made the process of reimbursement quite short
_________ 1999/2000 Indian Rupees (N = 422)__________
and simple. As well, it is possible that TF can monitor
SD
CV
Year
Mean
Median
N
and influence the quality of care received by its
members at Shri Krishna Hospital. It is far more
261
19.5%
1,510
94/95
39
1.338
difficult for SEWA to have an influence on the many
345
29.3%
1.396
| 95/96
62
1,179
hospitals that may be visited by its members.
303
25.1%
96/97
75
1,207
1,307
It is difficult to estimate the level of cost-recovery for
302
29.3%
1.212
97/98
92
1,032
—
TF’s referral services, as the premium paid to TF is
25.0%
285
1,321 —
98/99
117
1,142
used in providing preventive and primary care in the
22.5%
1,200'__
245
99/00
37
1,087
villages, while the inpatient care is covered (in part )
by a donation from Kaira Can. Suffice it to say that
26.7%
307
1,212
Overall
1,148
422
TF has relied on external donors to fund the referral
services, and that the prepayment scheme for hospital
care
has
recently broken down due to financial difficulties.
discharge from hospital and reimbursement. This can be
Premiums paid to the SEWA Medical Insurance Fund
broken down into: 78 days from discharge to submission of
consistently cover more than 100% of the benefits paid out
9
mfc bulletin / nov-dec 2000
to members. Administrative costs are. however, covered by
an external donor.
It seems that utilisation of both schemes is quite low. A 1993
study carried out by the National Council of Applied
Economic Research (Sundar 1995) found rates of
hospitalisation of 85 per 1,000 people per year in rural India
(6,354 households), and 56 per 1,000 people per year in
rural Gujarat (only 304 households). The rate of claim
submission is only 20 per 1,000 women per year in the
SEWA scheme. Utilisation of Shri Krishna Hospital by TF
members is in the range of 20 per 1,000 households per year.
It is unlikely that members of SEWA and TF require fewer
hospitalisations per annum than the average population.
Rather, it seems likely that many SEWA members do not
submit claims for their hospitalisations, and that many TF
members are hospitalised in facilities other than Shri Krishna
Hospital.
Notes
1. In India, the formal or organized sector “is defined to consist of
all government institutions and of enterprises using power and
employing ten or more persons, as well as those not using power
but employing twenty or more persons” (van Ginneken 1998, p.
2). The informal or unorganised sector, by default, refers to all
' other forms of employment.
The absolute costs of hospitalisation under the two schemes
are not directly comparable as the TF costs and
reimbursements are actual, while the SEWA costs and
eimbursements have been standardised to 1999/2000. On
average, SEWA has reimbursed 49% of the cost of
hospitalisations for which claims have been submitted, and
TF has covered 45% of the costs of hospitalisations. For
both schemes, members have been responsible for finding
other resources to cover, on average, more than half of the
cost of hospitalisation.
This brief background paper highlights some of the main
differences between the SEWA and TF community-based
prepayment schemes. I have touched aspects of both
schemes that could be improved upon. Nonetheless, it is
also important to appreciate these schemes, with all their
weaknesses, as unique innovations in health-care financing.
I hope that analysis of the household level data I have
collected will shed some light on the extent to which these
schemes have influenced households, particularly in meeting
the high costs of hospital care and medical indebtedness.
2. Recently, the computerization of all membership books has
started, which will provide the exact number of members enrolled
by TF
3. I have included in the analysis the records for which the dates
of duration and discharge are the same, i.e. duration of admission
is zero days. I have confirmed these cases with TF; generally
they are cases where people were admitted for short procedures,
like minor surgeries or blood transfusions.
4. Interest on the 700 Rupee fixed deposit is used to pay the
annual Social Security Scheme premium. When the woman reaches
age 58, she is automatically withdrawn from the scheme, at which
time she receives her initial deposit as well as any surplus interest
that has accumulated.
5. Fund administrators explained that lifetime membership is much
more popular state-wide than in Kheda District because many of
the members state-wide have been required to pay the fixed deposit
when they have taken a loan from SEWA Bank, whereas the
majority of members in Kheda have joined the scheme voluntarily.
6. Some claims for 1996-97 and the corresponding register have
been lost. It is impossible to know how many claims are missing.
7. The rate of claim submission was calculated only for 1997-98
and 98-99 as reliable information on the number of Medical
Insurance Fund members in Kheda District was only available for
1997-98 onwards.
Table 9. Differences in design between Tribhuvandas Foundation’s
medical referral services and SEW A *s Medical Insurance Fund_____
Aspect of Scheme
Tribhuvandas
SEW A
______ Design______
F oundation
A nnual premium
10 Rs
72.5 Rs (lifetime
membership also
_____ available)_____
Unitof membership
Households
Female SEW A
members aged 1 8 to
______ 58 years______
Exclusion of preNo
Yes
existing disease
Provider of inpatient
Shri Krishna Hospital
Any public, private
________ care_________
or trust hospital
Level of
Vanes depending on
Full cost of
reim bursem ent
total cost of
hospitalisation to
hospitalisation and
maximum of 1,200
level of financial need
_______ rupees_______
Mode of
Directly to Shri
Paid to insured after
reimbursem ent
Krishna Hospital on
approval of
fee for service basis
certificates and
________ receipts________
Time (o
reimbursement of the
insured
Immediate (insured
pays only the
difference between
total cost and
concession )
Average of 161 days
References
Chatterjee, M. and J. Vyas (1997). Organizing Insurance for
Women Workers: The SEWA Experience. Ahmedabad, Self
Employed Women’s Association: 21 pages.
Hsiao, W. C. and P. Dave Sen (1995); Cooperative financing
for heatlh care in rural India; International Workshop on
Health Insurance in India; Bangalore, India.
Sundar, R (1995). Household survey of health care
utilisation and expenditure; New Delhi; National Council
of Applied Economic Research; 95 pages.
Self Employed Women’s Association (SEWA, 1999).
SEWA in 1999 (Annual Report); Ahmedabad, Self
Employed Women’s Association; 83 pages.
van Ginneken, W. (1998). Overview, Social Security for All
Indians; W. van Ginneken; Delhi; Oxford University Press;
1-20.
mfc bulletin / nov-dec 2000
19
Community Insurance - Which Way to Go? Wisdom out of the
Experiential Learning from SEVAGRAM
Ulhas Jajoo
The Concept: Primary Health Care should be considered a
fundamental right of the people (as it should be for primary
education)
The Challenge : The poor spend considerable amount on
medical care to unregulated and exploitative private sector,
primarily due to low credibility of public hospitals..
The privatisation of public health services offers an
opportunity to misutilise state health resources for private
sector. Therefore, the private sector needs regulation
The Disease : Inspite of wide health care infrastructure in
public sector medical care has not out-reached to the poor,
rural people in particular, essentially because of i) paucity
if funds and ii) lack of efficiency.
The maldistribution of centrally pooled resources is what
primarily ails our system. The distribution of Central/State
Government funds is lop-sided, favours ‘haves’ and
neglects *haves-not’ favours urban and not rural people.
Therefore the optimal resource allocation (per capita basis)
to primary care hospitals is first step towards building
credible services.
The Pre-Requisite : Primary health care services must
provide free curative care for its acceptability to the poorest
of the poor.
The egalitarian health services can never be economically
self reliant, if they have to preferentially serve the poor.
Thus, no private insurance will cater to the poor. Therefore,
the pro people service must be finacially shouldered by the
welfare state.
The Soul: The credibility of the system revolves around:
a) Accessible hospital services of an optimum quality.
b) Accountability of health care system to the consum
ers.
c) Affordability of the services to the poorest.
The Fact: It is possible to offer a just primary care to all,
within existing government resources, provided funds are
locally available and locally governable in an efficiently
decentralised set up.
The Direction : Accountability of the health-care system can
not be enforced vertically downward. To inculcate
responsiveness in the public health care system, a vigilant
public audit system is required.
Therefore, the empowerment of the people is the key for an
accountable system. The power emanates through the
control of public funds and through performance evaluation
of public servants. Public bodies should be entrusted with
the above responsibility in a decentralised structure. The
Gram Sabha in the Panchayati Raj system should be
empowered with public funds (per capita basis expenditure
that Central and State governments undertake.)
The Participatory Nature: Since charity corrupts people, the
beneficiary should contribute towards health care services,
albiet according to their capacity to pay and the priority
need. Contribution according to capacity and service
according to need must be the guiding principle, for pro
poor services. The social fnancing so raised can not meet
expenses towards medical care cost, it can at best,
supplement it. Apart from offereing an affordable post
payment mechanism to persons who need services but are
unable to pay for it, (Risk sharing) Social financing has
following spin offs benefits i) It increases accessibility of health services
ii) It promotes operators’ concern for health in the com
munity.
iii) It generates the concept of right to demand quality
health care by the beneficiary population.
iv) It responds to priorities as judged by the community.
v) It ensures the services are acceptable.
vi) It keeps service providers on their toes.
vii) It stimulates organisational self-confidence and paves
way for participatory culture at the community level.
The Essence: Primary health care is a fundamental right and
the welfare state has an obligation to fulfil it. The pro-poor
health care services should be financed by the welfare state.
Therefore, it should be obligatory for a welfare state to offer
a health insurance scheme through its existing infrastructure.
A decentralised Panchayati Raj set up should be entrusted
financial resources allocated on per capita basis by Central
and State governments. Emergency medical services should
be free and accessible to the poor. Social financing raised
through consumer contributions encourages demand for
quality care and inclucates community participation in
medical care.
The Path to Tread : As part of its constitutional obligation,
the state should run the community health care scheme,
through its rural hospitals (village or Mohalla of a city as a
unit of community). The health care scheme should raise the
finances as prepayments from Gram Sabha in the Panchayati
Raj system. The health care budget alloted on per capita
basis can then be routed as prepayment towards community
medical care scheme. The private sector can compete with
the public sector rural hospital by floating a community
medical care scheme, with the choice resting with the Gram
Sabha.
Annex III
Jawar Scheme
Total Beneficiaries
100% waive off________ __ _____
Total Indoor Admissions
Total Bill made in Rs._______ ~
Total Exp______________________ ~~
Exp. Per head under jawar scheme__________
Contributions collected from JS - Cash
Billing pattern for Jawar scheme (in%)_______
Number of people against which there is 1 adm.
Probable Cost recovery from JS
Co-payment for foreseeable event___________
Total Indoor Admissions_______________
Total bill made
~
Total Amount paid_______________________
Total expenditure________
Cost recovery from copayment (T his does not
include the contribution amount)______________
Total probable cost recovery from Jawar sch (100%
Non insured______________________
Total IPAdmissions
____________
Total Bill made
Amount paid_______________________
Cost recovery from non insured pop (in%)
—[1993-94 [1994-95 [1995-96
1986-87 [1987-88 1988-89 [1989-90 1990-91 11991-92 11992-93
1996-97 [1997-98 [1998-99 |1999-OO~ 2000-01 2001-02 [2002-03
7555
9349
~
10414
8770
14080 | 11812|
12345
|
11988
116051
5892
12101
12026
9294
7759
4122
7839
6125
488
39847,6
423920
____ 56
17465
_____ 9
____ 15
__ 4.1
604
80271.6
538551
____ 58
31952
____ 15
____ 15
___ 5,9
595
365
481
71996.6 59729.8, 80299,2
564791 519193 729032
____ 54 ____ 59 ____ 52
34681
39496
51693
____ 13 ____ 12 ____ 11
____ 17 ____ 24 ____ 29
__ 6J
7.6 __ 7J
533
597
574
700
304
675
552
547,
499
106639 114247 103894 158001 82365.8 219833 205640 219226 191673
954032 1228379 1079705 1477683 659089 1592457 1281619 1421336 1361392
___ 81
100 ____ 90
127
112
132
107
153
175
45093
70828
60533
58488
90695 105773
70277 148681 352928
__ 12 _____ 9 ____ 10 ___ 12 ____ 12 ____ 14 ____ 16 ____ 15 ____ 14
___ 22 ____ 21 ____ 21 ____ 17 ____ 19 ____ 18 ____ 22 ____ 17 ____ 16
4.7
5.8 ____5.6
4.0
13.8
6,6
5.5
10.5
25.9
217
34048
9657
188786
322
42973
11752.8
286942
286
31541
10916.1
271297
233
34992
10123.1
330731
337
54487
15470,4
510868
288
47234
13136.4
515693
354
45985
12214
728385
5.1
4.4
4,1
5.3
4.0
5.5
3.1
5.8
3.0
5.4
2.5
4.0j
1.7
4.2
1.9
4.2
2.4i
3.2
3.0
6.8
3.3
5.1
3.9
4.6
3.4
6.5
2.7
10.8
12.5
14.4
4.7
8.2
8.2
7.5
__ 92
13281
9248
11.5
162
22561
10462
183
34549
17637
10.1
161
26959
11987
__ 5,2
156
25596
14858
63
156
29203
15151
__ 5A
260
48465
25385
__ 4.7
275
58391
27757
5A
484
476645
64872
___ 6,3
604
136916
100564
7,7
421
151116
95629
9.6|
394
135752
94633
10.3
568
159843
113796
7.7
411
162887
119274
10.6
458
323750
57856
33
238
232876
152747
17.9
281
161818
140553
13.2
__ 7.2
212
462
485
229338 120369 344799
803919 1660637 1832801
195
212
299
130353 256156 105781
___ 29 _____ 7 ____ 19
___ 19 ____ 17 ____ 13
16.2
15.4
5,8
363
636
547
591
594
676
922
203
950
1123
48714 116136
79209 180636 207238 218660 245821 380891 614176 580338
12653, 32806.2, 35371.6 46564,7 53149.2 59385,3 67212.6 96447.4 161721
349881
682810 1342580 1185926 1394285 1379133 1755570 2513613 769791 3416168
4245416
Institutional Agenda of FRLHT
I
3 Major Thrust areas of FRLHT
Conserving natural resources used by ISM
through institutional and community involvement
C1 Conservation Research
1.
2.
3.
4.
Botanical & Ecological surveys in
different forest types & regions.
Threat assessment of species of
conservation - concern.
Species recovery.
Sustainable harvest studies.
C2 Conservation Action
1.
2.
In-situ conservation of wild
populations & habitats of natural
resources used in ISM.
Community gardens in district &
taluks & towns via local institutions.
C3 Conservation Databases
1.
2.
3.
Medicinal plant databases.
Trade bulletins for users on prices &
pharmacognosy.
User oriented databases, ENVIS,
Meta database, FRLHT website.
C4 Biocultural Herbarium & Raw drug
library of ISM plants
1.
Virtual Herbarium & R.D. Library.
Demonstrating contemporary relevance of theory and practice
of ISM.
> DI Participatory Documentation, Research & Assessment
of Local health nractices.
D2 Modem methods & tools for interpreting traditional
knowledge.
1.
2.
3.
4.
Application of chemistry, genetics, microbiology &
botany for quality, standardization & evaluation of
raw drugs.
Use of modem tools for development &
standardization of products & processes.
Development of pharmacognosy referral database on
medicinal plants.
Database on metals & minerals used in ISM.
Revitalizing Social processes
(institutional, non-institutional
commercial) or transmission of
traditional knowledge of health care.
> R1 Promotion of taluk level natti
vaidva associations.
R2 Promotion of self-help
> women groups for revitalization
of household health care
1.
2.
Home herbal gardens in rural
& urban areas.
Home doctor multi lingual
R3 Promotion community owned
> D3 Databases on traditional, medical knowledge focussed
on materia medica & diagnostics.
1.
Referral databases for assessment of LHTs.
D4 Cross cultural Research on strategically chosen aspects
of
traditional knowledge in order to build bridges of
>
understanding between Indian & Western systems of
medicine.
> enterprises engaged in cultivation
collection & processing of
medicinal plants.
R4 Creation of Ayurveda & Yoga
> research hospital, pharmacy &
training centre.
R5 Policy studies.
1.
2.
3.
4.
5.
Assessment of bone setting traditions in south India.
Studies on malaria.
Ethno botanical nomenclature program.
Database on traditional collection standards.
Studies on ethno-veterinary practices.
> D5 Manuscripts Conservation & Research Centre.
* R6 Publications, Education &
Training.
CjotA H
The Community Insurance - Which way to go.
( Wisdom out of experiential learning from SEVAGRAM )
Dr U N Jajoo
Professor in Medicine &
Incharge Health Insurance
Mahatma Gandhi Institute of Medical Sciences
Sevagram
The Concept
* Primary health care should be considered a fundamental right of the people (as it
should be for primary education )
The Challenge
* The poor spend considerable amount on medical care to unregulated and
exploitive private sector , primarily due to poor credibility of public hospitals .
* The privatization of public health services offers opportunity to misutilise state
health resources for private sector.
Thus , the private sector requires regulation .
The Disease
* Inspite of wide health care infrastructure in public sector , medical care has not
reached the poor , rural people in particular, essentially due to i) paucity of funds and
ii)lack of efficiency .
* The misdistribution of centrally pooled resources is what primarily ails our system
. The distribution of central and state government funds is lop sided , favoring “haves “ and
neglecting “have-nots” , favoring “urban “ and neglecting “rural “masses .
Thus , the optimal resources allocation (per capita basis ) to primary health care
hospitals is the first step to building credible services .
The Pre-requisite
* Primary health care services must provide free curative care for its acceptability to
the poorest of the poor .
* The egalitarian health service can never be economically self reliant, if they have
to preferentially serve the poor.
Thus , no private insurance will cater to the poor , and
The pro-people services must be shouldered by the state .
The Soul
* The credibility of the system revolves around
a) Accessible hospital services of an optimum quality
b) Accountability of the health care system to the consumers , and
c) Affordability of the services to the poorest.
The Fact
* It is possible to offer a non-biased primary care to all, within existing government
resources , provided funds are locally available and locally governable in a efficiently
managed decentralized setup.
The Direction
* The accountability of health care systems cannot be enforced vertically down . to
incalculate responsiveness in public health care systems , a vigilant public audit system is
required .
Thus , the empowerment of the people is the key towards accountability . The power
emanates through the control of public funds and performance evaluation of public servants
The public body empowered to undertake the above is a decentralized structure .
Thus , the gram sabha in the panchayat raj system be empowered with public funds
(per capita basis , expenditure that central and state governments undertake ).
The Participatory Nature
* Since charity corrupts people and does so absolutely , beneficiary should
contribute towards health care services . albeit. according to their capacity and the priority
need .
* The contribution according to capacity and services according to the needs ,
must be the guiding principle , for pro-poor services .
* Though the social finance so raised cannot meet the expenses of medical care ,
they can at least supplement them .Apart from offering an affordable post-payment
mechanism to persons who need services but who are unable to pay (Risk sharing ), Social
financing has some spin of benefits i) It increase accessibility of health services ,
ii) It promotes operator’s concern for health in the community ,
iii) It generates the concept of right to demand a quality health care among the
beneficiary population .
iv) It responds to priorities as judged by the community ,
V)
It ensures that services are acceptable .
vi) It keeps service providers on their toes , and
vii)
It simulates organizational self-confidence and paves a way for
participatory culture at community level .
The Essence
* Primary Health Care is a fundamental right and the welfare state has an obligation
to fulfill it.
* No private health insurance can cater to the poor.
* The pro-people health care services must be financially shouldered by the welfare
state.
Thus , it should be obligatory for a welfare state to offer a health insurance scheme
through its existing infrastructure .
* It is possible to offer just primary health care to all within allotted resources by
central /state governments . provide it is distributed on capita basis in a decentralized
panchayat raj setup.
* The credible emergency services should be for free , for them to be accessible by
the poor .
* The social finance raised through consumer-contributions according to their
capacity , raises the demand for quality care and incalculates community participation in
medical care .
The Path to Tread
* As a part of constitutional obligation , let the state run community health care
scheme, through its rural hospitals ( village or Mohalla of a city as a unit of community ).
* The health care scheme should raise the finances as prepayments from gramsabha in panchayat-raj system .
* The health care budget of central and state government can be allotted on percapita basis to panchayat raj system . The amount can be routed as pre-payment towards
community health care scheme .
*Let private sector compete with the public sector by floating a community health
care scheme of their own . The choice of selection rests with the gram sabha in panchayat
raj system .
* Gram Sabha should raise social finance for unforeseen emergencies which rural
hospitals fail to meet.
Key Words
Structural Change
- Decentralize
Empowering people - Just distribution of resources
Credible system
- Affordable , accountable , egalitarian
*
The Jawar Rural Health Insurance (Assurance} Scheme of the
MGIMS Hospital, Sevagram : A micro experiment in the spririt of
Sarvodaya ideology.
By Dr. Ulhas Jajoo.
Dr. Anant Bhan
The idea for the scheme started from the Medico Friends Circle (an informal
group that is concerned about issues of public health importance) students group that
Dr. Jajoo initiated in MG!MS. Sevagram when he joined as faculty there in the
Department of Medicine after completing his masters from the Medical College, Nagpur
in 1976. The group would regularly meet and discuss the various issues of relevance in
medicine. Fed up of their indoor discussions and ideological debates, the group decided
to move out into the community and work with them. The students divided themselves
into groups, which went to four different villages, one of which was to be chosen for the
proposed fieldwork. The students finally zeroed in on Nagapur village, which was around
5 kms away from the Sevagram hospital because of practical considerations, and not the
other village like Puiai though needy but was quite far away and transport facilities to
which were abysmal. It was the first lesson that roads and transport are related to health
care.
The group initially talked to the villagers about their health needs. In consultation,
it was decided to run a dispensary in the local school on a weekly basis. They decided
against using drug samples given by medical representatives because it was unethical.
A small token amount was collected towards the drug bank from the villagers and the
dispensary was started. The drug selection was based on effectivity. cost and toxicity.
The generic drugs were used. In the process, the group could get insight of the
exploitative drug market
However, pretty soon the durgs ran out and on analysis, the group realized that
the rich of the village were not paying up and it was actually the poor who had paid
regularly. In the next village meeting, this was brought up and addressed. The rich felt
hurt for being exposed publicly but then the flow of money became more regular.
Realizing that some kind of regular follow up was needed, it was decided to have
a village health worker (VHW). Initially, they thought that the traditional !Dai: could be
given this responsibility but they realized soon that the community did not give her
enough credibility. It bolied down to selecting a male health worker, from the community
who was not necessarily poor. Also, he needed to be respected by the community to be
able to provide a leadership role.
1
1
It was also decided that only those who could pay would be allowed to access
the services at the dispensary. This led to a situation where the absolutely poor were not
able to access the services. To cater to this target population, which needed support, the
scheme was linked to the hospital which would help in sustenance of the scheme. Dr
Sushila Nayyar, the Director and founder member of M G.I.M.S. agreed to a policy that
any person from the scheme would get free treatment from the hospital.
The next step was the establishment of a village fund. Dr. Jajoo had visited
various health projects before initiating this scheme and these visits had shown him that
the main reason for starting these projects was on compassionate grounds. The all
enveloping love often created dependency among beneficiaries. It breeds relationship of
a doler and the begger. Moreover, these projects were so heavily financed that their
replicability was not possible. (PRIA, 1986 study). Dr. Jajoo did not want donations from
outside to finance the healthcare (based on the feeling of “Charity Corrupts People”).
I he purpose of the fund was not to raise financial support to the outreach programme
but to generate demand for qualitative service from the providers: in fact it was a
tradition among villagers to collect voluntarily contribution graded according to capacity
for religious village function, sport competition or for temple construction. The fund would
finance tne salary of the VHW and the drug requirements of the local dispensary,
besides transportation cost of the mobile health team Since Jawar (Sorghum) cultivation
was quite common and it was easy to contribute in kind, it was decided to accept the
contribution in the form of Jawar (Sorghum) - the contribution would be according to
capacity and the services according to need (trie poor needed more supoort).
i he fund would act as a pre-payment scheme subscription, entitlements being
iree primary health care and subsidized referral care (Jajoo, 1993). A minimum amount
was decided which would have to be paid by every family and also additional amount of
Jawar would be charged depending on the kind of work that the family members were
engaged in or on additional holdings. At present the health insurance contribution from
the lowest income group (landless labourers) is 12 payali of Jawar per family per year (a
peyah is a measure equivalent to 1.25 kgs and a Payali of Jawar sells for around Rs. e
at present market rates).
Since this ensured that uniform healthcare would be available to all those who •
paid for the village fund, some of the rich farmers felt that they were financing the
healthcare of the poor and did not pay up. Thus, only 60% of the village was paying up
for first year. This was brought up at the next village meet. To ensure payment, it was
maoe clear that only those who contribute will get the benefits of the scheme. The
persons from the village who had paid would get free treatment, but who did not
contribute to the village fund would have to pay for the treatment. Those who had not
2
paid (after treatment) and absconded would he held accountable by the village and
made to pay.
To prevent misutilization of services at the hospital, it was fixed that 25% of the
costs of elective admissions like cataract, hernia, normal pregnancy would have to be
paid by the patient, while the treatment for an emergency ! unpredictable illness would
be free at the hospital.
Gradually over subsequent years, as scheme gained credibility; the coverage of
the scheme grew from 60% to 75% and finally 90-95%. The village fund would pay for
the drugs in the local dispensary, the VHW’s salary-' and the visit of the hospital vehicle
once in three months.
The meetings in the village (Gram Sabhas) about the various aspects of the
scheme would be held every year before Jawar collection and would occasionally be
‘stormy1 and heated discussions would ensue. This Gram Sabha would sewe a dual
purpose of evaluating the performance of the health structure and also enacting
disciplinary' action on irregularities committed by the villagers themselves. The Gram
Sabha helped to facilitate communication between the health system and the beneficiary/
on one hand, while on the other it helped the villagers to command control on the VHW
and the health team. On occasion, the Gram Sabha decided to change their VHW
(Jaioo, 1993). The scheme helped the community have a right to demand good quality
care from the system. It also ensured politeness and better behaviour in the hospital on
the part of the providers.
On the basis of the lessions learnt from Nagapur the team extended the health
insurance scheme to other villages (presently there are 40 villages within a radius of 25
tans around the hospital, covered under the scheme).
Inidaily the VHW was paid a fixed amount in the form of Jawar, but later on it was
decided that the honorarium would be decided in the village depending on the VHW’s
work performance, whether he had been helpful and accompanied the patients in the
time of the need. This was to bring in accountability to his / her work.
As the scheme slowly started spreading to other villages, each village openeo an
account with a withdrawal by cheques facility. All the Jawar collected as premium would
be sold and the money would be deposited in this account as the village fund. At the end
of the year, the money remaining in the accounts would be transferred to the village fund
for the next year - occasionally, a part of the fund would be transferred to the Kasturba
Health Society to form a common pool of money for all the villages - a corpus, the
interest of which could be used for procuring drugs (centralized distribution from the
hospital). The money would also be used for organizing educative camps and
3
'Prabhodan Saptabs’ (Educative lecture week series) where non health related topics
including social / spiritual issues would be discussed.
Only 10% of the expenditure on the scheme as recovered form the contribution in
the form of premium and 90% of the cost came from the hospital Since the MGIMS
hospital runs predominantly on Govt financing, which is public money, it was felt that
this would be a appropriate utilization of the same.
The structure of the scheme revolves around (Jajoo : unpublished)
> Accessible hospital services of optimum quality.
> Accountability of Heath care system to the consumers.
> Affordability' of the services to the poorest
Dr. Ja.ioo and M.G.I.M.S. realize that the sustainability of the scheme (that it has
to cater poor) without external support is not possible. It was and is their belief that the
government needs to support these kind of schemes and subsidize them as a part of its
social responsibilities.
Social financing has the following spin off benefits (Jajoo, unpublished) .>
It increases the accessibility of the health services
>
It promotes the operators concern of the health in the community
>
It generates the concept of the right to demand a quality health care
by the beneficiary population.
>
It responds to priorities as judged by the community.
>
It ensures that the services are acceptable.
It keeps the service providers on their toes.
>
It stimulates organizational self-confidence and paves the way for
participatary culture at the community level.
At this stage, the pre-requisite for adopting the scheme was - at least 75% of
village families should contribute for the village to be insured.' The scheme found
acceptability among villagers and once they insured, did not look back for the years to
come.
It was at this time when the scheme extenoecl focus from curative care to
preventive and promotive health aspects. The strategy of cluster immunisation to
achieve herd immunity was successfully implemented for vaccine preventable illnesses.
The village sanitation was addressed by evolving an appropriate model of latrine. ‘One
house one latrine scheme’ aimed at 100% coverage of village families. It was not a dole.
The part contribution in cash came from beneficiary villager and the rest from Gram
Panchayat and state funds. The model found acceptance of the state and central
government for its replication.
4
Poverty being the greatest evil behind most of the health problems, as a logical
corollary; the scheme extended its web to income generation programme, addressing
village as a social unit for development. All familes in a village were offered membership
of co-operative society for dairy development or lift irrigation scheme for agriculture
where ever feasible The later initiative could come through the bank funds. The
constitution of co-operative society was framed in such a way that decisions could only
occur with no less than 75% majority, thus making elections obsolete.
At this stage village health insurance scheme underwent first qualitative change.
In addition to 75% participation, at least one of the following criteria was needed for
elligibility.
>
Participation in “one house - one latrine” scheme with near 100% coverage
of village families.
> Organising lift irrigation scheme for al! village families
>
Organising milk co-operative for all village families
> Electing village panchayat by consensus
Organisation of people through income generation schemes became a focus
issue, benefitting the whole community, The eligibility criteria now heavily weighed in
favour of community action. The health insurance scheme had now reached a staoe
where it was helping and initiating action oriented culture of the village. The changed
face of the insurance scheme gave impetus to ‘one - house one latrine1 scheme in many
villages.
The various schemes available to the village are-
a) Jawar insurance scheme - under this 50% subsidy is given on outpatient
care and 100% on all indoor care except for elective admissions (50%
subsidy)
b) Subsidised family insurance scheme for rural area (Rs. 15 / person/year)
when 75% of village families contribute. In this scheme outpatient and
impatient services are provided with 50% subsidy. The village need not fulfill
thp AfonVP PDlidforl nritoris fr\r
*•••*•
c)
XZf ILk/l IKZ
VI II V!|| I IV/1 IL.
Indoor insurance scheme in which there is no insistence on 75% of village
families to contribute. The contributions are at the rate of Rs. -15 / person /
year, i here is no outpatient subsidy offered, inpatient charges are subsidised
by 50%.
d)
i he hospital runs a health insurance scheme for families living in semiurban
pockets and in Wardha town, at the rate of Rs. 150/year for a family of five.
The entitlement includes 50% subsidy in out patient and inpatient charges.
5
Income generation programme became quite successful and brought in visible
economic upliftment, with it vices like alcohol, gambling, fierce
party politics and
competitiveness found inroads in the village. The police frequently found entry and visits
to judicial court galloped. It was a lesson to be learnt - cultural development must race
ahead of economic upliftment for a effective change It was a turning point for the ethos
of health insurance scheme.
If the ultimate aim of the health insurance scheme is organising people at the
lowest ebb of society; we opted for women’s self help group (SHGs), since the women in
poor families are the 'prolitariat of the prolitariaf (as quoted by Dada Dharmadhikari).
The women are hard working among all classes and the ultimate sufferers. They are
also culturally sane. The organisation of this culturally sane section of society found its
initiative in the early 90s.
The organisation of women in to SHGs was need based, so that their
dependence on money could be addressed by forming collectives that would be able to
provide economic support when neded It was noticed that the women would stand by
each other and there would be transparency, leading to more accountability. The culture
of decision making by consensus was thoughtfully inculcated in SHGs. As the money
started coming (linkages with bank), women’s status in family changed as she was now
looked upon as a bread winner for the family too. The process helped empowerment of
women.
By now it was realised that though health care offers an ideal medium to get
entry in village life (albeit costly), organising the entire community around it had not
taken roots, simply because it was not and is not the priority need of the masses Illness
as a calamity afreets individuals and is rare to find epidemics sweeping the community
around which a sustained mass action can be initiated.
The income generation programmes attract people as they serve their individual
interest. Since the pregrammes addressing all village families were chosen (lift irrigation
and milk co-operatives), every one hugged together to harvest the gains, creating a false
irnpression
of an orr}anis
ed co^m^
' tnit
’w hi
in idwL thom
____ x-.^t
- -------- ----------- ......
uuy.
uicoc puyiQiiiiiica ;».»>
iiluuiuateu uumpeiiLive
life style and the greed that comes with it. The realisation dawned, that short of cultural
ethos, mere economic upliftment treads the wrong path.
The health insurance scheme had now reached a stage where it was helping
identify not only the action oriented culture of the village but also action oriented
individuals with capacity to do good. All are not equal in a village, some are more
reverable than others, i he culture evolution needs active participation of these revered
ones (Sajjan Samarth). With aim to organize them, the focus of health insurance scheme
shifted to indiviouals and families than the earlier insistence on an entire village. Action
6
plans for individuals now emerged like - organic farming and Vastra Swavalamban
(Cloth self sufficiency). These are acts in faith. For an intelligent direction of this kind,
study circles (Prabodhan) became the need of the hour. It could not have been
classroom learning. It had to be experiencial sharing
The educational talks based on experiencial Wisdom were organised after the
month of February, when the crop hanvest was over. The usual site was temple, after
“Arati” was over at 8 p.m. A discussion would be initiated on issues relating to their day
to day life, linking them to social - cultural values. Organic farming was encouraged. The
‘Role models’ in various fields were put before the community. The educational trips to
Role model’s work place helped people imbibe goodness. Thus evolved programmes
aiming Vastra Swavalamban and sustainable agriculture.
The focus of the scheme now shifted to organise and empower the revered ones.
It aimed at breaking their culture of silence with a hope that reigns of power be vested in
moral leadership. It is from this empowerment and leadership the anti-liquor movement
has taken roots in the villages around Sevagram.
The Jawar insurance scheme undewent a major conceptual change, focusing on
individuals and families than the entire village. The family had to fulfil at least one
Criteria for eligibility of enrollment.
Member of the SHG.
e
Experimenting organic farming
Taken a vow for Vastra Swavalamban
Active member of study circle in the village.
When the scheme began in 1979, the focus was on curative care; later on it
became preventable care; it then reached the stage of promotive care through income
generation schemes; the focus moved on to being social and now it is to encourage
moral issues iri society. Those that give priority to moral issues are insured under Jawar
scheme, while the rest can choose any of the other schemes listed above.
The changing focus gave impetus to SHG movement. SHGs were linked to
banks, enabling them to offer crop-loans to the members. It being a unregistered body,
entirely runs on faith. It selects office bearers by consensus who by rule, do not stay in
office for more than two years. All codes of conduct were evolved through group
discussions. The culture of decision making by consensus and transparency in all
transactions buttressed the faith women enjoyed among themselves. Since it enjoyed
credibility of a dependable source of financial support, hence it did not see any
defaulters of loan. The forum slowly took up educational role through experiencial
sharing sessions, educative trips and by attending educational camps.
7
It
realized that common marAvoman in particular, acts in faith and that is the
u/hing force fot him/her. This faith needs to be properly directed by the wise people.
Characteristics of the Oasis :
1
Affordable and accessible
It is due to fact that families enrolling for Health insurance contribute
according to capacity but services are provided according to need.
2. Acceptable :
The evidence -
More that 95% enroll in the village. It speaks of its quality. All
indoor hospitalization from adopted village occur in Kasturba
Hospital, Sevagram. They
do not go to the nourishing private
sector in Wardha town.
3. Effective :
The Evidence - No maternal mortality in past 15 years.
- No death due to non-accessibility of medical care.
- No Tetanus, Polio, Whooping cough, Measles in last 15 years.
Measles is the most sensitive indicator of herd immunity achieved.
- No misutilisation of resources.
4. Accountable :
The social finance has generated right to demand, which keeps the service
providers of their toes.
5. Vvhol'istic :
It is not an experiment planned from ivory towers with a tubular vision. The
experiment has evolved with the involvement and feedback from the people and has
transcended wholistically to the priority needs of the people.
6. Credible :
It is something that can not be quantitated but has be felt. It can be witnessed in -
* Late night village meetings where discussions turn in to educative sessions.
• ^self-help groups not only as a transparent financing body but transforming in to a
educative forum and Empowering women,
8
• Vastraswavaiamban (Khadi for own use) and sustainable agricultural practices
as a step towards freedom from exploitative market.
Se'f reliance in pnority needs is a key to empowerment.
7. Trustworthy :
The gains of this experiment have been the relationship of a friend / partner, the
free lines of communication with the beneficiary and the conversion to a big family.
There is implicit trust involved and this enables the poor to share their pathos. They
come to health care professional with the belief that they would do their best and leave
the rest to destiny A relationship of trust is thus established which brings people
together and keep the scheme going on.
8. Replicability':
The credibility of scheme revolves around the will of the hospital management to
support. Dr Jajoo is a pivot around which the scheme revolves. In his absence the need
based health insurance scheme would continue, though the outreach activities and other
dimensions of health would suffer
Research ;
The service to the people was main concern. Research was not really a focus
because or lack of interested manpower. The focus was instead on operational research
and on extending the scheme to community by emphasisng other dimensions related to
health ethics. Over the years, the scheme has generated a lot of data but this needs to
be analysed.
i he operational aspects :
The hospital has now become much more accessible to the community and this
has helped bring down the incidence of deaths like that due to pneumonia and
diarrhoea. Vaccine preventable illnesses (tetanus, polio, whooping cough, measles)
have disappeated once herd immunity was established and maintained by cluster
approach to immunisation. From the year (1995) government adopted cluster approach
to immunisation, vaccination is left to government ANM. The village worker performs a
watch aog function to see that all eligible receive it.
The deliveries are free in the hospital for primiparous and for complicated
pregnancy, i he women can choose to have delivery either in the villages assisted by
traditional birth attendant (TBA) or in the hospital. The services now being accessible,
women choose to have hospital delivery. ANC (Antenatal care) up to 7,h month are
s
handled by village health worker While around 7th month, women report to Kasturba
Hospital for assessment of pelvis, toxaemia and for receiving booster of tetanus toxoid.
The area catered by health insurance scheme has not witnessed maternal mortality- from
last 15 years and the natal / prerinatal mortality has reduced significantly.
The monthly ANC visits in the villages have been given up. ANM visits villages
once in three months, checking all records maintained by village workers (ANC
registration, Vaccination, Birth, Death). With appropriate strategy for vaccination and
ante-natal care, which utilises village based manpower to the maximum, the need of
skilled manpower is reduced to the obligatory minimum. The ANM under the scheme
acts at the second tier managing the administrative work of all the villages in addition to
supervision of village based activities in 40 villages. She visits al! hospitalised patients,
assures expeditious services, entertains their complaints, keep records and informs
tricky problems to Dr. Jajoo.
The process of selection of VHW has undergone a sea change. Initially TBA was
preferred with a notion that she has natural access to pregnant women and new-borns.
She belongs to lowest socio-economic class, is needy, hence would be most appropriate
choice. The experiences was contrary. She was called only for conducting delivery and
taking care of new born for next ten days since no body else would do it. She did not and
does not enjoy enough credibility' in the minds of people, that advice would be heeded
She had to take permission from her husband to accompany a patient in the night to the
hospital, if emergency so demands.
The option shifted for a male member. With the evolving role of VHW, a person
with leadership qualities, one who is respected in the community and has aptitude to
serve, happened to be the choice. Since the village fund that could be raised from
prepayments did not permit lucrative honorarium (it is hardly 1000 -1500 Rs. Per year),
only a personi from middle class background with aptitude to serve could be selected.
Since the selection was done in consultation with wise and elderly men and women of
different caste groups in the village, often in front of the temple, the person acceptable to
al! had to be one beyond village party - politics.
With SHG movement taking shape, it was easy to locate women with leadership
potentiality and serving aptitude. Most of the villages, at present have two village
workers, one male and other female, assisting each other for the comprehensive
development of village.
As the vision behind the scheme was ever evolving, Dr. Jajoo, ANM (Mrs
Bagade) and village workers all underwent a problem based learning. Frequent
meetings (Late night) with Gram Sabha, generated directions which way to go. At no
time, need for a formal training was experienced. The team learned by doing and
10
experiential sharing. Every thing needed had to be learned by all. The learning
transcended beyond scientific to socio-economic-political-spiritual dimensions of life.
According to Dr. Jajoo, the propagated glorified role of VHW as a liberator in late
80s and early 90s had to settle down to ground realities. For a peripheral health workers
to perform successfully, an effective back-up referral system needs to be in place. The
credibility, ultimately in the community is for curative care and not preventive care. The
experience in Sevagram has shown that the acceptability of VHW depends greatly on
how much support the medical team can give him ! her as a link between the community'
and health delivery' system (PRIA study 1986).
Community involvement in health care :
Community' involvement is a glibly used slogan. It has different shades -
-
Community complacence where community is a passive receiver.
-
Community co-operation - where manpower support is offered by community.
Community partnership — demands material support from the community in addition.
In all these, there is a ‘big brother that dictates.
Community participation is a politicised concept. The decision making lies with the
people. There is a common feeling and hence spontaneity in action
Health being a service sector, professional relationship is vertical
Health
Insurance scheme, has horizontalised this relationship to the extent possible. It
exemplifies health for the people. Sevagram could achieve community partnership while
evolving models like ‘one house one latrine scheme’, milk co-operatives and lift irrigation
co-operatives, i he scheme did succeed in unifying village community through income
generation programmes. But money brought with it liquor, gambling, party politics, police
and judicial courts. The fact brought home the painful realisation that pooling people
together for material gain is not development.
Village around Sevagram has witnessed community participation emerging
during farmers movement. It breathed its last because it aimed only for material gain.
The scheme experienced right kind of community participation emerging with
Vasiraswavalamban Yojana, sustainable agricultural practices and SHG movement of
women in particular. It is an empowering experience, evidenced by the anti-liquor
movement that is taking roots in village around Sevagram. The right kind of community
participation emerges when spiritual wisdom leads and lights.
11
Experiencial Wisdom of last 20 years
For pro-people (poor) health services, self reliance is a myth. The Jawar scheme
could raise around 10% of what is spent, by social finance. The private insurance which
works on tne principle or financial risk sharing on no loss basis, can never cater poor. Dr.
Jajoo emphasizes that pro-poor health care must be domain of state's welfare activity.
It is possible to offer just primary' health care to all within presently allotted
government resources (250 Rs /Per capita year). The maldistribution of centrally pooled
resources is what primarily ails our system. The percolation theory* - that centrally
allotted funds will reach to the periphery - fails. If the government decides to hand-over
its percapita expenditure on health directly to Gram Sabha then there can be better
control of the health services. Where they control health finances, they can negotiate
services from the providers, it gives them a better pedestal. The community can then
ouy the So vices from the public or the Voluntary sector which is arguably propeople.
Empowerment of people without ownership of resourses is not possible. The bottleneck
o- Sevagram experiment was the fact that people did not own resources and 'were on
receiving end and hence the programme remained vertical and complete participation
was not possible.
It requires a radical political will to truly decentralise up to Panchayat Raj system
and distributing resources to it on percapita basis. The structural adjustments of this kind
can see replicability of Sevagram experiment.
Short of these structural adjustments where-ever 90% of the finances can be
granted to the voluntary sector (as is the case of Kasturba Health Society), mechanisms
and organisational part of the scheme would be replicable. The will has to exist, it can
not be replicated.
Ethos:
We live in a society where “al! men are equal, but some are more equal than
others ! It is not an egalitarian society, social relationships are exploitative.
The fact reminds of a story form Panchatantra There was a forest. Out of all the animals, a wolf and a crane together were
invited for the feast KHIR. (sweet rice-milk) was served to them in a plate and both were
invited to enjoy the same. Guess who must have gulped it? The wolf had its day The
host was intelligent. He invited them again for a second round., but KHIR was now
served in a MATAKA (earthen vessel) It was the crane's turn; whose beak could reach
the depth of the vessel while wolf s tongue could not.’:
12
'
Mero availability of public facility does not make it accessible to ‘‘Have-Nots". In a
democratic society, “more equal” (Haves) have to be restrained, for public benefits to
percolate down. It calls for appropriate structural adjustments.
Sevagram Village Health Insurance Scheme idolizes Health Care for the people.
Uniqueness of the Oasis :
The Health Insurance Scheme reaches out to the unorganized sector,
poorest of poor.
> It is the lone health care experiment, which considers village as a social unit
and adopts villages.
> Thereby it attempts to empower the Gram Sabha in Panohayat Raj System
> We believe that blind charity corrupts people. It is not a dole. It raises social
finance
>
It evolves a relationship with the people by talking ‘with them’ and not talking
‘at them'
> The vision behind this experiment comes from our role model - Vinoba
Bhave.
Our generation has heard about Gandhi and read of Gandhi. We have not seen
Gandhi in action We saw Vinoba in action. The line sketch of Vinoba that appeared on
First Day Cover1 where his postal stamp was released, aptly depicts what Vinoba stood
for.
13
He has a lantern in his hand. The title reads - Lead kindly light or tamso ma
Jyotirgama\fa He leads the path
He has his vision on the horizon, which dreams the concept of an ideal society — a
society based on principles of freedom and fraternity i.e. Gram Swarajya.
Look at the compassion that embraces the poor. He empathizes with the poor and
the oewntrodden (Antyooaya) and leads them from darkness to light.
It is this specter that haunts us.
. f..
• -i .ij-L
-Fi li
L/cdu ki&dij- iigni
14
The ethos of the whole process of the scheme's evolution has to develop a
democratic society, especially revolving round the village as a unit of society. The
concept oi village republic (Gram — Swarajya) of Gandhi- Vinoba — Jaiprakash Narayan,
is the ultimate vision of the scheme Vinoba gave a structural form to the vision in
Gramdan The power lies with the Gram Sabha which consists of one adult male and
female member of each family in the village It is the highest decision making body. The
decisions are needed to be taken by near consensus. Election is considered a foul mean
and purity of end is decided by purity of means. The leaders are selected and not
elected. It is in sharp contrast to Panchayat Raj system which has in place narrowly
elected (51% against 49%) group of representatives. The representative democratic
structure is not pro-people in true sense and has been replaced by participatory'
democratic structure of Gram Sabha.
The concept is detailed under the Gramdan act of the Indian constitution that was
engineered by Vinoba. Under this act, at least 75% of the population of the village
should transfer the title of their land to Gram Sabha, then only such a village be called as
Gramdan village The villagers enjoy the right to plough, cultivate and consume the
produce (Crop) from the land. However the land can not be sold to any body outside the
village They decide their own land records. Under this act, the ownership is collective,
but the individuals continue to enjoy consumption right over fruits of their labour for
generations io come. Thus it promotes a society which survives on. 'bread labour and
does not permit intellectual labour’ to exploit. The ideal society would be one that would
revolve around concept of 'bread labour. In such society there would not be much
difference between the members and interdependence be obligatory. The decision
making then would be a collective exercise which would decrease the possibility of unfair
or wrong decisions.
The concept of 'labour currency which equals physical labour to intellectual
labour is considered prerequisite for the equality in socialistic philosophy.
By
underpaying for physical labour, exploitative society pools the 'surplus value' in control
of 'more equals', thus creating classes. By virtue of collective ownership of natural
resources like land, water and forest, the Sarvodaya philosophy in Gramdan digs out
roots of exploitative structure in present society and paves the way to nurture values of
equality and freedom.
Empowering Gram Sabha is the key to Gram - Swarajya. Empowerment occurs
when resources are owned and freedom of decision making rests with Gram Sabha,
when decision making is obligatorily by consensus or overwhelming majority, no wrong
decisions can occur. The opinion of the silent majority now supervenes. The 'culture of
15
silsnce’ of revered-ones is now broken As is a saying in eastern culture - "God speaks
through them."
It is not a wild dream. A tribal village - Mendha (Lekha) in Gadchiroli district of
Maharashtra, having population of around 400, has implemented their slogan “Delhi-
Bombay exemplifies 'Our3 government, 'We' are the government in Mendha ” The poor
and illiterate people of Mendha exemplify empowering of people and the culture of Gram
Swarajya.
How should health system be in the context of Gram Swarajya ? It has to be
health by the people, for the people and of the people. Since the resources must be
owned by Gram Sabha, the Sevagram experiment proposes distribution of centrally
pooled resources by the State and Central government to be distributed back to village
on per capita basis. S^eeThe freedom-which services to buy - should also rest with
Gram Sabha so that just decisions can evolve. Short of these structural adjustments
(which requires strong political will); Kasturba Hospital Sevagram holds the government
grants in trust and distributes public money appropriately by raising a mode! of health for
the people
Jawar health insurance scheme at Sevagram is an attempt to identify revered
individuals (SAJJAN SHAKTI), empower by bringing them together, inculcate a culture of
decision making by consensus and initiate acts of common faith.
Looking back at the experiment that this scheme has been. Dr Jaioo feels that a
model has been developed, which is ideal and is replicable in an ideal kind of society
envisaged The lamp needs to keep burning until the fire catches on. This is a !micro:
experiment for a macro ideal. Multiple experiments need to be done and time would
only decide when they would be replicable. The need is to act locally, while thinking
globally. One step in the right direction is enough.
16
References :
1. Key informant interview with Dr. Jajoo Ulhas, Professor, Dept of Medicine, MGIMS,
Wardha and Incharge, Jawar Rural Health Insurance Scheme.
2
Jajoo UN ■ When the search began Mahatma Gandhi Institute of Medical Sciences.
Sevagram, Wardha, 1985
3
Ranson Kent M, ; Community Based Health Insurance Schemes in India : A review ;
National Medical Journal of India 2003 ; 16 (2) : 79-89.
Ora! discussions with scheme beneficiaries
5. Health Insurance Scheme : Learning for Health Care 1986 ; a PRIA publication ; 74 -
100.
6. Jajoo UN. The Social Security in Health Care for the Unorganized Sector the
Sevagram alternative ; The Journal of MGIMS 1997 ; Vol 2 ; 43 - 49.
7. Jajoo UN : Role of the village health worker - a glorified image “Under the lens
health and Medicine : Medico Friend Circle 1986:13.
8. Jajoo UN : Community participation in primary health care : Under the lens - Health
and Medicine : Medico Friend Circle 1986 ; 37 - 44.
9
Jajoo UN : Health is not villagers first priority : World Health Forum 1983; 4: 365.
10. Jajoo UN : Rural health services towards, a new strategy : World Health Forum
1985, 6, 150 and Health Care - WHO pays ? " WHO 1987 : 99.
11. Jajoo UN . Health education alone can do little : World Health Forum, 1985, 6, 220.
12. Jajoo UN : Risk sharing in rural health care : World Health Forum : 1992 :13 :17.
13. Jajoo UN : Annual Cluster (Pulse) Immunisation experiences in villages near
Sevagram : Journal of Tropical Medicine & Hygiene 1985 : 88 : 277.
14. Jajoo UN . Feasibility of measles vaccine in and around Sevagram : Indian Journal
of Paediatrics : 1983 ; 50 : 379.
15 Jajoo UN : A decade of community based immunisation : World Health Forum 1993.
Vol. 14, No. 3 : 290-91.
16. Jajoo UN . Towards an appropriate maternal care (unpublished).
17
Co aa
2-A
-4
HEALTH SECURITY FOR THE POOR :
HEALTH INSURANCE THROUGH HEALTH CARE COOPERATIVE
Dr P.R.Panchamukhi
I
Nayantara Nayak
3
Fears are sometimes expressed particularly in the context of developing countries
-3
that economic reforms consisting of liberalization, privatization and globalization,
primarily focus on economic objectives of efficiency of resource allocation and the social
objectives of distributive equity and social development are likely to receive a back seat
in the course of pursuit of economic objectives. Much is documented in the literature on
the compression of the government budget in general and the overall budget of the social
3
1
sector in particular, especially in developing countries during reform. This compression is
more likely to affect primarily the poor and the less privileged in the society. Obviously,
it is not enough if the problem is diagnosed. What is necessary is to introduce
immediately the counter measures to tackle these likely developments. It should be noted
that such counter measures to safeguard the interests of the poor are required under all
occasions, whether there are economic reforms or no economic reforms, for, the
3
' 3
problems of equity ( inequity ) lie very much in the nature ot the components of social
-3
brought out from Section I of the present paper. Economic reforms however are likely to
* >
sector itself, particularly in the context of a stratified society like India. This will be
aggravate the problem.
Demand for health and education, the main components of social sector, is
-JI
- 3
-
*
-
>
*
generally highly income elastic. Similarly, access to health care and educational
opportunities is also found to be highly income elastic. In a regional perspective,
demand for and access to health and education seem to be elastic with respect to the level
and rate of economic development of the region. It is also worth noting that health and
Director CMDR. Dharwad Karnataka
’ Associate Fellow CMDR Dharwad
Acknowledgements: Thanks are due to Dr.G.K.Kadekodi . V.B.Annigeri . S.Puliaswaniiah and Mythili N.
for their observations on earlier draft of the paper. B.P.Bagalkot offered secretarial assistance.
- *
1
*
^5
)
^4
education confer both private and social benefits. Opportunity costs of education and
health are generally fairly high particularly for low-income households.
Costs of
i
maintaining health, costs of getting education and avoidance costs of ill health and noneducation are too high to be overlooked. From all these poinlj^yiew, education and
health are considered in public finance literature as merit goods, implying that they
are so meritorious from the point of view of social welfare that issues of' their provision
cannot be left to the decision making of the individual or private sector alone but they
need to be considered by the collectivity or public sector also. In the present paper an
attempt is made to focus on issues relating to the provision of health care facilities
particularly for the poor keeping in mind the characteristic features of health calling for
involvement of the collectivity or public sector in its supply or making provision for it.
The paper suggests a mechanism of involvement of the collectivity - community and the
v i
government, which would help better access and utilization of health care services by the
poor. The focus of the paper is on health insurance facilitated by the health care
cooperative ofproviders of and beneficiaries from health care services.
© >
The paper is divided into four sections.
In Section I, unique characteristic features of health relevant in the present
a-
context are briefly outlined.
Section II examines some of the resource allocation plans to the health care sector
suggested in the literature, keeping in mind the requirements of' the poor in general and
the poor among the socially less privileged sections of population in particular. Its main
focus is on the basic issues that need to be considered while implementing the plan.
o
Section III presents a brief review of the experiments of health care cooperatives
and health insurance as in practice in selected countries with a special focus on the
experiments and proposals in India.
G\
Q.
G
8.
0
Q.
<
• >
Section IV, which is the concluding section, outlines major elements of a health
I
security plan for the poor incorporating the insurance strategy first in general terms and
then particularly for one of the villages in Karnataka, for which field data were collected
I
I
I
for the purpose. This example attempts to indicate the order of resource requirements if
such a plan needs to be implemented on a wider scale. It also examines whether there
would be resource savings if such a plan with community involvement and contribution
is implemented in place of the present practice of government itself taking the entire
)
responsibility towards health security for the poor.
I
I
I
I.
HEALTH AND HEALTH CARE SERVICES AS AN ECONOMIC GOOD IN
THE INDIAN CONTEXT
I
)
Health is an economic good, the peculiarities of which need to be explicitly
recognized in any health security plan. We briefly outline below some of these peculiar
features particularly in the typical Indian context, with her own unique value system,
traditions and socio economic conditions. In the Indian context health services would also
have their own peculiarities in respect of their supply and demand, which deserve a
special attention while developing a health security plan for the poor. It can be seen that
inequality in access and utilization are inherent in the very nature of health and health
care sendees as an economic good, particularly when it is left to market forces.
Is Inequality in Access and Utilization Intrinsic to
Health and Health Care ?
i
From the following characteristic features of health and health care it would be clear that
conscious efforts have to be made to safeguard the interests ot the poor so far as the
needs of the poor are concerned. Social and economic backwardness would further
aggravate these inequities.
-
i'
••
■■■
:
-
-
’
There is no universally acceptable yard-stick for measuring health level of
■
individuals. Also, there is no acceptable definition of health. As a result, there is a
greater probability of episodes of general ill health (which might, at times, lead to
major ill health episodes) being overlooked or treatment of whicfils likely to be
postponed. This happens particularly in the case of poor households and in the
case of those who have low social status even in the case of a well to do family.
«■
On the other hand, rich households and only socially better of f members of even a
€ ’
better off family ( such as earning members or male members or members who
are accepted as heads of households, even though they are not earning members,
I
or those who are ritually superior, such as mother in law rather than daughter in
1
law, etc ) are likely to receive more attention regarding even small health
ۥ 1
problems also, since they can afford the high costs of such medical attention and
treatment or resources are made available for them rather than for others for this
e '
purpose in view of their ritual status. Thus, the prohtihiliiy of medical care
.r*
attention is a positive function of socio-economic and ritual status of the
e2
I
$
individual / household in question. In other words, in the Indian context,
availability of medical care attention is not just in accordance with the demand
and needfor it but it is most often in accordance with factors other than these.
In view of the low economic status of the members of poor households, who
depend upon their physical capabilities and skills for meeting their daily
e
e
e -«
C -:
subsistence needs, it would be imperative for them to maintain their physical and
mental well-being at a fairly high level, which enables them to put in work and
C’^~-
earn daily livelihood. Illness causes immiserization of the poor and hence it is
necessary' for the people to avoid illness or debilitating morbidity causing further
c
impoverishment and immiserization.' This is particularly seen in the case of those
members who work in the unorganized sector and who work on a daily wage
c
basis. Thus, what one may call, the ‘ subsistence need for medical care attention
1 Hsio and Sen reported that 40 percent of the entrants to poverty in a particular year in India attributed
poverty to illness episodes in the family. Hsio. William and Priti Dave Sen (1095) ■Cooperativejmancmg
of Health Care in Rural India’ Quoted in TN Krishnan : Economic and Political II eekly April 1j 1996
4
(-
tj
t
6J>
I
is a negative function of economic status of the individual member in question.
This should not be taken to mean that better off people give less importance to
health and health care. On the other hand, they pay more attention to even a small
disturbance in their health, as stated earlier. What is implied here is that/or the
purpose of subsistence earning, meeting the need for health care is more
mandatory for the poor than for the rich.
Some of the health care facilities are, by and large, in the nature of indivisible
goods, while services from these facilities are characterized by a fair degree of
divisibility and rival-ness in consumption. These may be termed as lumpiness in
supply but a fair degree of divisibility in utilization. In view of this lumpiness,
large investments are needed to supply these facilities. There is a tendency of
cost recovery charges from the purchasers of services being over estimated in
such a situation. In view of speedy technological changes in the field of medical
science and public health and hence expectation of foreign initiatives in the
background of globalization, uncertainties associated with the occurrence ot
morbidity episodes requiring the use of a particular facility, uncertainties
associated with the use of the created facilities by the affected persons, etc. there
seems to be an undue haste in cost recovery by the investors making the charges
I
for the users unduly high. Added to it, the instinct of greed and a desire for more
I
and more and more also contributes to this tendency for over -charging.
)
>
Another factor also contributes to this tendency, which is the result ot some ot the
I
recent developments under economic reform regime. In view ot the declining
)
interest rates on borrowings and trends of privatization, such facilities are likely to
)
be created with the help of borrowed funds- by tew private initiatives that can
)
provide the necessary collateral required for loans from financial institutions. This
I
would also give rise to a situation ot few sellers operating in the health care
>
I
I
>
►
2 CMDR proposes to study the changes in financing of activities ot medical care providers before and
during the period of economic reforms. For such a study micro level field data need to be collected from
private sector providers. We have not come across any such longitudinal micro level studs in the literature.
commodities markets.
Such sellers can control price of services and also
indirectly the clientele utilizing these services. This characteristic feature would
<
have significant implications for access of the poor to health care services.
(
(
Health care services consisting of both material and manpower services - are
I
likely to get concentrated in urban areas in view of their characteristic
(
features outlined above. Since large percent of agricultural labourers are located
I
in rural areas, they are more likely to be deprived of the necessary benefits from
I
health care facilities, which are not adequately available in rural areas. Health
facility mapping for rural and urban areas in different states of the country would
(
reveal how the facilities get clustered disproportionately to the population in
urban areas.
It is useful to work out regional inequalily indices of health care
facilities in rural and urban areas of different states.
District-wise facility
mapping would more clearly bring out the deprivation of rural areas. Field studies
show that the rural folk have to walk down / travel in bullock carts or tractors for
miles together in search of medical assistance in the case of illness episodes. It is
also worth noting that most of the health care centres located in many villages are
mostly non-functional, ill equipped and inadequately manned. This also suggests
that the health facility mapping needs to be done keeping in mind the functional
existence of the facilities rather than merely their physical existence.
Intra
regional facility distances are most often found to be an inverse function of
the level of economic development of the region, suggesting that the poor in the
less developed regions are likely to be more adversely affected than the poor in
the more developed regions.
Considering gender dimensions of commodity of health and health care would
bring out many important aspects worth noting while developing a health security
plan for the poor. Generally, women are considered as health care providers in the
family. However, health of the health care providers in the family is generally
One such attempt is in progress at CMDR in the case of Karnataka state. In view of information gaps only
public medical care facilities are being mapped.
6
'sb®*'
<
overlooked, not only by other members of the family, but also by women
themselves. Traditionally, low social status of girls and women in Indian family
contributes to this. As a result, female members, right from baby girls to elderly
women in the family are likely to be more deprived of health care services than
male members, starting from baby boys to elderly men in the family. This
discrimination is more severe in poorer families, rural areas and poorer states.
Health condition of female members in poorer environment- regions and
households is likely to be much worse than that in more developed regions.
Access to, utilization of and benefit from*health care services are thus a
function of gender with adverse effects in the case offemale members.
If health and health care are under-priced in the present period even though
the price payable for them by the beneficiaries in the long-run works out to be
much higher, then generally, there is a likelihood of the normal law of
demand to operate vigorously in the short run keeping in mind the price in
the present period only. Thus, in the case of demand for health care services
defective telescopic faculty seems to operate. Price elasticity of demand is
generally very high for the people of all economic levels and at all price levels.
But, at high income levels and at high price levels price-elasticity is likely to be
higher, other things remaining the same.
There is an asymmetric information'flow for medical care providers and
patients, with some information available more with providers and some other
crucial information available more withT patients: ' For example, scientific,
medical information about diseases-causes.and.cure in general, is available with
medical care persons-doctors, nurses, etc. But, information about how they feel
while suffering from disease, while receiving treatment and after treatment, etc
lies essentially with the patients. Information about preventive care and promotive
care is available with medical and public health personnel whereas information
about the effects of these measures of care is available with onlv the clientele-
beneficiaries.
7
5
.
Considering the,aspects under the above two paragraphs, it follows that there is a
risk of overuse of certain types of care by the people, particularly at higher
income levels, since they can afford larger expenditures on drugs. Excessive use
of drugs and medical services is termed in the health insurance literature as 'moral
hazard’ implying probably that people consume more of medical care than what
they really require and that such over use is likely to be hazardous also. People's
expenditures might be guided by what one may call, presumptive prescriptions by
medical experts, who in turn might act under wrong information or self-interest
considerations. Provider-induced-over-use of drugs and medical services or even
self-induced over use might ultimately exaggerate demand for drugs and services
and distort long term planning in the case of the health care sector.
Price and income elasticities of demand for health and medical care are likely
to be high at high income and price levels than at low income and price levels.
In view of this, generally, special attention seems to be paid by providers to those
drugs and services, which cater to the needs of high-income groups of population.
This leaves the needs of the poor unconsidered in normal circumstances, unless
special initiatives are made for the purpose. This is evident from the location of
medical care services in urban areas, where, generally richer sections of
population live, the rate of growth of tertiary care investment is higher than that in
in
primary care in rural areas and similar indicators^ Analysis of drug prices meant
for the common care and for tertiary care should also be revealing from this point
of view.4
Preventive health care services are characterized by special features, which
deserve attention of analysts, while designing health security plan for the poor.
Demand for preventive care is much less clearly articulated than demand for
curative care. Also, effort for meeting this demand is also much less in this case
as compared to curative care. Articulation of the need lor preventive care is
CMDR has commissioned a study of drug prices, the results of which would throw a light on these issues.
8
obviously a function of level of awareness among the people about its importance.
Since the effect of absence of such care is felt much later after a long time lag
immediate appreciation of the importance of preventive care is generally not
seen both by the individual beneficiary or the collectivity as a whole. This is one
of the reasons why the decision makers do not undertake the projects for
preventive care so enthusiastically. Even at the individual level much attention is
not given to measures for preventive and promotional care as in the case of
curative care.
As indicated above, preventive care can be of two types, viz. individual-specific
preventive care and collectivity specific preventive care. Demand for both types
of preventive care is a positive function of level of income of the individual
and the collectivity apart from the level of awareness about the importance of
such care in the functional capabilities of the individuals. Hence, preventive
care becomes a predominant merit good, being so meritorious from the point of
social welfare that it calls for collective intervention for provision over and above
private initiative for its provision. Since the poor in particular, are likely to be
more vulnerable if such care is not available it becomes necessary to devise
ways and means for its provision to help them.
From the above conceptual background relating to health and health care services
as economic goods, it is clear that generally the poor cannot safeguard their own health
care interests and that such interests can be safeguarded only if suitable mechanisms are
evolved. Such mechanisms should be developed incorporating the involvement of the
people, invoking the spirit of altruism and mutual sympathy among those who have
higher ability to pay and better capacity to organize services with a longer out-reach
both with respect to time and number of people. It is felt that the spirit of cooperation,
which already prevails among the people in India, particular!) in villages, needs to be
aroused for invoking this spirit of altruism and mutual sympath). Sympathy and mutual
sympathy have been considered as one of the six springs of human conduct by Adam
Smith. In his Theory of Moral Sentiments Adam Smith devotes one full chapter to
9
eulogize the ‘ Benefits from'Mutual Sympathy’. Mutual Sympathy has received the
highest importance in the codes of conduct sanctioned by many religions of the world
also. Therefore it would be useful if this spirit of mutual sympathy is utilized for
helping the poor in their health care needs. Since the poor cannot bear the high costs of
health and medical care it would be necessary to devise a mechanism invoking the
spirit of mutual sympathy and cooperation, through which it is possible to provide
health care services at reasonably low current costs spreading the rest of costs in
suitable installments in the future. The mechanism should explicitly note the
seasonality ( as in the case of agricultural labourers, for example, who get earning
1
opportunities mainly during the agricultural seasons ) and at limes irregularity of the
income flows to the poor households and adjust the payments towards health care costs
to such income flows. This mechanism should also recognize the fact that occurrence of
<
illness and its duration are uncertain. Any organizational mechanism that can pool the
<
risks of illness of the poor households and that can provide for convenient cost
(
payment arrangements should greatly help the poor. Health insurance is considered as
such a mechanism, which can greatly help the poor. Health insurance is also a
mechanism for gaining access to health care that would otherwise be unaffordable/ If
<
cooperative elements were integrated with health insurance then it would have an added
<
advantage for the poor.
<
<
II
MAIN ISSUES REGARDING HEALTH INSURANCE AND HEALTH
CARE COOPERATIVES
I
Health insurance and health care cooperatives can be considered as the methods
for pooling of risks of different types of ill health across individuals and over the period
of time. A number of issues in this connection have received the attention of researchers.
<
<
<
Some of the important ones are briefly outlined below.
<
(
5 John A.Nyman : ‘The Value of Health Insurance : The Access Motive' Journal of Health Economics 18
(1999) This study shows that even in the U.S. access motive is facilitated by insurance and that the poorer
of the Americans are enabled to have access to costly medical care, which they could not have afforded
before
(
10
I
I
(
I
•
When health sector budgets are getting compressed during the period of economic
reforms can health insurance mechanism maintain the overall budgets for health
care sector at high levels ? In other words, can insurance be considered as a
dependable source of financing of health ?
•
Government provision of health care services is believed to safeguard the health
care needs of the poor. In this background, to what extent can health insurance
mechanism be considered as responsive to the needs of the poor ?
•
Does health insurance mechanism lead to what is termed in the literature as moral
hazard, implying more than an optimal use of medical care sendees ? Choice of
the best health insurance plan involves a trade off between the gains from risk
reduction in connection with the disease/s covered under insurance and the loss of
moral hazard.6 How far are people in a country like India in a position to make
such a best choice ?
•
Does this excessive consumption of medical care ha\ e its own implications for
health of the users ? Studies have tried to show that having insurance is
associated with having better health.'
The hypothesis of effect of excessive
consumption on health status, needs to be tested with micro level data.
Does this excessive use of medical care services bv the rich result in less
availability of sendees for the needy, who may not be in a position to bear the
cost of health insurance itself? Does this also result in inefficient allocation of
scarce medical care and financial resources of the economy in the ultimate
analysis ?
’ Willard G. Manning, M. Susan Marquis : ’Health Insurance : the trade off between risk pooling and moral
hazard' Journal of Health Economics 15 ( 1996 )
Beth Hahn. Ann Barry Flood : ’No Insurance. Public Insurance and Prixate Insurance : Do these options
contribute to differences in general Health ?’ Journal of Health Care lor the Poor ana I nderservecl VI 6
1995.
11
I.
Q
- «—» — -d to tender
..................................................
'
.-“XX
Does insurance mechanism sustain itself in the long
relevant because the overhead costs and
bkely to be quite heavy and which
run? Ibis question is
operating costs of such a mechanism are
might not be recovered from the clients
through premia ?
’ ~xx^*zx:r:rcovw,h'coflste"“*health care services
peop... so
A rise in
—- - - pn..>^
for
^anee cost would lead LTlT
“ ' Percem r“
p-batilit, of persons seek.ng insuIMCe cov„ .
•
8
SUppb' °f
Pr'Vate
‘ PerC“,
eS"”’°Ie‘i
“ "»
Should health insu
rance be provided by g,
-or initial or
„
tbe prlra.e
byj both
If both
both private sector 'mH
ofn ?. If
operating at the same
rnment
same time,
time, would
would there
there be a t H
crowed out by the normally aggressive privat
"
gg ssive pnvate sector mitiatives ? In the context
Michael Chernew et al • ‘ Work
_
n
S---* n°" .be ,elf emptoyed.
12
. ......... ....
of the U.S. however, employer delivered health benefits are reported to have been
replaced by the government insurance mechanism.
•
Some studies have also shown that significant health status differentials among
the insurers are observed in the case of public and private health insurance
systems, with lower status in the case of the former.
Would this mean that
provision of publicly managed insurance for the poor and privately managed
insurance for the rich would lead to health status disparities among the poor and
the rich in the society ? What is the optimum public private mix in the case of
health insurance ?
•
Does insurance mechanism in general ensure high quality' of health care services
? Does government operated Health Insurance ensure better quality of services or
private sector operated insurance would achieve that objective ?
•
Whose out reach is better- private sector’s or government’s, so as to ensure
availability' of health care services to the poor, to the socially less privileged, to
the people in remote areas, to children and to the eldeily also ( as, normally
private health insurance operators are found to exclude people outside a certain
age)?
•
Does health insurance mechanism provide tor articulation of the health caie
needs by the people who are in need of such services ? Or. does this
mechanism strengthen the dominance of the providers in the health care sector
? Would this imply the relevance of Say’s Law of Markets in health care market (
Supply creates its own demand ) with its concomitant implications for the
clientele ?
Can health insurance mechanism be so structured as to integrate the equity
considerations ? Thus, can there be differentiated premium system, distribution
of claims in cash or kind, coverage of all types of health care needs such as
A number of studies are conducted to examine the relationship between public and piivate health
insurance systems. For a list of some of such studies please see references at the end of this paper.
13
d.
(
preventive, promotive and curative needs, etc. ?
I
Can a Health Insurance
mechanism co. er. the risks also of common ailments of masses, which at times
become economically costly for those who lose their work days on account ol
such weakening common ailments and which reduce their work output ? Should
premia alone be graded or service charges also be so graded or both, to ensure
equity in access and utilization ?
Are people in a country' like India aware of the advantages from health
insurance so that it would have a fairly good demand just enough to sustain it in
the long run ? What measures need to be taken to raise the level of their
3
awareness about the value of health insurance ? 12
o
Can health insurance be extended to rural areas, un organized sector, all types of
occupations and all income levels, all age groups, etc. for. inclusion of these
under the insurance cover is feared to increase the risk of' losses of insurance
providers who are traditionally considered as loss leaders in the economy ?
o
If health insurance supply is opened up to the private sector and also to the
international operators then there is allegedly a risk of foul practices in health
care supply. In the case of foreign companies operating in the system there is also
a risk, of repatriation of profits and resources from India to the other countries.
Under such circumstances, what countervailing checks and safeguards need to
be introduced to regulate their activities ?
•
How should clientele beneficiaries’ involvement be ensured in the functioning
f
of the health insurance system so that people themselves become a watch dog
for its functioning ? Can co-payment, coinsurance, group insurance, etc serve this
*
purpose ?
<
11 Beth Hahn and Ann Barry Flood : Op cit.
12 Over 92 percent of the non insured households both in rural and urban areas are not aware of the existing
health insurance schemes. This is the result of a NCAER -SEWA survey (1999) as reported by Anil
Cumber : ‘Health Care Burden on the households in the Informal Sector’ Indian Journal of Labour
Economics Vol 45 No. 2. 2000.
4
t
14
J
f
These and many other issues deserve the attention of policy makers and analysts
having an objective of improving the access and utilization of health care services for the
poor and provide a useful health security plan for them. We believe that health insurance
can be a useful health security plan for the poor if it is managed neither by the public
sector nor by the private sector but by the people's sector. By people's sector we mean a
cooperative of the people, which is specially created for the purpose of fulfilling the
health care needs of the poor. Health insurance through health care cooperative is thus
considered as a mechanism worth trying in the Indian context. Such a mechanism has
been tried in some form in India and in some other countries also It would be useful to
learn from these experiments and design a mechanism based upon the principles of
mutual sympathy and pooling of risks for the benefit of the poor particularly in the rural
areas of the country.
III
A BRIEF REVIEW OF EARLIER EXPERIMENTS;
We noted above that health care cooperative and health care insurance are the two
organizational initiatives that can be suitably integrated to help the cause of the poor. In
what follows we briefly review the experiences of selected countries for which
information is available, about the experiments of health insurance through health care
cooperati\'e. This review would help us in designing a health security plan for the poor,
which we propose to develop in one of the villages of Karnataka for which data were
specially collected. CMDR proposes to adopt this village or a cluster of villages in the
region to implement the plan in its action research programme.
The review is presented for thirteen countries, for which the information was
readily available, starting from a developing country like India to the developed country
like USA. Only the salient features are outlined without going into the details. For
convenience the Indian experiences are outlined at the end.
15
: ••...
I
...Cln, a13
The replacerm.
of cc ’ective agricu’ iral production by the household
responsibility system as a result of economic reforms is said to have led to the decline of
collectively fund d Co-operative Medical Scheme (CMS) in China. The study by Yu Hao
and others
reports that during collective farming CMS assisted farmers to meet health
care costs in more than 90% villages. Considering this the government of China is
encouraging the establishment of such CMS, which are said to have been set up in rural
China with the help of local government.
Cooperative Medical Scheme (CMS) in Wuzhaun Township:
4
The plan for CMS was drawn by researchers of Shanghai Medical University,
Based on household survey, the design for CMSs with varying service coverage,
I
premium and reimbursement ratio was developed.
I
I
I
Features:
*♦* Membership in 5 villages is said to be voluntary and open to all
households.
Premium of
individuals
rural
¥ 5 per member, with ¥ 4 (0.5% of annual per capita) from
and
¥ 1 from county government. Village collective or local
government though agreed to pay premiums for extremely poor households, did
not pay in actual practice. Few farmers paid in terms of produce (grains). ($ 1=¥
8.3,¥l=Rs. 5.5)
v Services: Free registration, reimbursement for treatment and injection fees at
village level, free immunization for children(up to 7), pre and postnatal maternal
care and delivery service.
ij Yu Hao et al (2000), Financing Health Care
in poor rural Counties in China:Fxperience from a
C;
Township- Based Cooperative Medical Scheme, IDS Working Paper 66
16
3
•
Management: Committee established with members from township government.
Salary of Manager was paid by local govt.
*Drugs: Village doctor is allowed to buy drugs from township health center and
i
sell them to patients at fixed prices.
<*
*VilIage doctor has. to hand over prescriptions to CMS Committee for
examination and reimbursement of drugs, treatment and injection fees. 1/3 rd of
the difference between wholesale and retail price of drugs was paid to the
Committee which redistributed the money to village doctors at the end of the year
as a performance bonus.
*In each of the five villages one village doctor was contracted to provide health
care irrespective of membership. Maternal and preventive care were organized
with the help of township health center.
Health Bureau supplied equipments and published regulations, cards and forms.
54 per cent of the households were members (984 HHs with 3355 population).
HHs. which had access to health care did not become members. There was an average
of 2.2 visits per member per year. The level of reimbursement was
¥ 2.08 per
member and it varied from ¥ 3.73 to ¥ 0.8. Full time doctors were more popular.
Share of drugs in total fees reduced due to CMS, which was service oriented (from
90% in 199o to 76% in 1997). Need for continued assistance from goxernment.
encouraging poor households to become members. Increasing maternal care, which is
lacking and promotion of health education are suggested measures.
2. Philippines14
Voluntary Health Insurance for residents of poor rural communities: In
Philippines National Health Insurance Law passed in 1995 aims at universal coverage for
Ron Aviva and Kupferman Avi(1996), A Community Health Insurance Scheme in the
Extension of a community based integrated project, Technical Paper iw.iy.wHO, Geneva.
17
a range of health care benefits. In the meantime government has encouraged community
health projects to develop health insurance scheme.
ORT (Org. for Education Resources and Training) Mother and Child Care
Community Based Integrated Project (MCC) is run by ORT which is an International
Voluntary Orgamsation. This project was launched in La Province of Philippines. The
project provides pre- school
education and basic health services. ORT Health Plus
Scheme was launched in 1994.
Population: Covered the families of children attending 13 ORT centers, members of
ORT co-operative and the general population of the communities where day-care centers
were located. Total coverage was expected to be 2500 HHs. But. only 300 families
registered in the first year. Family was the membership unit.
Services: ambulatory and in-patient care, prescribed drugs and ancillary services
provided by doctors and nurses in day care centers.
Finance: considering the income flow patterns in the population contributions were
collected monthly, quarterly, bi-annual and annually. Differential level of contribution for
members and non-members of medi-care and family size was followed.
Contributions:
P 50-single person
P 100- standard family
P130-large family (25 pesos=l S)
These accounted for less than half the amount that the families spent on basic
health care, excluding in-patient care. For those with medicare the premium for out
patient care was P 70 per month.
For the initial period ORT project continued to pay the salaries of doctors and two
nurses in day care center. Non insured persons had to pay P 50 per consultation and for
18
i
drugs at cost plus 50%. For insured the cost of drugs was cost plus 20% much below the
market rates.
Management: CMS is administered by ORT Multi-Purpose Cooperative which is
formed by parents and staff of day care center to increase household income and
sustainability of day care centers.
3. Brazil
One of the largest provider^usually owned by doctors) owned Cooperatives is
said to have been established in Brazil in 1967. By 1994 its member owners were said to
be 60000, with independently practicing doctors(l/3 rd of national total). Under this
Unimed system an individual or 30000 enterprises which provided health insurance to
their employees could get agreed services from any member doctor anywhere in Brazil.
4. Tanzania1'^
Tanzania is reported to be among the first countries in Southern Africa to
introduce prepayment scheme. Tanzania has implemented Community Health Fund
(CHF) based on prepayment system in rural areas. Strong community organizations
existing in the country are reported to be the facilitators of growth of community
dispensaries. The CHF aims to provide primary health care, maternal and child health
care (including deliveries) preventive and promotive health care. The risks and
benefits are shared among large pools of households and each pool is reported to be
consisting of 50000 individuals. Each household will be given a health card at a cost
of $ 2.57 per person per year and hospital charges add up to additional premium.
There is political support, matching funds by donors and government to community
fund and cooperation from health care providers!doctors). But. these CHFs are said to
be facing operational problems, management and rising costs.
Beattie Allison et.al.ed.( 1996), Sustainable Health Care Financing In Southern Aliica-EDI PolicySeminar held in Johannesburg, South Africa. EDI-World Bank.
19
5. Spain
In Catalonia, a combination of
known as Integral Health Care
Foundation.
user-owned and provider- owned
cooperative
Cooperative system is developed by the Espriu
Stmtiar cooperatives operatmg at community leve! are sa,d to exist m Italy In
.. ,3 reported that govenunent and doctors are expioring the ways to set up .
eontpie^ system of provider-owned and use,-owned eo.,^ '
‘
‘
6. Ghana16
“n t phr ™,s ,h“Nk— —■>
x
—x „, t ::xz: * *—- - of
scheme and was funded by DIDA and WHO.
’ ‘ '
Peratl°" °f the
........................
th're is a ,m °f scope f°r 'mp'o'eM
The
b: “w'n8o‘”? 3o% °f
~
mtaonceptas in the communitv' ab“" ^sehmT "“rr”0
communicaion lack nf an
povenv is no, recX
_____
■’
™rkeling (educational)
rz-z:z
“f P^-
'
3 ma'°r
°r f°r P°Or C0Verage- There is said to be demand
Scheme. Gnana. Tecnn.cal RepJn.X.ZX^'^Cuo.'"' N,C"
'
Health Insurance
20
for maternal and child health services including deliveries lor which members were
willing to pay extra amount. But, there is said to be resistance for co-payments or
deductions on the existing hospitalization cover. The PHR research team has
recommended incentives for registration of all members organizing Annual General
meetings with the help of funding from district government, supervision from community
volunteers, steps to improve relations between the hospital staff and the community and
inclusion of maternity care to boost membership.
7. Italy:
In Italy, it is reported that local governments support community based health and
social service cooperatives
8. Canada:
The report of the International Cooperative Alliance states that in Canada, as per
the study undertaken by Federal and Provincial governments, community health centers
were a cost-effective alternative to private practice as they are operated at lower cost per
patient and offered more preventive and health promotion services and also accessible to
disadvantaged persons.
9. USA
(i)
In USA, user-controlled health cooperatives operate as 1-lMOs. Group Health
Cooperative of Puget Sound in Seattle is said to be the largest of these with
478000 members (1993). Medical care along with preventive care is provided tor
a fixed prepaid fee.
(ii)
The United Seniors Health Cooperative provides the 9000 elderly owner
members high quality, affordable long term health care services.
21
*
(iii)
User owned health cooperatives operating in partnership of government exist in
USA. In 1994, there were 900 democratically governed and community owned.
Community and Migrant Health Centres in rural areas and inner cities serving
low-income communities. For 500 such centers funding was available from US
Public Health Services.
10. Japan
(i)
Members of the consumers movement have set up Health cooperatives supponed
by the Medical Cooperative Committee of the Consumer's Cooperative Union.
(ii)
Members of
multi-functional agricultural cooperatives have organized health
services supported by the National Welfare Federation of
Agricultural
cooperatives.
11. Singapore
In Singapore Health Cooperatives have been established by The National 'Irade
Union Congress in 1992 which represents 52 trade unions.
12. Sweden
In 1990s, the Medicop Model, a model for consumer owned cooperative medical
care centers is reported to have been developed in Sweden on behalf of the' housing and
insurance cooperatives. It is reported to be providing cooperative partners for local
government authorities interested in contracting health care services and facilities.
s
13. India
The following paragraphs present a somewhat detailed account of some of the
important experiments17 in India in this connection. We also briefly evaluate a plan of
medical care provision for the poor through insurance as presented by TN Krishnan, one
of the pioneer thinkers in this field.
1. SEWA: The Self Employed Women's Association (SEWA) provides health care
to its members through two health -co-operatives viz. Mahila Sewa Lok Swasthya
Co-operative
and Krishna Dayan Co-operative. The services are particularly
preventive health and immunization services. Rational drugs are supplied at low
prices at 3 centres. Childcare is provided through 3 childcare centers and Creches.
Health Insurance coverage is reported to be not mandatory for SEWA
households. Coverage is extended to members who make contributions. And. for
members who have linked their fixed deposit savings with the insurance scheme,
there is also the coverage for maternity benefit.
SEWA bank runs Integrated
Social Security Insurance Scheme with the help of L1C and United India
Insurance Corporation. It covers events of death, accidental death, sickness,
accidental widowhood and loss of household goods and work tools. On an
average insured person in SEWA households is reported to be paying Rs. 70 to
Rs.80 p.a. (Cumber A. and Kulkarni V.. 2000). Cumber and Kulkarni's study in
Gujarat brought that. SEWA beneficiaries are interested in extending coverage to
additional household members and that there is strong preference
for SEWA
type of health insurance scheme by the people. People in rural areas preferred
public sector hospital services with some contributions Irom community and
managed by Panchayat. Their study revealed that out-of -pocket expenses of
insured (ESIS) households were lower by 30% for acute and chronic diseases and
NIHFW (2000), Development of Health Insurance in India- Seminar Report.
Other studies worth considering in this context. from which information is gathered for the analysis below,
are listed in the References at the end of this paper.
23
by 60% for hospitalization cases as compared io SEW A and non-insured
households.
2. Sugar Producers’ supply, processing and marketing cooperatives in
Maharashtra State are reported to have set up a chain of hospitals and
dispensaries for members throughout the region of their operation. These
function in the nature of cooperatives though they are not formed as health care
cooperatives themselves.
According to a study by Dr. P.R.Sodani in Rajasthan, people preferred to pay an
annual premium of Rs. 243 per capita under health insurance given a package of
services and coverage of expenses excluding transport, for coverage of transport
they preferred to pay Rs. 286 p.a. and Rs. 347 for coverage of transport and wage
loss.
4. A public school in Delhi has introduced Health Insurance coverage with the
help of GICI, to its students (a group) with a premium of Rs. 50 per child per
year covering a risk unto Rs. 100000 per year.
5.
According to a study conducted by K.S.Nair in Delhi’s slums, households in
informal sector spent 8.87 % of their per capita income on health care as against
4.47% by households in formal sector. Households in formal sector were willing
to pay Rs. 145 per capita per annum and households in informal sector were read\
to pax Rs. 10j per capita p.a. They preferred a combination of hospitalized . non-
hospitalized and chronic illness care benefit under health insurance.
6. VHS in Tamil Nadu has been providing health care services to rural poor for
nearly d0 years. Based on the joint family income, membership fees are charged.
The scheme provides members, free annual check-up and curative and diagnostic
services at concessional rates. There is no waiting period between joining the
scheme and the right to receive health care. Dr. N.S.Murali reported that most
^4
members renewed or enrolled only at the time of acute illness. He has reported
that an NGO cannot sustain Health insurance scheme from the premia received
from poor members. Support by government in terms of subsidy and levying
minimal user charges to users are important for the sustainability of the
insurance scheme.
18
7. U.N.Jajoo15 and Co-Professors from the Dept, of Medicine. Mahatma Gandhi
Institute, Wardha set up a co-operative health service unit in a village, in a
school building with an initial contribution of Rs. 4 per family. Later a health
insurance scheme was mobilized by collecting agricultural produce @ of 2.5 kgs
per acre for farmers and, at a flat rate of 5 kgs for agricultural labourers. Village
dispensary is linked to Sewagram hospital. Village dispensary is run by VHW.
VHW is supported by a medical kit and monthly service of a mobile medical
team. Only acute and emergency cases are treated free of charge and for normal
deliveries and chronic illnesses 25% of the hospital bill is charged.
8. In Mallur village in Karnataka, a Health Cooperative attached to a Milk
Cooperative was set up long back in 1973. Encouraged by the success of the
milk cooperative the members persuaded doctors of the St.John Medical College
to start a health care center which would be self sustained, financed and managed
by the community. The health cooperative provides services to nearby six
villages. In the first two years, members contributed one-two paise per litre of
milk. Later. 5% of the profits from milk sale were given to health center.
Presently there is no funding from milk cooperative. Interest earnings from the
initial fund created by milk cooperative and user charges arc the source of finance
for health center. State government has given land. ANM service, family planning
senice. vaccines and nutritional supplies. St.John Medical college contributes Rs
230 p.m towards health care costs of the poor. The Health center is managed by
Gramabhivruddi Sangh and a Committee of 9 members including doctors from
Jajoo U.N.er.al (1985). Rural Health Services : Towards a new strategy
Health Forum 6:WHO.
I Icallli Care Who Pays? WHO
25
health cooperative and St.John Medical college. There is said to be frequent
absence of doctors in health center as the cooperative cannot pay the service
charges of doctors at market rate.19
9. Insurance scheme for the Poor as proposed by TN Krishnan :
T.N.Krishnan proposes
hospitalization insurance plan for persons below poverty
line, which he suggests, can later be extended to other sections of the society.
Health insurance for the poor is justified on the ground that illness episodes take
away a major portion of the income of the poor. The present Jana Arogya
Scheme seems to be similar to the insurance scheme proposed by Krishnan.
He argues that as the proportion of falling ill requiring hospitalization is
small in a large population, risk pooling can be done al a small cost with an
appropriate insurance scheme.
Total cost of hospitalization is based on the NSS data (1986-87) which is
adjusted to 1995. The average cost of treatment is taken to be Rs.500/- for the
poor. The NSS data showed that about 4% of the bottom 40% of the population
were inpatients. Taking 50% increase for 10 years the proportion of inpatient for
1995 is taken to be 6%. With this rate the total cost would be Rs.900 crores (6%
of 300 million poor i.e. 18 crores x Rs.500). This works out to be an average cost
of (900 crores / 30 crore population) Rs.30 /- per poor person which would cover
cost of medicines, room rent, tests and consultation charges upto a limit of
Rs.5000/- per family per annum. He suggests that the Govt, should provide for the
total cost under anti-poverty programme or by re-allocation of expenditure.
H Dave Priti Sen(1997), Community Control Of Health Financing In India: A review of Local Experiences.
Tech. Report No.8, PHR, Maryland.
Krishnan T.N.(1996), Hospitalization Insurance : A Proposal. 1:PW. April 3. Vol.XVI
26
c
To manage the health insurance implementation he suggests that the
subsidiaries of GIC be converted into separate Health Insurance Corporations
which work as not for profit organizations.
Panchayats will be responsible for identifying the poor and the
consolidated list at the block level should be sent to Finance Ministry. Health
insurance corporations should canvass and cover other population groups to meet
their administrative costs and it is felt that the expansion of coverage may help to
cross subsidise the poor, which will ultimately reduce the burden on government.
Hospitalisation is to be referred by the PHC doctor and Corporations are required
to directly settle the bills with the provider hospital. The cost of treatment should
be indicated on the card issued to families. It is also proposed to set up block level
Hospital Monitoring Committees to check the quality and price structure in
hospitals.
He suggests that, village panchayats should levy a health cess on
landholdings and businesses for universalizing the health insurance coverage. As
suggested by Hsiao & Sen, he opines that a portion of this can be retained for
strengthening PHC. In urban area health insurance is proposed to be implemented
through trade unions, business and factory establishments and through NGO’s for
the urban poor. Contributions to health insurance could be made compulsory for
all persons who have regular employment. These experiments he suggests should
be taken up initially in two districts in each state and later can be expanded to all
the districts based on experience.
OBSERVATIONS ON HEALTH INSURANCE SCHEMES IN INDIA.
•
People are ignorant about health insurance. Mediclaim and. the Jan Arogya Bima
policies designed to help the poor are not known to people.
27
•
Many diseases are excluded from risk coverage (treatment for cataracts, dental
care, sinusitis, tonsillitis, hernia, congenital internal diseases, fistula in anus, piles
etc.) in the first year of policy unless such diseases are totally excluded as pre
existing. Expenses incurred in respect of any treatment relating to pregnancy and
childbirth is also excluded.
•
Jan Arogya covers only patients who are hospitalized, it is not lor out- patients.
•
There is lack of marketing. Villagers and the poor have to come to district places
to know about the scheme and to become members. Offices of the insurance
companies have not made any efforts to popularize these schemes in rural areas
and even among urban poor and also middle class people.
Officers of the insurance companies say that it is waste ol time and money to go
to people and market Jan Arogya Bima Policy. They say that it is difficult to
convey common man about the policies.
They agree that they have not taken
up comprehensive marketing for popularizing the scheme.
Health insurance policies for the employees ol the organized sector are highlx
subsidized by government. Employee's contribution accounts for a small ponion
of total coverage (ESI and CGHS).
•
Health insurance policies are introduced mainly by public sector.
•
Health insurance adopted so far (except for employees) is a reimbursement policy.
Individual patient has to pay to hospitals first and then claim the reimbursement
and there is a long delay in getting the claim.
28
i
MAIN LESSONS FROM COUNTRY EXPERIENCES
The above thirteen country experiences seem to suggest the following conclusions
that would help designing a Health Security Plan for the poor in the selected regions of
Karnataka.
•
To formulate a health insurance scheme for a community or a region reliable
data on health care costs and expenditure, utilization patterns and morbidity
in the target population would be useful.
•
The Indian and other countries' experience in community financing of health care
through pre-payment suggests that co-operatives linked to economic activities
have been the base for creating health co-operatives.
Members have
contributed a part of the sale or produce or the profits to meet the health care
expenses of their families and themselves.
•
China s experience with CMS reveals that it is not possible to sustain them with
voluntary contributions. Contributions need to be mandatory and members
should confine to rules and regulations set in for CMS.
•
The study on CMS in China emphasizes that in addition to community'
contributions there is need for specific and effective mechanism to support
CMS in the long run.
•
In developing countries the issue of cross subsidization for the poor to meet health
care needs through health insurance needs to be worked out. In the absence of
mechanism to make rich compensate for the poor, the local. State or the Central
government should subsidize the provision of health insurance.
•
In rural areas people are unaware of health insurance. People are willing to
provide land, building and labour for setting up health facilities.
If there is
29
-ARU' . iitf
proper guidance and education, they are even willing to contribute in terms
of cash for future health risk. The Indian studies by Dr. Sudani and K. S. Nair
reveal this. The currently on going study of CMDR in Karnataka also brings out
the willingness of the people to contribute to the development health care
cooperative.
•
People prefer health insurance schemes which arc cheaper and with
minimum administrative procedures for getting the claim.
•
People prefer maternal health care, hospitalisation and outpatient curative
care to be covered under health insurance.
•
People do not prefer to join health care co-operative when there are health
facilities near by.
•
Co-ordination with government agencies and officials in implementation of
certain health services like maternal health care is essential for a health
cooperative.
•
Though members of co-operative health centers make prepayment for health care
in terms of membership fees, it is necessary to lev)’ user charges for two
reasons. Firstly, to avoid misuse or over use of health facilities (as reported in
U.N.Jajoo’s Study). Secondly, it is generally opined that people do not take free
services seriously.
•
To control "moral hazard’ or the excess use of medical care, we can also adopt an
incentive mechanism in the insurance plan in the form of reduced
membership fees for those who have not taken treatment for two or more
years. As said above, in Sewagram hospital, to prevent excess use nominal
charges were taken from hospitalized patients for treatment of certain cases.
30
Contributions should be based on economic status of the families. But, there
should be fixed minimum payment for the poor.
•
Since community programme involves creation of awareness, erosion of interest,
trial and error in the application of the project and adoption of the project by the
community, it takes a long time (nearly 5 or more years) for any programme
to be deep rooted in the community .
•
Treatment by VHW at the village level indicates that a trained health worker
can attend many of the diseases suffered by villagers and there is no need for
expert doctor all the time.
Hiring the services of a medical expert daily would be costly for the villagers.
Existing health insurance structure, which relies on low and differential premium
system cannot meet these expenses. Therefore, as done in some experiments,
monthly or fortnightly or alternate day services of expert doctors can be provided
in different villages by mobile medical unit.
•
It is not possible to treat all the cases free of charge. A financial limit needs to
be fixed based on the severity^ of illness, number of cases/times of treatment
per patient, etc. Based on these considerations the extent of contributions by
beneficiaries can be determined. All these aspects can be incorporated in the co
operative health scheme financed by health insurance, as is done in Sewagram
health care services in Maharashtra.
31
L\ i
IV
HEALTH CARE OF THE POOR THROUGH HEALTH INSURANCE
AND HEALTH CARE COOPERATIVE: A CMDR PROPOSAL
In the background of the above experiences about people's involvement in health
care plan for the poor, we have attempted to develop such a plan lor a small region of
Karnataka. The main elements of the health care strategy for the poor should be the
following:
i.
This plan should cover all the poor, irrespective of their social status and
ability to pay.
n.
It should provide for curative care in the case of all ailments, starting
from the common cough and cold to major diseases.
in.
The plan should assign an added weightage to the medical care
requirements of the poor and female members of the family for the
reasons mentioned earlier.
iv.
The plan should make efforts to provide for cross subsidization of costs of
care. This implies that there should be a provision for community
contribution according io ability to pay rather than benefit received. This
community contribution should be mandatory and not optional.
The plan should cover not simply curative care but also promotive and
preventive care services.
vi.
Health care needs should be articulated by the people themselves and
medical services set up should only aid this process of articulation.
vn.
Services should be supplied in accordance with the articulated needs.
Considering the above norms, it appears that a mechanism with cooperation
between providers and beneficiaries for the purpose of supply of health care services and
32
also for recovery of service costs would be helpful. As it is, in the Indian social set up,
forces of mutual cooperation do exist in the institution of family, neighbourhood, village .
etc.. Family is the most effective health care cooperative with elements of cross
subsidization and support. Any health security plan tor the poor should consider
integrating the main elements of cooperative spirit witnessed in the case of family.
Health Security Plan should also recognize that costs of services are found to be
rising in recent vears so fast that individually they cannot be met, as incomes do not
rise as fast as the costs. In such a situation cost sharing has to be visualized through a
mechanism of a cooperative among beneficiaries and providers and through the principle
of cross subsidization. The following flow chart brings out the important components of
the suggested Health Security Plan for the Poor keeping in mind some of the norms laid
down above.
33
Health Security Plan particularly for (he Poor
through HCC and Health Care Insurance mechanism
)us links
>
(◄-------------- Sfl-op panel of
doctors &
Tertiary
care
service
centre
Medical
Personnel
b^efi^aries
and
providers ◄-
Supply of
Medicare
services v
Arti
-culation
of need
Village /a
clusters of
villages as a
co-op of
health care
beneficiaries
Meeting costs of
Medicare services
through cross
subsidization :
Differential
membership fee
& service charges
4A4
District
hospital
Collective irMurance
agency for h salth care
Cross
51 bsidization
of services
►
Is(Y)noinfestivities pf
Low
Income
Group
villagers
Share of
membership
fee as annual
premium
]
High Income
Grou p
Group
v Differential
I )if Irrrnl ial
)
Membership
I ?cc
and
Differential
Membership Feo and
^Service Charges__
Membrishij) In-e and Scrvic
Sr i vice
►
K
OPERATIONAL ASPECTS OF METHODOLOGY OF HEALTH INSURANCE
THROUGH HEALTH CARE COOPERATIVE:
The proposed health insurance through pre-payment and user charges is to be set
up initially in one village (Chandanmatti or a manageable group of villages) and later
extended to other villages each Panchayat being the unit of administration.
I. Membership:
Each Household will be a membership unit. All the households in
the Village will be covered under health insurance. A card will be
issued to each household with details of No. of members, category
of households and the details about the amount of user charges to
be taken for treatment from household members. Each card should
have provision to enter details of illness, treatment and cost of
drugs for each member during one year.
IL Services:
HCC will provide to its members curative, out patient and in
patient care, child and maternal care (excluding deliveries),
preventive and promotive health care services. Out patient care is
provided at HCC clinic in the village. For in-patient care a link will
be established between HCC and a private or district hospital
which will provide referral sen ice to members.
III. Management:
The health insurance scheme will be managed by a Health
Committee consisting of HCC doctor. PHC doctor, panchayat
president, local doctor, mahila mandal
vouth center member.
school headmaster and five members from I ICC.
IV. Membership fees: Considering that the burden of illness will be greater on poor
households, a differential rate structure for membership may be
visualized for households based on income level.
During the household survey in C'handanmatti village in
Dharwad district of Karnataka, for example, respondents from the
surveyed households expressed their willingness to pay an average
of Rs.225 per household. Membership fee can be fixed keeping
willingness to pay by the households. In view of different income
levels willingness to pay by the households also would be
different. Hence, differential membership lee can be determined
accordingly. Membership is fixed for a family of two plus two.
Advantages from the Proposed Health Security Plan
From the proposed health security plan there are mainly lour types of gains:
First, each individual becoming a member of the HCC and also linking his health
care needs with insurance system through HCC. would find that he would get the health
care facilities at his door step, without being required to meet various types of transaction
costs. Transportation costs, cost of loss of wages for those attending upon the morbid
person, additional food and other costs, etc can be avoided under this scheme. These
health care services would be available at lower costs now than w ithout HCC.
Second, provider of health care sendees like the providers' cooperative, would
find costs of provision to be lower than before in view of the likely economies of large
scale of operation. Even the insurance agency linked with providers' cooperative would
find ready clientele for its insurance business ensuring better business.
Third, under the present scheme there is less chance of any resident member of
HCC being deprived of health care facilities when needed, for. through the operation of
the force of mutual sympathy, felt needs for health care services would be articulated, the
needed services would be provided through the linkages of HCC and insurance schemes.
As a result, finally, the likely direct and indirect costs of morbidity would be avoided.
Cost avoidance is obviously the gain for the needy, particularly the needy poor.
36
Fourth, since the government had to bear the entire responsibility towards health
care needs of the poor in a scenario without HCC the financial burden on the government
would be higher than in the scenario with HCC, for, some of the costs of provision are
now borne by the community itself through the system of cross subsidization. The spring
of human conduct, viz. sympathy and mutual sympathy, which is a tremendous resource
tor social welfare, would be used and would stand promoted by the health security plan
for the poor.
A concrete Health Security Plan for the Poor with data for one of the villages of
Dharwad district of Karnataka is presented in the Appendix to this paper.
37
I
<-■
Appendix
*
A CONCRETE PLAN FOR HCC IN A VILLAGE IN
DHARWAD DISTRICT
About the Village
Chandanmatti is a small agricultural village situated 8 Kms. from Dharwad. The
village consists of 172 households with 1018 population.
Fifty two percent of the
population belongs to SC/ST. backward and minority communities. Fifty six percent of
the population is literate. Twenty Seven percent of the households live below poverty
♦
line(<l 1000). But. nearly fifty eight percent of the household earn less than Rs. 20000
annually. Villagers do not have access to health facilities in the village. There is a
*
primary school in the village. Bore well water is the main source of drinking water in the
€
\illage. \ illagers get this water through tap connections to individual houses.
Baseline Scenario
Analysis of out-patient situation
1.
On the basis of reporting from the village during the survey, the estimated
probability of incidence of sickness (outpatient type) "0.13
c
c
Therefore, annual prevalence of illness on average per resident person
0.13*12=1.56
f
As per the reporting during the survey, the average cost incurred per
morbid case per month =Rs.221
4.
C
Therefore, the average annual expenditure on such sickness per resident of
c
c I
e
e
the village=Rs.344 (=221 * 1.56)
38
1
I
>
)
• )
As against this private cost directly incurred by the residents of the village,
5.
)
the average indirect costs likely to be incurred (based on the FGD and
)
survey) are also estimated:
)
•
)
According to the survey, the time lost by the morbid person is four
days on average per incidence. With a prevalence ot 1.56. the
)
labour time lost per average resident is 6 person days. Value of
this labour time is Rs. 300.
•
)
On average two person-day of time is lost by another member of
the morbid family to attend the patient. The implied opportunity
wage cost is rs. 100. Therefore, for a prevalence of 1.56 on average
per resident, the value of labour time lost is Rs. 156.
•
9
9
the survey, the cost of travel plus incidenals such as food per
morbidity' is Rs 20. Therefore, the incidence of this cost per
9
average resident is Rs 31(=1.56*20)
•
9
9
3
9
i
£
With the treatment to be availed from outside of the village, as per
The total indirect cost per resident
= 156 - 300 +31=487
Scenario with HCC
Assumptions:
1. Only 50%of medicines will be provided free of cost, the rest will be borne
by the patient.
2. Cost of pathological/radiological tests will be borne by patients.
3. A promoting agency will provide the subsidy for the initial years(covering
costs of consultation and 50% ot medicine cost. I here is avoidance ot
travel and special food cost due to HCC.)
..
■
-
39
4. The HCC s cost on each out-patient per annum then works out to Rs. 115
(rs.68 on medicines +rs. 47 doctors' fees). With the prevalence of 1.56.
the average cost to be borne by HCC per resident is Rs. 1 79 (1.56*115).
5. The patient himself spends Rs 86 (68+16+2) per illness. Therefore, with
the prevalence of 1.56, the private cost to the average resident is Rs. 134
(68+16+2*1.56).
6. The average based on a three tier differential rates, a membership plus
user charges of Rs. 87 to be collected per resident.
?
7. The balance sheet of financial and direct costs and benefits of HCC
‘i
(in Rs.)
ForHCC
For resident
For
Travel
For the village
promoting
and
economy
agency
special
4
food
Cost
179
134+87=221
92
0
221+92+0=313
Income or
87+92=179
179+134=313
0
31
313+0+31=344
CI
e '
benefit
€
Comments:
1.
The individuals have to spend only Rs.221 on average, and get benefits
worth Rs. 313.
For HCC, there is a break even.
The promoting agency will bear the initial burden al the rate of rs.92 per
resident as additional system cost.
4.
<4
Saving in travel cost and food costs: since the patient and the attendent do
not have to travel to places outside of the village, the saving on account of
c
40
*
J
travel cost and food costs will be 31(18+2*1.56)per resident (as worked
out under the baseline scenario).
◄
5.
The gains (indirectly) in the reduction of transactions costs are:
<
•
On average the morbid patient loses only 3 days of his/her labour
time (as against 4 days in the base scenario). This amounts to a
-^3
labour time loss per average resident as 5 days (=1.56*3). The
value of this time is Rs 250. Therefore the net gain because of
HOC in labour time is Rs.50 (= 300-250)
•
The loss of labour time of another member of the morbid family is
also reduced. Assuming that only one day of labour time is lost, the
value of the lost labour time is Rs. 78. The net gain in saving in
T
labour time is Rs. 78 (as compared to the base line scenario, 15678).
•
The total indirect benefit therefore will be rs.50+78=128 per
resident of the village.
4 g
Total savings
-
a. Residents =Rs.92+31+128
=4-..
*
251
b. Village economy = Rs.31+Rs.l28 -92
67
The case of in-patient treatments
1 --B
As per the survey, the average cost of an in-patient per year was Rs.
3084.
The probabiliyt fo illness leading to hospitalisation, according to the
survey data is 0.035
k
I
JS--
e
Therefore, the hospitalisation cost per .year per average resident is Rs.
109 (=3084*0.035)
41
©
I; case, a 1 .-alih insu. am : schei e is worked ot.. for all the residents
with the Jan arogya scheme of united insurance co (or any other), the
insurance premium is Rs. 107 per year.
o
Therefore, with proper promotional efforts and implementation, the
HCC can bring in the insurance scheme to cover all the residents of the
village, at no extra cost either to HCC or to the government.
•
Needless to mention that the promotive and implementation efforts
e
will be the basic catalists to be set in motion b\' the promoting agency.
How to manage the HCC in the long run????
1. In the long run, the HCC has to breakeven at the average cost of Rs. 179 per
resident. There are several options that can be considered.
•
The memebrship fee and user charges can be gradually increased to go up
to cover the cost at Rs. 179 per resident. This can be designed at a
gradually increasing rate of 10% per year. Then, it will take a minimum of
7 years to be self-reliant. Till such time, the HCC' will have to subsidised
€.,
by one or the agency, be it the governemnt or a non-govemment.
•
Alternatively, since the HCC will reduce the pressure on the government
4'1
outlets in health care (phc, chc and subcentres), the state governments can
transfer some funds to manage the HCC under the zp or other direct
allocations to the health sector.
c
c
42
<
References
Abel-smith Brain (1986), Funding health for all is insurance the answer ? World Health
Forum. 3-32.
.Abusaleh Shariff. Anil Cumber, Ravi Duggal & Moneer Alam (1999).
Health Care
Financing and insurance : Perspective for the ninth plan. 1997-2002’
Margin, Vol 31, No.2, (Jan-Mar 1999)
Atim Chris and Sock (2000), An external Evaluation of the Nicoranza Community-
Financing Health Insurance Scheme. Ghana. Technical Report. 50. PHR
Project Publication.
Berman Peter (ed.) (1993), Health Sector Reform in Developing Countries : Making
Health Development Sustainable. United Slates Agency for International
Development, Office of Health and Nutrition.
Beth Hahn. Ann Barry Flood (1995), No Insurance. Public Insurance and Private
Insurance: Do These Options Contributed to differences in General Health
Journal of Health Care for the Poor and L'nderserved. Vol.6. No. 1. 1995.
Biswajit Chatterjee and Amit Kundu (2000) Health Insurance for Rural Poor and
Employment The Indian Journal of Lahour Economics. Vol.43. No.4..
2000
Blomqvist Ake (1997), Optimal non-linear health insurance. Journal of Health
Economics 16 (1997), 303-321.
Blumberg Linda J (et.al...) (2000), Did the Medicaid expansions for children displace
private insurance ?An analysis of using the S1PP. Journal of Health
Economics. 19(2000). 33-60.
43
I
Charles Normand, Axel Weber (1994) Social Health Insurance
.-I Guide Book for
Planning, World Health Organization.
Chemew E.Michael (et.al...) (2000), Optimal health insurance : the cae of observable.
severe illness. Journal of Health Economics. 19 (2()()0). 585-609.
Deolalikar & Vashishtha Prem’S, The health and Medical Sector in India : Potential
Reforms and problems.
Douglass. Richard L & Others, Health and Human Resources. Health and Human
Resources 559.
Dranove David, Spier Kathryn E, Barker Laurence. ‘Competition' among employers
offering health insurance Journal of Health Economics. 19 (2000) 121-
140.
Families USA (2000), Go Directly to Work, Do Not collect Health insurance : Low
Income Parents Lose Medicaid. A Report The Open Society Institute.
2000.
Farber (Henry S) & Levy Helen (2000), Recent trends in employer-sponsored health
insurance coverage : are bad jobs getting worse ? Journal of Health
Economics, 19 (2000), 93-119.
Gumbar Anil (2000), Health care burden on households in the informal sector :
Implications for social security assistance. The Indian Journal Economics.
Vol43, No.2. 2000.
Cumber Anil and Kulkarni Veena (2000), Health Insurance lor Informal Sector : Case
study of Gujarat. Economic and Political Weekly. September 30.
Hahn Beth, Flood Barr}7 Ann (1995), No insurance, public insurance and private
insurance : Do these options contribute to differences in general health ?.
Journal of Health core for the poor and underserved. Vol6. No.1.1995.
44
International Co-operative Alliance (ICA), Co-ops and the Health Sector, Background
Information note 6.
Jajoo UN. Gupta OP. Jain AP (1985), Rural Health Services : Towards a new Strategy ?
World Health Forum, 6, 150-152.
Kabra Kamal Nayan (1986), Nationalization of Life Insurance in India. Economic and
Political Weekly, Vol XXI, No.47. November 22. 1986.
Krishnan T.N. (1996), Hospitalization Insuraqnce : A Proposal Economics and Political
Weekly April 13, 1996.
Liljas Bengt (2000), Insurance and imperfect financial markets in Grossman’s demand
for health model - a reply to Tabata and Ohkusa. Journal of Health
Economics, 19 (2000), 821-827.
Marquis Susan.M (1992). Adverse selection with a multiple choice among health
insurance plans : A simulation analysis. Journal of Health Economics, 11
(1992) 129-151, North Halland.
Michael Chemew. (et.al...) (1996), Worker Demand for Health Insurance in the non
group market: A note on the calculation of welfare loss. Journal of Health
Economics, 15(1997) 375-380.
NCPA-NCPA. Twenty Myths About National Health Insurance. Po/iuv Report # 166.
NIHFW (2000) Development of Health Insurance in India : Current Status and Future
Directions. The Seminar Report, December -29.30. 2000.
Nyman John A. (1999), The value of health insurance : the access motive Journal of
Health Economics 18(1999). 141-152.
Ormand Barbara, (er al...) (1999). Health care for low-income people in the district of
Columbia The Urban Institute .
45
V
r
Pant Manoj (2000), What do we do about healthcare ? The Kuonomic limes, July 18.
2000.
Pant Niranjan (1999), Insurance Regulation and Development Bill: An Appriasal.
Economic and Political Weekly, November 6, 1999.
1
Parikh, Jyoti. Laxmi Vijay (2000), Biofuels, Pollution and Health Linkages : A Survey of
Rural Tamil Nadu Economic and Political Weekly November 1 8. 2000.
Petretto Alessandro (1999), Optimal social health insurance with supplementary' private
insurance. Journal of Health Economics, 18 (1999) 727-745.
Ranade Ajit. Ahuja Rajeev (1999), Life Insurance in India : Emerging Issues Economic
£
and Political Weekly January 16-23. 1999.
Rao Tripati D. Life Insurance Business in India : Analysis of Performance. Economic
and Political Weekly, July 31, 1999.
€
Rask N.Kevin & Rask, J.Kimberly (2000), Public insurance substituting for private
insurance : new evidence regarding public hospitals, uncompensated care
funds and Medicaid. Journal of Health Economics, I 9 (2000), 1-31.
Selden M.Thomas (1999), Premium subsidies for health insurance : excessive coverage
vs. adverse selection, Journal of Health Economics. 18 (1999). 709.725.
€
€
€
€
Sheppard Shore Lara (^/.al...) Medicaid and crowding out ol private insurance : a re
examination using firm level data. Journal of Health Economics. 19
e
(2000), 61-91.
Sloan Frank A.(1992), Adverse selection : Does it preclude a competitive health
<
insurance market ? Journal of Health Economics 11 (1992), 353-356.
North-Hal land.
Sodani P.R. & Gupta SD. Household Health Care Expenditure in Tribal Areas of
Rajasthan. Asian Economic Review.
r
46
3
3
Stephen H.Long (et.al...) (1998), Do people shift their use of health services over time to
h3
io
take advantage of insurance ?. Journal of Health Economics. 17. (1998).
105-115.
Strohmenger R. Wambach A (2000), Adverse selection and categorical discrimination in
a
the health insurance markets : the effects of genetic tests. Journal of
Health Economic, 19 (2000), 197-218.
Stubbs Michael (1996), Co-operative Enterprise in Health and Social Care. Review of
.3
Intgernational Coperation Vol.89.
Susan L.Ettner (1996), Adverse selection and the purchase of Medigap insurance by the
0
elderly, Journal of Health Economics. 16 (1997) 543-562.
0
0
Swamy T.L.N (1999), Employment and Manufacturing Sector in India : Some Issues.
Margin. Vol.31,No.2 (Jan-Mar. 1999)
□
Tabata Ken. Yausashi Ohkusa (2000), Correction note on The demand for health with
3
uncertainty and insurance. Journal of Health Economics. 19 (2000). 811-
820.
3
3
3
3
Wickramasinghe J.W (abt), National Health Insurance Scheme for a Developing country
with special reference to Sri Lanka. Asian Economic Revie.
Wynand P.M.M (et.al...>(1999), Access to coverage for high-risks in a competitive
individual health insurance market : via premium rate restrictions or riskadjusted premium subsidies ? Journal of Health Economics
3
19 (2000).
31 1-339.
International Co-operative Alliance (ICA). Co-ops and the Health Sector. Background
Information note 6.
Stubbs Michael (1996). Co-operative Enterprise in Health and Social Care. Review of
Intgernational Coperation Vol.89.
47
Position: 2257 (4 views)