Reduction of catastrophic health care expenditures by a community-based health insurance scheme in Gujarat, India: current experiences and challenges
Objective To assess the Self Employed Women’s Association’s Medical Insurance Fund in Gujarat in terms of insurance coverage according to income groups, protection of claimants from costs of hospitalization, time between discharge and reimbursement, and frequency of use.
Methods One thousand nine hundred and thirty claims submitted over six years were analysed.Findings Two hundred and fifteen (11%) of 1927 claims were rejected. The mean household income of claimants was significantly lower than that of the general population. The percentage of households below the poverty line was similar for claimants and the general population. One thousand seven hundred and twelve (1712) claims were reimbursed: 805 (47%) fully and 907 (53%) at a mean reimbursement rate of 55.6%. Reimbursement more than halved the percentage of catastrophic hospitalizations (gt;10% of annual household income) and hospitalizations resulting in impoverishment. The average time between discharge and reimbursement was four months. The frequency of submission of claims was low (18.0/1000 members per year: 22–37% of the estimated frequency of hospitalization).
Conclusions The findings have implications for community-based health insurance schemes in India and elsewhere. Such schemes can protect poor households against the uncertain risk of medical expenses. They can be implemented in areas where institutional capacity is too weak to organize nationwide risk-pooling. Such schemes can cover poor people, including people and households below the poverty line. A trade off exists between maintaining the scheme’s financial viability and protecting members against catastrophicexpenditures. To facilitate reimbursement, administration, particularly processing of claims, should happen near claimants. Fine-tuning the design of a scheme is an ongoing process — a system of monitoring and evaluation is vital.
KeywordsHealthexpenditures;Insurance,Health/utilization/trends;Insurance,Health,Reimbursement;Insurance,Hospitalization;Insuranceclaimreview;Women,Working;Consumerparticipation;Poverty;India
Introduction
For over 20 years, calls have been made for communities in developing countries to plan, finance, organize and operate health care services. The Declaration of Alma-Ata implied that community participation was integral to the achievement of health for all, and it stated that ‘‘primary health care requires and promotes maximum community and individual self- reliance and participation ... making fullest use of local, national and other available resources’’ (1). The Bamako Initiative aimed to make primary health care universally accessible through community financing and management (2), but questions remain as to whether, how and how much poor people in poor countries can or should be expected to contribute towards health care.
Theissueofprimaryhealthcareanditsfinancingmattersmosttopoorpeoplethemselves.Materialwealth,healthandtheabilitytocopewithadversehealtheventsareintimatelyrelated.TheWorldBankdefinespovertyas‘‘encompassingnotonlymaterialdeprivationbutalsolowachievementsineducationandhealth...[and]vulnerabilityandexposuretorisk’’(3).Apersonwithalowincomemaybeunabletoaffordpreventivecare—orcurativecareintheeventofillness—andthismayworsentheirhealth.Intheeventofseriousillness,thepoorareparticularlyvulnerabletothefinancialburdenoflostincomeandout-of- pocketmedicalexpenses,astheyhavelowlevelsoftheassets(forexample,accesstosavingsandcreditorlandandbelongingsforsale/mortgage)necessarytocope.Diseaseorillnesscanforceaperson,andtheirhousehold, intoaviciousdownwardspiralinwhichpoorhealthdepletesassetsandlowlevelsofassetsleadtoworseninghealthandaninabilitytocopewithfutureillness.Intheory,healthcareprovidedbygovernmentsshouldcoverpoorpeople;inpractice,itoftendoesnot.Waystoprotectthepoorfromthecostsofmedicalcareareneeded.
Community-based health insurance
Community-based health insurance schemes allow manypeople’s resources to be pooled to cover the costs of unpredictable health-related events. They protect individuals and households from the risk of catastrophic medical expenses in exchange for regular payments of premiums. Prepayment (even in the absence of pooling) can facilitate access to expensive medical care, because it spreads costs over time and prevents people having to pay at the time of treatment. By pooling resources, health insurance schemes can improve equity of and access to health care and can offer financial protection.
Inrisk-sharingschemes,theinsurancepremiumisunrelatedtothelikelihoodthattheinsuredwillfallillandbenefitsareprovidedonthebasisofneed—hence,paymentsgo to the peoplewho aremost ill.Becausepeoplewith lowerincomesandthosewhoare less educatedtendtobeinpoorerhealththanthosewithhigherincomesandthosewhoaremoreeducated,theformerstandtogainmorefrominsuranceschemes(4).Incross-subsidizationschemes,premiumsareindexedtothemember’sincome,andaccesstohealthcareforthepoorisasgoodas(orbetter)thanthatforthewealthy.Insuchschemes,wealthymemberssubsidizehealthcarecostsforpoorermembers.
Policy-makers hope that community-based health insur- ance will contribute to WHO’s recently proposed ‘‘final’’ health system’s goals of better health, fair financing and responsiveness (5). Community-based health insurance allows pooling in settings where institutional capacity is too weak to organize nationwide risk-pooling, especially in low-income countries. A basic question is whether community-based health insurance can cover populations large enough to put the pooling functions— risk-pooling and cross-subsidization — to use.
Most evaluations of community-based health insurance schemes have focused on instrumental goals — scheme design and management, percentage coverage of target populati
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