Background

In the 1980s and 90s, health care costs were unaffordable for most Indians, especially the poor and vulnerable sections. Families were being impoverished or indebted because of medical expenses. In this context, many NGOs initiated community health insurance schemes across the country. At its peak, this movement had about 100 such schemes.

However, very little was known about these schemes, their design features, their outputs and their impact. Dr. N. Devadasan decided to investigate these aspects and worked on it from 2003 to 2008.

Objectives

The main objectives of the study were

• To describe the landscape of community health insurance in India
• To analyse the effect of community health insurance vis-à-vis enrolment, utilization and quality of care
• To analyse the effect of community health insurance vis-à-vis out of pocket payments and catastrophic health expenditure
• To make recommendations for strengthening community health insurance schemes

Methods

We used mixed methods to study the  schemes. First we used a case study approach to study 10 of the existing 23 schemes in the country. Following this we selected 3 schemes, each with an unique design feature and conducted household surveys to analyse the effects of CHI. Indepth interviews with organisers as well as with patients helped us understand the strengths and weaknesses of the schemes.

Results

In India, all the schemes were initiated and implemented by NGOs and covered mainly the poor like adivasis, women in informal sector, farmers, etc. There were basically 3 types of CHI schemes, one was the provider model, wherein the hospital was the provider of care as well as the organizer and insurer of the scheme. The second was the insurer model, wherein the NGO was organizer and insurer, but purchased care from an independent provider. And finally, there was the linked model, wherein the NGO just initiated the scheme, the insurer was an insurance company and there were independent providers. In all the schemes, the providers were private sector providers – either for profit or not-for-profit.

The household surveys indicate that while CHI schemes increased access to hospital services, there was not much effect of them on quality. Also they were only partially protective against OOP expenses, mainly because most of them had a very low upper limit for the benefits. Some design features that needed to be strengthened were a) strategic purchasing, b) affordable premiums, c) higher upper limits, d) better information systems and e) more insurance education.

Discussion

CHI in India played an important role in improve access to hospital care for the poor and marginalized sections of the community. It was the predecessor of the subsequent government health insurance schemes that followed (UHIS, RSBY, etc). Lessons learnt from these schemes helped design better and stronger HI schemes in the country, both in the government and private sector.