By Bharathi Ghanashyam Three years after a community health insurance scheme was implemented by the government of Karnataka and Karuna Trust, around 200,000 poor people have benefited, paying annual premiums of just Rs 30 per year for insurance cover of Rs 50 per day of hospitalisation Mahadevi, 25, belongs to a below-the-poverty-line (BPL) family and is being treated for severe burns at the Naganur primary health centre (PHC) in Bailhongal taluka, Belgaum district, Karnataka. Her condition will require a fairly long stay in hospital. Mahadevi is a daily labourer; her stay in hospital will mean loss of wages on days she does not make it to work. This will negatively impact her family in a number of ways, mainly financial. Even though Mahadevi's treatment at the PHC is free she will have to pay for any medicines that are not stocked at the PHC. All of this will come at a price that she and her family can ill afford. It will, in all likelihood, push them into a vicious debt trap. Mahadevi's is not an isolated example. It is representative of the lives of a huge section of society in India that cannot afford healthcare of any kind, quality or otherwise. Illness is one of the largest causes of indebtedness among the poor in India. This despite the government's huge infrastructure of healthcare services in the country, including sub-centres, PHCs, community health centres (CHCs) and general hospitals to provide free and comprehensive healthcare to all. The failure of this public healthcare delivery system in India has meant that the better-off can turn to the private sector, but the poor have no options. "...On an average, the poorest quintile of Indians is 2.3 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 population 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 (2003) estimated that at least 24% of all out-of-pocket spending on hospital care might have raised by 2% the proportion of the population in poverty (Peters, Yazbeck et al 2001)." (Excerpt from 'Community Health Insurance in India -- An Overview', by N Devadasan, Kent Ranson, Wim Van Damme, Bart Criel, Economic and Political Weekly, July 10, 2004.) As Dr H Sudarshan, secretary of the Bangalore-based NGO Karuna Trust and vigilance director (health) Karnataka Lokayuktha says: "Poverty and disease have pushed the families of the unorganised sector into indebtedness. Both macro and micro studies on the use of healthcare services show that the poor, especially scheduled castes and tribes, are forced to spend a significantly higher proportion of their income on healthcare than the better-off. The burden of treatment is particularly high on them when seeking in-patient care. Even when they access public hospitals, 'out-of-pocket' expenditure is significant." But studies indicate that even the poor can make small, periodic contributions towards meeting their healthcare needs. Health insurance for the rural poor is one possible option for pooling the risks of ill health and thereby increasing access to healthcare through pre-payment of premiums.
Community health insurance (CHI) is slowly gaining momentum in India. A number of agencies have put in place schemes for providing health security to the poor. Models of such insurance schemes include SEWA, Ahmedabad, Yashasvini Health Scheme launched by Narayana Hrudayalaya, Bangalore, the central government's Universal Health Insurance Scheme, and Arogya Raksha Yojana launched by Biocon and Narayana Hrudayalaya, Bangalore. A particularly unique scheme is the one that has been initiated as a pilot scheme in Bailhongal taluka, Belgaum district, Yelandur taluka and B R Hills in Chamrajnagar district, and T Narasipura taluka in Mysore district. Implemented through a public/private partnership that evolved in 2002 between the zilla panchayat and Karuna Trust, this CHI scheme has provided relief to a large number of people who were at risk of sinking into serious debt as a result of illness. The CHI scheme had twin objectives. By stipulating compulsory use of government facilities in order to be eligible for benefits, it sought to drive up demand for government healthcare facilities. It also sought to spread awareness about the importance of CHI in the community, motivate them to seek primary and secondary healthcare in time, and set aside a small sum of money every year for health security. The scheme involved several partners, including the government-owned National Insurance Company, which was the insurance provider. The partners and their roles UNDP Funding agency Karuna Trust, Yelandur â Implementing agency - T Narasipura, Yelandur and B R Hills Monitoring agency - Bailhongal and Belgaum talukas Zilla panchayat, Belgaum Implementing agency - Bailhongal and Belgaum talukas Government of Karnataka (Directorate of Health and Family Welfare) Healthcare service-provider through PHCs And government hospitals National Insurance Company Insurance provider
Centre for Population Dynamics Baseline survey, monitoring and evaluation The scheme -- simple in design, big on social dividends The project sought to put two models in place -- one with Karuna Trust as the implementing agency and the other with the government implementing the scheme. Dr Sudarshan explains the rationale behind the two models: "The model in Bailhongal, where the government itself was the implementing agency, was planned to show that the CHI model is workable within the government framework too. The unique factor here was that Karuna Trust monitored the activities in Bailhongal and Belgaum." Dr V D Dange, district TB officer, and nodal officer, UNDP, Belgaum, says: "A very important clause in the scheme was that the patient had to use PHCs or CHCs to be able to claim benefits under the insurance scheme. It made sense to put to use the huge government infrastructure already available, rather than create a new one. This made all the difference and set the pace for improved healthcare delivery as well as increased demand. It has also demonstrated a significant increase in utilisation of government health services." A simple scheme, it ensured that for a small annual premium of Rs 30 the beneficiary was covered for Rs 50 (which s/he would get as compensation for wage loss) per day of hospitalisation, for a maximum of 25 days. It also provided Rs 50 per day for medicines not stocked by the PHC and required to be bought from outside. The scheme did not exclude any illness and provided for immediate claim settlement, even before the beneficiary left hospital. This often gave beneficiaries the much-needed funds for convalescence. Considering that a large section of the population belongs to the BPL category, and in order to popularise the scheme, the premiums were initially subsidised by the UNDP in slabs based on the economic status of the community. Category Premium structure BPL/SC/ST Premium of Rs 30 per person per annum, fully subsidised Persons below the poverty line but not SC or ST, ie BPL/non-SC/ST Premium partially subsidised. Rs 20 per person per annum - beneficiary contribution; Rs 10 per person per annum - subsidised by Karuna Trust through UNDP funds Rest of the community, ie SCs, STs and others who are above the poverty line (APL) Entire premium of Rs 30 per person per annum to be paid by the beneficiary
No easy task... Awareness and motivation were seriously lacking in the community when the project began. Whilst in some cases, superstition prevented the community from insuring against illness, in others it was unaffordability. As Malligamma Vyasarajapura of T Narasipura taluka says: "We were apprehensive about the idea of insuring against sickness, as this meant imagining that trouble would come to us even before it did." Mahadevamma adds: "The thought of setting aside money for medical insurance when we did not even know when we would need it was not received well by our community in the beginning. But it helped that the premium was paid for initially. When my son was admitted to a PHC with fever, I saw the benefits. In future I will pay and insure." Quality of service too was initially a cause for concern among the insured groups. As Savitri Sainappa Birje of Bailhongal says: "The insurance scheme demanded that we get treated only at PHCs or government hospitals, but we were worried about the kind of service we would get there. In the past, when we had tried getting treated in PHCs, the staff either did not cooperate, there were no medicines available, or the wards were full up. We were not satisfied with the kind of treatment given to us and preferred to get treated at private nursing homes, even if we had to take loans at high rates of interest." The services of auxiliary nurse midwives (ANMs), anganwadi workers and Karuna Trust health workers were extensively used to address the concerns of the community and spread awareness about the benefits of the CHI scheme. Three years into the programme, perceptions appear to have changed in the project areas, with the community happy to avail of the services offered by the improved health infrastructure. Satyavva Yellappa says: "Insurance takes care of loss of wages, and the treatment at the PHC has been satisfactory. If the situation continues, my family and I might stop going to private doctors." The benefits of this partnership have accrued to almost 200,000 people living in economically challenged circumstances in the region. While the pilot phase is over, in recognition of the value of the scheme and in an effort to cover a greater number of rural poor across the state, there are plans to evolve a CHI scheme, in a phased manner, with World Bank assistance. It is also proposed to include HIV/AIDS treatment in future CHI schemes. Dr Sudarshan says: "The rural poor cannot afford to lose even a day's work whilst seeking treatment. This was one of the causes for under-utilisation of government hospitals, despite the up-scaling of facilities with World Bank assistance. The pilot phase of the CHI scheme has demonstrated that it can have many benefits. It can give the poor ready access to medical help without financial stress in the short-term, and, in the long-term, it will lead to improved health status among them, something that can indirectly contribute to improved productivity. Increased demand has also ensured that the health centres function better." (Bharathi Ghanashyam is with Communication for Development and Learning (CDL), Bangalore. She has been documenting NGO best practices across the country in areas such as
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