DISCUSSION AND CONCLUSION 4.1 Discussion
4.5 Policy Recommendations
Based on this study it can be argued that achieving universal health insurance coverage with an equitable and effective health care system is a great challenge to the development policy and strategy of India in the near future. We could identify problems from each component of
the study and the solutions too came from within the study. The final recommendations which this study would like to mark are as follows:
• To improve the coverage expansion more households should be encouraged to participate in the scheme. For that there should be more private providers empanelled under the scheme. This will not only ensure a higher coverage rate, but also financial viability of the scheme, given their contribution rate and anticipated low health care needs.
• Close monitoring of the private empanelled hospitals can improve the coverage. Such movement can ensure a higher health purchasing power for the poorer groups, which in turn can increase coverage of the SHI towards more effective use of financial sources.
• To revise and update the benefit packages accordingly to the demand for health care, as well as affordability of the participants and the SHI fund. Considering specific benefits to accommodate different needs of different members (e.g., children and elderly people) will ensure effective uses of limited resources. Also, contribution rates need to be appropriately revised to cover medical costs, because the current rates are far below the sustainable rate.
• Need to create more awareness among people on insurance and the scheme to increase the risk pool and the funding pool with the help of media.
• Appointment of an ombudsman for the timely and effective complaint management of the people enrolled under the scheme.
4.6 Conclusions
The present study looked into the social health insurance scheme in Kerala, tried to explore the people’s perspectives regarding insurance and it should be treated as a beginning towards further research in the broad field of universal health coverage. This study addresses some critical issues with regard to extending health insurance coverage among the BPL households. The scheme failed to enrol the neediest households among the BPL. Insurance was found to be non-protective against the OOP expenses, though it came as a significant variable for the hospitalization. The households covered by insurance was comparatively well of as compared to the un-insured. The scheme failed to attract the private providers into the program. The two major objectives of CHIS, protecting people from financial catastrophe and providing choice to the poor were not achieved by the scheme.
References
1. WHO. World Health Report 2000: Health Systems-Improving Performance. Geneva, Switzerland: World Health Organization, 2000.
http://www.who.int/whr/2000/en/whr00_en.pdf (accessed Jun 7, 2011)
2. WHO. Declaration of Alma-Ata. Alma-Ata: World Health Organization, 1978. http://www.who.int/hpr/NPH/docs/declaration_almaata.pdf (accessed Jun 5, 2011) 3. WHO. World Health Assembly resolution WHA 58.33 Sustainable health financing, universal coverage and social health Insurance. Geneva: World Health Organization, 2005. http://www.who.int/health_financing/documents/cov-wharesolution5833/en/index.html (accessed June, 2011)
4. Carrin G, James C, Evans DB. Achieving universal health coverage: developing the health financing system. Geneva: World Health Organization, 2005.
5. WHO. The world health report—health systems financing: the path to universal coverage. Geneva: World Health Organization, 2010. http://www.who.int/whr/2010/en/index.html (accessed July 21, 2011).
6.WHO. National health accounts. Geneva: World Health Organization, 2010 http://www.who.int/nha ( accessed 23 July, 2011).
7. WHO. Health Transition. Geneva: World Health Organization, 2010.
http://www.who.int/trade/glossary/story050/en/index.html (accessed 20 July, 2011).
8. Preker A et al. Rich-poor differences in health care financing. In: Preker A, Carrin G, eds. Health financing for poor people: resource mobilization and risk-sharing. Washington, DC: The World Bank, 2004.
9. Su TT, Kouyaté B, Flessa S. Catastrophic household expenditure for health care in a low- income society: a study from Nouna District, Burkina Faso. Bulletin of the World Health Organization 2006; 84: 21-27.
10.Wagstaff A. The economic consequences of health shocks: evidence from Vietnam. Journal of Health Econ. 2007; 26:82-100
11. Van Doorslaer E et al. Catastrophic payments for health care in Asia. Health Econ. 2007; 16(11):1159-84.
12. Baeza C, Packard T. Beyond survival: protecting households from health shocks in Latin America. Washington, DC: The World Bank, 2006.
13. Xu K, Evans DB, Carrin G, Aguilar-Rivera AM, Musgrove P, Evans T. Protecting households from catastrophic health spending. Health Aff (Millwood) 2007; 26(4):972-83. 14. Xu K, Evans DB, Kawabata K, Zeramdini R, Klavus J, Murray CJ. Household
http://www.who.int/health_financing/Lancet%20paper-catastrophic%20expenditure.pdf (accessed July 20, 2011)
15. Arora D, Nanada L. Towards alternative health financing: the experience of RSBY in Kerala. RSBY Working Paper 4. http://www.rsby.gov.in/documents.aspx?ID=14 (accessed 29 Jan 2011)
16. ILO. Social health protection: an ILO strategy towards universal access to health care. Geneva: International Labour Organization, 2008.
17. ILO, GTZ, WHO. Berlin recommendations for action - final version. International conference on social health insurance in developing countries. Berlin,Eschborn: German Technical Cooperation, 2006.
www.socialhealthprotection.org/pdf/Berlin%20recommendation.pdf (accessed Jan 5, 2011) 18. ILO. World social security report 2010-11: providing coverage in the time of crisis and beyond. Geneva: International Labour Organization, 2010.
19. WHO. The world health report—health systems financing: the path to universal coverage. Geneva: World Health Organization, 2010. http://www.who.int/whr/2010/en/index.html (accessed July 21, 2011).
20. Akin J, Birdsall N, de Ferranti. Financing health services in developing countries: an agenda for reform- A World Bank Policy Study. Washington, DC: The World Bank, 1987. 21. Scheil-Adlung, X et al. What is the impact of social health protection on access to health care, health expenditure and impoverishment? A comparative analysis of three African countries. Geneva: World Health Organization, 2006.
http://www.who.int/health_financing/documents/dp_e_06_2-access_africa.pdf (accessed Jan 2, 2011)
22. Normand C, Weber A. Social Health Insuranc-A Guidebook for Planning. Geneva: World Health Organization, 1996. http://www2.gtz.de/wbf/4tDx9kw63gma/Guidebook_SHI_WHO- GTZ-ILO-ADB.pdf (accessed Feb 13, 2011)
23. Carrin G. Social Health Insurance in Developing Countries: A Continuing Challenge. International Social Security Review 2002; 55: 57–69.
24. Ron A, Abel-Smith B, Tamburi G. Health insurance in developing countries: the social security approach. Geneva: International Labour Office, 1990.
25. Carrin G, James C. Social Health Insurance: Key Factors Affecting the Transition towards Universal Coverage. International Social Security Review 2005; 58 : 45–64. http://www.who.int/health_financing/issues/shi_key_factors.pdf (accessed Feb 13, 2011) 26. WHO. The world health report 2008: primary health care – now more than ever. Geneva: World Health Organization, 2008.
27. Rannan-Eliya R, Sikurajapathy L. Sri Lanka: “Good practice” in expanding health care coverage. Colombo. Institute for Health Policy 2008
http://www.ihp.lk/publications/docs/RSS0903.pdf (accessed 8 July 2011).
28. Damrongplasit K, Melnick GA. Early results from Thailand’s 30 Baht Health Reform: something to smile about. Health Aff (Millwood) 2009; 28:457-66.
29. Kutzin J et al. Bismarck meets Beveridge on the Silk Road: coordinating funding sources to create a universal health financing system in Kyrgyzstan. Bulletin of the World Health Organization 2009; 87: 549-54.
30. Franco LM et al. Effects of mutual health organizations on use of priority health-care services in urban and rural Mali: a case-control study. Bulletin of the World Health Organization 2008; 86: 830-38.
31. Jowett M, Hsiao WC. The Philippines: extending coverage beyond the formal sector. In: Hsiao W, Shaw PR, eds. Social health insurance for developing nations. Washington, DC, The World Bank, 2007; 43: 81–104.
32. Axel son H et al. Health financing for the poor produces promising short-term effects on utilization and out-of-pocket expenditure: evidence from Vietnam. International Journal for Equity in Health 2009; 8: 20-25.
33. Baeza C, Packard T. Beyond survival: protecting households from health shocks in Latin America. Washington, DC: The World Bank, 2006.
34. Missoni E, Solimano G. Towards universal health coverage: the Chilean experience. World health report 2010 background paper, no. 4
http://www.who.int/healthsystems/topics/financing/healthreport/whr_background/en(accesse d Feb 13, 2011)
35. Whiteford LM, Branch LG. Primary health care in Cuba: the other revolution. Lanham, Rowman and Littlefield Publishers, 2008.
36. Macinko J, Guanais FC, de Fátima M, de Souza M. Evaluation of the impact of the Family Health Program on infant mortality in Brazil, 1990–2002. Journal of Epidemiology and Community Health 2006; 60: 13-19.
37. Sáenz M, Acosta M, Bermudéz JL. Universal coverage in Costa Rica: lessons and
challenges from a middle-income country. World health report 2010 background paper, no.11 http://www.who.int/healthsystems/topics/financing/healthreport/whr_background/en
(accessed Feb 13, 2011)
38. Meessen B et al., eds. Health and social protection: experiences from Cambodia, China and Lao People’s Democratic Republic. Antwerp, ITG Press, 2008.
39. Arfa C, Achouri H. Tunisia: good practice in expanding health care coverage. Lessons from reforms in a country in transition. In: Gottret P, Schieber GJ, Waters HR, eds. Lessons from reforms in low- and middle-income countries. Good practices in health financing. Washington, DC, the World Bank 2008: 385–437.
40. D’Almeida S, Durairaj V, Kirigia J. Ghana’s Approach to Social Health Protection. World health report 2010 background paper, no.2
http://www.who.int/healthsystems/topics/financing/healthreport/whr_background/en . (accessed March 13, 2011)
41. Bayarsaikhan D, Kwon S, Ron A. Development of social health insurance in Mongolia: successes, challenges and lessons. International Social Security Review, 2005, 58: 27-44. 42. Musango L, Aboubacar I. Compulsory health insurance in Gabon: an asset for the well being of the population. 2010. World health report 2010 background paper, no.16 http://www.who.int/healthsystems/topics/financing/healthreport/whr_background/en . (accessed June 13, 2011)
43. OECD. Reviews of Health Systems – Turkey. Organisation for Economic Co-operation and Development and the World Bank, 2008.
http://www.oecd.org/document/60/0,3343,en_2649_33929_42235452_1_1_1_1,00.html (accessed 06 July 2010).
44. Gakidou E et al. Assessing the effect of the 2001–06 Mexican health reform: an interim report card. Lancet 2006; 68: 1920-35.
45. Health at a glance. Paris, Organisation for Economic Co-operation and Development, 2009.
46. McIntyre D et al. Beyond fragmentation and towards universal coverage: insights from Ghana, South Africa and the United Republic of Tanzania. Bulletin of the World Health Organization 2008; 86:871-76.
47. Witter S, Garshong B. Something old or something new? Social health insurance in Ghana. BMC Int Health Hum Rights. 2009 ; 9: 20.
http://www.biomedcentral.com/content/pdf/1472-698X-9-20.pdf(accessed Feb 13, 2011) 48. WHO. Regional Overview of Social Health Insurance in Southeast Asia. New Delhi: Regional Office for Southeast Asia. World Health Organization). 2003
http://203.90.70.117/PDS_DOCS/B3457.pdf (accessed Feb 13, 2011)
49. Jeong H-S. Expanding insurance coverage to informal sector population: experience from Republic of Korea. World health report 2010 background paper, no. 38
http://www.who.int/healthsystems/topics/financing/healthreport/whr_background/en(accesse d Feb 13, 2011)
50. Ahuja R. Health Insurance for the Poor in India- working paper 123. Delhi: Indian Council for Research on International Economic Relations, 2004.
51. Swarup A, Jain N. RASHTRIYA SWASTHYA BIMA YOJANA - A CASE STUDY FROM INDIA. http://www.rsby.gov.in/documents.aspx?ID=14 (accessed 29 Jan 2011). 52. Government of India .Rashtriya Swasthya Bima Yojna (RSBY).
http://www.rsby.gov.in/documents.aspx?ID=14 (accessed on 12 Dec 2010) 53. Centre for Development Studies. Human Development Report 2005- Kerala. Thiruvananthapuram: State Planning Board, Government of Kerala, 2006.
http://planningcommission.gov.in/plans/stateplan/sdr_pdf/shdr_kerala05.pdf (accessed on 12 Dec 2010)
54. De Allegri M, Kouyaté B, Becher H, Gbangou A, Pokhrel S, Sanon M, Sauerborn R.Understanding enrolment in community health insurance in sub-Saharan Africa: a population-based case-control study in rural Burkina Faso. Bull World Health Organ 2006; 84: 852-858. http://www.cerdi.org/uploads/sfCmsContent/html/201/De_Allegri_ppt.pdf (accessed on 12 Dec 2010)
55.Gumber A. Extending health insurance to the poor: some experiences from sewa scheme. Health and Population: Perspectives and Issues 2001; 24: 1-14.
http://medind.nic.in/hab/t01/i1/habt01i1p1.pdf (accessed on 12 Nov 2010)
56. Basaza R, Criel B, Van der Stuyft P. Low enrolment in Ugandan community health insurance schemes: underlying causes and policy implications. BMC Health Services Research 2007; 7: 105. http://www.biomedcentral.com/1472-6963/7/105 (accessed on 12 Nov 2010)
57. Mathauer I, Schmidt JO, Wenyaa M. Extending social health insurance to the informal sector in Kenya. An assessment of factors affecting demand. Int J Health Plann Manage 2008; 23: 51-68. http://onlinelibrary.wiley.com/doi/10.1002/hpm.914/pdf (accessed on 12 Nov 2010)
58. Mtei, G. and J. Mulligan ,2007. Community Health Funds in Tanzania: a literature review. Dar es Salaam, Ifakara Health Research and Development Centre
(IHRDC).http://www.crehs.lshtm.ac.uk/downloads/publications/Community%20health%20fu nds%20in%20Tanzania.pdf(accessed on 12 Nov 2010)
59. W. Hsiao and P. Shaw, Social Health Insurance for Developing Nations (Washington: World Bank, 2007). http://www.hsph.harvard.edu/health-care-
financing/files/hsiao_and_shaw_2007_-_shi_for_developing_nations.pdf(accessed on 12 Nov 2010)
60.Dror DM, Soriano ES, Lorenzo ME, Sarol JN Jr, Azcuna RS, Koren R. Field based
evidence of enhanced healthcare utilization among persons insured by micro health insurance units in Philippines. Health Policy. 2005; 73: 263-71.
61. Moens, F., 1990. Design, implementation, and evaluation of a community financing scheme for hospital care in developing countries: a prepaid health plan in the Bwamanda Health Zone, Zaire. Social Science and Medicine 1990; 30: 1319-27.
62.Atim C. Contribution of mutual health organizations to financing, delivery and access to health care: synthesis of research in nine west and central African countries. Bethesda, MD: Partnerships for Health Reform; 1998.
63. WHO (World Health Organization). 2005. Social Health Insurance: Selected Case Studies from Asia and the Pacific. Geneva: WHO.
64. Scheil-Adlung, X., Asfaw, A., Booysen, F., Lamiraud, K., Reynaud, E., Juetting, J. Xu, K., Carrin, G., Chatterji, S. (2006). What is the impact of social health protection on access to health care, health expenditure and impoverishment? A comparative analysis of three African countries. Geneva: World Health Organization, Department of Health Systems Financing, Discussion Paper No.2. http://www.who.int/health_financing/documents/dp_e_06_2- access_africa.pdf (accessed on 2 Jan 2011)
65 Vogel, R.J., 1990b. Health insurance in sub-Saharan Africa: a survey and analysis. Policy, Research and External Affairs Working papers. WPS 476. Africa technical Department. The World Bank, Washington. http://www-
wds.worldbank.org/servlet/WDSContentServer/WDSP/IB/1990/08/01/000009265_39609291 74758/Rendered/PDF/multi0page.pdf(accessed on 2 Jan 2011)
66. 56. Polonsky J et al. Equity in community health insurance schemes: evidence and lessons from Armenia. Health Policy and Planning 2009; 24: 209-16. http://www.internal- displacement.org/8025708F004CE90B/(httpDocuments)/AF07094FB9B4F8FAC12576A900 5882D6/$file/czp001v1.pdf (accessed on 2 Jan 2011)
67. Andersen RM. Revisiting the behavioral model and access to medical care: does it matter? J Health Soc Behav 1995; 36: 1-10
68. Freeman JD, Kadiyala S, Bell JF, Martin DP. The causal effect of health insurance on utilization and outcomes in adults: a systematic review of US studies. Med Care. 2008; 46: 1023-1032.
69. Shepard, D., Vian, T., Kleinau, E.F., 1990. Health insurance in Zaire. Policy, Research and External Aairs Working papers. WPS 489. Africa technical Department. The World Bank, Washington.
70. Moens, F, Carrin, G 1992. Prepayment for hospital care in the Bwamanda Health Zone (Zaire). In: Strategies for Health Care Finance in Developing Countries with a focus on Community Financing in Sub-Saharan Africa.
71. Criel B, Kegels G. A health insurance scheme for hospital care in Wamanda district, Zaire: lessons and questions after 10 years of functioning. Tropical Medicine and
International Health 1997; 2: 654-72.
72. Lia PA, Chang HH, Yang FA. Does the Universal Health Insurance Program Affect Urban-Rural Differences in Health Service Utilization Among the Elderly?
Evidence From a Longitudinal Study in Taiwan. The Journal of Rural Health 2011; 4: 1–8 . http://onlinelibrary.wiley.com/doi/10.1111/j.1748-0361.2011.00363.x/pdf (accessed on 2 Jan 2011)
73.Gruber J, Madrin BC. Health-insurance availability and the retirement decision. Am Econ Rev. 1995; 85: 938-48.
74.Wong R, Díaz JJ.Health care utilization among older Mexicans: health and socioeconomic inequalities.Salud Publica Mex 2007; 49: 505-14.
75. Valencia-Mendoza A, Bertozzi SM. A predictive model for the utilization of curative ambulatory health services in Mexico. Salud Publica Mex 2008; 50: 397-407.
76. Dror DM, Soriano ES, Lorenzo ME, Sarol JN Jr, Azcuna RS, Koren R. Field based evidence of enhanced healthcare utilization among persons insured by micro health insurance units in Philippines. Health Policy. 2005; 73: 263-71.
77. Wong R, Díaz JJ. Health care utilization among older Mexicans: health and socioeconomic inequalities. Salud Publica Mex 2007; 49: 505-14.
78. Cheng SH, Chiang TL. The effect of universal health insurance on health care utilization in Taiwan. Results from a natural experiment. JAMA. 1997; 278: 89-93.
79.Yiengprugsawan V, Carmichael G, Lim LY, Seubsman S, Sleigh A. Explanation of inequality in utilization of ambulatory care before and after universal health insurance in Thailand. Health Policy Plan, 2011; 26: 105-14.
80. Peabody JW, Yu JCI, Wang YR, Bickel, SR. Health system reform in the Republic of China. JAMA 1995; 273: 777-81.
81. Devadasan N, Criel B, Van Damme W, Manoharan S, Sarma PS, Van der Stuyft P. Community health insurance in Gudalur, India, increases access to hospital care. Health Policy Plan. 2010 ; 25: 145-54.
82. Panopoulu, G. and C. Velez (2001). Subsidized Health Insurance, Proxy Means Testing and the Demand for Health Care among the Poor in Colombia. Colombia Poverty Report Volume II. Washington DC, World Bank.
83. Gakidou E, Lozano R, González-Pier E, Abbott-Klafter J, Barofsky JT,
Bryson-Cahn C, Feehan DM, Lee DK, Hernández-Llamas H, Murray CJ. Assessing the effect of the 2001-06 Mexican health reform: an interim report card. Lancet. 2006; 368:1920- 35.
84.Chongsuvivatwong V, Phua KH, Yap MT, Pocock NS, Hashim JH, Chhem R, Wilopo SA, Lopez AD. Health and health-care systems in southeast Asia: diversity and transitions. Lancet. 2011; 377: 429-37.
85. Tangcharoensathien V, Patcharanarumol W, Ir P, Aljunid SM, Mukti AG, Akkhavong K, Banzon E, Huong DB, Thabrany H, Mills A. Health-financing reforms in southeast Asia: challenges in achieving universal coverage. Lancet 2011 ;377:863-73.
86.Mills, A., 1983. Economic aspects of health insurance. In: Lee, K., Mills, A. (Eds.), Health Economics in Developing Countries, Chap. 4. Oxford University Press.
87. GTZ. 56 Million Steps Towards Universal Coverage: RSBY Health Insurance for the Poor in India. Deutsche Gesellschaft für Technische Zusammenarbeit (GTZ) mbH . 89. Reddy KS, Patel V, Jha P, Paul VK, Kumar AK, Dandona L; Lancet India Group for Universal Healthcare. Towards achievement of universal health care in India by 2020: a call to action. Lancet. 2011;377:760-8.
90. Mahal A, Karan A, Engergau M. The Economic Implications of Non-Communicable Disease for India. Washington: Wold Bank, 2010.
91. Wagstaff, A. 2006. Health Insurance for the Underprivileged: Initial Impacts of Vietnam's Health Care Fund for the Poor. Washington DC, World Bank, Mimeo
92. Long, G.T. 2008. Social health insurance in Vietnam: Current issues and policy recommendations, Social Security Extension Initiatives in East Asia Series (International Labour Organization (ILO) Subregional Office for East Asia). Available at:
http://www.ilo.org/public/english/region/asro/bangkok/events/sis/download/paper33.pdf. (accessed 23 Jan 2011)
93. Jowett, M., P. Contoyannis and N. D. Vinh. "The impact of public voluntary health insurance on private health expenditures in Vietnam." Soc Sci Med, 2003, 56: 333-42. 94. Gakidou E, Lozano R, González-Pier E, Abbott-Klafter J, Barofsky JT, Bryson-Cahn C, Feehan DM, Lee DK, Hernández-Llamas H, Murray CJ. Assessing the effect of the 2001-06 Mexican health reform: an interim report card. Lancet 2006 ;36:1920-35.
95.Criel B. 1998. Insurance and solidarity: concepts and typology. District based health insurance in sub-Saharan Africa. 1st edition. Antwerp: Institute
of Tropical Medicine.
96. Sen A. Health: perception versus observation. British Medical Journal2002; 324: 860–1.
97. Trivedi, P 2003. Patterns of health care use in Vietnam: Analysis of 1998 Vietnam Living Standards Survey data. Economic Growth, Poverty and Household Welfare: Policy Lessons from Vietnam. P. Glewwe, N. Agrawal and D. Dollar. Washington DC, World
Bank. 98. Jowett M, Deolalikar A, Martinsson P. Health insurance and treatment seeking behaviour: evidence from a low-income country. Health Econ 2004; 13: 845-57.
99. Wagstaff A, Pradhan M 2005. Health insurance impacts on health and nonmedical consumption in a developing country. Washington, D.C., World Bank, Policy Research Working Paper 3563.
100. Sepehri A, Sarma S,Simpson W. Does non-profit health insurance reduce financial burden? Evidence from the Vietnam Living Standards Survey Panel. Health
Econ 2006; 15: 603-16.
101. Panopoulu, G. and C. Velez 2001 . Subsidized Health Insurance, Proxy Means Testing and the Demand for Health Care among the Poor in Colombia. Colombia Poverty Report Volume II. Washington DC, World Bank.
102. Gaviria, A., C. Medina and C. Mejía 2006. Evaluating The Impact Of Health Care Reform In Colombia: From Theory To Practice. Bogota, Universidad de Los Andes-CEDE, Documentos.
103. Knaul, FM et.al. Evidence is good for your health system: policy reform to remedy catastrophic and impoverishing health spending in Mexico. Lancet 2006; 368: 1828-41.
Annexure I.
Informed Consent form
MINOR, MAJOR MORBIDITY AND UTILIZATION OF COMPREHENSIVE HEALTH INSURANCE SCHEME, KERALA: A COMPARATIVE STUDY OF INSURED AND UN-
INSURED BPL HOUSEHOLDS IN TRIVANDRUM Achutha Menon Centre for Health Science Studies
Sree Chitra Tirunal Institute for Medical Sciences & Technology, Thiruvananthapuram, Kerala-695011
MPH dissertation June - September ‘2011
“Namaskaram”- my name is Ms. Neena Elezebeth Philip and presently I am studying the course-Master of Public Health (MPH) at Sree Chitra Tirunal Institute for Medical Sciences &Technology, Thiruvananthapuram. As part of my dissertation, I am conducting this survey and interviewing the BPL(below poverty line) households living in the rural area