Post hospitalization medicine coverage

1. Response by the hospital 2. Rating of satisfaction

3. If you were not covered by the health insurance scheme, whether you would have gone to the same provider?

4. Based on your experience, will you recommend your relatives/friends to take treatment from the same hospital?

Distress financing: Distress financing was defined as financial activities, such as Sale of assets, Un-secured loans, Gold loans, Mortgage of assets, Mortgage of land, Assistance / gift that were directly related to the patient's hospitalization. Presence of distress financing was inquired in one question.

Knowledge and understanding about insurance: To find their Knowledge and understanding about insurance the following open ended questions were asked: awareness about the term insurance and what do they understand by it; Types of insurance they are aware of; Knowledge of the insurance scheme CHIS/RSBY; Ideal health insurance in their concept; Why did they join/ not join in the scheme; Their opinion about the scheme; Suggestions for improving the scheme.

2.3.7 Data Entry and Analysis

Data entry and cleaning was done using EPI-Data version 3.1 programme. Data analysis was done using SPSS 17.0 version. Descriptive analysis was done to look at the sample characteristics. Bivariate analysis was done to find the relationship between predictor and outcome variable. Figure describes the framework for the analysis that has been described in the subsequent chapters. Details regarding the outcome and the predictor variables are discussed subsequently.

Figure 2.2 Framework for analysis

2.3.8 Data storage

All data are kept with the principal investigator, who shall bear sole responsibility for safe keeping and breach of any confidentiality. Transfer of data was kept to a minimum. Data shall be with the PI for any future reference.

2.3.9 Quality Control

Quality of the data was maintained by giving a 2 days training to the 3 field assistants (two male and one female) using the training manual on administering the consent form and interview schedule. All the field assistants were graduates and had experience in the field of data collection. Mock interviews were conducted by them and each question was explained to

Uni-variate analysis

• Estimation of both outcome variables and its related variables

• To estimate satisfaction and perceived quality of the scheme among the insured households

• To identify the prevalence of minor and major morbidity.

Bivariate analysis

• Chi square test: To identify the association between each of the household and individual characteristics with insurance status and major morbidity and to compare the health seeking behaviour, Knowledge and

understanding about insurance across the insured and un-insured households

• Man-whitney U Test: To estimate the association between direct and indirect expenses and insurance status

Multi-variate analysis

Step-wise logistic regression: To identify the factors significantly associated with insurance status

them. Data collected by them was daily checked by the principal investigator. Cross checking was done by randomly selecting five households the next day administering the same interview schedule by the principal investigator and cross-checking the responses for each questions.

2.4 CASE STUDY

An additional informed consent with particular reference to the use of voice recording device was obtained from the four households which were selected as case studies. The case studies were selected whenever two extreme situations were identified in during the survey. Four case studies were done only after the completion of the survey. Data was collected after receiving consent. The respondents were interviewed in Malayalam and in a place of his/her choice. All participants agreed for the case studies were digitally recorded. These recordings were later transcribed and translated by the researcher.

2.5 KEY INFORMANT INTERVIEW:

2.5.1 Sample selection

The study population considered of the hospital managers or administrators of both empanelled and un-empanelled hospitals. They hospitals were selected after the cross sectional survey of the BPL households from which the participants had sought care from. Care was taken to approach both the private and public hospitals. They were approached at random and whoever agreed to be interviewed was included. Only seven of the nine approached agreed to participate in the study.

2.5.2 Sample size: sample size was seven. It consisted of 4 private and 3 public hospitals. The sample size was limited to seven as the researcher felt saturation in information and no new facts forthcoming.

2.5.3 Data collection and storage: Data was collected after receiving consent, using a pre- designed guideline. The respondents were interviewed in English/ Malayalam according to his/her choice. All participants agreed for the interviews were digitally recorded. These recordings were later transcribed and translated by the researcher. All digital recordings and transcripts were kept safely with the principal investigator. It shall be completely destroyed within one year of submission of the study.

2.5.4 Data analysis: Deductive themes were generated after interviews using the guidelines as templates.

2.5.5 Reporting of the result: Results are reported as themes and comments on each theme. There is also a final comment on the overall utilization of the CHIS.

2.6 Triangulation

I have tried to triangulate the findings from my interview schedule, case studies and key informant interviews. I have also tried to give certain suggestions on policy gaps and the improvements needed.

2.7 Ethical Consideration

After obtaining clearance from the Institutional Ethical Committee of Sree Chitra Tirunal Institute for Medical Science and Technology, Thiruvananthapuram, data collection was started. Permissions were also obtained from the hospitals selected for the in-depth interview. Confidentiality of the study participants was maintained. Study subjects were included in the study only after taking written informed consent from them. Participation was totally voluntary, and they were permitted to withdraw from the interview at any time. All the quantitative data was coded and the coded data were entered into the data entry sheet and identities of the individuals were kept completely confidential.

CHAPTER 3

RESULTS