Community health insurance in India an overview

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Community health insurance in India an overview

• Dr. N. Devadasan, MBBS, MPH
• Institute of Public Health
• Bangalore

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Health financing - Individuals
PROVIDER
FEES
CARE
PATIENT
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Health financing - Government
GOVT.
PROVIDER
SALARY
TAXES
CARE
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Health financing - Insurance
PROVIDER
INSURANCE COMPANY
FEES
PREMIUM
CARE
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Health financing in India
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Health insurance in India

• Social health insurance ESIS, CGHS
• Private health insurance NIAC, ICICI,
• Community health insurance SEWA, ACCORD,
  Yeshaswini,.

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Community health insurance

• Community health insurance is any not-for-profit
  insurance scheme aimed primarily at the informal
  sector and formed on the basis of a collective
  pooling of health risks, and in which the members
  participate in its management.

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Community health insurance schemes in India
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Characteristics of CHI in India

• Initiated by NGOs / CBOs
• Mainly to improve access to health care
• Covers about 1,000 to 100,000 people
• Covers mostly poor and near poor. Poorest are
  usually not covered by CHI
• 3 basic models of CHI
• Provider model
• Insurer model
• Linked model

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Provider model of CHI
Hospital
Community
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Insurer model of CHI
NGO
Hospital
Community
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Linked model of CHI
Hospital
NGO
Community
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Community

• Ranges from tribals to SHGs to farmers
• Usually organised groups
• Had some problem wrt
• Access to health care
• Expenses
• More success where there is a feeling of
  solidarity also

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Organiser

• NGOs or CBOs
• They have been working in the field of
  development for many years
• So there is a lot of trust and credibility

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Premium

• Ranges from Rs 20 per person per year to Rs 150
  per person
• In cash or kind
• Usually collected through existing community
  mechanisms
• Individual / family unit
• Waiting period
• Collection period

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Benefits

• Usually covers hospitalisation expenses
• Maximum limit varies from Rs 1250 to Rs 1,00,000
• Some schemes also cover
• OP
• Transport
• Loss of wages
• The larger the benefit, the higher the premium

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Providers

• Usually hospitals
• Very few have negotiated for lower costs or
  better quality
• So danger of cost escalation or unnecessary
  interventions
• Reimbursement Vs Cashless
• One of the most important, but very weak aspect
  of CHI in India

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Administration

• Neglected aspect of CHI
• Many tasks
• Convincing people
• Collecting premium
• Negotiating with insurance companies / hospitals
• Monitoring the utilisation of services and
  financial status
• Giving feedback

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Risk management

• Adverse selection
• Moral hazard patients
• Moral hazard doctors
• Risk pooling
• Cost escalation
• Assuring quality

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Performance of CHI

• Enrolment rates range from 10 40 of population
• Has improved access to health care
• Has protected households, but only partially
• Has not improved quality of care for the patient
• Many of them require external subsidies

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Yeshasvini

• Eligibility Cooperative farmers and their
  families
• Organised by the Yeshasvini Trust
• Premium Rs 120 30 per person per year
• Benefit any surgery upto Rs 1 lakh per
  hospitalisation and 2 lakh per patient per year
• Providers Empanelled hospital - gt 300
• Administration by TPA
• gt 20 lakh members this year.

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Karuna Trust

• Eligibility BPL families in taluks where Karuna
  trust works
• Organised by Karuna Trust
• Premium Rs 20 per person per year
• Benefit hospitalisation expenses upto Rs 2500
  loss of wages upto Rs 1500 payment to the
  doctors upto Rs 1500
• Providers Only government hospitals
• First year gt 60,000 members, now around 10,000.

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Universal Health Insurance Scheme

• BPL families in India
• Organised by 4 Govt. Insurance companies
• Premium Rs 250 per family of 5
• Benefit hospitalisation expenses upto Rs 30,000
  per year
• Providers both government and private
• Only about 11 lakhs so far.

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Conclusions

• CHI can be an useful tool to improve access to
  health care and protect families from
  impoverishment
• But there are some pre-conditions that need to be
  met
• Trustworthy organisation
• Good quality providers
• Community with some means
• Managerial skills
• REMEMBER THAT CHI IS NOT A MAGIC BULLET THAT WILL
  SOLVE ALL THE PROBLEMS IN THE HEALTH SYSTEM

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Some useful resources

• www.comhealthins.org
• www.ilo.org/step
• www.phrplus.org/
• www.cgap.org/

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THANK YOU

• Dr. N. Devadasan
• mail_at_iphindia.org