Wednesday, March 14, 2007

Health for Sum

THE NEXT BIG IDEA by Ajit Chaudhuri

This two-pager is the result of a series of coincidences. Buried away in a pompous piece in India Today on ways to make our country a better place was a tiny, completely unsubstantiated but yet interesting statistic - that a health insurance scheme for the poor would cost Rs. 248 per poor family per year (way number 13, for the superstitious). A little before this, EPW had one article outlining community health insurance in general and another detailing the CHI scheme managed by an NGO in southern India. Somewhere in-between was the request made to me by India Today’s watchman, a daily wager called Hira Lal, for a loan to help meet the costs of his brother’s son’s operation in AIIMS – connecting the articles to a problem faced by a real person.

We all know a Hira Lal, and we all know the financial problems caused by serious illness within the family. We all know that identifying the poorest ten percent in any community is simply a matter of finding the women headed households and those which have or had a long term illness within the family. We all see that the public health system has collapsed, and is now accessible only to government servants, politicians (the lower ones on the pecking order, who can’t leverage the public exchequer to push off to the US) and their friends and relatives. We all see that most private hospitals would give leeches and bloodsuckers an inferiority complex. We all see that the poor avoid getting healthcare and, when they do, go broke in trying to pay for it – in fact, the families of 24 percent of all Indians hospitalized fall below the poverty line as a direct result of hospitalization, and expenditure on healthcare is the single biggest cause for a non-BPL household to go BPL. There is a need for radical new ideas in the field of healthcare for the poor.

What is CHI? The definition, for the definitionally inclined, is: any not-for-profit insurance scheme that is aimed primarily at the informal sector and is formed on the collective pooling of health risks in which members participate in its management. CHI schemes (should) aim to provide low cost healthcare, protect participants from high hospitalization costs and encourage participation by communities in their own healthcare. A CHI scheme has three basic stakeholders - the community, the insurer and the health maintenance organization or healthcare provider. The former EPW article studied 12 existing CHI schemes in India and identified three basic designs –
· HMO-led, where an NGO/hospital provides healthcare, purchases insurance from an insurance company and runs the insurance programme, i.e. generates awareness within the community, collects premium, submits claims, manages reimbursements and monitors for fraud.
· Insurer-led, where an NGO is the insurer, runs the insurance programme and purchases healthcare from independent providers.
· Intermediate, where the NGO runs the programme and plays the role of an agent, purchasing healthcare from providers and insurance from insurance companies.

Some of the characteristics of the CHI schemes studied were –
· The communities insured included tribal populations, dalits, farmers, women SHG members, self-employed women, etc. Some used existing CBOs to piggyback the scheme upon, such as SHGs, unions, cooperatives, etc. In some the unit of enrollment was individual and membership in the scheme voluntary and in others, enrollment was in groups or families and membership mandatory. Enrollment ranged from 1000 to 17 lakh members. Premiums per person per annum were always under Rs. 100.
· Many schemes had important exclusions such as pre-existing illnesses, self-inflicted injuries, chronic ailments, TB, HIV, pregnancies. Most reimbursed the direct cost of treatment, while some reimbursed the loss of wages as well. Some, especially the HMO-led ones, were cashless, while others had the patients paying bills and getting compensated later. Most schemes had a fixed upper limit ranging from Rs. 1250 to Rs. 1 lakh per person per annum.
· The problem of adverse selection (only the old/sick enrolling in the scheme) could be prevented by mandatory enrollment or having a larger enrollment unit. The problem of moral hazard (the health provider sticking you for as much as they can) could be prevented by capping fee structures and ensuring standard treatment guidelines.
· The subscription rates to CHI schemes varied from 10 to 50 percent of the target community when enrollment was voluntary. The reasons for this being low were – no immediate benefit perceived, premium too high, family size too high, confidence in own well-being and the source of healthcare too far.
· Utilisation rates ranged from 1.4/1000 to 240/1000. The low rates were usually because of non-financial barriers to accessing health care (hospital too far, loss of wages), while adverse selection caused the high rates.
· Some were run purely from premiums raised from the community, some relied completely upon external resources such as government or donors, and most supplemented local resources with external ones.

In the authors’ opinion, good CHI schemes protect the community by covering 100 percent of the direct cost of illness and some of the indirect one’s as well. They cover all illnesses and provide the financial benefit at the source of healthcare, thus ensuring that there are no waiting periods which patients have to cover. In addition, the premium needs to be affordable, the NGO and CBO credible and the administrative load of the scheme minimal. The insurer has to be involved hands-on. The main pitfall is the lack of good providers as the Indian private healthcare sector is unregulated and unaccountable.

The second article was of particular interest to me because it described the efforts of Ashwini, an NGO that I visit about once a year, in the field of CHI and it was to Dr. Nandakumar Menon of Ashwini, one of the authors of the paper, that I was able to address specific questions on the practicalities. He said that, in addition to all the above, CHI is viable only when all stakeholders to the scheme have an interest in reduced costs, and this is possible only in an HMO-led design in which preventive health care and a decentralized outreach programme are part of the package. Including all costs, i.e. in-patient, referral and community outreach, a CHI would come to Rs. 150 per person per annum or about 15 lakhs a year for a population of 10,000.

There is a gradual realization that access to healthcare is a serious problem, that access to medical insurance is available only to the middle class and above, that platitudes about the importance of public sector health care remain what they are, and that something needs to be done. Community health insurance schemes could be the next big idea.

Point 13, “57 Ways to Make a Better Place”, India Today issue of August 23 2004
Devadasan, Van Damme, Ransom and Criel, “Community Health Insurance in India: An Overview”, Economic and Political Weekly of 10-16 July 2004.
Devadasan, Manoharan, Menon, et al, “Accord Community Health Insurance: Increasing Access to Hospital Care”, Economic and Political Weekly of 10-16 July 2004.

BPL Below the Poverty Line
CBO Community Based Organisation
CHI Community Health Insurance
EPW Economic and Political Weekly
HMO Health Maintenance Organization
NGO Non-governmental Organization
WHO World Health Organization

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