Community Health Insurance Network

Vol 2 Issue 1 Jan 2006

Dear Friends

Season’s greetings and wishing all of you a joyful, healthy and peaceful 2006.

It has been almost a year since we published our newsletter. There were many reasons for this delay. For one, I am partly to blame as I was caught up with my research activities and was in the field most of the time. Secondly our guest editor could not help us, as she was caught up with some personal problems. And finally, with the active egroup, I felt that most of the recipients of this newsletter are in touch and informed about what is happening in our country.

Nevertheless, it is important to keep this newsletter going, first to address the needs of those who are not in the egroup, and secondly to discuss issues other than those brought up in the egroup.

In this newsletter, I share some of the new health insurance schemes that have been flooding our country in the past one

year. Also I try and capture the essence of some important conferences on health insurance, both nationally and internationally. And finally I review some of the important articles that have been published on health insurance in India. Full text of these articles are available at our website www.comhealthins.org for those who are interested in reading. Ad you will notice, most of the contributions are from yours truly. I would really appreciate if some of the members could share even a small paragraph of what they are doing in the field of community health insurance – for the sake of the other members. It would really add value to this newsletter. So Mukti, Prof Varatharajan, Prof Narayana, we are waiting for your contributions.

With warm regards,

Dr. N. Devadasan.

New Health insurance schemes in India.

Kerala government

The Kerala government is planning to cover about 25 lakh BPL families under a health insurance scheme. The scheme will apparently be implemented through the government sponsored Self Help Groups called Kutumbashrees. These micro savings organizations will collect premium from their members and pass it onto the government. Both the central government and state government subsidize the premium. Thus the individual family has to only pay a small amount. In return they will be covered for any hospitalization expenses upto Rs 30,000 in select hospitals – both public and private. The benefit package also includes reimbursement of loss of wages of Rs 50 per person per day if the patient is the breadwinning member of the family. This scheme is a partnership between the Central government, the State government and ICICI – Lombard Insurance company.

Assam government

The Assam government announced a ‘tertiary care’ package in July 2005. Using money normally used to pay the hospital bills of patients with serious illness, the government designed a special ‘tertiary care’ package for the 30 million individuals in Assam. The Jeevan Jyoti Insurance scheme (in association with ICICI-Lombard Insurance company) covers for personal accident (upto Rs 25,000 for injury and Rs 50,000 for death) and also for hospitalization expenses for the following diseases - Alzheimer's, cancer, open heart surgeries, end-stage renal failure, burn cases, cardiac arrests and major organ transplantations. The people have to enroll at the village level and the premium is fully subsidized by the government of Assam. The patients can get treatment at any of the accredited hospitals. It is clear that this scheme will benefit the elite of the state, as very few poor patients will be suffering from Alzheimer’s or cardiac illnesses warranting by-pass surgery.

Weaver’s scheme

The ministry of textiles and the ICICI – Lombard launched a ‘comprehensive’ health insurance package for the 12 lakh handloom weavers in the country. The annual premium is Rs 1000, of which the weaver will pay Rs 200; the rest will be subsidized by the government. The benefit package includes OP care (50% of bill) and IP care upto Rs 10,000. Under the inpatient care, all conditions including pre-existing illnesses and maternity benefits will be covered. The insurance company will identify select hospitals and will provide a cashless policy. It is not clear however, who will collect the premium and provide the insurance education.

Yeshasvini scheme

While the Yeshasvini scheme is not a new one, there is so much interest in it, that I am describing it for those who joined late.

This is run by the Yeshasvini trust and the Ministry of Cooperatives – Government of Karnataka. The target population is the members of cooperative societies and their families. They pay an annual premium of Rs 60 per person per year and in return is reimbursed hospitalization expenses for any surgery – upto a maximum of Rs 1,00,000 per surgery (Rs 2,00,000 lakh per year). The premium is collected by the cooperative societies and the scheme is administered by a third party administrator (Family Health Plan Limited). They are responsible for selecting the hospitals, the processing the claims and reimbursing the hospitals.

Conferences and workshops

Health insurance has been the flavour of the year and there have been a host of conferences on health insurance. I report here on 3 such conferences that I attended. I am sure that there were many more, and I hope that this will inspire those who have

West Bengal government

The West Bengal government alongwith GTZ organized a workshop in August 2005. Titled "Scope and options for health insurance in West Bengal, the way forward" the main aim was to facilitate consultations among decision makers, experts and other stakeholders on the options of health insurance in West Bengal. After the inaugural session, the decision makers left the hall. The first technical session was on the basics of health insurance, social health insurance, private health insurance and community health insurance. This was followed by sharing of experiences in various countries – China, Germany and Philippines. The next few sessions were about health insurance in India – experts sharing from Maharashtra, Gujarat, Rajasthan, ESIC, Karnataka and West Bengal. The final session was a wrap up, when the policy makers made their appearance again and decided that

1. ?? Health insurance is a complex issue and hasty decisions should not be taken
2. ?? The West Bengal government is committed to insuring the poorer sections of society
3. ?? Piloting in some sites with accurate documentation to learn some lessons.

Proceedings of the workshop are available at the www.commhealthins.org website.

Uganda conference

The Ugandan government organized a workshop in Sept 2005 to understand the role that community health insurance can play in the march towards universal health coverage. Senior government policy makers, CHI practitioners and visitors from neighbouring countries were invited to this workshop. Unlike the West Bengal experience, I was pleasantly surprised to note that the Ugandan policy makers sat through the entire three day proceedings, asking relevant questions about community health and learning in the process. The CHI practitioners shared their experiences from Uganda, Tanzania, Rwanda and Kenya. It was encouraging to hear about the Rwandese experience, where the government is very pro-active about CHI. The president himself has put it high on the political agenda and has fixed enrolment targets for government servants. As of 2005, more than 25% of the population were enrolled under CHI in Rwanda. At the end of the workshop, the Government has promised to give space for CHIs to grow and cover the unreached segments of the Ugandan population.

Berlin conference

GTZ, WHO and ILO organized a massive ministerial level conference on Social Health Insurance at Berlin in December 2005. The location was historic, as Berlin was the place where social health insurance was conceived in 1883 by Bismarck.

Ministers from various countries in Asia, Africa and Latin America attended the conference and learnt about Social health insurance and its advantages and disadvantages. The Mexican Minister made a very inspiring speech – exhorting other ministers to use technical leverages to get more funding for health. Unfortunately, India was represented only by a Deputy secretary from the Ministry of Finance, who had very little understanding about health insurance.

Proceedings of the workshop are available at the www.commhealthins.org website.

Interesting reading

Below are some reviews of interesting articles for your information. They are of interest both for the practitioner of CHI as well as the academician.

CHIs in Gujarat.

Akash Acharya and Kent Ranson have given us an overview of four CHIs in Gujarat in the article "Health care financing for the poor: CBHI schemes in Gujarat." Published in the EPW in September 2005, the authors describe CHIs organized by SEWA, Tribhuvandas Foundation, Aga Khan Health Services and Navsarjan trust. Most of the readers are familiar with SEWA, so I will not repeat the details here. Tribhuvandas Foundation (TF) is a CHI run by a milk cooperative. The eligible population is the members of the dairy cooperative societies and who provide at least 300 litres of milk per annum and who contribute 3 paisa per litre of milk supplied towards the CHI. In return they are allowed free hospital services in 9 NGO hospitals. The patients have to meet the medicine costs –as a form of co-payment. The entire scheme is subsidized to the tune of 80% by the dairy cooperative through its profits.

The Aga Khan Health services is one of the few CHIs that provide for OP care. Members of the dairy cooperatives are eligible for enrolling, though non members can pay a flat rate of Rs 200 to become members. Contributions are collected at source, like in the TF. The benefit package is limited to ambulatory care. Co-payments are considerable. The enrolment rate is low compared to the TF scheme.

Lessons from SEWA

There is very little evidence that CHIs are effective. While most activists promote any community based venture as the answer, we need to know whether such enterprises actually benefit the poor. Kent Ranson and his team at SEWA have provided us with some evidence about the following two questions:

1. 1. Who joins CHIs?
2. 2. Who benefits from CHIs?

The authors conclude that while both the poor and not poor join the vimo SEWA CHI in equal proportions, the better off seem to benefit more from the scheme than the poor. This is because the tedious measures to stake their claims usually act as a barrier for the poor. Thus to conclude it appears that even in CHIs, the poor appear to be subsidizing the rich. This is an important lesson for us and we need to learn from this and similar tales from Africa. Prof Bart Criel also showed many years ago how those living in the remote rural areas were actually subsidizing the ‘rich’ from the towns. This was mainly because CHIs charge a flat rate, irrespective of the income or the distance from the hospital.

A compilation of CHI schemes in India

Many may have received a hardcopy of this book. Published by FWWB, this book describes 10 CHI schemes in our country. This book is now available as a soft copy on our website for those who are interested.

Lessons from ACCORD / ASHWINI

Continuing in the similar vein as SEWA, N.Devadasan et al has used empirical evidence to show how CHIs can be useful in improving access to hospital care. Preliminary findings of the panel survey "Does CHI increase access to health care for the poor: evidence from India" have been presented at the 9^{th Global Forum for Health Research in September 2005. The results show that there is considerable increase in access to hospital care among insured, even when correcting for distance and chronic patients.}

I hope that you found this newsletter useful and informative. We are open to suggestions and views on how to improve it further. Any volunteers for publishing the next issue in July?

There is considerable interest in health insurance. As practitioners and academicians, we should not get carried away by the wave of enthusiasm. Let us reflect for a moment and review our activities? Are the CHIs really benefiting the poor? Can they be replicated in other contexts? Are they dependent on charismatic individuals? We need to ask these hard questions and provide the others with answers? Currently the policy makers are struggling to find the ‘magic bullet’. We are probably the most experienced in this field and need to step forward and help our country in this matter. Each CHI is a pilot programme that can be of immense learning value. For example, the poorest sections of society –eg. SC/ST etc can only afford to pay Rs 20 – 30 per person per year as premium. This is evident from three schemes that cover SC/ST. Yet the government’s scheme proposes much higher premiums. We need to advocate for a more realistic premium if this section of society is to be covered. We need to share our experiences, so that the government listens to us, rather than to the insurance industry or to academicians who may be far removed from reality.

And finally I would like to close this newsletter with the sad news about the attack on RAHA’s office by misguided elements in the Chattisgarh government. I am sure that most of you have seen the exchange in the egroup. Some of you’ll have helped by talking to people in the corridors of power. This has all helped and I would like to thank you’ll for your support to one of our colleagues.

With regards

Devadasan

Website – www.comhealthins.org - please visit it, there are a lot of new publications on it

Egroup – IGHPM@yahoogroups.com  - for those interested in joining