Health Policy and Planning Advance Access published online on October 20, 2009
Health Policy and Planning, doi:10.1093/heapol/czp044
Community health insurance in Gudalur, India, increases access to hospital care
1Institute of Public Health, Bangalore, India.
2Achutha Menon Center for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology (SCTIMST), Trivandrum, Kerala, India.
3Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium.
4Action for Community Organisation, Rehabilitation and Development (ACCORD), Gudalur, Nilgiris, India.
* Corresponding author. Institute of Public Health, 250, 2nd C Main, Girinagar 1st Phase, Bangalore, India – 560085. Telefax: +91–8026421929. E-mail: deva{at}iphindia.org
Background To reduce the burden of out-of-pocket payments on households in India, the government has introduced community health insurance (CHI) as part of its National Rural Health Mission. Indian CHI schemes have been shown to provide financial protection and have the potential to improve quality of care, but do not seem to improve access. This study examines this dimension of CHI performance and explores conditions under which a CHI scheme can improve access to hospital care for the poor.
Methods We conducted a panel survey at the ACCORD-AMS-ASHWINI (AAA) CHI scheme in India. The AAA CHI scheme protects the poorest sections of society against hospitalization expenses. 297 insured and 248 matched uninsured households were observed by village volunteers on a weekly basis for 12 months. Any patient presenting with a ‘major ailment’ in these households was interviewed using a structured questionnaire. Outcomes measured were utilization of hospital services, cost of treatment and quality of treatment received.
Results The two cohorts were similar regarding demographic, social and economic parameters. More insured than uninsured households expressed trust in the CHI scheme organizers. Both groups had similar levels of minor ailments, but the insured had higher incidence of chronic and major ailments. Insured patients had a hospital admission rate 2.2 times higher than uninsured patients, independent of confounding factors. This higher rate among the insured was also found in children and those with pre-existing conditions. Vulnerable sections of the insured population—children, pregnant women, the poorest—had the highest admission rates. Most admissions, in both cohorts, took place in the ASHWINI hospital. Credible and trustworthy organizers, effective providers, low co-payments, and low indirect costs contributed to this result.
Conclusions A well-designed CHI scheme has the potential to improve access to hospital care, even for vulnerable sections of the community—the poorest, individuals with pre-existing conditions like diabetes and hypertension, and pregnant women.
Key Words: Community health insurance, India, utilization, access to care
Accepted for publication 12 August 2009.