Micro Insurance Academy

Delhi, India

Micro Insurance Academy

Delhi, India
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May C.,University of Cologne | Roth K.,University of Cologne | Panda P.,Micro Insurance Academy
BMC Health Services Research | Year: 2014

Background: In 2005, the Indian government launched the National Rural Health Mission (NRHM) to improve the quality of and access to rural public health care. Despite these efforts, recent evidence shows that the rural poor continue to primarily consult private non-degree allopathic practitioners (NDAPs) for acute illness episodes. To examine this phenomenon, we explore the rural poor's perception and utilization of the rural health care system and the role and accessibility of NDAPs therein. Methods. Our study is based on qualitative data from focus group discussions conducted in three rural districts in Bihar and Uttar Pradesh, two high-focus states of the NRHM in northern India, in 2009/2010. Our study population consists of female micro-credit self-help group members and their male household heads. We apply a directed content analysis and use a theoretical framework to differentiate between physical, financial and cultural access to care. Results: Our study population distinguishes between "home treatment" (informal self-care), "local treatment" (formally unqualified care) and "outside treatment" (formally qualified care). Because of their proximity, flexible payment options and familiarity with patients' belief systems, among other things, local NDAPs are physically, financially and culturally accessible. They are usually the first contact points for patients before turning to qualified practitioners, and treat minor illnesses, provide first relief, refer patients to other providers and administer formally prescribed treatments. Conclusion: Our findings are similar for all three study sites and reinforce recent findings from southern and eastern India. The poor's understanding and utilization of the rural health system deviates from governmental ideas. Because of their embeddedness in the community, private NDAPs are the most accessible medical providers and first contact points for acute illness episodes. Thus, they de-facto fulfill the role envisaged by the Indian government for accredited social health activists introduced as part of the NRHM. We conclude that instead of trying to replace NDAPs with public initiatives, the Indian government should regulate, qualify and integrate them as part of the existing public health care system. This way, we argue, India can improve the rural poor's access to formally qualified practitioners. © 2014 May et al.; licensee BioMed Central Ltd.


Binnendijk E.,Erasmus University Rotterdam | Koren R.,Tel Aviv University | Dror D.M.,Micro Insurance Academy
Tropical Medicine and International Health | Year: 2012

Objective Non-communicable diseases (NCD) are on the increase in low-income countries, where healthcare costs are paid mostly out-of-pocket. We investigate the financial burden of NCD vs. communicable diseases (CD) among rural poor in India and assess whether they can afford to treat NCD. Methods We used data from two household surveys undertaken in 2009-2010 among 7389 rural poor households (39205 individuals) in Odisha and Bihar. All persons from the sampled households, irrespective of age and gender, were included in the analysis. We classify self-reported illnesses as NCD, CD or 'other morbidities' following the WHO classification. Results Non-communicable diseases accounted for around 20% of the diseases in the month preceding the survey in Odisha and 30% in Bihar. The most prevalent NCD, representing the highest share in outpatient costs, were musculoskeletal, digestive and cardiovascular diseases. Cardiovascular and digestive problems also generated the highest inpatient costs. Women, older persons and less-poor households reported higher prevalence of NCD. Outpatient costs (consultations, medicines, laboratory tests and imaging) represented a bigger share of income for NCD than for CD. Patients with NCD were more likely to report a hospitalisation. Conclusion Patients with NCD in rural poor settings in India pay considerably more than patients with CD. For NCD cases that are chronic, with recurring costs, this would be aggravated. The cost of NCD care consumes a big part of the per person share of household income, obliging patients with NCD to rely on informal intra-family cross-subsidisation. An alternative solution to finance NCD care for rural poor patients is needed. © 2012 Blackwell Publishing Ltd.


Binnendijk E.,Erasmus University Rotterdam | Dror D.M.,Erasmus University Rotterdam | Dror D.M.,Micro Insurance Academy | Koren R.,Tel Aviv University
Social Science and Medicine | Year: 2013

Community-Based Health Insurance (CBHI) (a.k.a. micro health insurance) is a contributory health insurance among rural poor in developing countries. As CBHI schemes typically function with no subsidy income, the schemes' expenditures cannot exceed their premium income. A good estimate of Willingness-To-Pay (WTP) among the target population affiliating on a voluntary basis is therefore essential for package design. Previous estimates of WTP reported materially and significantly different WTP levels across locations (even within one state), making it necessity to base estimates on household surveys. This is time-consuming and expensive. This study seeks to identify a coherent anchor for local estimation of WTP without having to rely on household surveys in each CBHI implementation. Using data collected in 2008-2010 among rural poor households in six locations in India (total 7874 households), we found that in all locations WTP expressed as percentage of income decreases with household income. This reminds of Engel's law on food expenditures. We checked several possible anchors: overall income, discretionary income and food expenditures. We compared WTP expressed as percentage of these anchors, by calculating the Coefficient of Variation (for inter-community variation) and Concentration indices (for intra-community variation). The Coefficient of variation was 0.36, 0.43 and 0.50 for WTP as percent of food expenditures, overall income and discretionary income, respectively. In all locations the concentration index for WTP as percentage of food expenditures was the lowest. Thus, food expenditures had the most consistent relationship with WTP within each location and across the six locations. These findings indicate that like food, health insurance is considered a necessity good even by people with very low income and no prior experience with health insurance. We conclude that the level of WTP could be estimated based on each community's food expenditures, and that this information can be obtained everywhere without having to conduct household surveys. © 2012 Elsevier Ltd.


Binnendijk E.,Erasmus University Rotterdam | Koren R.,Tel Aviv University | Dror D.M.,Erasmus University Rotterdam | Dror D.M.,Micro Insurance Academy
BMC Health Services Research | Year: 2012

Background: This study examines health-related "hardship financing" in order to get better insights on how poor households finance their out-of-pocket healthcare costs. We define hardship financing as having to borrow money with interest or to sell assets to pay out-of-pocket healthcare costs. Methods. Using survey data of 5,383 low-income households in Orissa, one of the poorest states of India, we investigate factors influencing the risk of hardship financing with the use of a logistic regression. Results: Overall, about 25% of the households (that had any healthcare cost) reported hardship financing during the year preceding the survey. Among households that experienced a hospitalization, this percentage was nearly 40%, but even among households with outpatient or maternity-related care around 25% experienced hardship financing. Hardship financing is explained not merely by the wealth of the household (measured by assets) or how much is spent out-of-pocket on healthcare costs, but also by when the payment occurs, its frequency and its duration (e.g. more severe in cases of chronic illnesses). The location where a household resides remains a major predictor of the likelihood to have hardship financing despite all other household features included in the model. Conclusions: Rural poor households are subjected to considerable and protracted financial hardship due to the indirect and longer-term deleterious effects of how they cope with out-of-pocket healthcare costs. The social network that households can access influences exposure to hardship financing. Our findings point to the need to develop a policy solution that would limit that exposure both in quantum and in time. We therefore conclude that policy interventions aiming to ensure health-related financial protection would have to demonstrate that they have reduced the frequency and the volume of hardship financing. © 2012 Binnendijk et al; licensee BioMed Central Ltd.


Gautham M.,Erasmus University Rotterdam | Binnendijk E.,Erasmus University Rotterdam | Koren R.,Tel Aviv University | Dror D.M.,Erasmus University Rotterdam | Dror D.M.,Micro Insurance Academy
Indian Journal of Medical Research | Year: 2011

Background & objectives: Against the backdrop of insufficient public supply of primary care and reports of informal providers, the present study sought to collect descriptive evidence on 1 st contact curative health care seeking choices among rural communities in two States of India - Andhra Pradesh (AP) and Orissa. Methods: The cross-sectional study design combined a Household Survey (1,810 households in AP; 5,342 in Orissa), 48 Focus Group Discussions (19 in AP; 29 in Orissa), and 61 Key Informant Interviews with healthcare providers (22 in AP; 39 in Orissa). Results: In AP, 69.5 per cent of respondents accessed non-degree allopathic practitioners (NDAPs) practicing in or near their village; in Orissa, 40.2 per cent chose first curative contact with NDAPs and 36.2 per cent with traditional healers. In AP, all NDAPs were private practitioners, in Orissa some pharmacists and nurses employed in health facilities, also practiced privately. Respondents explained their choice by proximity and providers' readiness to make house-calls when needed. Less than a quarter of respondents chose qualified doctors as their first point of call: mostly private practitioners in AP, and public practitioners in Orissa. Amongst those who chose a qualified practitioner, the most frequent reason was doctors' quality rather than proximity. Interpretation & conclusions: The results of this study show that most rural persons seek first level of curative healthcare close to home, and pay for a composite convenient service of consulting-cum-dispensing of medicines. NDAPs fill a huge demand for primary curative care which the public system does not satisfy, and are the de facto first level access in most cases.


Panda P.,Micro Insurance Academy | Panda P.,Institute for Human Development | Chakraborty A.,Micro Insurance Academy | Dror D.M.,Micro Insurance Academy | And 3 more authors.
Health Policy and Planning | Year: 2014

This article assesses insurance uptake in three community-based health insurance (CBHI) schemes located in rural parts of two of India's poorest states and offered through women's self-help groups (SHGs). We examine what drives uptake, the degree of inclusive practices of the schemes and the influence of health status on enrolment. The most important finding is that a household's socio-economic status does not appear to substantially inhibit uptake. In some cases scheduled caste/scheduled tribe households are more likely to enrol. Second, households with greater financial liabilities find insurance more attractive. Third, access to the national hospital insurance scheme Rashtriya Swasthya Bima Yojana does not dampen CBHI uptake, suggesting that the potential for greater development of insurance markets and products beyond existing ones would respond to a need. Fourth, recent episodes of illness and self-assessed health status do not influence uptake. Fifth, insurance coverage is prioritized within households, with the household head, the spouse of the household head and both male and female children of the household head, more likely to be insured as compared with other relatives. Sixth, offering insurance through women's SHGs appears to mitigate concerns about the inclusiveness and sustainability of CBHI schemes. Given the pan-Indian spread of SHGs, offering insurance through such groups offers the potential to scale-up CBHI. © 2013 Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine © The Author 2013.


Panda P.,Micro Insurance Academy | Chakraborty A.,Micro Insurance Academy | Dror D.M.,Micro Insurance Academy | Dror D.M.,Erasmus University Rotterdam
Indian Journal of Medical Research | Year: 2015

Background & objectives: Despite remarkable progress in airborne, vector-borne and waterborne diseases in India, the morbidity associated with these diseases is still high. Many of these diseases are controllable through awareness and preventive practice. This study was an attempt to evaluate the effectiveness of a preventive care awareness campaign in enhancing knowledge related with airborne, vector-borne and waterborne diseases, carried out in 2011 in three rural communities in India (Pratapgarh and Kanpur-Dehat in Uttar Pradesh and Vaishali in Bihar). Methods: Data for this analysis were collected from two surveys, one done before the campaign and the other after it, each of 300 randomly selected households drawn from a larger sample of Self-Help Groups (SHGs) members invited to join community-based health insurance (CBHI) schemes. Results: The results showed a significant increase both in awareness (34%, p<0.001) and in preventive practices (48%, P=0.001), suggesting that the awareness campaign was effective. However, average practice scores (0.31) were substantially lower than average awareness scores (0.47), even in post-campaign. Awareness and preventive practices were less prevalent in vector-borne diseases than in airborne and waterborne diseases. Education was positively associated with both awareness and practice scores. The awareness scores were positive and significant determinants of the practice scores, both in the pre- and in the post-campaign results. Affiliation to CBHI had significant positive influence on awareness and on practice scores in the post-campaign period. Interpretation & conclusions: The results suggest that well-crafted health educational campaigns can be effective in raising awareness and promoting health-enhancing practices in resource-poor settings. It also confirms that CBHI can serve as a platform to enhance awareness to risks of exposure to airborne, vector-borne and waterborne diseases, and encourage preventive practices. © 2015, Indian Council of Medical Research. All rights reserved.


Dixit S.,Micro Insurance Academy | Panda P.,Micro Insurance Academy
International Journal of Geoinformatics | Year: 2013

Most of the cluster randomized controlled trials (CRCTs) are conducted in a geographical area, but the present CRCT evaluation model does not capture "place" component. CRCTs reported without providing the information on spatio-temporal changes taking place at the experiment site, during the course of intervention, present only a part of the picture and also pose a great difficulty in finding out causal relationship between the intervention and outcome. We conclude that a complete evaluation model should have tools to capture people, place and time. Usually, "people" are captured using quantitative tools and "time" component is taken using different waves of data collection, "place" dimension needs to be integrated to make CRCT evaluation more comprehensive and effective. This research article reports the spatial methodological protocol followed in a project that assesses the impact of community-based health insurance schemes in rural India and demonstrates various advantages of incorporating spatial tools in the evaluation model. Results highlight the potential for applying this methodology in other studies. © Geoinforniatics International.


Ranga V.,Micro Insurance Academy | Panda P.,Micro Insurance Academy
Geospatial Health | Year: 2014

Access to health care in rural areas is a major concern for local populations as well as for policy makers in developing countries. This paper examines spatial access to in-patient health care in northern rural India. In order to measure spatial access, impedance-based competition using the Three-Step floating Catchment Area (3SFCA) method, a modification of the simple gravity model, was used. 3SFCA was chosen for the study of the districts of Pratapgarh and Kanpur Dehat in the Uttar Pradesh state and Vaishali in the Bihar state, two of India's poorest states. This approach is based on discrete distance decay and also considers more parameters than other available methods, hence is believed to be a robust methodology. It was found that Vaishali district has the highest spatial access to in-patient health care followed by Pratapgarh and Kanpur Dehat. There is serious lack of health care, in Pratapgarh and Kanpur Dehat with 40% and 90% of the villages having shortage of in-patient care facilities in these respective districts. The most important factor affecting spatial access was found to be the distance to the nearest major urban agglomeration.


Panda P.,Micro Insurance Academy | Chakraborty A.,Micro Insurance Academy | Dror D.M.,Micro Insurance Academy | Dror D.M.,Erasmus University Rotterdam
Tropical Medicine and International Health | Year: 2015

Objective: To evaluate an insurance awareness campaign carried out before the launch of three community-based health insurance (CBHI) schemes in rural India, answering the questions: Has the awareness campaign been successful in enhancing participants' understanding of health insurance? What awareness tools were most useful from the participants' point of view? Has enhanced awareness resulted in higher enrolment? Methods: Data for this analysis originates from a baseline survey (2010) and a follow-up survey (2011) of more than 800 households in the pre- and post-campaign periods. We used the difference-in-differences method to evaluate the impact of awareness activities on insurance understanding. Assessment of usefulness of various tools was carried out based on respondents' replies regarding the tool(s) they enjoyed and found most useful. An ordinary least square regression analysis was conducted to understand whether insurance knowledge and CBHI understanding are related with enrolment in CBHI. Results: The intervention cohort demonstrated substantially higher understanding of insurance concepts than the control group, and CBHI understanding was a positive determinant for enrolment. Respondents considered the 'Treasure-Pot' tool (an interactive game) as most useful in enhancing awareness to the effects of insurance. Conclusions: We conclude that awareness-raising is an important prerequisite for voluntary uptake of CBHI schemes and that interactive, contextualised awareness tools are useful in enhancing insurance understanding. © 2015 John Wiley & Sons Ltd.

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