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Wednesday, Aug 11, 2004

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Community health financing — A Gandhian approach that is modern too

P. Srivatsan

THE health sector has been receiving low priority in India in terms of infrastructure and funds allocation. Even 50 years after Independence, a majority of the people in both rural and urban areas have no access to proper health care and sanitation. One aspect is lack of adequate medical facilities and another is the exorbitant cost which gets aggravated in the absence of an affordable medical insurance for the poor and elderly.

Most poor households, especially in the rural areas, depend on quacks, unqualified practitioners and even faith healers. Even where there are primary health centres, they are mostly dysfunctional or provide low quality services. Studies on the use of health centres show that the poor have to spend a higher proportion of their income on health compared to the rich. In India, even subsidised health schemes tend to be misutilised. A recent survey by the National Council for Applied and Economic Research (NCAER) reveals that the richest 20 per cent of the population enjoys three times the share of the public subsidy for health compared to the poorest quintile.The same study also showed that the poor on an average spend 12 per cent of their income on health care opposed to only 2 per cent by the rich. The cost of in-patient care is also high. According to a World Bank study, on an average a hospitalised Indian spends more than half of his income on health care; more than 40 per cent of the hospitalised people borrow money or sell assets to cover expenses and 35 per cent are below the poverty line.

The high incidence of morbidity cuts into the household budget in two ways, loss of incomes during illness and high cost of treatment. The study also suggests that out of pocket medical costs alone may push 2.2 per cent of the population below the poverty line every year.

There is also a gender bias with men having better access to health care due to various socio-economic and cultural reasons. Poor women are most vulnerable to disease and ill health due to unhygienic living conditions, heavy burden of child bearing and severe constraints in seeking health care for themselves. Because health measures influence, the health status of individuals and families finally impacting on the total community, community involvement in this area, through minimal financial investment, is particularly necessary in rural and under-privileged urban segments. There is also need to put in place mechanisms that will provide for the active involvement of women in the scheme for empowering them.

Recognising this, a pilot UNDP-Government of India project on community initiatives on health has been launched in Kerala, Delhi, Uttaranchal and Uttar Pradesh focussing on children and decentralised health planning.

Community health-care financing in Karnataka and West Bengal, launched on experimental basis, has relevance in the context of privatisation of healthcare. The cost of health insurance makes it beyond the means of the poorer sections of the community. The project is based on combining Gandhian and modern medical approach.

The pilot project aims to explore issues related to the health insurance coverage for the poor, especially women. It has also tried to relate to the structuring and testing of systems of community health financing so as to develop a model capable of replication elsewhere, particularly with women's participation. Before the project was launched, a comprehensive baseline study was undertaken to obtain information on basic features of the local community, use of existing medical facilities in the public and private sectors and acceptance of health insurance. The study was conducted by the Centre for Population Dynamics, a Bangalore-based NGO.

The survey reinforced earlier findings that loans constitute the single largest source of meeting the costs of illness and hospitalisation, followed by the sale of farm assets. Though knowledge of health insurance was not widespread, there was considerable recognition of its utility and willingness to subscribe to affordable insurance schemes. Armed with this knowledge, the project was designed to increase access to public medical care through prepaid insurance, improve quality primary health care facilities and create awareness of the need for preventive health care. The launch of the project was preceded by intensive campaigning through display of strategically placed public hoardings, display of posters and focussed group discussions with community leaders. Capacities of the village health workers, the anganwadi workers, and most of the staff of the public health centres were strengthened to create awareness and promote health insurance, motivate villagers to utilise public health institutions and involve them in health promotion and disease prevention.

Though the project essentially meets the treatment costs and, therefore, addresses the curative component, special effort has been made to include preventive health through strengthening the use of traditional/herbal medicine and training of members of the self help groups (625 members from 28 villages) and interested individuals; provision of herbal saplings (8,000 already provided) for plantation, thus, facilitating growing of herbal and kitchen gardens; and organising workshops to help strengthen capacities for use of herbal medicines. As regards the curative health component, the project addresses both in-patient and outpatient health concerns. Self-help groups (SHGs) have been mobilised. Dedicated savings for health care as well as micro-credit not only pay for the emergency outpatient health expenses but also serve to pay in-patient medical bills upfront because settlement of insurance claims takes time. The project has helped set up some 110 SHGs, which had till last year extended health loans to 202 members.

The highlight of the project is the insurance of in-patient health care expenditures. The pilot is orientated towards the poor, especially the Scheduled Castes and Tribes. For the purpose of insurance, the family has been taken as the unit of membership. For a premium of Rs 30 per person per annum, health insurance coverage is for Rs 2,500. This premium is fully subsidised for those belonging to the Scheduled Castes and Tribes and for those below the poverty line. The project partially subsidises the premium from project funds for those not belonging to the Scheduled Castes and Tribes.

The insurance policy covers all hospitalisation cases (with no disease excluded) at public health facilities. Interestingly, for the first time in the country the insurance has extended coverage to compensate for wage loss. A sum of Rs 50 per day is given to patients for loss of wages. An additional Rs 50 per day is given directly to the hospital for procuring the needed drugs.

To enhance the referral services from the primary health centre to the community health-care centre and further to the district health-care centre and then to the district hospital, special efforts have been made to link all public health-care centres in the taluks where the pilot is being tried.

This connectivity not only helps in facilitating easy communication in case of emergency but also helps in maintaining client health history and claim settlement details. Data till last year shows that a maximum of 45 per cent of the patients are in the 15-35 age group, followed by 40 per cent in the 30-60 age group. In a community where the in-patient rate is 6.5 per 1,000 per annum, it is interesting to note that males account for 54 per cent of the in-patients. The claim ratio has been about 23 per cent of premium paid.

The success of this pilot has generated interest from academics, researchers as well as the State and the Central Governments. While the State government is extending the scheme to cover all those below the poverty line, the Centre is reviewing the project in the light of the national health insurance scheme announced in 2003 to provide health coverage for a premium of Rs 365 per annum.

This is a Gandhian approach with modern inputs. Gaining confidence from this success, the UNDP is now exploring mechanisms for health financing/insurance to include the treatment of HIV/AIDS.

(The author is a Delhi-based freelance writer.)

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