Data Analysis and Findings - Shodhgangashodhganga.inflibnet.ac.in/bitstream/10603/12250/13/13_chapter 4.p… · The Sampoorna Suraksha was started as an integral part of the tradition

Data Analysis and Findings

Data Analysis and Findings Chapter 4

Acceptability and Effectiveness of Two Community Based Health Insurance Schemes P a g e | 69

Data Analysis and Findings

This chapter is a culmination of the study, by describing the analysis and interpretation

of the data. This chapter is an effort to objectively address all the three research questions

systematically, so that conclusions can be arrived at on the basis of the analysis described in the

subsequent pages.

Reiterating the objectives of the study:

1. To describe the technical and organizational characteristics of the two community based

health insurance schemes, Manipal Arogya Suraksha and Sampoorna Suraksha.

2. To find out the determinants of acceptability of the two schemes among people who

were the beneficiaries in comparison to those who were not enrolled for either of the

schemes.

3. To find out the performance of the schemes Manipal Arogya Suraksha and Sampoorna

Suraksha

4.1: A brief overview

The study used both quantitative and qualitative methods of data collection, as per the

methodology. The quantitative data collection was followed by carrying out a household survey

among representative sample of the beneficiaries of both Manipal Arogya Suraksha; Sampoorna

Suraksha and a sample of people who had not enrolled for any of the schemes. The qualitative

study was carried out by using two focus group discussions each among the beneficiaries, one

among the non-enrolled and one each among the field supervisors of the schemes.

The data collected was subjected through a quality check and analysis in case of the

quantitative data by appropriate methods in SPSS version 20 The report of the focus group

discussion was prepared after following certain set procedures for interpreting the discussion.

4.2: Assumptions, variables, variable descriptions and statistical tools used

The following assumptions were stated for the study, for interpreting the quantitative data;

4.2.1 Socio-demographic profile of the study population and the surveyed households, health

status are determinants of acceptability of the schemes.

The individual level variables (age, gender, marital status, literacy status and

occupational status) and household level variables (age and gender of household head,



socio-economic status as per Udai Pareekh Scale, average household expenditure on

health, type of family, size of household, number of adults, children, women and elderly

in the family). A chi-square test was carried out to find out the association between

insurance status and the above mentioned variables. Therafter the variables which

showed significant association were then subjected to a multivariate analysis using

binary logistic regression. In the regression model ‘1’ was acceptability of the CBHI

scheme and ‘0’ was non-acceptability. The results were then interpreted accordingly.

The potential variables were included by considering all the variables which showed

statistical significance in the univariate analysis. The p –value of <0.05 was considered in

contrary to the usual practice of including p<0.1 to 0.15.This was necessary as in cases

where variables where the p-values of the univariate analysis were anywhere between

0.05 to 0.1, the differences between the comparison groups were insignificant, the

possibility of such a p-value might have been due to the large sample size.

4.2.2 Revenue collection, out of pocket expenditure, trend of enrolment, perception of

beneficiaries are significant factors influencing the performance of the scheme.

Chi-square test for association was carried out find out the perception of

beneficiaries towards the scheme they enrolled. A Mann-Whitney -U test was carried

out to find out the differences in the out of pocket expenditure between the two

schemes.

4.3 Organization of the analysis of data

The analysis and interpretation of the data is described as follows:

Section 1(4.4): This section presents the findings which fulfils the first objective of the study

.The technical and organizational characteristics of the two community based health insurance

schemes MAS and SS have been divided under the following heads:

Scheme benefit package

Institutional arrangement

Risk management

Section 2(4.5): This section present the findings of the quantitative data interpretations under

the following heads, categorised according to the insurance status of the study population and

surveyed households.

Baseline Socio demographic profile the study population

Baseline Socio demographic profile the surveyed households



Household expenditure for health and others

Morbidity and health status of the study population

Determinants of acceptability (Results of Univariate and Multivariate analysis)

Coverage details among the beneficiaries of MAS and SS

Out of pocket expenses of the beneficiaries

Rating of services of the among beneficiaries of MAS and SS

Summary of responses of non-enrolled

Section 3(4.6): This section presents the findings of the Focus Group Discussions under the

following heads:

MAS beneficiaries

SS beneficiaries

Non-Insured

4.4 Section 1: Technical and Organizational Characteristics

Technical and Organizational Characteristics of the CBHI schemes: Manipal Arogya Suraksha and

Sampoorna Suraksha.3

The first objective of the study was to find out details about the functioning of the

schemes in terms of its technical and organizational characteristics. This was done by collecting

the data in the following ways:

1. In-depth interviews with the managers of the schemes

2. Focus group Discussion with the supervisors of the scheme

3. Secondary data from the organizations’ records

This chapter is further divided into the following sections:

A brief introduction of the schemes - MAS and SS

Scheme Benefit Package

Institutional Arrangement

Risk Management Strategies

3 Bhageerathy Reshmi, Noore Sanah,Sreekumaran Nair and Bhaskaran Unnikrishnan (2011). An Evaluation of two health insurance schemes in India. British Journal of Healthcare Management.Vol 17(8):353-359



The following is an overview of the two schemes

Manipal Arogya Suraksha (MAS)

The MAS was initiated in the year 2005, as a social initiative by the Manipal Group, to provide

subsidized health care facilities to the Konkani linguistic minority group in coastal Karnataka.

This was then extended to a population along the geographic area covering coastal Karnataka,

northern districts of Kerala and Goa covering a population of 2.65 lakhs.

Sampoorna Suraksha (SS)

The Sampoorna Suraksha was started as an integral part of the tradition of disbursing charity

prevalent at a temple trust an important place of worship in the coastal part of the state which is

the Shree Kshetra Dharmasthala Rural Development Project (SKDRDP). There are about

11,76,906 members, covering nine districts of Karnataka participating in this programme by

contributing an annual subscription. A part of the total subscription amount is invested in

Insurance companies to look after the hospitalization expenses and the remaining amount is

used in emergencies like births and deaths, natural calamity. The programme has been

formulated after study of different health insurance models in the country.

Table 4.1: Scheme Benefit Package and Premium

Characteristics MAS SS

Year of Initiation 2005 2004

Scheme benefit package and premium

Premium (for a family of five) Rs 350 Rs 800

Package Rs 30000 Rs25,000

Co-payment Exist Exist

4.4.1. Scheme Benefit Package and Premium of MAS

This scheme offers a medical coverage up to Rs. 30,000 per family, on a family floater basis per

year. The family size is restricted to seven members’ consisting of the proposer, spouse,

dependent children and parent(s)/parent(s)-in-law. The scheme covers outpatient discount and

hospitalisation expenses incurred due to accident or illness. In addition to this the members are

also covered under a personal accident policy which pays up to 100% of the sum insured in case

of death/permanent total disablement due to rail/road accident or 50% in case of partial total

disablement. The members are entitled to avail unlimited outpatient benefits at the stipulated

discount rates and are entitled to get admitted in general wards for inpatient service. The

coverage of Rs 30000 is irrespective of the number of members enrolled.



Table 4.2: Outpatient facilities are:

Outpatient Department Discount

Consultation fees 100%

Diagnostic services 25%

Method of treatment/surgery(including professional fees) 25%

C.T scan, M R I doctors’ fees included 25%

Dental treatment (in outpatient department and excluding

consumables/materials/implant)

25%

Dialysis 100%

Medicines (doctors drug card must be shown) 10%

Inpatient facilities are described as under:

Any of the family members admitted as inpatient in the hospital because of any illness or

accident, can avail Rs 30000 medical costs from the scheme. Members of this scheme are eligible

to get general ward facilities. Admission to any other than general ward will necessitate

payment of difference in the bill. In this scheme only first two delivery expenditure are

permitted. Newly born child care expenditure not covered in this scheme. Within the period of 1

year if any of the family member has died in accident or lost both eyes or part of bodies such as

limbs will be entitled to the full sum insured that is Rs 30,000 and in case of partial disability it

will be Rs 15,000

The following costs are available under this scheme if admitted as inpatient in hospital,

these are inclusive of Room fees, bed fees / nursing fees/surgeon doctor fees, anesthesia fees/

operation fees, medicine, cost of laboratory, blood. Oxygen, x-ray, Dialysis, chemotherapy,

radiotherapy. The cost of hospitalization exceeding this amount are have to be borne by the

beneficiary. Co-payment-For admission cases co-payment of Rs 500 is levied on the beneficiaries



Table 4.3 Coverage limit of procedures

Procedure Cost covered in Rs.

Hysterectomy 10000

Appendectomy 8000

D H S surgery 12000

Lithotripsy 10000

Hernia 10000

Tonsillectomy 4000

Cataract 4000

Pace maker implantation 10000

Normal delivery 5000

Delivery Caesarean Section 7500

FIG 4.1: Hospitalization process followed by MAS



Details about exclusion from the scheme

Administrative expenditure:

Entry fees of Rs 500, registration fees, medico/ legal charges, attendant day charges, additional

charges, gate pass/attendant pass, overhead charges, establishment charges, tax/surcharges,

incidental charges and waste disposal charges.

Other Services:

Naturopathy, Ayurveda treatment, private nanny cost, telephone cost, Xerox/fax cost,

TV/internet cost, water/electricity, newspaper, AC, stationery, linen / laundry cost, mortuary,

coffin and ambulance cost etc.

Cost of record collection:

Cost of medical records, cost of the record collection, birth/death certificate and medical

certificate.

The use of appliances:

bed/ air cushion, ultra ted hot water bag, bed fan/ kidney tray/ sputum cup, crutches/walker,

sling bag, sling/cap splints, knees belt, abdominal belt, nebulizer /steam inhaler/ Temperature

gauge spacer, chest binder mirror/ lens/ humidifier spirometer, Spectacles/frame, denture/list

of dental/dental implant, speech aids/BP control equipments, other preventive equipments,

glycometer, feeding bottle, cradle cost. Antiseptic/ infection prevention solutions, soap/powder,

oil/cream tissue paper, toilet paper, oxygen, cassette /CD/film cost

Special note:

1. The plan does not apply to group of KMC (Kasturba Medical College) evening clinic and other

special payable clinic.

2. One identity card is provided to 5 members of one family.

3. Without any pre-communication project sponsors can change the facilities and membership

fees.

4.4.2. Scheme Benefit Package and of Sampoorna Suraksha

Facilities are described as under:

There is a membership renewal drive every year. Every family has to renew its membership

every year by paying the specified amount. There is a flexibility to pay the premium can be

collected on a weekly basis also. Yearly contribution is collected along with the weekly savings of



the members of the self-help group so that it does not strain the finance of the family. Every

family has to renew its membership every year by paying the specified amount. A family of five

members can get cashless treatment for a whole year up to the family limit Rs.25000/- at a

contribution of Rs.800-00 by paying the amount 20-00 per week for 40 weeks. Health security

and other benefits for just Rs.2.85 per day for 5 members. In a single member family, they get

cashless treatment to the maximum of Rs 5000/- For more members in the family cover under

the programme, increases by Rs 5000/-per member. The coverage is on floater basis in

multiples of Rs.5000/-per person. In case of necessity, any one member of the family can avail

the benefits for any one ailment to the extent of maximum limit available to the family. The Zero

rejection policy ensures that no persons admitted to hospital will be denied of settlement if he

makes claim under the scheme. In case of normal/accidental death of stake holder of the family

(head of the family) Rs 5000/- and Rs. 2000/- in case of members will be paid to the nominee as

consolation within 24 hours of death. In case of accidental death of stake holder of the family, Rs

20,000 additional amount will be paid to the nominee. In case of disability of the primary

member of the family Rs.12500/- is given as consolation for partial disability, Rs.25000/- in case

permanent full disability. Maternity expenses reimbursement of first two deliveries of the

members of Sampoorna Suraksha at Rs.2000/- for normal delivery and Rs.5000 for caesarean

delivery. In case of delivery at home Rs. 1500 maternity allowance for the first members and Rs.

750/-for the members. In case the beneficiary under goes domiciliary treatment and not able to

attend to his routine work, compensatory allowance at Rs.50/- per day maximum for 30 days is

paid depending on his domiciliary treatment. In case the dwelling house of the family is

damaged due to natural calamities such as cyclone, heavy rainfall etc. consolation amount

maximum Rs.1000/- is paid to the family. Approval from other members of family is needed to

utilize the amount of the primary /registered members to be used in the treatment of a single

member.

Prerequisites and conditions to follow for the beneficiaries to get cashless treatment:

Sampoorna Suraksha treatment facilities are available on only cashless treatment., which

requires a preauthorization from the network hospital. It has to be submitted within 24

hours of hospitalization. The sevaniratha has to be informed about the admission.

Treatment and operation facilities available on the basis of package and facility will be

applicable only for general ward. On the basis of disease severity, related test reports

and treatment method will account to get cashless facilities. There are few outpatient

facilities like fracture, dialysis, and chemotherapy are available in under cashless



treatment. The registration information details should conform to the information in the

hospital. A confirmation from the SS authorities required with in 24 hours of admission.

In case of any queries regarding suraksha facilities, problems and doubts in hospital, the

beneficiaries have to contact Sampoorna Suraksha helpdesk, stationed at the network

hospitals. In case of differences in the hospital registration and suraksha registration

form an affidavit to hospital and fax to suraksha office, only then it will considered for

which a copy of affidavit has to be given to the hospital for the purpose of claim

settlement.

Exclusion criteria:

Outpatient treatment expenditure, dental treatment including cosmetic surgery and treatment of

external derived defects, voluntary abortion, delivery, infertility, pregnancy related treatment or

operation, the disease is caused by intoxication, substance abuse, aids and STD venereal disease

treatment, attempted by suicide by poisoning ingestion or wound healing, without specific

treatment for all types of treatment cost, cost of physiotherapy, natural treatment, traditional

healing treatment cost, physical weakness or anemia treatment all kind of vaccine and

vaccination, spectacles, crutches, belts and speech and hearing aids cost, hospital registration

fees, ambulance, food, transport cost, telephone cost etc. natural calamities like earthquake,

cyclone, tsunami, war and transmission of infectious diseases caused by the treatment or

surgery and treatment cost.

Eligibility rules:

Other than hospital treatment facilities SKDRDP also provides other financial support through

Sampoorna Suraksha. The Executive director is only authorised to take a final decision in this

regard. In one family of more than five members or at least family 5 members have to enroll. In

case of women needing maternity benefits, then they have to enroll their husband also. If it is for

the second delivery, they have to enroll first child name, too avail concession. This way entitles

them to more provisions under the scheme. Only two delivery facilities are permitted in this

scheme, in case of institutional delivery, a normal delivery entitled to an amount of Rs. 2,500 and

a caesarean section Rs. 5000. It is subject to submission of all the details of hospitalization, like

producing bills and discharge summary from the hospital. The hospital need not be a network

hospital, it can be a Government hospital or any nursing home too .In case of home delivery a

doctors confirmation letter and child’s birth certificate, then only first member will entitled the

woman beneficiary get Rs.1500. A wage loss compensation at the rate of Rs 50 per day while



undergoing treatment for an ailment is permitted .The treating doctor needs to certify the

gravity of the problem, only then he/she will be entitled to this benefit. The primary member, in

case of a loss to any of his body parts such as eye or limbs in an accident they are entitled to

Rs12,500; if it is more than one limb or a permanent disability they are entitled to a disability

benefit of Rs25,000. In this regard a disability certificate has to be produced from district health

officer and with an identity proof. In case of death of primary member who passed away a

natural death, the nominee is entitled to Rs 5000 and for secondary /dependent members the

amount is Rs 2000 .In case of primary member’s death due to accident, the family will get total

Rs 25000. They have to submit death certificate, first information report, inquest report, test

report, to avail the claim.

Table 4.4: Institutional Arrangement

Institutional arrangement

MAS SS

Model of CBHI Linked model Linked Model

Network with

providers

Seven Manipal group in Udupi

and Karkala

Eight each in Udupi and Karkala

taluk

Provider payment

mechanism

Through insurance company Through insurance company

Tie –up with insurance

companies

One general insurance

company-ICICI Lombard

Four general insurance

companies- National Insurance,

Oriental Insurance, United

Insurance, New India Assurance

Existence of entry

point& criteria for

scheme membership

Clusters identified by Manipal

Foundation, Beneficiaries

under RMCW homes

Members of Self Help Groups

patronized by SKDRDP

4.4.3: Tie-up with insurance company

ICICI Lombard is the general insurance company which offers this scheme to low income groups.

It is insures on a group premium basis the community groups (or clusters) who are members of

as churches, temples and self-help groups. The facilities under this plan can be availed at 11 of

the network hospitals of the Manipal Group. Administration of the product is shared between

ICICI Lombard which is a general insurance company based in India and the Manipal Group.



Manipal Foundation, a corporate social responsibility team of the Manipal Group is engaged

closely with the scheme in identifying the poor households who cannot afford to pay premiums

for this scheme. This foundation provides premium subsidies in varying proportions to families

who cannot afford the premiums. The enrolment of the members who are given the card free of

cost takes place through RMCW centres (These are centres which are under the field practice

area of the Department of Community Medicine, Kasturba Medical College, Manipal, which is a

constituent institution of Manipal University) those visiting these health centres for primary

health care. The field staff of these centres are involved in enrolling members for the scheme.

The scheme extend benefits to approximately 60,000 members of these centres by insuring

them under the scheme. This would ensure that the members get quality health care at

affordable costs and network hospitals will benefit with referrals generated out of these

members. The enrolment is usually renewed annually. For the other areas there are agents and

volunteers who are involved in coordinating with the trusts which enroll their members into the

schemes. They are usually the linguistic minority groups, socially backward groups and

members affiliated to religious trusts.

Fig 4.2: Hospitalization process followed by SS

The members of, Self-help groups of SKDRDP and their family members, staff of SKDRDP

and Shree Ksethra Dharmasthala institutions and their family members, can enroll under the



scheme for 12 months commencing from 1st April to be renewed every year by paying the

specified premium. Family will be given registration form cum policy document to be preserved

and produced to the hospitals whenever requires admission and cashless treatment facility. The

enrolment takes place every year during February-March. The supervisors of SKDRDP will

register the members to the scheme through its village level field staff and collect contribution.

The enrolled member’s record is maintained at SKDRDP office. Arrangement is made for

providing cashless treatment claims from hospitals are processed and submitted to the insurer.

The Insurance company verifies the submitted claims and remit the claim amount to SKDRDP.

The facility is provided through sixteen network hospitals in Udupi district with whom the

organization has arranged. On providing medical service and hospitalization services, these

network hospitals with receive the claim settlement amount from SKDRDP.

Criteria for membership

The following Self-help groups are which are sponsored by the SKDRDP: praghti bandhu,

jnana vikasa, nava jeevana sameethi group members and their family members.

Any employee and their family members of the SKDRDP.

Age limit 3 months to 80 years and living in same house.

The SHG members can enroll through the through sevanirathas.

The employees can enroll through their section managers.

Enrollment requirements

The name, age and relationship to household head should be provided, and then the

membership is activated, once the payment modalities are completed. The group members need

to certify the membership, if it is a new membership. The sevanirathas would complete the

enrollment process and the person /household is eligible for the cashless hospitalization. The

list of beneficiaries submitted to the network hospital should also conform to the details.

Table 4.5: Risk Management Provision of the CBHI schemes

Risk management MAS SS

Moral hazards Control exists Control Exists

Adverse selection No Control exists No Control exists

Waiting period NIL NIL

Risk pooling Community enrolment Community enrolment



The design aspect of moral hazard is likely when the consumer of beneficiary tends to

over consume the services for which they actually do not pay the costs and the hospital trying to

inflate the cost of services. The institutionalization of the arrangement by having a tie up with

one insurance company in case of MAS and four, in case of SS to a great extent eliminates the

possibility of moral hazard. The insurance companies reimburses the coverage claims to the

hospital directly, thereby creating checks for the hospital and the beneficiary to detest them

from attempting any discrepancy.

The next is adverse selection, households with sick or chronically ill members enroll in

large numbers in to an insurance scheme, thereby affecting the viability of such a scheme. Here

in the case of both MAS and SS there were no controls which existed to check it, as the exclusion

of those with pre-existing illness was not undertaken, like that of any other insurance product.

There was no waiting period for utilizing the facilities and benefits for both the schemes,

and the beneficiaries could avail the benefits once they are enrolled, barring few administrative

procedures, once the enrollment process is completed.

The aspect of risk pooling is taken care of since both the schemes enroll the members

either as a household a cluster, through SHGs and other community groups, this will ensure that

selectively only the sick or ill members of a family or household cannot enroll in the scheme.

4.5 Section 2: Determinants of Acceptability of CBHI Schemes

The following section describes the results of the quantitative analysis of the house hold serve

which was carried out among 1639house hold. The insured households were 1108 in number,

whereas the no-insured were 530. This made out there total study population to 3558 who were

insured and 1348 who were not insured

4.5.1: Baseline Socio-demographic Characteristics of the Study Subjects4

The following set of tables describes the socio-demographic characteristics of the study

population in terms of age, gender, marital status, literacy and occupational status. A comparison

has been carried out between the insured and the non-insured population.

4 Presented as a paper Reshmi. B and Nair. N.S “Acceptability of Two Community Based Health Insurance Schemes in Karnataka “ in the 56th Annual National Conference of Indian Public Health Association , “IPHACON 2012” held from 10th to 12th February 2012.



Table 4.6: Distribution of the study population according to age

Age group

in Years

Insured

(n=3558)

No (%)

Non-Insured

(n=1348)

No (%)

Chi-Square

(P-Value)

<20 1014(28.4) 426(31.6)

7.02 (0.072) 20-40 1748(49.2) 658(48.8)

41-60 610(17.1) 208(15.4)

>60 186(5.3) 56(4.2)

The table 4.6 depicts the comparison of age between the insured and the non-insured

study population. Majority of the study subjects were in the age group of 20-40 years, followed

by that of less than 20 years. The insured had 49.2% in the 20-40 age category which was the

majority and in case of non-insured it was 48.8%.

Table: 4.7: Distribution of the study population according to gender

Gender Insured (n=3558)

No (%)

Non-Insured (n=1348)

No (%)

Chi-Square

(P-Value)

Male 1597(44.9) 569(42.2) 2.86(0.091)

Female 1960(55.1) 779(57.8)

The gender distribution of the study population as described in table 4.7, depicts that

majority of the population were female, closely followed by the male population. The female

population represented 55.1% in the insured, whereas it was 57.8 % in the non-insured group.

Table 4.8: Distribution of the study population according to marital status

Marital Status Insured (n=3490)

No (%)


No (%)

Chi-Square

(P-Value)

Married 1829(52.4) 633(47.1) 21(<0.0001)

Unmarried 1633(46.8) 709(52.8)

Widowed 28(0.8) 1(0.1)



The above table on the marital status it was found that majority (51.1%) of the insured

population were married as compared to the non-insured group, the majority (52.6%) were

unmarried. This association was found to be statistically significant

Table 4.9: Distribution of the study population according to literacy status

Literacy Status Insured (n=3271)

No (%)


No (%)

Chi-Square (P-

Value)

Illiterate 20(0.6) 39(3.0)

30.6(<0.001)

Primary School 99(3.0) 56(4.3)

Secondary School 2263(69.2) 801(60.9)

Pre-University 506(15.5) 202(15.3)

Graduate &Above 383(11.7) 218(16.6)

The table 4.9 describes the literacy status of the study population. Majority of the study

population had a literacy status of secondary school that constitutes 69.6% in the insured group

and 62.7% in the non-insured group. There was a difference in the graduate and above

population, where it was 11.8 % in the insured and 17.1 % in the non-insured. The illiterate

category representation was higher (3.1%) in the non-insured group as compared to insured

where it was 0.6%. This association were found to be statistically significant.

Table 4.10: Distribution of the study population according to occupational status

Occupational Status Insured (3108)

No (%)


No (%)

Chi-Square

(P-Value)

Semi Professional 75(2.4) 29(2.3)

33.52(<0.0001)

Clerk/Shop Owner 143(4.6) 58(4.6)

Skilled Worker 129(4.2) 32(2.5)

Semi-Skilled 315(10.1) 97(7.7)

Unskilled Worker 762(24.5) 251(19.8)

Unemployed 1684(54.2) 799(63.1)

The occupational status distribution as shown in table 4.10 shows that majority of the

population were unemployed, which was 54.2% in the insured group and 63.1% in the non-

insured group. The skilled workers had a higher representation in the insured 4.2% as

compared to non-insured where it was 2.5%.But in case of unskilled workers also found a higher



representation in the insured group constituting 24.5%, whereas it was 19.8% in the non-

insured. This association was also found to be statistically significant.

4.5.2: Baseline Socio-Demographic Characteristics of the Surveyed Households

The following set of tables describes the socio-demographic characteristics of the surveyed

household, where household is considered as a unit. The tables depict the distribution of the

households in terms of age and gender of the household head, religion, socio-economic status

and type of family. A comparison here too has been carried out between the insured and the

non-insured population and univariate analysis carried out to find out if there is an association

between the following variables and the insurance status of the population.

Table: 4.11: Distribution of the household head according to age

Age group in

years

Insured (n=1108)

No (%)

Non-Insured (n=530)

No (%)

Chi-Square

(P-Value)

21-40 194(17.5) 103(19.4) 1.16(0.561)

41-60 610(55.1) 281(53.1)

>61 304(27.4) 146(27.5)

The table 4.11 above shows the age of the household head. Majority of the study subjects

were in the age group of 41-60 years of age, followed by that of more than 60 years. The insured

had 55.1% in the 41-60 age categories which was the majority and in case of non-insured it was

52.9%.This difference was not found to be statistically significant.

Table 4.12: Distribution of the household head according to gender

Gender Insured (n=1108)

No (%)

Non-Insured (n=530)

No (%)

Chi-Square

(P-Value)

Male 815(73.6) 438( 82.5) 15.89(<0.0001)

Female 293(26.4) 93(17.5)

The gender distribution of the study subjects as described in table 4.12, majority of the

subjects were male. The males represented 73.6% of the insured group, whereas it was 82.5 %

in the non-insured group. This difference was however found to be statistically significant.



Table 4.13: Distribution of the household according to socio-economic status

Socio-Economic

Status

Insured (n=1108)

No (%)

Non-Insured (n=530)

No (%)

Chi-Square

(P-Value)

High 104(9.4) 53(10.0)

0.83(0.659) Middle 437(39.4) 219(41.2)

Low 567(51.2) 259(48.8)

The socio-economic distribution of the households as in table 4.13, it can be inferred that

there is a similar distribution of the different socio-economic groups that is high, middle and low

across both the groups. In both the groups the majority were in the low socio-economic

category, 51.2% in insured and 48.8% in the non-insured group. The differences were not found

to be statistically significant.

Table 4.14: Distribution of the household according to religion

Religion Insured (n=1108)

No (%)

Non-Insured (n=530)

No (%)

Chi-Square

(P-Value)

Hindu 1031(93.1) 467(88.1)

12.08(0.002) Muslim 59(5.3) 46(8.7)

Christian 17(1.5) 17(3.2)

Others 1(0.1)

The above table 4.14 describes the distribution of households according to religion, the

hindus constituted 93.1% in insured and 88.1%in non-insured. The muslims constituted 8.7%

in the non-insured group, whereas it was 5.3% in the insured group, these differences were

found to be statistically significant.

Table 4.15: Distribution of the household according to type of family

Type Of Family Insured(N=1108)

No (%)

Non-Insured(N=530)

No (%)

Chi-Square

(P-Value)

Nuclear 812(73.3) 439(82.7) 19.62

Joint 272(24.5) 89(16.8) <0.0001

Extended 24(2.2) 3(0.6) -



As per table 3(e), majority of the households were nuclear families across the groups,

although there was a difference in the distribution. There were 73.3% of nuclear families in

insured group, whereas it was 82.7% in the non-insured, the differences were found to be

statistically significant.

4.5.3: Family Composition of the Surveyed Households

Table 4.16- Distribution of the household according to size of family

Family Size

(no. of members)

Insured (n=1108)

No (%)

Non-Insured (n=531)

No (%)

Chi-Square

(P-Value)

≤5 659(59.5) 377(71.0)

21.26(<0.0001) 6-10 399(36.0) 141(26.6)

>10 50(4.5) 13(2.4)

The households were categorised on the basis on average number of members in each

household. The table 4.16 describes it on the basis of insured and non-insured households.

Majority of households had a family size of less than five members, it was 59.5%in case of

insured households, whereas it was 71.0% for the non-insured households. The family size of

more than ten members had a proportion of 4.5 % in insured, whereas it was 2.4% in case of the

non-insured. This difference was found to be statistically significant.

Table 4.17: Average Number of Children in the household and Insurance Status

Average number of

children

(0-18 years) in family

Insured

(n=1056)

No (%)

Non-Insured

(n=490)

No (%)

Chi-Square

(P-Value)

≤2 1013(95.9) 472(96.3) 0.14(0.708)

>2 43(4.0) 18(3.7)

The table 4.17 describes the number of children aged 0 to 18 years in the surveyed

households, it was found that majority that is 95.9% in insured group and 96.3% in the non-

insured group had less than two children in their family. There was no association between the

number of children in the household to the insurance status of household.



Table 4.18: Average Number of Adults in the household and Insurance Status

Average number of

adults

(18-60) In Family

Insured

(n=1104)

No (%)

Non-Insured

(n=528)

No (%)

Chi-Square

(P-Value)

≤2 554(50.2) 330(62.5) 21.83(<0.0001)

>2 550(49.8) 198(37.5)

The distribution of average number of adults in each family is described in table 4.18.

The majority of the families had less than or equal to two adults in their family, it was 50.2% in

insured and 63.5% in the non-insured households. The difference was found to be statistically

significant. There was a difference in both the groups with regards to more than two adults in

the family, it was 49.8% in the insured group as compared to 37.5% in the non-insured group.

Table 4.19: Average Number of elderly in the household and Insurance Status

Average number Of elderly

(>60years) in family

Insured (n=1021)

No (%)

Non-Insured (n=528)

No (%)

1 1021(100) 469(99.6)

>1 0 2(0.4)

The table 4.19 shows the distribution of average number of elderly members in each

family is described in table 3d. It shows that majority of the families had less than one elderly

member in their family, all the insured families had one elderly member in their family, the non-

insured households, there were two households where there were more than one elderly

member.

Table 4.20: Average number of women in the household and Insurance Status

Average number of

women in family

Insured (n=998)

No (%)

Non-Insured (n=450)

No (%)

Chi-Square

(P-Value)

≤2 912(92.3) 434(96.4) 8.84(0.003)

>2 76(7.7) 16(3.5)

The table 4.20 depicts the average number of women in each household, it was found

that there were 7.7% of households in the insured group with more than two women, whereas it

was only 3.5% in case of uninsured group. This difference was found to be statistically

significant.



4.5.4: Average Household Expenditure for health care among Surveyed Households

Table 4.21: Expenditure on Health Care of Household and Insurance Status

Average yearly

Expenditure on

Healthcare in Rupees

Insured

(n=1107)

No (%)

Non-Insured

(n=530)

No (%)

Chi-Square

(P-Value)

<3000 273(24.7) 111(20.9)

33.99(<0.0001) 3001-10000 656(59.3) 382(72.1)

>10001 178(16.1) 37(7.0)

The table 4.21 describes the average yearly expenditure on health care in both the

insured and non-insured households. Majority of the households had an average expenditure

ranging from Rs 3001-10,000. In case of insured household 59.3% of households had their

average expenditure on health care within this limits and for the non-insured household it was

72.1% of them who had a similar expenditure. The results also shows that 16.1% of insured

households spend more than Rs 10,000 as their annual health care expenditure, whereas it was

7.0% in the non-insured. This difference was found to be statistically significant.

Table 4.22: Annual Median Household Expenditure in Rupees

Household

Expenditure

Insured

Median (Q1, Q3)

Non-insured

Median (Q1, Q3)

Education 5000(0,10000) 3500(0,10000)

Health Care 5000(4000,10000) 5000(4000,8000)

Overall Expenditure 24000(14000,31000) 21000(11000,30000)

Table 4.23: Monthly Median Household Expenditure in Rupees

Household Expenditure Insured

Median (Q1, Q3)

Non-Insured

Median (Q1, Q3)

Medicine 500(250,600) 500(300,800)

Food 3000(2000,4000) 3000(2000,4000)

Overall Expenditure 5300(4000,6500) 4950(3300,6300)



The above tables shows the median and the quartiles of the household expenditure

incurred by the households and the comparison between the insured and non-insured

households

The table 4.22 shows the annual expenditure stated by respondents on education, health

care and overall annual expenditure. There were no differences in the median expenditure of all

the categories between the insured and the non-insured, except in case of overall annual

expenditure.

The table 4.23 depicts the monthly expenditure in terms of food, medicines and total

monthly expenditure. The trend was similar to that of the annual expenditure. The results shows

a difference of Rs 350/- in the average monthly expenditure between the insured and non-

insured group.

Table 4.24: Presence of morbidity in the household and insurance status

Factors Insured

No (%)

Non-

Insured

No (%)

Odds Ratio

(95%C.I)

Chi-Square

(P-Value)

Presence of chronic illness

Yes 228(20.6) 86(16.2) 1.3(1.0-1.7) 4.35 (0.037)

No 881(79.4) 444(83.8)

Total 1109 530

Severity of illness

Severe 95(40.3) 18(20.5) 2.6(1.4-4.9) 11.06(0.0008)

Not Severe 141(59.7) 70(79.5)

Total 236 88

The table 4.24 describes the association between insurance status and presence and

severity of illness of the households. The presence of chronic illness was found to be 20.6% in

the insured households, whereas it was 16.2% in the non-insured. This difference was found to

be statistically significant. The analysis reveals the likelihood of those members who have

chronically ill members in the family opting for insurance to be 1.34 times more than that of

those who do not have.



The severity of illness described as severe in 40.5% of insured households, whereas it

was only 20.5% in non-insured households. This difference was found to be statistically

significant. The households who had members who expressed illness as severe were 2.62 times

more likely to take up insurance than those who don’t.

Fig 4.3: Limitation in daily activities due to illness in the surveyed population

The response to whether the households had physical limitations in their daily activities,

due to their illness is depicted in FIG 4.3.In the insured households 85.8% of respondents stated

that they had limitations, whereas it was only 38.9% of the non-insured respondents who

expressed having any limitations.

Fig 4.4: Financial constraints due to illness in surveyed population

85.8

38.9

14.2

61.1

0

10

20

30

40

50

60

70

80

90

100

Insured Non-insured

Pe

rce

nta

ge o

f R

esp

on

se

Insurance status

limitation

Yes

61 67.6

39 32.4

0

10

20

30

40

50

60

70

80

Insured Non-insured

Pe

rce

nta

ge o

f R

esp

on

se

Insurance status

Financial constraints

Yes

No



The issue of financial constraints due to illness was similar across both insured and non-

insured households were similar across the groups.

4.4: Results of Univariate Analysis

Table 4.25: Determinants of acceptability of CBHI schemes –Set A

Individual Level variables Unadjusted Odds Ratio 95% C.I p-value

Marital Status

Married Ref - -

Others 0.81 0.71-0.92 0.001

Literacy Status

Graduate &Above Ref - -

Pre-University 1.61 1.34-1.93 <0.0001

Secondary School 1.43 1.13-1.80 0.003

Primary School 1.79 1.01-3.00 0.028

Illiterate 0.29 0.17-0.51 <0.0001

Occupational Status

Semi Professional Ref - -

Clerk/Shop Owner 0.98 0.57-1.68 0.94

Skilled Worker 1.60 0.89-2.29 0.12

Semi-Skilled 1.29 0.78-2.13 0.32

Unskilled Worker 1.20 0.75-1.92 0.44

Unemployed 0.84 0.53-1.32 0.45

The results of the univariate analysis and the unadjusted odds ratio for individual level

variables are described in the table 4.25(a). It can be inferred from the results above that the

likelihood of married beneficiaries taking up insurance was more than that of the others which

included the unmarried and the widowed (O.R-0.81). This was found to be statistically

significant.

When compared to those who had studied up to graduation level or above, the study

population who had studied up to pre-university, secondary level and primary level schooling



were more likely to take up the insurance. There were less chances of the illiterate (O.R-0.29)

taking up insurance. These results were not found to be statistically significant.

Among the different occupational categories, it was the skilled, semi-skilled and

unskilled workers who were more likely to take up insurance, compared to the other categories,

but these results were not found to be significant.

Table 4.26: Determinants of acceptability of CBHI schemes - Set -B

Household Level variables Unadjusted Odds Ratio 95% C.I p-value

Gender

Female Ref - -

Male 0.90 0.79-1.02 0.089

Religion

Hindu Ref - -

Others 0.42 0.34-0.51 <0.0001

Family Type

Nuclear Ref - -

Others 1.79 1.55-2.05 <0.0001

Number of members in the family

≤5 Ref - -

6-10 1.53 1.34-1.74 <0.0001

>10 1.44 1.15-1.82 0.002

Yearly Household Expenditure on healthcare (Rs)

<3000 Ref - -

3001-10000 0.69 0.31-0.44 <0.0001

>10001 1.95 0.41-0.66 <0.0001

No. of Women in the household

≤2 Ref - -

> 2 1.83 1.46-2.29 <0.0001

No. of Adults in the household

≤2 Ref - -

> 2 1.42 1.25-1.61 <0.0001



The univariate analysis for the variables at the household level was gender of household

head, religion, and number of adults, women and the type of family.

The households were female members were heading the family were more likely to take

up insurance as compared to their male counterparts in the acceptability of CBHI, with an O.R of

0.90, but this was not statistically significant.

The likelihood of Hindus taking up insurance was higher than others (O.R-0.42), this was


The average annual expenditure of less than Rs 3000 had higher odds (1) of taking up

insurance as compared to those with more than Rs 3000. These results were found to be

statistically significant

The likelihood of nuclear families taking up health insurance was less than the others

(O.R-1.79) which consisted of joint and extended families.

With regards to number of members in the family it was evident that the likelihood of

family members who had more than 5 members in the household were more likely to take up

insurance.

The representation of number of adults and women in the households when compared,

the households where there were more than two adults and two women were more likely to

take up insurance. Odds ratio of 1.42 and 1.83 respectively, and these results were found to be


All the above factors were found to be statistically significant determinants of

acceptability of CBHI schemes, except gender of the household head

The table 4.25 & 4.26 shows odds ratio of the individual level independent variables

from the univariate and multivariate logistic regression analysis. The p values and the odds

ration indicate that the results are similar. This points out to a low level of confounding by the

independent variables. The marital status, literacy status and the occupational status of the

individual insured population was a determinant to their acceptability of the CBHI schemes.



4.4: Results of Logistic Regression Analysis

Table 4.27: Socio-demographic determinants of acceptability of CBHI schemes

Individual Level variables Adjusted Odds Ratio (95% C.I) p-value

Marital Status

Married Ref - -

Others 0.97 0.82-1.15 0.74

Literacy Status

Graduate &Above Ref - -

Pre-University 1.65 1.32-2.07 <0.0001

Secondary School 1.44 1.10-1.88 0.009

Primary School 1.39 0.77-2.52 0.27

Illiterate 0.27 0.14-0.53 <0.0001

Occupational Status

Semi Professional Ref - -

Clerk/Shop Owner 0.82 0.46-1.49 0.52

Skilled Worker 1.12 0.59-2.14 0.72

Semi-Skilled 0.96 0.55-1.69 0.90

Unskilled Worker 1.02 0.61-1.70 0.96

Unemployed 0.71 0.43-1.17 0.18

A multivariate analysis was carried out using logistic regression, to ascertain whether

the independent variables as per the hypothesis were significant determinants of acceptability

of community based health insurance schemes. The variables were subjected to a multivariate

analysis, as the univariate analysis revealed a strong association of the following variables to the

insurance status of the individual. The socio-demographic factors at the individual level were

included in the multivariate analysis were marital status, literacy status, and occupational status.

In case of the marital status of the study population the unmarried and the widowed

which were grouped as others (0.97) were less likely to take up insurance as compared to

married, which was not found to be statistically significant



The literacy status where the reference category of the analysis was the graduate and

above group, the likelihood of persons who studied up to pre-university, secondary school and

primary school taking up insurance were higher as compared to the illiterate.

The analysis revealed that in comparison to those individuals who were in the

occupational status category of semi-professionals the likelihood of skilled and unskilled

workers were higher than those who were semi-skilled workers and also the unemployed. These

results were not found to be statistically significant.

Table 4.28: Determinants of acceptability of CBHI schemes (Results of Multiple Logistic

Regression)

Household level variables Adjusted Odds Ratio (95% C.I) p-value

Gender

Female Ref - -

Male 0.98 0.82-1.18 0.87

Religion

Hindu Ref - -

Others 0.41 0.32-0.52 <0.0001

Family Type

Nuclear Ref - -

Others 1.86 1.50-2.32 <0.0001

Number of members in the family

<5 Ref - -

6-10 0.98 0.80-1.20 0.85

>11 0.51 0.35-0.75 0.001

Yearly Household Expenditure on health care

<3000 Ref - -

3001-10000 0.36 0.29-0.45 <0.0001

>10001 0.46 0.34-0.61 <0.0001

No. of Women in the household

≤2 Ref - -

> 2 1.77 1.31-2.44 <0.0001

No. of Adults in the household

≤2 Ref - -

> 2 1.15 0.95-1.39 0.14



The multivariate analysis for the variables at the household level were gender of

household head, religion, and number of adults, women and the type of family. The average

annual household expenditure on health care was also found to have an association in the

univariate analysis, therefore this was also included for the multivariate analysis.

The household were female members were heading the family were more likely to take

up insurance as compared to their male counterparts in the acceptability of CBHI with an O.R of

0.98.

The likelihood of other religions which included the Muslims, Christians and Jains were

less than the Hindus in taking up insurance as per the multivariate analysis with an adjusted

O.R(0.41).

The nuclear families were less likely to take up insurance as compared to the others

which included the joint and extended families.

With regards to number of members in the family it was evident that the likelihood of

family members who had less than 5 members was higher compared to the other categories in

taking up insurance.

The households where the annual expenditure on health care was less than Rs 3000

were more likely to take up CBHI as compare to those households where the expenditure was

more than Rs 3000.

The representation of number of adults and women in the households when compared

the household where there were more than two adults and two women were more likely to take

up insurance.

The table 4.27 & 4.28 shows odds ratio of the household level independent variables

from the univariate and multivariate logistic regression analysis. The p values and the odds

ration indicate that the results are similar. This points out to a low level of confounding by the

independent variables, such as gender of household head, religion, type of family, average

expenditure on health care. In the case of family size due to joint modeling there is a

confounding effect as more the number of women and adults more is the family strength, this

has resulted in a lower adjusted odds ratio for the same variable .



Table 4.29: Decision to enroll in the CBHI scheme

Decision to enrol MAS

No (%)

SS

No (%)

Odds Ratio

(95%C.I)

Chi-Square

(PValue)

Family decision 545(98.0) 399(73.6) 17.76 135.57

Reduce expenditure 11(2.0) 143(26.4) (9.22-35.11) (<0.0001)

Total 556 542

The decision to enroll for the scheme for the beneficiaries of MAS & SS is described is

table 4.29. Majority of the respondent said it was a family decision (98.0% of MAS & 73. 6% of

SS) and 26.4% of respondent of SS said that enrolling for the scheme helped them reduce

expenditure, whereas it was 2.0% for MAS. This difference was found to be statistically

significant. The odds ratio of 17.76 reveal that family decision influenced the choice of the

particular CBHI scheme.

Table 4.30: Premium Payment between the MAS and SS

Premium Payment MAS SS Odds Ratio

(95% C.I)

Chi-Square

(P-Value)

Difficult

Yes 66(37.5) 87(16.2) 3.11

(2.12-4.55)

35.83

(<0.0001) No 110(62.5) 451(83.8)

Total 176 538

Contribution by earning members of household

Yes 151(84.8) 516(93.8) 0.369

(0.21-0.63)

14.15

(0.0002) No 27(15.2) 34(16.2)

Total 178 550

Premium Vs Benefits

High 62(34.6) 84(15.4) 2.92

(1.99-4.30)

30.21

(<0.0001) Low 117(65.3) 463(84.6)

Total 179 547



The table 4.30 describes the premium payment modalities between MAS & SS. It was

found that 83.8% of the SS card holders did not find any difficulty in paying the premium

amount as compared to 62.5% of the respondents with MAS. This difference was found to be

statistically significant. The odds of MAS respondents stating difficulty in paying premium was

3.11 times more than that of SS.

In case of contribution by the household members towards premium, it was 84.8% of

MAS enrollees whereas it was 93.8% of SS enrollees stating that there was monetary

contribution by other earning members of family, this difference was also found to be


The response to whether their perception of benefits was high or low as compared to

their contribution as premium. Only 34.6% of respondents of MAS as compared to 15.4% of SS

said that it was high. This difference was found to be statistically significant.

Table 4.31: Self Reported Out of Pocket Expenditure on health care among the CBHI scheme

holders

Expenditure MAS

Median (Q1, Q3)

SS

Median (Q1, Q3) P-VALUE

Treatment 10000(3000,44500) 29000(10000,50500) 0.033

Consultation 200(0,200) 1000(200,5000) <0.0001

Medicine 2000(300,5000) 6000(3000,10000) <0.0001

Transport 600(175,2000) 2000(800,3000) 0.002

Payment In Hospital 400(100,1000) 500(0,1000) 0.580

Other Expenditure 250(125,2750) 400(0,1375) 0.908

Total 12750(6000,52500) 37750(10000,74750) 0.060

*Mann-Whitney test

The out of pocket expenses incurred on hospitalization by the insured groups both MAS

and SS were elicited as self reported responses from those who had utilized the card benefits for

hospitalization at the network hospitals. The responses has been expressed as median and

quartiles. As per the results the average expenses incurred by MAS respondents were

approximately Rs 12, 750, whereas it was Rs 37, 750 in case of SS. The major out of pocket

expenditure incurred was the treatment expenses for both the groups, but it was higher in case

of SS. These differences was found to be statistically significant at p<0.05



Table 4.32: Comparison of Perception of Quality of Health care Services between the MAS and

SS CBHI schemes

Perception MAS SS Odds Ratio (95% C.I)

Chi-Square (P-Value)

Hospitalization Benefits

Average 37(24.2) 8(3.2) 9.57 (4.11-23.06)

41.71 (<0.0001) Good 116(75.8) 240(96.8)

Total 143 248

Quality Of Services

Average 17(11.1) 6(2.4) 5.04 (1.82-14.68)

13.22 (0.0002) Good 136(88.9) 242(97.6)

Total 153 248

Quality Of Treatment

Average 46(30.1) 17(6.9) 5.83 (3.09-11.16)

38.49 (<0.0001) Good 107(69.9) 231(93.2)

Total 147 248

OP Services

Average 96(62.3) 194(78.2) 0.46 (0.29-0.74)

11.93 (0.0005) Good 58(37.7) 54(21.8)

Total 154 248

IP Services

Average 20(13.0) 9(3.6) 3.96 (1.66-9.70)

12.43 (0.0004) Good 134(87.0) 239(96.4)

Total 154 248

Claims Settlement

Average 64(51.6) 25(10.1) 4.47 (2.55-7.86)

33.16 (<0.0001) Good 90(58.0) 157(90.5)

Total 154 182

Administration

Average 72(46.8) 27(10.9) 7.19 (4.19-12.37)

65.84 (0.0001) Good 82(55.3) 221(89.1)

Total 154 248

Volunteers

Average 80(52.0) 18(7.3) 13.81 (7.52-25.62)

102.92 (<0.0001) Good 74(48.0) 230(92.7)

Total 154 248

Complaint Redressal

Average 98(63.6) 42(17.0) 8.58 (5.25-14.09)

91.29 (<0.0001) Good 56(36.4) 206(83.0)

Total 154 248



The table 4.32 describes the perception of the respondents on various aspects of their

scheme benefit package. This ranges from their perception of hospitalization benefits, the

quality of services, their perception on the administration of the scheme, the attitude of the

volunteers. Even though majority of the respondents perceived the services of the CBHI schemes

as good, but there was a difference in the perception among the two CBHI schemes.

All the above mentioned aspects were rated on a 5 point likert scale of 1 to 5 (excellent

to very poor). The responses were than clubbed to average & good.

In case of perceived hospitalization benefits. Majority of the respondents rated it as good,

it was 75.8% for MAS, whereas it was 96.8% for SS responded rated it as good. This difference

was found to be statistically significant.

With regard to quality of services at the provider hospital a majority of MAS respondents

(88.9%) rated it as good, whereas in case of SS it was 97.6%. This was also found to be

significant statistically.

Regarding perceived quality of treatment they received at the hospital it was found that

69.9% of MAS as compared to 93.2% of SS had rated it as good. This differences was found to be


In case of out-patient services only 21.8% of SS respondents rated it as good as

compared to 37.7% of MAS respondents. This difference was also found to be statistically

significant.

The majority of respondents had rated the in-patient services as good .The proportion of

MAS respondents were 87.0% whereas it was 96.4% for SS. This difference was statistically

significant.

There were few questions on perception of the administration of the scheme with regard

to volunteers’ complaint redressal & administration.

The administration of the scheme, the perception of respondent rating it as good was

55.3% for MAS where it was 89.5% for SS. This difference was found to be statistically

significant.



With regards to assistance from volunteers the perception of respondents was such that

only 48.0% of MAS rated it as good, where as it was 92.7% of the SS respondents rated the

service of their volunteers as good. This difference was found to be statistically significant.

On the complaint redressal issues the response was that only 36.4% of MAS respondents

rated it as good, whereas 83.0% of SS respondents rated it as good. This difference was also


Fig 4.5: Methods of resolving financial constraints

The fig above explains how the issue of financial constraints were resolved. Majority of

respondents stated that it was through a loan, where they had to borrow. It was 87.0% in MAS &

70.5% in SS.

87%

70.5%

13%

29.5%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

MAS SS

Pe

rce

nta

ge o

f R

esp

on

se

CBHI Schemes

Loan

Others



Fig 4.6: Source of awareness about the CBHI schemes among insured households

The fig 4.6 shows the source of awareness of the scheme & majority of the respondent

stated that it was agent 87.8% in MAS and 87.7% in SS.

Fig 4.7: Years of enrolment in the CBHI schemes The fig 4.7 shows that number of years of enrolment in the scheme by both MAS & SS

members. The majority of respondents had enrolled for less than 5years it was 92.2% in MAS &

98.7% of SS.

87.8 87.7

12.2 12.3

0

10

20

30

40

50

60

70

80

90

100

MAS SS

Pe

rce

nta

ge o

f R

esp

on

se

CBHI Schemes

Source

Agents

Others

0

20

40

60

80

100

MAS SS

92.2 98.7

7.8 1.3

Pe

rce

nta

ge o

f R

esp

on

se

CBHI Schemes

Years

< 5 Years

> 5 Years



Fig 4.8: Expenses covered elsewhere

A series of responses were elicited from the MAS and the SS beneficiaries on whether the

of pocket expenses they incurred for hospitalization expenses were covered under any other

insurance plan, only 2.5% and 2% of MAS and SS respondents reported so.

The response to whether they had to borrow money for the same, 6.1%of MAS and 6.7%

of SS respondents stated they had to do so. On whether the hospitalization expenses were not

affordable had about 5.4%and 5.8% of MAS and SS respondents agreeing that they found it

unaffordable.

2.5

6.1 5.4

2

6.7

5.8

0

1

2

3

4

5

6

7

8

Expenses coveredunder any other

schemes

Borrowed money fortreatment

Treatment notaffordable

Pe

rce

nta

ge o

f R

esp

on

se

MAS

SS



Fig 4.9: Membership renewal by members

The fig 4.9 depicts the response of members to whether they would renew their

insurance status with the same CBHI scheme, the response was 98.7% from MAS beneficiaries

and 99.1% from SS beneficairies

Fig 4.10: Frequency of utilizing services

The utilization frequency of the card by the beneficiaries in the past year is depicted in

the fig 4.10. Majority that is 96.8% of MAS and all the SS respondents reported of having utilized

the card on an average of 1-3 times.

0

10

20

30

40

50

60

70

80

90

100

MAS SS

99.6 99.1

0.4 0.9

Pe

rce

nta

ge o

f R

esp

on

se

CBHI Schemes

Renewal

Yes

No

0

10

20

30

40

50

60

70

80

90

100

MAS SS

96.8 100

3.2 0

Pe

rce

nta

ge o

f R

esp

on

se

CBHI Schemes

Frequency

1-3 Times

>3 Times



Fig 4.11: Accessibility of network hospital

Majority of the respondents found the network hospital as accessible and considered it

near, which was 69.3%of MAS and 70.4 % of SS respondents. But there were 30.1% and 24% of

both MAS and SS respondents who felt that the distance to the network hospital was far. This is

as per the fig 4.11.

Fig 4.12: Frequency of Paying Premium

The option of paying premium in instalments was only available to the SS respondents

and the results are depicted in Fig 4.12. Majority of respondents preferred the yearly premium

payment, but there were 26.9% of them who felt the weekly premium payment mode

convenient.

30.1 29.6

69.9 70.4

0

10

20

30

40

50

60

70

80

MAS SS

Pe

rce

nta

ge o

f R

esp

on

se

CBHI Schemes

Hospital

Far

Near

0

10

20

30

40

50

60

70

80

90

100

Yearly Half Yearly Monthly Weekly

100

0 0 0

60.5

12.2

0.4

26.9

Pe

rce

nta

ge o

f R

esp

on

se

Frequency of premium Payment

MASSS



Fig 4.13: Reasons for Renewing Card

The various reasons for renewing the card is described in the fig 4.13 above. In case of

MAS respondents the availability of free services and reduced medical expenditure elicited

maximum response. For the SS respondents it was again reduced medical expenditure and

flexibility of paying premium in installments which elicited maximum response. In case of MAS

respondents 26.4% stated that the free card facility was a reason for renewing. Timely

availability of services was also an important reason cited by 21.7% of SS respondents whereas

it was 15.2% in case of MAS.

0

5

10

15

20

25

30

35

40

45

Reducedmedical

expenses

Timelyservices

Premium ininstalments

Enrolling asa

community

Regularmeetings of

group

Freeservices

26.4

15.2

0

5.7

0

26.4

44.2

21.7

35.1

3.8

10.3

0

Pe

rce

nta

ge o

f R

esp

on

se

Choice of CBHI Scheme

MAS

SS



Fig 4.14: Response of the non-insured

The above fig 4.14 shows the attitude of the non-insured towards enrolling for

insurance. The awareness about insurance and also about MAS and SS was approximately fifty

percent. There were 81.9 % of respondents who wanted to enroll for a health insurance. There

were 43.7% of respondents who said that their neighbours were enrolled in health insurance

schemes. The general awareness no-enrolled towards health insurance was also 50% and a good

majority of them reported to having been approached by agents to enrolled either for MAS or SS.

49 47.9

41.2 44.2

81.9

51 52.1

58.8 55.8

18.1

0

10

20

30

40

50

60

70

80

90

Knowledge abouthealth insurance

Knowledge aboutMAS/SS

Approached bysomebody to enroll

People livingaround enrolled

Plan to enroll forany insurance

Pe

rce

nta

ge o

f re

spo

nse

Response of non-insured

YES NO



Fig 4.15: Reasons expressed by non-insured on not enrolling for MAS/SS

The above figure shows the reasons given by the non-insured respondents on not

enrolling for either of the schemes. Of all the reasons mentioned, majority that is 32.3% stated

that affordability of premium was one reason, whereas, 22.5% said that they did not find any

necessity in enrolling, whereas 13.6 % stated that they felt the benefits were not good enough to

enroll and 14.5 % state that they were not part of the Self Help Group. There were various other

reasons cited by the respondents apart from the reasons depicted above which totaled to 9.2%

of the responses. These included reasons like they were enrolled in other schemes like Vajpayee

Arogya Shree, Rashtriya Swasthya Bima Yojna, Yeshaswini etc. they were few respondents who

were covered under ESI (Employee State Insurance) which was provided in the organizations

they work.

32.2

13.6

3.4

22.5

14.5

4.6

9.2

0

5

10

15

20

25

30

35

premium notaffordable

benefits are notgood

provider hospitaltoo far

did not feel it isnecessary

not part of shg prefer to go togovt facilities

others

Pe

rce

nta

ge o

f re

spo

nse



Fig 4.16: Preferred health care facility

The non-insured respondents preferred to use private health care facilities which was

evident from their response as depicted in fig 4.16, it was 76.4% of them preferring so.

23.6

76.4

0

10

20

30

40

50

60

70

80

90

Government Private

Pe

rce

nta

ge o

f R

esp

on

se

Choice of Hospital

Hospital

Government

Private



4.6 SECTION 3: RESULTS OF FOCUS GROUP DISCUSSIONS

4.6.1 Introduction:

The focus group discussions were conducted for the qualitative part of the research .This

was necessary to obtain more information about issues which were not captured in the

household survey. The focus group discussions were conducted among the beneficiaries of

Manipal Arogya Suraksha, Sampoorna Suraksha, which were the CBHI schemes selected for the

study and non-insured participants, who had not enrolled in either of the CBHI schemes

4.6.2Purpose of the focus group discussion:

To understand the existing levels of health care services present in the community and

how much the CBHI schemes had helped to reduce the burden of health care

expenditure on the households

To find out the barriers and problems faced by the card holders while utilizing the

benefits of the CBHI scheme

To identify the knowledge& perceptions about the CBHI schemes

To understand the attitude of the non-insured group towards the CBHI schemes selected

for the study.

To understand their attitude of the non-insured group towards enrolling for health

insurance.

4.6.3 Method:

The focus group discussions were conducted in a systematic manner as described in the

methodology. The physical arrangements were set up in a way so as to ensure proper

communication and interaction between the participants. The team conducting the FGD

comprised of the moderator, a facilitator, and two recorded. The number of participants differed

for each of the different FGDs carried out (Details in Appendix-V). An audio recorder was used to

record the discussions. The participants were then given identification numbers and only the

numbers were used to refer to them. Each FGD lasted for 90 minutes.

The purpose of the FGD was briefed to the participants, and a consent was obtained form

them. The moderator then explained the general ground rules and discussion guidelines such as

the importance of everyone participating in the discussion and expressing their views on the

issue being discussed. The purpose of audio recording was, the session was also clarified to the

participants if they had any apprehension with regards to recording.



The issues to be discussed for the FGD were prepared on the basis of the results obtained

in the household survey. The areas where the required information could not be captured were

the issues which were then formulated to be put forth as issues for discussion

The moderator then put forth the issues one by one and facilitate the flow of discussion

.The recorders were recording each of the responses in the vernacular language itself. The

facilitator drew the socio-grams for the same. At the end of each FGD the participants were

acknowledged for their participation and seen off after refreshments.

Finally after each of the FGDs the team sat together to translate the transcript into

English and also interpreted the recordings. The discussions were then summarized .The finding

of the FGDs were then combined and is presented in the subsequent pages under different

sections:

4.6.3 Results

1. Section 1:Findings of FGD among beneficiaries of MAS

2. Section 2: Findings of FGD among beneficiaries of SS

3. Section 3: Findings of FGD among the non-insured

4. Section 4: Findings of FGD among the field workers of SS

5. Section 5: Findings of FGD among the field workers of MAS

List of the issues for CBHI scheme benficairies

1. Morbidity in the family , limitation and utilization of health care services

2. Awareness and source of information about the CBHI scheme

3. Reasons for enrolling

4. Attitude of volunteers

5. Facilities , Benefits and Premium

6. Out of pocket expenditure

List of the issues for non-insured

1. Awareness about health insurance ,CBHI schemes

2. Reasons for not enrolling

3. Future plans to enroll for health insurance



Section A: Report of Focus Group Discussion among Beneficiaries of Manipal Arogya

Suraksha

The following findings were the result of two FGDs (sociograms in Appendix-V) conducted

among the beneficiaries of MAS.A total of 23 (Twenty three) participants views have been

summarized below. The participants were a mix of those availing the free card, and those who

were paying the premium

The first issue on the illness in the family and utilization of health care facilities and their

ways of coping with limitation, both physical and financial was put forth. The participants stated

that for minor ailments they preferred going to private health care facilities the government

facilities were used only very rarely, like for immunization of children .They also made use of the

outpatient facilities at the network hospital .They said that limitations due to morbidity in the

family was very common, but they were sometimes drained monetarily due to it. Losing wages

was a common cause of concern, especially if it was the household head and also any other

member in the family. They expressed concern that a single episode of visit to an outpatient

clinic, they had to spend a minimum of Rs 500 and lack of facilities at the public health centre

added to their problems. They were happy that the RMCW centers provided them the basic

facilities.

The main source of information and awareness were the Rural Maternity and Child

Welfare centre field workers in case of Udupi taluk, whereas it was volunteers /agents of MAS in

Karkala taluk. There were some participants who said that neighbors had told them about the

MAS

The reasons for enrolling for many of them were the rising expenditure on health care

.Since government hospitals were not able to provide quality health care facilities; they had to

depend on CBHI schemes like this to reduce their health care expenditure. Those who were

paying the premium did not mind paying it as they found it affordable. Those who were given

free facilities felt privileged to be part of it. They were of the opinion that health care conditions

were very unpredictable so it helped them in many ways to be enrolled for the scheme.

The respondents were very appreciative of the effort of the volunteers / field workers in

helping them enroll and also helping them in availing the facilities and benefits at the network

hospital. They also help them with their queries if any at the time of admissions.



The participants were appreciative of the outpatient facilities which was not there in

other schemes. Although they found that the specific limits of the different treatment facilities,

which restricts the coverage benefits .They also found the waiting time at the network hospitals

as one of the main barriers to availing facilities and benefits. They also felt discriminated against

other patient who come to the hospital. The participants felt that they were asked to wait for

their turn as they were covered under the card. The expenses exceeding the limits had to be paid

in cash at the hospital. The help desk at the hospital were not supportive when there was a case

of missing data, or when they could not produce their card, due to an emergency, there were

instances when they had to go back and either get the card, or get treatment at another hospital.

The participants wanted the coverage limits to be increased of the various conditions to include

more services in the outpatient facilities. The medication discount they wanted it to be raised to

more than 10%.The conditions which were excluded in the scheme, they wanted the

organization to include those too .The participants who were paying he premium felt that since

they were paying the premium, their coverage limits should be raised, they found the premium

affordable, but wanted the coverage to be raised, also the caps /limits for the conditions also to

be increased. The delivery package they said should include the new born and this adds to their

expenses in the hospital

The participants expressed the opinion that in spite of the coverage they end up paying

cash at the hospital at the time of discharge and also for outpatient visits. The medications, by

standers expenses for an inpatient etc. The limit or cap of coverage allowed on certain

procedures like delivery, where the coverage limit was only Rs 5000, in that they felt that they

had to spend the balance amount on their own. These expenses they said were sometimes

difficult to pay, and very often they had to borrow, or spend from their savings. The cost of many

of the treatments they felt has become more due to cost of investigations and procedures.

Although being insured helped them with part of the expenses covered, still they had to spend

for each episode in the hospital.

Comments from the respondents

“Manipal hospital treated us very well, the availability of good doctors and that they do not

send us further anywhere is an advantage” .

“For a premium of Rs 250 the benefit of Rs 30,000 is very good, otherwise we would have

had to spend money from our savings or borrow from others”



“Card is helpful as it reduced expenditure for us. I know of many people who want to enroll

in this plan”.

“The new born child also should be covered, if it is only delivery, it is not beneficial to us

since the coverage for delivery is only Rs 5000 . But the hospital bill came to Rs 24000, so we had

to pay for that. If for one person bill is like this, they should give full coverage as they are from the

same family”.

“We can pay more premiums, but there should be more facilities also and no caps or limits

on the amount for one condition”.

“A months medical expenses itself is so high, and even with having a card it is so difficult to

pay hospital expenses”.

“We cannot tell about our future health care situation, so a health card should always be

there for every person. Government should also give card to everybody, who cannot afford to go to

private hospitals”.

“The charges at Manipal hospital are very high, and so it can only be used by the rich, even

if the coverage if there, all other charges have to be paid from pocket. The discounts are also very

less, this makes us pay for the services”.

“The MAS should selectively be given to only those who cannot afford to go to private health

care, but it seems, there are rich people who get this card, in this way the real beneficiaries are left

out, since only limited cards are distributed for each area”.

“The waiting time at the Manipal hospital is too long, we have to go very early and register,

and sometimes wait till evening to see the doctor, we cannot go for work, they should give

preference to health card patients, but they cannot understand the problem. We are made to wait

and also have to go to different counters for different investigations; this also takes up a lot of time.

This is one reason why we go to other private hospitals for out patient consultation”.

“The volunteers and sisters are very helpful, sometimes they help in case of any problem in

the hospital, by calling the help desk and confirming our card“.



“We are really grateful to Community Medicine for the services they give, we are able to get

the card because of them, every year we hope we will get the card”.

Following are the key findings summarized from the discussion

For minor ailments, private clinics were the preferred choice

Would not like to rely on government facilities

For chronic illness/surgery -facilitates of network hospital preferred

The field staff of RMCW centers, volunteers, agents were the main source of information

and awareness

Enrolling in CBHI scheme has helped reduce burden of expenses on treatment and

hospitalization

The economically backward people should be preferably given the cards instead of those

who can afford to pay.

An affordable premium with increased coverage is what they expect

The trust in the hospital made them enroll

The attitude of volunteers was appreciated by the participants

There was an overall satisfaction with regards to facilities an d benefits

The resentment was the waiting time at the hospital

The medication and outpatient benefits should be increased

The newborns should be included in the delivery package

Coverage of many of the excluded conditions

Out of pocket expenses were very high

The limits of coverage needs to be raised to reduce hospitalization charges

Section B: Report of Focus Group Discussion Conducted Among SS Beneficiaries

There were two FGDS (Sociogram in Appendix-V) which were conducted among the

beneficiaries of SS comprising 27 (twenty seven-individuals

All the participants in the discussion confirmed that they preferred using private health

care facilities, and the network hospitals under the CBHI scheme. In case of minor ailments they

preferred going to private clinics, as outpatient was not covered in their scheme. They did not

rely on government facilities due to their erratic nature of services and facilities. They expressed

concern, that even if they are not able to afford, they cannot depend on public health services.

Most of the time the doctors or other health care personnel will not be present, the non-



availability of drugs makes the matters worse. They preferred the network hospital in case of

any chronic ailments in the family. When we enroll, we might get ill, was a common statement

.Most of the chronic ailments in the family leads to financial constraints. They sometimes relied

on alternative forms of medicine like ayurveda to help them cope with many conditions, as they

felt it was within the limits of payment which they could afford. They also trusted their services.

The main source of awareness about the scheme and source of information were through

their group SHG meeting. The sevanirathas who were the facilitators of the functioning of the

SHG s had introduced them to the SS. They also mentioned about neighbours and friends who

had benefited form enrolling about providing them information.

The membership in the SHG as mentioned above influenced their decision to enroll. In

many cases the membership of one family member would be extended to more members to

include all of them and that, it would help in reducing expenses for health care. The SHG

activities always kept them with a regular source of income, so SS was an added advantage

where they could keep aside a part of their earnings for spending on health care. The limitations

of auyurveda and absence of government facilities had influenced their decision to enroll. They

understood the fact that there were limitations in other forms of medicine, and since allopathic

treatment was expensive, they felt that to enroll for such a scheme would be helpful. Trust in the

organization was also one of the reasons for enrolling, since they had been part of the SHG s for a

long time. The participants also felt that CBHI schemes like these would be beneficial for the BPL

population, since being part of the SHGs gave them a constant source of income and in addition

to that insure their health too.

The volunteers influenced them to join the scheme and were very prompt in case of any

administrative hassles they encountered at the network hospitals. The claim settlement process

was also made, easier due to their active interest in giving the rightful to the beneficiaries. The

resentment was with regards to volunteers going to the household to extract the premium, and

would not accept any default in the payment. Although they felt they knew that it was their

responsibility to ensure collection of premium.

The beneficiaries were wary of the fact that the premium was too high compared to the

benefits and facilities they receive .they felt that the premium of Rs 380/head/year was quite

unaffordable most of the time. The concern was that in case of non-payment of premium the

same would be deducted from their group savings and the group members would pressurize



into paying the premium, which they felt was unjust. The facilities they felt were satisfactory, but

since there was a restriction on the coverage limits for the first registered member and the

subsequent members. The non-inclusion of outpatient facilities was one of their concerns. They

felt that in most cases in spite of paying a premium, for outpatient facilities they had to pay on

their own. The scheme maternity benefits should be allowed for more than two children. They

also felt that there should be differential premium for the APL and BPL families, since they felt

that those who could afford to pay were also getting the same benefits which would otherwise

have been useful to those who cannot pay. Although some of them felt that the weekly premium

paying facility was convenient.

There was a lot of concern on the out of pocket expenditure which they had to pay in the

hospital .For most of the case, there was a requirement to pay cash in the hospital, although this

was supposed to be a cash less facility. The limit and caps on the coverage for different

conditions and norms of hospitalization made it necessary to pay out of pocket .Some

participants said they own multiple scheme membership, like Yeshaswini, RSBY etc, which

helped to tide over crisis situations like a huge hospital bill. They would get discharged from the

hospital, and get admitted again to avail the benefits of the other card. This was permitted by the

hospitals. This helped them to some extent. They were of the opinion that government should

come out with subsidized schemes for the BPL population.

Comments from respondents

“Each time a family member falls sick we are worried, as we have to spend money. When there is

health card it is like protection from illness, as we are not worried about money. So we feel, if we do

not renew we may get illness and then there is difficulty in spending money for that”.

“Ayurveda treatment is very effective and lasting also, and disease will not come back soon.

This is effective for many illness, and SDM ayurveda hospital services are very effective”.

“If you give us an insurance saying it is cashless facility, then there are restrictions on

coverage, so it is better not to continue, because anyway we spend a lot of money when anybody is

hospitalized”.

“Doctors do not prefer to treat health card members. I went once and doctor told me that

health card patients created problems in one hospital in Udupi. Reimbursement was very late and

delivery payment claims are settled almost after two months”.



“Waiting for billing is very difficult, doctors will not sign on time and and only original bills

are required by suraksha office. Sometimes the delay makes us loose a whole day and we wait up to

evening for discharge”.

“Facilities under the plan are very less. Only Rs 5000, whereas there are other plan have

more facilities, but cannot leave as we have taken loan from group account”.

“I am a member of sneha SHG so when they said suraksha gives benefit for health for Rs 1

per day, I readily enrolled as most of the time we spend money in private hospital for family

members’ illness., at least this will help if somebody gets admitted”.

“Why do we have to pay premium the same premium like APL members they do not find

difficulty in paying more, so it should be more premium for them and less for us?”.

“Paying premium is difficult sometimes and then they also take weekly loan installment. So

much money for everything, there is no end to it. We cannot stop renewal because this year’s loan

has to be paid next year”.

“ We go to other hospital for minor problems as the card is useful only for hospitalization”.

“I have two cards MAS and SS, I use one card, and limit crosses, I get discharged and use the

other card to continue, hospitals help us to do this”.

“Reimbursement for delivery should be more, Rs 2000 is very less, a one time admission

costs almost Rs 7000 to 8000”.

“Distance to hospital is not an issue, but hospitalization and lot of other expenses, makes us

to spend more”.

“We can give Rs 500 as premium for more facilities for one family, but there should not be

any restrictions on coverage and minimum of Rs 50,000 per family should be available”.

“For the first delivery I got benefits of card, but not for the second one as my husband was

not enrolled, it is very bad experience”.

“We attend all meetings, and pay regularly all group premium money also sometimes they

should consider we are not able to pay on time”.



“Whatever it is we have to take loan for hospital bills. Treatment is expensive, we have card,

but limited facility only, so there should be more concession as we are poor.”

“They give loan from group account to pay premium, but we have to give interest for that

loan. So premium for six member family becomes difficult to pay”.

“We get job in SHGs so the scheme and SHGs job were helpful for us to have income and

treatment benefits”.

“Hospitals will always make us wait if we have card, they want only money to be deposited

first before treatment”.

Key findings of the results of the FGD is as follows:

1. They depend a lot on alternative forms of medicine as it is cost effective

2. In case of allopathic treatment, government facilities are the last resort.

3. For chronic illness in family scheme hospitals facility is used

4. Enrolling might have increased chances of illness

5. The sevanirathas were the main source of information, and also through neighbours and

fellow SHG members

6. Enrolling for CBHI scheme has helped to some extent in reducing health care expenses.

7. An affordable premium with a good coverage is acceptable, but in this case the premium

was too high.

8. Trust in the organization was one of the main reasons for enrolling

9. Help form volunteers were always forth coming when it came too any queries and issues

in the network hospitals

10. The participants had an overall satisfaction about the scheme

11. They expressed resentment at exclusion of out patient facilities.

12. They wanted an increase in the maternity benefits

13. Inclusion of many of the excluded conditions and facilities

14. Increase the coverage limit to reduce out of pocket expenses.



Section B: Report of Focus Group Discussion Conducted Among Non-Insured

Only one FGD (Sociogram in Appendix-V) was conducted among the non-insured to elicit their

responses to the issues mentioned total of 16 participants were there for the discussion .Among

the participants none of them were enrolled for any health insurance scheme or the CHBI schemes.

With regards to the awareness of health insurance and CBHI schemes, most of them had

heard about it. They said they have heard about MAS, SS, Yeshawini and RSBY etc. They knew

about MAS being free card, and Yeshwaswni was for farmers. In case of SS they knew that only

SHG members were allowed, and they knew of several of their neighbours who were members

of the above mentioned schemes and were availing the facilities.

Participants opined that they also felt the need for a card like that, but did not know how

to enroll for it. They felt there was not much information available as to how to enroll for such

schemes. They said that they knew of many who were enrolled for the free services of MAS.

Some of them the high premium of SS discouraged them form joining, and also since they were

not part of the SHGs, they did not do so. There was an instance of one participant complaining of

ill treatment at one of the group hospital, due to which she decided not to enroll.

The next issue of whether they knew of health insurance helping to reduce health care

expenditure, the members felt that they also knew of the advantages of it When it was probed as

to whether they were approached by anyone to enroll for such programs, they said that it was

due to their inability to pay premium, and also their status as not being a BPL category

enlistment probably. They also felt it was a missed opportunity, as most of them had chronically

ill members in their family. There were two participants who were superstitious and felt that if

they enroll, they would fall ill.

On future plans to enroll, the participants said that they were ready to enroll, and can

afford a premium of about Rs 50/head /year. But they said it should include all outpatient and

inpatient exepense. They also would like to be benefitted by free services, as they felt that there

were many well to do persons who were getting undue benefits at the expense of BPL category

Anganavadi teacher’s opinion

The teacher stated that most of the times when the panchayats call for meetings ,people do not

turn up, this might have led to them not getting information about distribution of these kind of

scheme. They only think about it in case of an emergency, it has to be blamed on people, for not

being alert.



Comments from respondents

“There is no proper information, many of us did not get government facilities, and we also

do not know about health insurance”.

“Those who know about health card will not tell others, because they feel other should not

get benefits”.

“Proper information about cards is not there, even if we come to know about it and go and

ask panchayath they will ask to come later, or they will tell us to come next year”.

“We go to private hospitals, government hospitals facilities are not good, but in private if

we pay money we get all facilities, in government we do not get medicines, so what is the use”.

“I was having SS card before, but I cannot pay premium so I left it, there is no much use, I

had to spend one time Rs 35000 for treatment of my wife. The group also split after that”.

“We are ready to pay Rs 500 for one family, depending on illness they can give discount”.

Key Findings

5. The participants said that they did not have proper information; the people who are aware

would not share the information thinking that they would be deprived of it.

6. Some of the participants said that they know some of the health insurance like,

Yeshaswini, RSBY and Chaithanya etc.

7. In general many participants said that although they heard of such kind of schemes, they

did not get any detailed information as to how to enroll.

8. The participants said that they knew of many household who were enrolled for some kind

of health insurance

9. When they wanted to enroll, they could not, as they could not get the information in time

10. Most participants knew about the MAS and SS.

11. They also knew that MAS was providing premium free facilities and in case of SS it was

through SHG enrollment and dissemination of information by the sevanirathas.

12. The authorities should come forward to disseminate the information. They would want to

enroll for such kind of schemes, but it seemed like a missed opportunity.



13. All the participant s opined that health insurance or a health card , will always be

beneficial especially for any medical emergencies, since most of them seemed to have

economic problems, so they realize the importance of having their health insured.

14. Some of the participants said that they wanted to enroll for MAS and SS, but was given

wrong assurances and this led to them missing the opportunity .At the time of this FGD,

they said they would be more alert the next time.

15. The participants totally agreed that, they would not prefer going to a government hospital,

and would prefer a private one, as even if they can avail consultations at a govt. hospital,

they would have to depend on drugs to be brought form outside. And it is most likely that

the doctor may either come late, or not come at all.

16. In case of chronic illness of any family member, they depend on either taking a loan or end

up borrowing form different sources.

17. They all opined that it would ease their economic burden, if they would have enrolled for

any of the schemes.

18. Participants said that they are ready to join the health insurance scheme. But it should be

at a nominal premium



Section C: Report of Focus Group Discussion Conducted Among Supervisors and Field

Workers of SS

The FGD was conducted among 12(twelve) supervisors and field workers

The Sampoorna Suraksha health insurance is a community based health insurance scheme and is

the only one which is a part of self-help group.. The supervisors take the initiatives to enroll

members for the health insurance scheme. The entire self-help group comes under the

jurisdiction of the supervisors. They have designated areas under which they operate. Most of

them have been working for 10-12 years. The supervisors said that the organizational setup of

the health plan was good enough and people were voluntarily coming forward to join the

scheme. The supervisors given the information to the people who are there in self-help group

about the health insurance their rules regulations. Only self-help group’s member and their

families were covered under this scheme. There are family packages also under this scheme.

Beneficiary can avail facilities only at network hospital. They have to provide the health

card within 24 hours. HIV; TB etc. are excluded, people have to renew the card yearly. Any of the

issues related to admission or claim process are handled by them before it reaches the

organization.

The beneficiaries are getting facilities and benefits as per the plans. Since the

concessions available are reasonable there are very few drop outs. Membership trend is

increasing every year. The volunteers keep the record of the beneficiaries of his /her designated

area. The confidentiality of the records is also maintained.

There are two ways of the claim process, either they submit the bills to the organisation

office and get the bills reimbursed, or the claim is directly handled by the hospital with the

insured. There is a no specific waiting period after the premium payment.

The flexibility of premium payment is unique to this scheme and helps the beneficiaries.

The people before have to pay the premium amount yearly. Since there is a zero rejection policy,

all the claims are settled as per the norms allowed.

Overall the supervisors felt that people should common forward to join the schmee,

since they have good quality facilities of private hospitals under the network provider hospitals.



“We supervisors take all the initiatives to enroll people in to the SHG and in turn enlist the

members in to this health insurance scheme. The entire self-help group comes under the

supervisors, who are given area wise jurisdiction”.

“We have had the experience of working in various capacities in the same organization and

similar type of grassroots level experience of about 10-12 years”.

“Many people are coming forward to join the SHG, and they seemed to realize the

importance of having a health insurance we sensitize the beneficiaries about the rules and

regulations to avoid moral hazards”.

“Since only self-help group’s member and their families are covered under this scheme, it is

our responsibility to help both the organization and to the people”.

“The delivery of services is very systematic in nature, and concessions available from the

hospital as an agreement with network hospital is indeed beneficial to a large extent”.

“There are no drop outs, there is an increasing trend in the annual membership”.

“We work under our Project Officers who were always working towards providing facilities

to beneficiaries”.

“Only remuneration is our dissatisfaction, as we have to ensure all members pay premium

on time, organize meetings of SHGs, we should be paid more than what we are getting now, many

of our supervisors left because of that”.



Section D: Report of Focus Group Discussion Conducted Among Supervisors and Field

Workers of MAS:

The FGD was conducted among 12(twelve) supervisors and field workers.

The Manipal Arogya Suraksha is a community based health insurance scheme and it is a free

service provided to help the poor and also to build referrals for the Manipal Group hospitals..

Only those who are listed under RMCW centres get the free card others pay the premium. The

field workers have designated areas and are responsible to build referrals for the tertiary care

hospitals they do not decide on the enlistment although they give a list to the organization office,

as to who are regular patients of the centres. There is only limited free cardship, but people

show resentment to them during their field visits on their names being not include in the list.

The organization decided the membership, there are donors who sponsor the card for particular

community members and these are then issues to the beneficiaries.

Many times people do not realize the importance of the free card, and would not even

bother to come and collect the card from the centre. In case of any emergency if they had been to

the group hospital, and they have been turned down due to card loss or any such issues, they call

up the centre and pass on the blame. The supervisors felt that some of them were not actually

poor and were getting the card, this is a cause of resentment among others.

During the time of renewal every year, it is announced at the panchayat meetings and

pamphlets are distributed for some who may want to voluntarily join the scheme. Later if some

are interested they come to the centre and register. This is then informed to the organization

office and a formal membership card is handed over to them. At the time of admission in the

hosptials they have to pay Rs 500 which is then adjusted in the coverage.

Comments of respondents

The Manipal Arogya Suraksha is a community based health insurance scheme.

“In many areas they are given this card free, if any body who is not in the field practice area

of the RMCW centres would have to pay a premium for enrolling”.

“We have designated areas and provide all the information to the people about the rules

and regulations of the health insurance”.

“There is a committee looks in to the matter of the scheme. They decide about the free card

enrollment beneficiaries not us”.



“The card holders create a lot of problem by not taking card along, while going to hospital,

each time we are called and then we have to check and confirm, this becomes difficult, as it happens

very often”.

Since they are getting free card, they do not realize the value of it and sometimes they don’t

even collect the card, we have to go and give it to them at their homes. The managers tell us not to

do so, but people keep complaining so we just do it”.

“The managers stated that are facing the problem like fraud while settling the claims, as

reported by the hospital at Manipal. Any such issues if it comes to their notice are reported as per

the instructions of officials and, the insurance company representative”.

Documents

Data Analysis and Findings - Shodhgangashodhganga.inflibnet.ac.in/bitstream/10603/12250/13/13_chapter 4.p… · The Sampoorna Suraksha was started as an integral part of the tradition