Pradeep Panda, PhD Micro Insurance Academy, New Delhi Ellen Van de Poel

Developing efficient and responsive community based micro health insurance in India

Reconciling Research and Implementation Needs in Community-Level Cluster

Randomised Trials:

An EC-FP7 Research Project

Pradeep Panda, PhDMicro Insurance Academy, New Delhi

Ellen Van de PoelErasmus University Rotterdam


• Micro-Insurance Academy is an Indian charity dedicated to training, research, technical assistance and advisory services for micro-insurance units serving the poor

• With our partners, we are running 3 separate, but similar, RCTs in northern India

• Each RCT will establish a Community Based Health Insurance (CBHI) scheme – a small-scale, member-operated health insurance scheme, offering limited coverage of defined events

• Each scheme will be evaluated for its effect on healthcare utilization and healthcare financing

• Now 30 months into this 5-year project – all CBHI units went live in 2011

Introduction


1. What do we Know about Micro Health Insurance

(MHI)?


Limited robust evidence on causal impact of MHI schemes:• Of the 22 most robustly studied trials, only 2 use

a randomised trial methodology…• … and only 7 use any form of counterfactual!• The remaining evaluations are prone to bias• No evaluation has examined a holistic list of

outcome indicators• And comparability of results across trials may be

limited, as all kinds of different schemes have been called “MHI:” national public schemes, private for-profits products, operator run pre-payment programs, and non-profit mutual finds!

1. What do we Know about Micro Health Insurance?


2. Overview of Trials


These trials aim to close knowledge gaps on MHI in three ways:

1. Use the “gold standard” randomised trial methodology to boost internal validity

2. Give clear and detailed descriptions of scheme setting and operation to clarify limits of external validity

3. Evaluate a holistic range of outcome indicators to broaden the knowledge base

2.1 Motivation for Trials


1. Kanpur Dehat

2. Pratapgarh 3.

Vaishali

Uttar Pradesh

Bihar

3 separate CRTs at 3 separate sites:

2.2 Scheme Areas & Target Populations


At each site, a particular type of MHI scheme is set up:

Community Based Health Insurance (CBHI)

CBHI schemes are locally based, mutual, not-for-profit programs:

• All schemes are owned by members• All schemes are managed by members• All premiums and coverage types are set by

members

This is why we call it Community Based!



• Implementation at each site is managed by an NGO implementing partner

• Each NGO has a network of Self Help Groups (SHGs): village level MFI groups

• At each site, there are 1400 – 1600 SHG members• Members and their families can take part in the

trial



4 sequential modules create an eventual impact:

2.3 Description of Treatment Program

2. AwarenessInsurance Education

(x3)CHAT (x2)

Finalization (x1)Enrollment (x1)

1. DesignBenefit Options workshop

(x1)Awareness Tools workshop

(x1)Design workshop (x1) 3. Launching

Selection of OfficersTraining of OfficersInstallation of MIS

Stakeholder Events

4. Live SchemeSubmission of

ClaimsProcessing of Claims

Payout of Claims

Key Outcome Indicators


3. Overview of Research Design


1. Effects of CBHI on Healthcare Utilization LevelsKey indicators depend on coverage of insurance packages at each trial. Will be drawn from:

Maternity Care Usage Rates

Outpatient Care Usage Rates

Hospitalisation Rates

Involuntary Non-Treatment

Rates

Use of Transport

3.1 Outcome Measures & Tools


2. Effects of CBHI on Healthcare FinancingKey Indicators include:

Total Healthcare Spending

Instance of catastrophic health expenditure (>10% HH Income)

Financial Exposure Index (Under Development)

3. Physical Accessibility of Healthcare

Village-wise Health Care Index

Instance of asset sales, savings liquidation, etc.



Quantitative• Household

surveys• Healthcare

Provider surveys

• Exit interviews• Income

surveys• Insurance

Understanding surveys

Qualitative• FGDs - SHG

members • FGDs - Heads

of SHG households

• KIIs - SHG leaders

• KIIs - Local Healthcare Providers


Spatial• GPS Mapping • Satellite

Imaging• GIS Imaging

3 mutually supportive and integrated research streams:

This presentation shows have quantitative and spatial baseline have driven experimental design….


3.2 Important design aspects of the RCT

• Staggered implementation– Each wave a random third of the target

population gets offered CBHI• Clustered trial

– SHGs are grouped into clusters– Clusters are randomized in 3 treatment

groups• En-bloc affiliation

– All hhs within a SHG need to join the CBHI


3.3 Defining an Implementation Friendly Unit of Randomisation

• combine Quantitative and Spatial data, and map locations of trial participants

• “3 Rules” to integrate implementation and research needs when forming clusters:

1. Non-Divisibility: A village cannot be divided over different clusters

2. Equal Size: Clusters must contain (roughly) equal numbers of SHG members

3. Continuity: Each cluster must be geographically continuous


3.3 Defining an Implementation Friendly Unit of Randomisation

This transforms villages into clusters….


3.4 Generating Power with a Fixed Population Size

Then MDES is calculated: If it is too low, one of the three rules must be broken somewhere to

improve power Trial 1 -

Pratapgarh Trial 2 - Kanpur Dehat

Trial 3 - Vaishali

No. SHG Members 1557 1226 1459No HH surveys complete

1272 1042 1248

No. Villages 15 42 34No. Clusters (J) 15 17 16Average HHs per cluster

86 61 84

Minimum Detectable Effect Size

0.45 0.45 0.44


3.5 Randomization

• Matching prior to randomization was considered (creating similar triplets of clusters) but did not improve balance on observables

• Simple randomization was chosen as it does not affect power

• Less balance on ethnicity/caste & health care supply


3.6 Limitations

• External validity:– Only effect of CBHI on SHG– Selection of implementation partners

• Internal validity:– Self-selection of SHGs in CBHI ->

intention to treat effect• Contamination effects• (health related) attrition• Multiple treatments (through participatory

design of CBHI)


Thank You!

Documents

Pradeep Panda, PhD Micro Insurance Academy, New Delhi Ellen Van de Poel