health insurance in india research paper

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• Volume 11, Issue 4
• Health insurance awareness and its uptake in India: a systematic review protocol
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• Bhageerathy Reshmi 1 ,
• Bhaskaran Unnikrishnan 2 ,
• http://orcid.org/0000-0002-8824-9198 Shradha S Parsekar 3 ,
• Eti Rajwar 3 ,
• Ratheebhai Vijayamma 4 ,
• http://orcid.org/0000-0002-3338-6478 Bhumika Tumkur Venkatesh 3
• 1 Health Information Management, Manipal College of Health Professionals , Manipal Academy of Higher Education , Manipal , India
• 2 Kasturba Medical College, Mangalore , Manipal Academy of Higher Education , Manipal , India
• 3 Public Health Evidence South Asia, Department of Health Information, Prasanna School of Public Health, Manipal Academy of Higher Education , Manipal Academy of Higher Education , Manipal , India
• 4 Manipal Institute of Communication , Manipal Academy of Higher Education , Manipal , India
• Correspondence to Dr Bhumika Tumkur Venkatesh; bhumika.tv{at}manipal.edu

Introduction Health insurance is one of the important approaches that can help in boosting universal healthcare coverage through improved healthcare utilisation and financial protection. This objectives of this review are to identify various interventions implemented in India to promote awareness of health insurance, and to provide evidence for the effectiveness of such interventions on the awareness and uptake of health insurance by the resident Indian population.

Methods and analysis A systematic review will be carried out based on the Cochrane handbook for systematic reviews of interventions. The review will include experimental and analytical observational studies that have included adult population (>18 years) in India. We will include any intervention, policy or programme that directly or indirectly affects awareness or uptake of health insurance. The following outcomes will be eligible to be included: awareness or health insurance literacy, attitude such as readiness to buy health insurance or decision making, uptake of health insurance, demand-side and supply-side factors for awareness of health insurance, and awareness as a factor for uptake and re-enrolment in health insurance. Databases such as MEDLINE (PubMed), Web of Science, Scopus, 3ie impact evaluation repository and Social Science Research Network will be searched from January 2010 to 15 July 2020. Additionally, important government websites and references of the included studies will be scanned to identify potential records. Three authors, independently, will carry out screening and data extraction. Studies will be categorised into quantitative and qualitative, and mixed-methods synthesis will be employed to analyse the findings.

Ethics and dissemination This review will be based on published studies and will not recruit human participants directly, therefore, ethical clearance is not applicable. We will disseminate the final review findings in a national or international conference and publish in a peer-reviewed journal.

• health economics
• health policy
• public health

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/ .

https://doi.org/10.1136/bmjopen-2020-043122

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Strengths and limitations of this study

This systematic review will use mixed-methods analysis involving findings from quantitative and qualitative studies conducted in India.

We will comprehensively search the evidence in various databases, grey literature and reference and forward citations of included studies, however, the publications will be restricted to English.

We anticipate heterogeneity owing to study designs of potentially included studies, however, to mitigate this challenge we have planned to conduct subgroup analysis based on PROGRESS-Plus framework.

Introduction

Low-income and middle-income countries (LMICs) contribute to around 84% of the world population and 90% of the global burden of disease. 1 People living in the LMICs rely majorly on out-of-pocket payments as the prime source for managing healthcare expenses, that results in a massive demand for services and financial burden of households (usually catastrophic), which in turn leads to impoverishment. 1–5 It is projected that every year approximately 150 million people experience financial catastrophe, by spending more than 40% on health expenses other than food. 6 Families generally spend more than 10% of the household income on illness-related expenses, due to which other household expenses are affected. 2 5 To make it worse, evidence suggests that per capita spending on healthcare in many LMICs is expected to increase in coming years. 4 Additionally, the increased costs of seeking and receiving care can hinder the access to healthcare. 7

The Universal Health Coverage (UHC) is embedded within the Sustainable Development Goals (SDGs) and aims ‘to ensure healthy lives and promote well-being for all at all ages by 2030’. 8 It includes financial risk protection and equal access to quality essential healthcare services. 8 9 In other terms, UHC encourages equitable healthcare 2 and nations across the world are committed to achieving SDGs through UHC. 10

Health insurance is one of the important approaches that can help in boosting UHC through improved healthcare utilisation and financial protection. 7–9 11 There are multiple types of insurance in LMICs that differ with providers (government vs private sector), scales and types of beneficiaries. 8 However, in many LMICs, due lack of acceptability and unwillingness to pay (WTP) premiums, health insurance coverage is limited. 2 4 This increases the risk of excluding vulnerable and at-risk population, who cannot afford to pay health insurance premium. 8 Additionally, the older adults, and the individuals with disability and chronic diseases, have less probability of enrolling in health insurance schemes or their specific needs may not be covered under the scheme. 8

The coverage of health insurance policies or programmes in India is improving, however, the publicly funded health insurance schemes are mostly restricted to socioeconomically backward people or government employees. 12 India’s first health insurance programme, launched in the 1950s, was limited to central government employees and certain low-income population. 11 Over the years, the private healthcare providers’ dominance in quality healthcare service provision can be seen. 11 Nevertheless, many economically backward families are either deprived of healthcare or are pushed into poverty in the absence of financial protection. 11 In 2002, targeted health insurance programmes for low-income households were introduced by central and state governments in partnership with private sector and non-governmental organisations (NGO). Since 2002 (recommendations of National Health Policy 2002), more than 17 health insurance schemes have been launched by various governments in India. 11 The most recent one is ‘Ayushman Bharat’ or Pradhan Mantri Jan Arogya Yojana (PMJAY) (Prime minister’s health assurance scheme) launched in 2018 to achieve UHC. PMJAY is fully financed by the government and seeks to cover 500 million citizens with an annual cover of approximately US$7000 per household. The main aim of the PMJAY is to lessen the economic burden experienced by poor and vulnerable groups for access to healthcare facility. 13

Despite the availability of multiple health insurance schemes, evidence suggests that the uptake of health insurance in India is poor. As per the recently concluded National Sample Survey Office data, there were as low as 14% rural and 18% urban residents of India having some form of health insurance. 14 The low coverage of health insurance was evident in other literature, wherein it was reported to be less than 20%. 5 12 Similarly, other LMICs have reported poor registrations in the national health insurance schemes. 8 9 12 15

There are multiple factors that are responsible for awareness and enrolment in health insurance schemes. 2 4 These factors can be broadly divided into individual (age, gender, education, employment status, marital status), 2 9 16 and household characteristics (wealth, size of family). 1 9 17 Other factors are programme-related (premium amount, rules, regulation and procedures), social capital (trust, networks and group participation, social norms and solidarity and togetherness features of the social organisation of the community), institutional factors (regulatory mechanisms, complaint handling systems and insurance education) and supply-side factors (quality of care and distance of house from the nearest health facility). 2 The aforementioned factors may also determine the consumer preference in selecting the health insurance. 17 Inadequate claim returns, poor accountability and non-transparent operations hinders the uptake of health insurance. 18

In Indian studies, a scant that is, 34% of the participants who did not have health insurance were willing to pay for any health insuance. 5 Previous research in LMICs suggests that financial status of household is positively associated with WTP. 2 4 9 18 Whereas level of education received contradictory findings, that is, a study conducted in Nigeria reported that education was negatively associated with WTP 4 contrary to study conducted in Uganda, 1 Ghana 16 and India. 5 Family who had good perceived health had less probability of getting insurance as compared with those individuals who perceived their health as poor. Similarly, those individuals who had chronic diseases were more inclined to have health insurance than those who did not have chronic diseases. 2 Corruption and mistrust in the health insurance scheme 1 5 18 and expensive plans 5 18 were some of the reasons for non-WTP. Lack of information or health insurance illiteracy is another important reason for non-WTP. 1 5 18

Health insurance literacy is defined as ‘the degree to which individuals have the knowledge, ability and confidence to find and evaluate information about health plans, select the best plan for their own (or their families) financial and health circumstances, and use the plan once enrolled.’ 1 Lack of health insurance literacy or education hinders the uptake of health insurance and in many LMICs health insurance literacy is poor. A study conducted in Uganda reported that about 34% of the studied population were not aware of health insurance. 1 Whereas, proportion of people having inadequate knowledge about health insurance was found to be high in countries such as India (46%), 5 Myanmar (66%) 3 and Hispanic American in the USA (70%). 19

Familiarity or awareness of the insurance schemes increases the utilisation of health insurance and subsequently help in healthcare uptake. 1 2 19 Individuals usually enrol into health insurance because of their personal experiences, awareness or word-of-mouth advertisements. 17 Mass media such as newspaper, radio and television play an important role in making people aware of health insurance schemes. 1 Friends, community meetings, school gatherings and health workers have an influence on increasing the health insurance awareness of the people. 1 Although, aforesaid factors help in increasing the awareness and enrolment in health insurance scheme, some enrollees may not pay premium on regular basis and might not get to know even after health insurance is lapsed. 9 Women farmers, as compared with other occupations, had more odds of unawareness that their insurance was lapsed. 9

It is evident from the above description that there is inadequate awareness of health insurance among general population in LMICs. Knowledge about health insurance can boost individuals’ confidence and self-efficacy; thus, it is an important a priori factor that is required to get enrolled in health insurance scheme. 19 Outreach programmes to increase general knowledge of health insurance and integrating health insurance education within health delivery systems may help to improve the uptake of health insurance. 19 Globally, there are different methods available to promote and raise awareness about different health insurance schemes. However, India is a diverse country with a complex health system and numerous contextual factors. A ‘one size fits all’ approach for any policy or intervention is not suitable for the country. Therefore, it is imperative to understand the different approaches implemented to raise awareness about health insurance in the country. Additionally, due to increased population and a meagre public health spending on healthcare, it is important to understand if the resources are being used appropriately. To ensure this, understanding the effectiveness of such policies is essential, so that focus is directed towards the suitable interventions. ‘Ayushman Bharat Scheme-PMJAY’ is implemented to ensure increased utilisation of the healthcare facilities with financial protection of the beneficiaries. The evidence available on the effectiveness of the PMJAY scheme states no effect of the scheme on utilisation of healthcare and financial protection of enrolled beneficiaries, 13 however, this evidence is limited. Therefore, in the Indian context, it is important to understand if awareness is a factor that has led to decreased utilisation of PMJAY or failure of the other schemes (viz. Rashtriya Swasthya Bima Yojana-RSBY) in securing financial protection of the beneficiaries. 20 Also, it is vital to understand the importance of awareness programmes for success of the health insurance schemes, which will be the focus of this review.

A systematic review will help in synthesising high-quality evidence in a systematic manner, for this important topic of interest. The proposed systematic review will, therefore, identify the different approaches and interventions for increasing health insurance awareness in India and will give information about the impact of these interventions. This review is planned to address the following research questions:

What are the various interventions implemented in India to promote awareness of health insurance?

What is the effectiveness of the above interventions on the awareness and uptake of health insurance by people of India?

Methods and analysis

Methodology for this systematic review will be based on the Cochrane handbook for systematic reviews of interventions 21 and we have adhered to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-Protocols guidelines for reporting this protocol. 22

Criteria for including studies in the review

Population: The review will include studies conducted in India that involve adult population (>18 years). We will consider the studies having household as a unit of analysis, if the head of the family (or the family member who was interviewed) is an adult.

Intervention/exposure: We will include any intervention, policy or programme that directly or indirectly affects awareness of health insurance. The health insurance scheme could be of any type, including but not limited to, public, private, for profit and not-for-profit. Contribution for premiums could be made by individual, NGO, employer or government. There is no restriction on focus of health insurance for example, hospital stay, surgery or critical illness.

Intervention/exposure could be educational, informative, training, technology and m-health or e-health related. The interventions could be focused on raising income threshold to be eligible for health insurance, such as, conditional or unconditional cash transfers that indirectly influences awareness of health insurance. Similarly, training and performance-based financing for healthcare staff or other groups will be eligible for inclusion. The intervention could be a modification of the enrolment procedure, changes in the premium or organisational changes in handling health insurance. Intervention could be directed on general population or targeted groups such as vulnerable population, indigenous groups, community leaders, employees, formal or informal groups and healthcare staff.

Comparison: This review will not restrict the studies based on comparison, as having a comparison group may not always be feasible.

Awareness/health insurance literacy (refers to knowledge of the household head or household member on the presence of insurance schemes, its principles and significance. The outcome measure can be objective or subjective).

Attitude: Readiness to buy health insurance, decision making.

Uptake of health insurance.

Demand-side and supply-side factors for awareness of health insurance.

Awareness of health insurance as a factor for uptake or re-enrolment of health insurance.

Types of study designs: This review will include experimental studies that assessed the effect of intervention to promote awareness and uptake of health insurance. It is sometimes not practical to conduct randomised controlled trials (RCTs) to measure the effect of public health interventions, therefore, the review will also include other study designs. Studies with following designs will be included: RCTs, interrupted time-series studies, difference-in-difference, regression discontinuity designs, statistical matching, quasi-randomised and non-randomised trials. Additionally, this review will include prospective, retrospective, analytical cross-sectional and studies related to process evaluation and policy analysis, if the studies have provided description of intervention or exposure of our interest. Qualitative studies are important source of information about barriers and enabling factors that can complement the findings, therefore, we will also include these types of studies. This review will exclude descriptive cross-sectional (prevalence) studies, commentaries, perspectives, editorials, reviews and conference abstracts. Policy papers that do not provide details of implementation of intervention will not be considered.

Searching and locating the studies

The electronic databases such as MEDLINE (PubMed), Web of Science and Scopus will be searched to identify potential records. Additionally, 3ie impact evaluation repository and Social Science Research Network will be searched. Databases will be searched from January 2010 to 15 July 2020 and publications will be restricted to English language. Ministry of Health and Family Welfare, RSBY, Ayushman Bharat and other state health insurance websites will be searched for reports on the health insurance schemes. We will also scan through references of the included studies for any additional eligible records. After identifying the keywords, initial search will be carried out in PubMed, which will then be replicated in other databases. A designated information scientist will be responsible for conducting search. The preliminary search concepts and key terms are given in table 1 .

• View inline

Search concepts and key words

Applying eligibility and screening the studies

The results of search will be imported to Endnote X7 reference manager software and duplicates will be removed. MS Excel spreadsheet will be used to screen the records. Based on inclusion and exclusion criteria, all the records will be subjected to two stage—title/abstracand full text (FT)—screening process, independently by three (SSP, ER and BTV) reviewers (in pairs). Any disagreements between the reviewers will be resolved by discussion, and senior reviewer will be involved in decision making in case of disagreements between the reviewers. The reasons for excluding FTs will be documented and the PRISMA flow diagram will be provided. A detailed screening protocol will be used as a back-up document to aid the screening process. Table 2 gives detailed screening protocol.

Screening protocol

Data extraction

Data will be extracted independently by three reviewers (SSP, ER and BTV). A predesigned data extraction form will be used for extraction of the data. The data extraction form will be subjected to pilot testing and will be revised as per the suggestions by the reviewers and the experts at this stage. Any disagreements during data extraction will be resolved by consensus supported by the senior reviewer. Data will be extracted based on the characteristics mentioned in the table 3 .

Data extraction format

Critical appraisal of included studies

Effective Public Health Practice Project (EPHPP) tool 23 will be used to assess the methodological quality of quantitative studies (except observational studies) and Newcastle-Ottawa scale (NOS) 24 will be used for the observational studies. The EPHPP rates the study as ‘strong’, ‘moderate’ or ‘weak’ based on eight domains. These domains are selection bias, study design, confounders, blinding, data collection methods, withdrawals and drop-outs, intervention integrity and analysis. 23 NOS rates the study based on three domains viz. selection, comparability and outcome, and the final score ranges between 0 and 10. 24 Reviewers (BTV, ER and SSP), independently in pairs, will appraise the included studies. Any discrepancies between the decisions of reviewers will be resolved by discussion until consensus is achieved. If required, a senior reviewer will be involved as arbitrator and final decision maker to rate the study quality.

Data analysis

Study characteristics consisting of population, intervention/exposure, comparator, outcome, study design components across studies will be tabulated, which will help us to compare and analyse. Subsequently, studies will be categorised into quantitative and qualitative and will be analysed separately. This step will be followed by mixed methods synthesis as suggested by Panda et al . 25

Quantitative studies

Studies will be grouped based on study design, and type of data available (continuous or categorical). If possible, similar studies will be pooled to perform meta-analysis using random effect model. If data are continuous, standardised mean difference will be calculated with 95% CI. For categorical data, OR or risk ratio will be calculated and reported with 95% CI. Meta-analysis will be visually represented with a forest plot. We assume possibility of heterogeneity owing to differences in study design or analysis, intervention, type of insurance and other contextual factors. If heterogeneity exists due to aforementioned components, we will not perform meta-analysis. After ruling out clinical or methodological heterogeneity, we will statistically measure heterogeneity by using I 2 test. If significant heterogeneity (>50%) persists for a particular outcome, meta-analysis will not be conducted. In this case, our focus would be on conducting narrative synthesis and undertaking a subgroup analysis. Key findings of the studies will be summarised in tables/figures or vote counting will be considered. Subgroups could be based on study design, intervention type, insurance type (such as private and public), region and other contextual factors (eg, urban/rural).

Qualitative synthesis

We will carry out thematic analysis as suggested by Thomas and Harden. 26 An iterative process of line-by-line coding will be undertaken as a first step, which will be followed by categorising the codes into code families. Subsequently, a code tree will be created, and themes and subthemes will be generated. Three reviewers (SSP, ER and BTV) will code the data independently and resolve the discrepancies by discussion until consensus is achieved.

Mixed-methods synthesis

The result from both, qualitative and quantitative synthesis will be merged for each outcome. Parallel synthesis will be carried out, and the findings will be summarised narratively. 25 To understand the influence of inequality in uptake of health insurance based on type of insurance, we will explore the possibility of conducting subgroup analysis based on some of the components of PROGRESS ( P lace of residence, R ace/ethnicty/culture/language, O ccupation, G ender, R eligion, E ducation, S ocio-economic status, S ocial capital)-Plus framework. 27

Grading the evidence

We will use the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to evaluate the certainty of evidence for each outcome. 21 Using GRADE profiler software, we will present the main findings of the systematic review in a summary of findings table.

Patient and public involvement

We did not involve patients or public while designing and writing this protocol.

Ethics and dissemination

This review will be based on published studies, therefore, an ethical clearance is not applicable. We have planned following activities to communicate and disseminate the findings of this review. We plan to make at least one national or international conference presentation. We will prepare policy brief to be shared with funder and to get a wider reader, we plan to submit the manuscript to a peer-reviewed journal. On journal publication, we intend to circulate the findings through our social media platform and website.

Acknowledgments

We are grateful to Dr Prachi Pundir, Research Officer, public Health Evidence South Asia, Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, for proof reading the final document.

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Twitter @ParsekarShrads

Contributors RB is the guarantor of the review. RB, SSP, ER and BTV conceptualised the manuscript. SSP drafted the first manuscript, which was further edited by ER. RV developed the search strategy. All the authors (RB, BU, SSP, ER, RV and BTV) read, edited, provided feedback and approved the final manuscript.

Funding This work was supported by PHRI-RESEARCH grants awarded by PHFI with the financial support of Department of Science and Technology (DST). We appreciate the technical support provided by public Health Evidence South Asia, Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal.

Disclaimer Funder did not have any role in writing this protocol and decision to submit it for publication.

Competing interests None declared.

Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

Provenance and peer review Not commissioned; externally peer reviewed.

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Effect of Health Insurance in India: A Randomized Controlled Trial

We report on a large randomized controlled trial of hospital insurance for above-poverty-line Indian households. Households were assigned to free insurance, sale of insurance, sale plus cash transfer, or control. To estimate spillovers, the fraction of households offered insurance varied across villages. The opportunity to purchase insurance led to 59.91% uptake and access to free insurance to 78.71% uptake. Access increased insurance utilization. Positive spillover effects on utilization suggest learning from peers. Many beneficiaries were unable to use insurance, demonstrating hurdles to expanding access via insurance. Across a range of health measures, we estimate no significant impacts on health.

We thank Kate Baicker, Amitabh Chandra, Pascaline Dupas, Johannes Haushofer, Rick Hornbeck, Joe Newhouse, Neale Mahoney, Julian Reif, Joshua Gottlieb, and seminar participants at Brown University, University of Chicago, Harvard, and Stanford for comments. This study was funded by the Department for International Development in the UK Government; the Tata Trusts through the Tata Centre for Development at the University of Chicago; the MacLean Center, the Becker-Friedman Institute, the Neubauer Collegium, and the Law School at the University of Chicago; the Sloan Foundation; SRM University; and the International Growth Centre. The views expressed herein are those of the authors and do not necessarily reflect the views of the National Bureau of Economic Research.

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Effect of Health Insurance in India: A Randomized Controlled Trial

In lower middle-income countries like India, households face enormous challenges to finance healthcare. For example, in 2018, 62% of Indian households paid for healthcare out-of-pocket, compared with just 11% in the United States. Further, research shows that many Indian households fall into poverty by health costs, and care is often foregone due to expense.

To address these concerns, the Indian government in 2008 launched a hospital-insurance program for below-poverty-line households in India with a roughly 60% uptake (abbreviated RSBY) that was replaced 10 years later by an expanded program covering 537 million people (all those the below the poverty line plus nearly 260 million above). The new program, PMJAY, provided insurance largely for free in the hopes of attracting more people to enroll. However, utilization remained relatively low, reflected in the low fiscal cost of the program to India’s government, about 1% of GDP.  

Why is utilization low? Could lower-income countries like India reduce pressure on public finances, without compromising uptake, by offering the opportunity to buy insurance without subsidies (i.e., pure insurance)? Importantly, does health insurance improve health in lower-income countries? To address these questions, the authors conducted a large randomized controlled trial from 2013-2018 to study the impact of expanding hospital insurance eligibility under RSBY, an expansion subsequently implemented in its successor program, PMJAY. The study was conducted in Karnataka, which spans south to central India, and the sample included 10,879 households (comprising 52,292 members) in 435 villages. Sample households were above the poverty line, not otherwise eligible for RSBY, and lacked other insurance.

To tease out the effects of different options for providing insurance, sample households were randomized to one of four treatments: free RSBY insurance, the opportunity to buy RSBY insurance, the opportunity to buy plus an unconditional cash transfer equal to the RSBY premium, and no intervention. To understand the role that spillovers play in insurance utilization, the authors varied the fraction of sample households in each village that were randomized to each insurance-access option.  

The intervention lasted from May 2015 to August 2018, including a baseline survey involving multiple members of each household 18 months before the intervention. Outcomes were measured at 18 months and at 3.5 years post intervention, and included measures to address factors that could distort results (see paper for more details). The authors’ findings include the following:  

• The sale of insurance achieves three-quarters of the uptake of free insurance. The option to buy RSBY insurance increased uptake to 59.91%, the unconditional cash transfer increased utilization to 72.24%, and the conditional subsidy (i.e., free insurance) to 78.71%.  
• Insurance increased utilization, but many beneficiaries were unable to use their insurance and the utilization effect dissipated over time, reflecting such obstacles as households forgetting their card or trying to use RSBY at non-participating hospitals. The failure rate was lower among those who paid for insurance, which may indicate that prices screen for more knowledgeable, higher value users, lead to a “sunk cost,” or signal quality in a manner that increases successful use. Also, utilization fell over time: 6-month utilization was just 1.6% in the free-insurance group after 3.5 years. Instead of learning-by-doing, perhaps households were disappointed by the difficulty of using the new insurance product.
• Spillovers play an important role in promoting insurance utilization. The magnitude of spillover effects is roughly twice that of direct effects in the free-insurance arm at 18 months, suggesting that peer effects may play a role in learning how to utilize insurance.
• Finally, health insurance showed statistically significant treatment effects on only three outcomes among 82 health-related outcomes across two survey waves. That said, the authors do not rule out clinically significant health effects, and they stress that even this study, which is among the largest health insurance experiments ever conducted, may not be powered to estimate the health effects of insurance.

These findings have implications on the implementation of public insurance in India on two related counts: household use and marketing. In the first case, many households were unable to use their insurance due to complexity and/or lack of understanding. Likewise, policymakers could consider improved educational materials, higher reimbursement rates, and increased investment in IT to expand awareness.  

Regarding marketing, spillover effects on utilization have implications for marketing insurance. With a fixed budget, the government may achieve greater utilization by focusing on increasing coverage within a smaller number of villages rather than spreading resources over more villages with lower coverage in each.

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Health insurance in India: what do we know and why is ethnographic research needed

Affiliations.

• 1 a University of Amsterdam, Amsterdam Institute of Social Science Research , Nieuwe Achtergracht 166 , 1018 WV Amsterdam , the Netherlands.
• 2 b School of Anthropology , University of Arizona , 1009 E. South Campus drive, Tucson , AZ 85721 , USA.
• 3 c University of Leiden, Leyden Academy on Vitality and Aging , Poortgebouw LUMC, Rijnburgerweg 10, 2333 AA, Leiden , the Netherlands.
• PMID: 26828125
• DOI: 10.1080/13648470.2015.1135787

The percentage of India's national budget allocated to the health sector remains one of the lowest in the world, and healthcare expenditures are largely out-of-pocket (OOP). Currently, efforts are being made to expand health insurance coverage as one means of addressing health disparity and reducing catastrophic health costs. In this review, we document reasons for rising interest in health insurance and summarize the country's history of insurance projects to date. We note that most of these projects focus on in-patient hospital costs, not the larger burden of out-patient costs. We briefly highlight some of the more popular forms that government, private, and community-based insurance schemes have taken and the results of quantitative research conducted to assess their reach and cost-effectiveness. We argue that ethnographic case studies could add much to existing health service and policy research, and provide a better understanding of the life cycle and impact of insurance programs on both insurance holders and healthcare providers. Drawing on preliminary fieldwork in South India and recognizing the need for a broad-based implementation science perspective (studying up, down and sideways), we identify six key topics demanding more in-depth research, among others: (1) public awareness and understanding of insurance; (2) misunderstanding of insurance and how this influences health care utilization; (3) differences in behavior patterns in cash and cashless insurance systems; (4) impact of insurance on quality of care and doctor-patient relations; (5) (mis)trust in health insurance schemes; and (6) health insurance coverage of chronic illnesses, rehabilitation and OOP expenses.

Keywords: Health Policy and Systems Research (HPSR); Health insurance; India; ethnography.

• Anthropology, Medical
• Health Services Accessibility / economics*
• India / ethnology
• Insurance, Health / economics*

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Out-patient coverage: Private sector insurance in India

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1 Department of Public Health Dentistry, BRS Dental College and Hospital, Panchkula, Haryana, India

Ravneet Malhi

Saru khosla.

2 Department of Periodontology, DJ College of Dental Sciences and Research, Modinagar, Uttar Pradesh, India

3 Department of Prosthodontics, BRS Dental College and Hospital, Panchkula, Haryana, India

Arvind Bhardwaj

4 Department of Periodontics, Rayat and Bahra Dental College and Hospital, Mohali, Punjab, India

Mandeep Kumar

5 Department of Prosthodontics, Rayat and Bahra Dental College and Hospital, Mohali, Punjab, India

Background:

There has been a growth of 25% in the health insurance business in India during the last few years with the expansion of the private health insurance sector. The share of the private health insurance companies has increased considerably, despite the fact that from the patients’ point of view, health insurance is not a good deal.

To provide information and assess the current status of private sector insurance with regard to out-patient coverage in India.

Materials and Methods:

The present review was conducted after doing extensive literature search of peer review journals in Pubmed and various search engines like Google. Data of Indian private health insurance companies was also utilized. No limitation in terms of publication date and language was considered. The main focus of the present review would be on the private health insurance sector with a spotlight on the out-patient coverage and various obstacles faced by the private health insurance sector.

Out-patient (OPD) coverage is one of the important emerging trends in the private sector health insurance. OPD cover assists the insured to claim expenses other than that incurred during hospitalization. However, it is still not a full-fledged offering under health insurance and major insurance companies are providing this cover for an additional premium.

Conclusion:

Private is strongly being advocated and receiving growing consideration by our country's policy makers that can deal with alarming health care challenges in India. However, it is not the only option.

Introduction

Health care has always been a problem area for a country like India with a large population, majority of the people residing in urban slums and rural areas, below the poverty line. The Indian health care sector has received lowest percentage of the country's national budget and as a result health care expenditures are largely out of pocket (OOP). However, in recent years, Indian health care planners have advocated for the expansion of health insurance schemes in order to improve the health care reforms and reduce poverty.[ 1 ] This goal can only be achieved by implementing universal health insurance, which can be a major step in reducing health disparities and OOP health expenditure. Presently, numerous public, private, and community-based insurance schemes have come to coexist and even merge with each other, a situation that is hardly surprising in a country as diverse as India.[ 2 ]

There are various forces which have brought health insurance to the attention of Indian policy makers. These include – high ill health burden, low public spending on health care, high expenditure with regard to private health care and partial coverage of the already existing health insurance schemes. In the recent years, there has been a substantial private spending on health especially in terms of OOP expenditures on medicines. This is probably due to low national public health spending in India.[ 3 ] As a result of this, the private sector has been blooming, providing 80% of outpatient and 60% of inpatient care.[ 4 ] Research has revealed that it is not the hospitalization cost but the drug expenditure, which accounts for 60%–80% of the total OOP spending.[ 5 ] These findings suggest that insurance schemes which cover only hospital expenses (national insurance schemes in India) will fail to adequately protect the poor against impoverishment due to spending on health. In view of all the above findings, this paper intends to explore private health insurance in India with a spot light on outpatient coverage under this insurance.

Literature Search

An extensive review of literature search was done (electronic and manual) which engaged most of the articles published in peer-reviewed journals and other search engines like Google were also used for extracting relevant information regarding private health insurance in India. The review itself began with the search of relevant key words like insurance, private sector, India, out-patient coverage, companies, benefits, etc., in various search engines including Pubmed, MEDLINE, etc. Information regarding OPD coverage by private insurers was very limited in Pubmed. Web sites selling health insurance of different companies in India were also consulted like policy bazzar.com and bankbazaar.com. Reports published only in English language were included in the review. The spot light of the present review would not only be on the out-patient coverage provided by private health insurance in India but also on various factors that hinder the growth of health insurance in private sector. We also compared the features or benefits regarding OPD coverage provided by major health insurance companies in India.

Understanding and awareness of public regarding insurance

Recent reports suggest that public awareness and understanding of health insurance in India is poor. However, general public awareness of health insurance in Kerala and in some other parts in India is increasing as a result of the efforts of private health insurance agents.[ 6 ] Lack of necessary education and “culture” are perceived as “barriers” due to which people have difficulties in managing money and health and difficulty in learning this new technology. Poor and less educated people residing in both the rural and urban areas, consult private practitioners more than government practitioners and spend about twice as much on treatment from them than from government practitioners.[ 7 , 8 ] This thing has led to the deepening of poverty in both rural and urban areas, pushing the millions of people into poverty each year.[ 9 ] According to recent surveys and field works carried out in India, understanding of the entitled benefits and privileges remains confusing not only to the poor and illiterate people but also to the educated middle class citizens.[ 10 ] This could be due to promotional languages of the insurance sellers that is difficult to understand for the general public belonging to different educational backgrounds.[ 11 ]

Private health insurance (PHI) in India

PHI in India began with the establishment of General Insurance Corporation (GIC).[ 12 ] Private health insurers recognize India as a potential market due to its increasing purchasing power, growing demand for healthcare, an expanding competitive private healthcare market, and rising rates of chronic disease.[ 13 ] Eyeing this lucrative business opportunity, number of foreign insurance firms have invested in India during the last few years. However, in a country like India, providing insurance is a risky business venture due to a low level of insurance awareness as well as poor healthcare infrastructure in rural areas.[ 14 , 15 ] Mainly the middle-class population is targeted by private health insurers due to this profit-oriented approach. The cost of insurance policies for middle class families range from Rs 4000 per member and covering only in-patient treatment for a maximum of Rs 400000. There is greater health disparity and rising health costs for the poor as a result of this limited coverage (in-patient) and targeting particularly this income group, which serves to undermine national health equity goals.[ 16 ] There is abundant theoretical basis and empirical evidence from other parts of the globe that private insurance drives up healthcare expenditure. Moreover, in Indian context, where PHI mainly contracts with urban-based corporate hospitals, it is likely to increase cost.[ 17 ] Critics call for regulation of benefit packages, restrictions on risk-selection procedures, and greater protection of customers.

Out-patient department (OPD) coverage in health insurance

Outpatient insurance coverage includes benefits ranging from medical practitioner and specialist fees, routine check-ups, and vaccinations. Out-patient coverage may also include policy benefits for prescription medications, alternative treatments, diagnostic tests such as X-rays, and home nursing.[ 2 ] This type of insurance is generally not well suited to routine ambulatory care because its requirements tend to reasonably predictable and are of relatively low cost and people might be expected to meet these costs out of the pockets. Most people, however, do prefer it to be included at least those services (diagnostic and clinical) having bearing on their pockets.[ 18 ] However, there are number of benefits of having health insurance with OPD coverage:

• OPD cover assists the insured to claim expenses other than that incurred during hospitalization days
• Insured are entitled to more tax benefits as compared to regular insurance plans as they can get tax exemption on the premium paid for such health insurance policies
• Claim reimbursement on expenses can be done multiple times by the insured during the policy period making the monetary value of a health insurance policy with OPD cover higher than that of a regular health insurance policy
• This type of policy also covers pharmacy bills of the insured and thereby prove beneficial for those who have more expenses from the same
• Under OPD cover, the sum assured is based on the age of the insured; not on the basis of 24-hour hospitalization as in case of regular insurance.

Top companies offering OPD cover

There are many companies which are offering OPD coverage with general health insurance in India. However, some of the top companies offering OPD cover are listed in [ Table 1 ]. The premiums charged by these companies may vary depending upon factors like age, location, and prevailing taxes/GST.[ 19 ]

Top insurance companies offering OPD coverage in India[ 19 ]

Pricing hurdles in out-patient insurance

According to recent reports, some insurers have bought out-patient (OP) cover under cashless scheme for those hospitals that are linked with that particular insurance company. However, many believe that it would take a while before OPD cover becomes common as a product category in private health insurance.[ 20 ] Some companies extend OP cover under cashless scheme by payment of some additional premiums. Claim management would not be an easy task if OP becomes a full-fledged offering under health insurance. This is because there are frequent visits to a physician (in case of lifestyle disease) in case of OP cover whereas hospitalization is not a frequent event and leads to one-time claim settlement. Some other issues like absence of a national brand in the OP space be it dental, eye or even diagnostic, controlling frauds in matters pertaining in billing and uniformity in service for claims assessment and payment are hurdles in regularizing the OP cover.

Factors that frustrate the growth of private sector health insurance

There are certain factors that have curtailed the growth of private health insurance in the past and are likely to have an influence in the near future.[ 21 ]

• Lack of awareness in promoting health insurance to the general public at large
• Non-availability of reliable data and epidemiological information on the disease pattern and treatment cost that is requited for designing health insurance product specifications
• Risk of adverse selection of people with pre-existing ailments and unhealthy persons opt for the coverage
• Morale and morale hazard have had a negative implication on the insurance business
• Lack of actuarial data for the development of new product
• Lack of technically skilled manpower that has sound knowledge in the research and development activities associated with medical aspects of the health insurance and well-trained staff to meet the expectations of the clients
• Lack of cooperation and coordination with health care providers regarding processing and settlement of claims
• Lack of neutral bodies to carry out “Accreditation and Categorization” of health care providers.

Insurance with OPD coverage vs. Health cards

Discount cards or health cards are exclusive schemes that provide discounted rates on medical, health, and drug expenses by charging monthly or an annual membership fee but are in no way replacement for hospitalization cover. Almost all healthcare expenses are covered under health cards, including cosmetic treatments.[ 22 ] It is also of huge help to individuals who are at high risk, such as those with pre-existing ailments, and those who are refused health insurance, especially senior citizens, who face refusals or have to pay significant amount as premiums for a policy surrounded with lot many clauses and exclusions.[ 23 ] While a loyalty program from a hospital chain, will limit your options to the concerned group's facility, a health card from an independent company having a tie-up with multiple hospitals, individual medical practitioners, pharmacy chains, pathology labs, and diagnostic centers gives more flexibility of choice.

A typical health insurance policy does not provide offerings, such as discounts on dental treatments, pathology, and radiology expenses. In case of a health card plan, there are no caps or sub-limits. Depending on the plan and number of members registered, the membership fee of these cards ranges between Rs 1,000 to Rs 8,000. A basic plan provides a discount of 15–30% on consultations and 10–20% discounts on OPD treatments and various hospital procedures. In case of dental care, you are provided with free check-ups and up to a 50% discount on the total treatment cost. However, one should be very careful while opting for any health card as they don’t fall under any regulation unlike health insurance.[ 23 ]

Strengths and weaknesses of the paper

This review involved the search of multiple electronic databases, with no restrictions on year of publication. The reference lists of literature reviews were searched for further information that could also be included. However, it was not possible to search technical reports, papers from research groups or committees and pre-prints and it is possible that some relevant data may have been left behind. This could have accounted for some publication bias. Moreover, there was under reporting of some relevant information regarding the out-patient coverage on internet websites dealing with private sector insurance. There was also very limited information (lesser number of articles) available regarding outpatient coverage in databases like Pubmed, etc. This could be due to the fewer studies conducted and published on the current topic in the past.

Importance of the paper in Primary care/Family medicine/General practice

The present paper highlights and provides significant information regarding outpatient coverage in private insurance sector and also compares the existing schemes in different insurance companies. It is reported in some studies that nuclear families and families with fewer members are more likely to buy insurance policies and socio-economic factors including literacy, religion, occupation, and gender are important.[ 24 ] This aspect can contribute significantly towards family medicine. The topics discussed in the paper indicate where most misunderstandings and tension occur while buying and making claim under private sector insurance. People sometimes land into far more debt when they avail more expensive care than they can afford without realizing their insurance coverage at a hospital is limited. This paper brings out important aspects that should be kept in mind while buying and making claims under private health insurance so that the general public are not misled by the insurance providers. Some family clinics limit the amount of insurance coverage a person could draw upon during any one hospitalization as a matter of policy, possibly to educate patients that coverage was not in fact free but against a balance. Families often slip into debt regardless of insurance coverage for medical procedures as a result of the costs of essential follow up care. A better grasp of the enumerated areas could potentially lead to improvements in providing, explaining, and implementing health coverage, especially for those with limited resources.

India, a country with relatively developed economy and a considerable middle class population, offers most suitable environment for the development of private health insurance. At present, only a marginal role is played by private health insurance in health care system but it is gradually gaining importance. Private health insurance is certainly not the only alternative or the ultimate solution that can deal with alarming health care challenges in India. However, it is an option that is strongly being advocated and receiving growing consideration by our country's policy makers. Thus, the question is not if this tool will be used in the future but whether it will be applied to the best of its potential to address the growing and impending needs of the health care system of the country. The main challenge is to see that poor and the weak are benefitted in terms of better coverage (both inpatient and out-patient) and health services at lower costs without negative aspects of cost increase and overuse of procedures and technology in provision of health care.

Financial support and sponsorship

Conflicts of interest.

There are no conflicts of interest.