Objective. To assess the Self Employed Women’s Association’s Medical
Insurance Fund in Gujarat in terms of insurance coverage according to
income groups, protection of claimants from costs of hospitalization,
time between discharge and reimbursement, and frequency of use.
Methods. One thousand nine hundred and thirty claims submitted over six
years were analysed.
Findings. Two hundred and fifteen (11%) of 1927 claims were rejected.
The mean household income of claimants was significantly lower than that
of the general population. The percentage of households below the
poverty line was similar for claimants and the general population. One
thousand seven hundred and twelve (1712) claims were reimbursed: 805
(47%) fully and 907 (53%) at a mean reimbursement rate of 55.6%.
Reimbursement more than halved the percentage of catastrophic
hospitalizations (>10% of annual household income) and
hospitalizations resulting in impoverishment. The average time between
discharge and reimbursement was fourmonths. The frequency of submission
of claims was low (18.0/1000 members per year: 22–37% of the estimated
frequency of hospitalization).
Conclusions. The findings have implications for community-based health
insurance schemes in India and elsewhere. Such schemes can protect poor
households against the uncertain risk of medical expenses. They can be
implemented in areas where institutional capacity is too weak to
organize nationwide risk-pooling. Such schemes can cover poor people,
including people and households below the poverty line. A trade off
exists between maintaining the scheme’s financial viability and
protecting members against catastrophic expenditures. To facilitate
reimbursement, administration, particularly processing of claims, should
happen near claimants. Fine-tuning the design of a scheme is an ongoing
process — a system of monitoring and evaluation is vital.
Ranson, K. Reduction of catastrophic health care expenditures by a community-based health insurance scheme in Gujarat, India: current experiences and challenges. Bulletin of the World Health Organization (2002) 80: 613-621.
Reduction of catastrophic health care expenditures by a community-based health insurance scheme in Gujarat, India: current experiences and challenges
Published 12 September 2006