Professional Documents
Culture Documents
According to the World Health Organization, greater than 80 per cent of total expenditure
on health in India is private and most of this flows directly from households to the
private-for-profit health care sector. Most studies of health care spending have found that
out-of-pocket spending in India is actually progressive, or equity neutral; as a proportion
of nonfood expenditure, richer Indians spend marginally more than poorer Indians on
health care. However, because the poor lack the resources to pay for health care, they are
far more likely to avoid going for care, or to become indebted or impoverished trying to
pay for it. On average, the poorest quintile of Indians is 2.6 times more likely than the
richest to forgo medical treatment when ill. Aside from cases where people believed that
their illness was not serious, the main reason for not seeking care was cost. The richest
quintile of the population is six times more likely than the poorest quintile to have been
hospitalized in either the public or private sector. Peters et al (2002) estimated that at least
24 per cent of all Indians hospitalized fall below the poverty line because they are
hospitalized, and that out-of-pocket spending on hospital care might have raised by 2 per
cent the proportion of the population in poverty. Given this context, health insurance
appears to be an equitable alternative to out of pocket payments.
In recent years, community health insurance (CHI) has emerged as a possible means of:
(1) improving access to health care among the poor; and (2) protecting the poor from
indebtedness and impoverishment resulting from medical expenditures. It represents an
effective way to protect people from the costs of health care.
Community Health Insurance can be defined as: “any not-for-profit insurance scheme
that is aimed primarily at the informal sector and formed on the basis of a collective
pooling of health risks, and in which the members participate in its management.”
CHI schemes involve prepayment and the pooling of resources to cover the costs of
health-related events. They are generally targeted at low-income populations, and the
nature of the ‘communities’ around which they have evolved is quite diverse: from people
living in the same town or district, to members of a work cooperative or micro-finance
group. Often, the schemes are initiated by a hospital, and targeted at residents of the
surrounding area. As opposed to social health insurance, membership is almost always
voluntary rather than mandatory.
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Underlying Objectives
Most of the insurance programs have been started as a reaction to the high health care
costs and the failure of the government machinery to provide good quality care. The
objectives range from “providing low cost health care” to “protecting the households
from high hospitalization costs.” BAIF, DHAN, Navsarjan Trust and RAHA explicitly
state that the health insurance scheme was developed to prevent the individual member
from bearing the financial burden of hospitalization. Health insurance was also seen by
some organizations as a method of encouraging participation by the community in their
own health care. And finally, especially the more activist organizations (ACCORD,
RAHA) used community health insurance as a measure to increase solidarity among its
members – “one for all and all for one.”
INSURANCE
PROVIDER+INS COMPANY
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P C F M PROVIDE
R ees NGO
A P PROVIDER B R
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M C P
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I A R
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COMMUNITY COMMUNITY U COMMUNITY
In India, there appear to be three basic designs, depending on who is the insurer (see the
Figure). In Type I (or HMO design), the hospital plays the dual role of providing health
care and running the insurance program. In Type II (or Insurer design), the voluntary
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organization is the insurer, while purchasing care from independent providers. Finally in
Type III (or Intermediate design), the voluntary organization plays the role of an agent,
purchasing care from providers and insurance from insurance companies.
At most of the schemes, the unit of enrolment is the individual and membership is
voluntary. While some of the CHI schemes limited the benefit package to only
ambulatory care, most provided inpatient care. Some also provide outpatient care as well
as outreach services. It is observed that the community prefers to have both outpatient
and inpatient care. Most schemes had important exclusions like pre-existing illnesses,
self-inflicted injuries, chronic ailments, TB, HIV, etc. While most of the schemes
reimbursed direct costs of treatment (consultation, medicines and diagnostics), one
scheme (Karuna Trust) also reimbursed loss of wages for the patient. Some CHIs had also
added other benefits like life insurance, insurance against personal accident and/or asset
insurance into the package to make it more attractive to the community.
In the Type I CHIs, there is a cashless system of reimbursement. However, in the other
two types, usually it is a fixed indemnity with patients having to settle bills and then
getting it reimbursed 2-6 months later from the NGO. The exception was the Yeshasvini
scheme, which, though a Type III scheme, had managed to negotiate a cashless system
with the private sector by using the services of a Third Party Administrator (TPA). Most
of the CHIs have a fixed upper limit of coverage.
One of the general weaknesses of the CHIs is the lack of techno-managerial expertise.
This is reflected in the fact that most of them do not have inbuilt mechanisms to prevent
adverse selection or moral hazard. Due to the asymmetry of information, it is possible
that only the sick enroll in these schemes (adverse selection). Because of the insurance
programme, the behavior of the patient or the provider may change (moral hazard). The
only measure consistently used by most CHIs to reduce the patient induced moral hazard
is co-payments and deductibles. The most common reasons found for not enrolling are:
(1) No immediate benefit; (2) premium too high; (3) “we are well, why we should pay in
advance? When we fall sick, we shall pay”; (4) large families – this is specially since
most of the CBHI’s unit of membership is the individual; (5) “(Insurance scheme)
Hospitals are far away and so we have to pay a lot to access hospitalization. Better use
the premium money to go to a nearby doctor”; and (6) “we pay every year, but do not get
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any benefit out of it. So we have decided not to pay anymore”. There is tremendous
variation in terms of claims submitted annually for inpatient care, ranging from only
1.4/1,000 insured per annum to more than 240/1,000 insured per annum. Among schemes
with the highest rates of utilization, adverse selection may be responsible for the high
rates.
Those schemes that provide the greatest degree of protection have the following
characteristics: (1) Cover 100 per cent of the direct costs; (2) cover all (or at least some)
of the indirect costs; (3) cover all kinds of illness (for example, all non elective causes of
hospitalization, including complications of delivery, chronic illnesses); and (4) provide
benefit right at the source of health care, i.e., with no period during which the patient has
to cope with the costs of care.
It was generally the Type I schemes, which provide health care directly, and usually with
no upper limit to the financial benefits, which provided the greatest degree of protection.
An important question is about the financial viability of these ‘small’ schemes. Some are
run purely on funds raised from the community. All the Type I schemes have
supplemented the locally raised resources with external resources (either from the
government or donors).
It is clear that what is required is a good product. Some of the conditions that have
allowed these schemes to succeed are:
– An effective and credible community based organization (or NGO). This is absolutely
necessary as it is the foundation on which health insurance can be built. The CBO helps
in disseminating information about health insurance and more importantly helps in
implementing the program with minimum costs.
– An affordable premium – this is very important. This is significant, and needs to be
taken into account by the insurers if they want their products to penetrate the rural
market.
– A comprehensive benefit package is necessary to convince the community of the
benefits of health insurance. While most insurance companies introduce exclusions,
based on economic reasons, one has to look at health insurance within a public health
context. Diseases like TB, HIV and mental illnesses have significant public health
importance and should be covered. Similarly it is ironic that while the country has
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invested tremendously in safe deliveries, most health insurance products do not cover it.
And finally as India enters an epidemiological transition and will have to encounter
chronic diseases like diabetes and hypertension, it becomes imperative that these diseases
are included in the benefit package.
– A credible insurer is imperative for people to have faith in the product. This is where
the NGOs and the CBOs score as they have a relationship with the community and so the
people are willing to trust them with their money.
– And last but not the least, the administration load of the scheme on the community
should be minimal. Unnecessary documentation leads to frustration.
Given the new Insurance act (IRDA Act 1999), another issue is the legality of these
schemes. Currently the act does not acknowledge the presence of these schemes and their
role in the larger insurance market. This could also be the reason why many of the newer
schemes have linked up with the formal insurance companies – to legitimize their
activity. But in the process, they may have lost on the flexibility and innovations
necessary for a successful CHI. The other issue that needs to be addressed is that of
financial sustainability. The very fact that many of them have been operational for more
than a decade itself is a proof that it may be a sustainable form of health financing. While
accurate financial data about the schemes were not available easily, rough estimates show
that they are able to raise about 60 to 100 per cent of their resources. This has important
policy implications, as it gives an indication towards the amount subsidy required to
make these schemes viable. And given the fact that most of these schemes target the poor,
it could help if the government comes forward to subsidize this equitable health financing
mechanism.
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INTRODUCTION TO THE SCHEME:
Provider and insurer - Shree Krishna Arogya Trust (SKAT):
SKAT is a not for profit organisation working under the aegis of Shree Krishna Hospital.
The primary objective of SKAT is to plan & implement programmes for easing the access
to modern medical services of this institution to all those desiring these but often failing
to afford.
Shree Krishna Hospital (SKH), managed by Charutar Arogya Mandal, is a 550-bed
hospital with state of the art facilities like Trauma centers, ICUs and Laboratories. The
hospital is operational since 1981. Based on its capacities, SKH desires to extend its
services to poor & marginalized rural communities in a manner that modern medicines
and medical facilities are easily accessed by rural masses in the district. The first
initiative for SKAT has been designed as a Health Security programme called “Krupa
Arogya Suraksha (KAS)”. SKAT is based in the premises of SKH at Karamsad. The other
location for extension of KAS subscription services is at Mayank Jayant Foundation,
Anand, extension centres at Petlad and Ardi.
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Network of Hospitals:
At present, arrangements have been made for treatment of members participating in KAS
at Shree Krishna Hospital, Karamsad. Arrangements have also been made for accessing
facilities for Cardiology (Heart related) being provided at Escorts-Bhailal Amin Heart
Research & Care Centre through an institutional arrangement with Bhailal Amin General
Hospital, Baroda and for Urology (Kidney related) at Muljibhai Patel Urological
Hospital, Nadiad. Patients requiring coronary or urological services are however required
to first get themselves admitted at Shree Krishna Hospital and based on the advice of the
specialists at the hospital only these services are made available to the persons.
Preamble:
Krupa Arogya Suraksha (KAS) is a social security programme aimed at extending the
safety net of good modern health facilities & services available at Shree Krishna Hospital
and other associated institutions to communities living in the villages and towns of the
districts of Kheda & Anand.
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The programme envisages an affordable annual subscription or one lifetime subscription
by a family participating in KAS for a certain limited free treatment of any illness
requiring Indoor Patient admission for which Shree Krishna Hospital or any other
hospital nominated by Shree Krishna hospital for the purpose has the facilities and
services. The programme does not cover free treatment or other services for outdoor
patients. There is a provision of a discount for the outdoor patients.
Subscription:
The following reckoner shows the extent of billed expenses at SKH, which may be
accessed as free services by paying a corresponding annual subscription by a person. All
the diseases/ailments of a general order requiring indoor patient admission at a designated
hospital would be treated up to a maximum limit of billed expenses based on a
corresponding annual subscription for KAS. The following amounts are to be paid and
the extents of free medical treatment are given in the table below:
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Any person above 18 years and below 45 years of age may contribute a one-time
subscription as per the table given below, which will enable him/her to avail
corresponding IP services for 25 corresponding years or up to 60 years of age (whichever
is less):
The food grain based participation in KAS can be obtained by giving 15 kgs of any
variety of wheat or 19 kgs of any variety of Bajra per family member as the annual
subscription of KAS. This facility would be available for billed treatment expense of up
to Rs.5000/- per person up to 5 members in a family. This will have to be deposited at
Shree Krishna Hospital.
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• The Maternity cases for normal treatments as well as for Caesarean cases are
accepted for the first two children for KAS subscribers.
• On a one time additional annual payment of Rs.50/per person, the KAS subscriber
may avail free OPD consultation services at SKH.
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Hormone replacement therapy.
Renal dialysis, except where this is in connection with acute secondary failure and
is part of the intensive treatment.
The treatment of psychiatric, mental or nervous conditions, insanity.
Any cosmetic, plastic surgery, aesthetic or related treatment of any description,
whether or not for psychological reasons, unless medically necessary as a result of
an accident.
Use of intoxicating drugs / alcohol and the treatment of alcoholism, solvent abuse,
drug abuse or any addiction and medical conditions resulting from, or related to,
such abuse or addiction.
Taking of drug unless it is taken on proper medical advice and is not for the
treatment of drug addiction.
Any fertility, sub-fertility or assisted conception operation.
Joints replacement or any artificial organ transplantation.
DECISION PROBLEM:
To assess the extent to which the social security scheme KRUPA is acceptable to the
community, and how to further improve its acceptability
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RESEARCH PROBLEM:
To study the perceptions and expectations of different decision-makers and develop
solutions to solve the problems.
The following information available from the concept-testing study done before
designing the product in 2003:
1) People’s awareness and perception about Karamsad hospital:
a. Most people (about 96%) were found to be aware of the hospital.
b. In urban areas, 80% of the respondents agreed or strongly agreed that the
services offered by the hospital were very good. The percentage in the
rural areas was 77%.
c. Around 80% of the respondents in the urban areas agreed or strongly
agreed that the hospital was accessible to them. The percentage was 85 for
the rural areas.
d. Around 73% of the urban respondents agreed or strongly agreed that the
hospital has all the services required by them or in their words, “all the
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diseases can be treated at the Shree Krishna Hospital”. This figure was
found to be high in the rural areas. A total of 85% of the respondents were
of the opinion that all the services are available in the hospital.
e. 58% of the urban respondents agreed or strongly agreed that the hospital
provides services at lower costs than the private doctors. In rural areas, it
was around 59%.
f. 62% respondents in the urban areas found the behavior of the staff good.
In rural areas, 72% respondents thought so.
2) The level to which the product is needed in the first place
Desire to buy such a product: In the concept-testing study, it was discovered that
in the urban population, 54% of the overall respondents expressed a desire to
purchase such a product. Among the respondents in the low income group, the
53% respondents expressed this desire. The above percentages for the rural
community were 83% each for the overall and those with lower income level.
Willingness to pay: In the urban area, the average premium respondents were
willing to pay was about Rs. 1075 per year for a family of five. For the urban
respondents from the lower income group, the average was Rs. 515. In the rural
area, the average premium respondents were willing to pay was about Rs. 1143
per year for a family of five. For the rural respondents from the lower income
group, the average was Rs. 480.
3) The general health scenario in the region:
Annual Morbidity Rate = (Acute illness X 12) + Chronic illness + Hospitalisation
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8000)
C (<=2500) 114.01 45.13 33.25 1446.56
Table 3: Morbidity profile of urban households
Class Acute Chronic Hospitalization Annual*
(Income/month) morbidity
A (>8000) 44.94 41.20 16.85 597.00
B (2501 to 56.84 61.05 35.79 778.00
8000)
C (<=2500) 83.52 47.40 36.12 1085.78
Table 4: Morbidity profile of rural households
* Per thousand population. This indicates the incidence of disease per thousand of
population.
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- The most important reason for not subscribing to any of the current policies
was that the 32 students out of 50 said that they would rather pay the money out
of their pocket then indulge in the cumbersome procedural hassles of getting the
hospitalization charges reimbursed.
The following information, available from the pre-launch survey done after
the designing phase was complete:
After the design of the product was done, a pre-launch survey was carried out
with the purpose of gauging the reaction to the product and to make any changes,
if necessary.
1) The overall morbidity rate for the respondents from the lower income group was
found to be much higher than that for the respondents from the higher income groups.
But this difference in not very significant for hospitalization category diseases.
2) Among the respondents, the awareness about a health insurance product was just
satisfactory. But, such awareness was very low among the rural respondents from the
lower income group.
3) The premium decided by the product-designers was very close to the premium
desired by the respondents from the target community i.e. the rural and urban poor
community.
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4) During the concept-testing study, the willingness to buy such a product was found in
about half of the respondents in the urban areas and about 5/6th of the respondents in
the rural areas. Such willingness is found to be very high when the details of the
product are told to the respondents during the pre-launch study.
5) The overall perception about the product before the launch was very high and must
have been encouraging for those launching the product.
Observations and insights about the post-launch experiences obtained during early
interactions with the KRUPA team:
- The donors have played an important role in getting the people from the poor
community involved in the scheme. Some of the donors donate the money with some
conditions, like one of the donors insisted that 50% of the premium be collected from
the beneficiary.
- The institutions like companies and schools have also provided a bulk of members.
There needs also need to be looked into. Students and employees form a good part of
the potential membership base.
- The individually bought memberships from the lower income group form a small part
of the total membership base.
- The number of individually bought membership in any village is not even in three
digits.
- Overall rate of renewal is between 50-60%.
- The reasons for non-renewal are different for different people:
- Some buy the policy with a belief that they would be definitely getting something
in return of their premium. In face of non-usage, they find it useless to get the
policy renewed. Here, the perception about insurance in general may be the issue.
The tangible benefits are more important for them than the intangible ‘security’.
- Some others are dissatisfied with the outpatient coverage. Their expectations were
not in congruence with the reality.
- The exclusion conditions also disappoint some of the members.
- The bad experience in the hospital is also one of the reasons why some of them
don’t get the policy renewed
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- In some of the families, insurance doesn’t even exist on the priority list. Even a
small investment looks like a waste. They have a fatalist approach towards health
and healthcare.
- Bad word of mouth is also a reason cited for non-renewal. This is also an
important reason for less new membership in some areas.
- Single deliverer of service is a problem. Mediclaim services can be availed
anywhere.
- The VHCS scheme being offered by the hospital for the employees of the
industrial concerns is competing with KRUPA. The premium for this scheme is
higher, but the coverage is far higher than that in KRUPA. Thus, some people opt
for it.
METHODOLOGY:
We neither accepted nor rejected the validity of the data available from the earlier
surveys. But, we took it as a starting point and decided on what we needed to test again
and what new information we needed to seek from the community.
Our observations and conversations with the fieldworkers lead us to divide the field study
into 4 different types of decision-makers, with different concerns. These are:
1) Individual community members who decided for themselves and for their
families.
2) Donors who decided to donate for people from their areas of residence or people
belonging to certain economic class.
3) Schools that decided about the membership of their students.
4) Companies that decided about the membership of their employees.
All these decision makers had different concerns. Thus, we needed to decide on the
information we wanted to seek from each and how we wanted to seek it.
In case of individual community members, we decided to go for a survey with structured
questionnaires.
In case of the other three categories, we decided to go for unstructured interviews.
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We also decided on the information we needed to seek in order to come to a meaningful
understanding of the situation and what can be done to improve things.
We selected village randomly and according to distance i.e. 0-10 kms, 10- 15 kms, and
15-20 kms from hospital. The selection of village also depended upon the minimum
number of potential respondents for one or more categories. Please refer annexure for the
list of villages. For urban poor, we identified two slums, one is near to hospital (Borsad)
and another one is far from hospital (Near Station). For this category, respondents were
also selected randomly from city area of Anand and VV Nagar.
The individual community member-centered investigation was conducted through
questionnaires with some common questions for all respondents and some questions
particularly for that category or sub-category of respondent. Apart from the structured
questionnaire, stress was on having a short conversation with each respondent, with the
purpose of getting some insights about the issues the salience of which might not have
come to our notice.
The other investigations (donor, school and company-centered) were carried out by semi-
structured interviews with the people concerned.
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Information sought:
The questions were arranged in a hierarchical manner.
Some questions were common for all respondents. These were the questions about the
hospital and insurance in general.
Some others were common to the category of respondent, i.e. KRUPA, non-KRUPA and
IP service beneficiary.
The rest of the questions were specific to the sub-category, i.e. KRUPA renewal, KRUPA
non-renewal, and donor-benefited KRUPA members.
The following listing gives an account of all the information sought, in a hierarchical
manner:
1) Common for all respondents:
- Respondents’ health-seeking preferences in case of different types of diseases. We
grouped the diseases into 3 categories, on the basis of time taking to heal and the need
for hospitalization. The total number of instances of diseases in each category was
divided as per the preferences of health service providers.
- For those not preferring SK hospital: reasons for not preferring.
- The awareness and perception about the hospital, if they have used the services of the
hospital in the last 3 years. (In terms of accessibility, availability of services, quality
of services, expenses, and behavior of doctors and staff)
- Suggestions for improvement in the hospital.
- Awareness and perception about insurance in general and health insurance in
particular.
- Question about the intra-household preferred beneficiary.
1.1) Specific to all those respondents who have never been with KRUPA:
- Awareness about KRUPA.
- Opinion about premium, coverage etc.
- If they are aware of or are members of some other scheme: comparison with
KRUPA and the main reason for not choosing KRUPA over the other scheme.
- Suggestions for improvement in the scheme.
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- For those who are aware but haven’t joined KRUPA or any other scheme: main
reasons for not joining. Changes that could make them buy the policy.
- Only those who are well aware of the scheme and its conditions: how much
extra premium they would be prepared to pay for: No exclusion? Two totally free
OP services?
1.2) Common for all those who have been or are with KRUPA:
- Source of information about the scheme.
- The instances of entire family enrollment.
- Level of awareness they have about the different conditions applicable to
KRUPA members
- Opinions about the scheme.
- How much extra premium would they be prepared to pay for: No exclusion?
Two totally free OP services?
- For those who availed of benefits: Their experience.
- For those who availed benefits before and after becoming member: comparison
of experience as a pre-KRUPA patient and as a KRUPA patient.
- Suggestions for improvement in the scheme.
1.2.1) Specific to the KRUPA member who didn’t renew the membership:
- Did they join some other scheme? If yes, compare that scheme with KRUPA.
- The most important reasons for leaving the scheme.
- If they had any specific bad experiences, elaborate on them.
- What changes in the scheme or the service provider could make them come
back to the scheme?
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- Those who considered other schemes as well: Reasons for choosing KRUPA.
- Willingness to help promote KRUPA
1.2.3) Specific to the KRUPA member who were initiated using donations:
- Whether they got the membership renewed.
- For those who got the membership renewed: The main reasons that made
them take the renewal decision
- For those who didn’t get the membership renewed: The reasons for non-
renewal?
- The level of membership fee they are willing to pay.
21
The survey was conducted in the rural and urban areas within in 20 kilometers radius of
the hospital.
Wherever the answers are on a scale of 1 to 5, following it’s the corresponding response:
1: Strongly agree
2: Agree
3: Neither agree nor disagree
4: Disagree
5: Strongly disagree
Categorization of diseases:
With the consultation of two doctors, we categorized certain commonly occurring disease
on the basis of severity, duration of treatment and expense, into three categories. Please
refer the annexure for a list of diseases and categories.
The following are the summaries of the findings under different categories:
Non-KRUPA respondents:
Preference of hospital:
We are presenting here the data about preferences of the respondents for the entire
category of non-KRUPA respondents, followed by the disaggregated data for different
sub-categories. The reasons for not preferring are also given for different sub-categories
of respondents. The number of instances in different categories 2 and 3 of diseases for
different sub-categories of respondents was so small that it was hard to derive anything
from that. When the data are aggregated, the number of instances is large enough to help
us get some indication about the preferences.
Total for all non-KRUPA respondents:
All in all, it can be said that SK hospital is not a highly preferred destination for the
respondents in this category. The aggregate data for this category of respondents gives a
large enough sample to give an indication of this.
Category Preference SK hospital Others Total
1 1 14 84 98
2 15 83 98
2 1 3 22 25
22
2 4 21 25
3 1 11 21 32
2 11 21 32
All 1 28 127 155
2 30 125 155
Table 5: Healthcare seeking preference for Non-KRUPA respondents.
Total number not preferring: 61 Total number not preferring: 22 Total number not preferring: 15
For category 1: For category 2: For category 3:
Accessibility: 35 Accessibility: 12 Accessibility: 6
Quality of service: 18 Quality of service: 6 Quality of service: 15
Expenses: 41 Expenses: 15 Expenses: 7
Availability of services: 0 Availability of services: 0 Availability of services: 0
Behavior of doctors and Staff: 18 Behavior of doctors and staff: 6 Behavior of doctors and staff: 9
Other reasons: Other reasons: Other reasons:
Table 6: Reasons for not preferring SKH (for Non-KRUPA)
Urban Poor:
For category 1 diseases, SK hospital is not a preferred destination for most of the
patients in this category.
For category 2 and 3, the number of instances of diseases is too small to say
anything decisively.
Overall, the hospital is not a preferred destination for most respondents in this
sub-category.
Category Preference Private SK hospital Others Total
doctor
1 1 26 0 2 28
2 26 1 1 28
2 1 7 0 0 7
2 7 0 0 7
3 1 3 4 0 7
2 3 4 0 7
All 1 36 4 2 42
2 36 5 1 42
Table 7: Healthcare seeking preference for urban poor Non-KRUPA respondents
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Accessibility: 12 Accessibility: 4 Accessibility:
Quality of service: Quality of service: Quality of service: 1
Expenses: 17 Expenses: 6 Expenses: 3
Availability of services: Availability of services: Availability of services:
Behavior of doctors and Behavior of doctors and Behavior of doctors and
Staff: 5 staff: 1 staff: 1
Other reasons: Other reasons: Other reasons:
Table 8: Reasons for not preferring
Urban non-Poor:
Preference of hospital:
For all the three categories, SK hospital is not a preferred destination for most of
the patients in this category.
Table 10: Reasons for not preferring (for urban non- poor Non-KRUPA
respondents)
24
Rural non-Poor:
Preference of hospital:
For category 1, SK hospital is more preferred than for other categories.
For categories 2 and 3, the sample was very small, but for that sample the SK
hospital is not a preferred destination.
Category Preference Private SK hospital Others Total
doctor
1 1 10 4 4 18
2 10 5 3 18
2 1 3 1 0 4
2 3 1 0 4
3 1 5 1 2 8
2 5 2 1 8
All 1 18 6 6 30
2 18 8 4 30
Table 11: Healthcare seeking preference for rural non-poor Non-KRUPA
respondents
Apprehensions about the quality of services are the most important reason for this group.
Table 12: Reasons for not preferring (for rural non-poor Non-KRUPA respondents)
Total people: 11 Total people: 4 Total people: 6
Rural Poor:
Preference of hospital:
For category 1 diseases, SK hospital is preferred by a good part of the
respondents.
For category 2, the sample was very small, but within that sample SK hospital is
not the most preferred destination.
25
For category 3, the sample was very small, but within that sample SK hospital is
the most preferred destination for majority of people.
Category Preference Village SK hospital Others Total
doctor
1 1 12 10 2 24
2 11 9 4 24
2 1 1 1 3 5
2 0 2 3 5
3 1 1 5 3 9
2 1 5 3 9
All 1 14 16 8 38
2 12 16 10 38
Table 13: Healthcare seeking preference for rural poor Non-KRUPA respondents
The aggregated data is not being presented for the entire category because the number of
instances of eligible respondents in each sub-category is large enough to be at least
indicative of some broad perceptions within the category.
Urban poor:
26
Total number eligible to respond: 25
The main concerns for this sub-category appear to be expenses and accessibility.
1 2 3 4 5
i) Accessibility easy 6 8 11
ii) Quality of services excellent 2 9 10 4
iii) Availability of services complete 14 10 1
iv) Expenses lower than pvt hospital and clinics 4 5 14 2
v) Doctors and staff behaviour proper 14 5 6
Urban non-poor
Total number eligible to respond: 27
The main concern for this sub-category appears to be accessibility.
1 2 3 4 5
i) Accessibility easy 3 4 20
ii) Quality of services excellent 1 11 8 6 1
iii) Availability of services complete 18 9
iv) Expenses lower than pvt hospital and clinics 13 6 8
v) Doctors and staff behaviour proper 15 5 6 1
Table 16: Perception about the hospital (Urban non-poor non-KRUPA)
Rural poor
Total number eligible to respond: 19
These sub-category respondents are not very dissatisfied by any of the parameters, but
expenses are a concern for some of them.
1 2 3 4 5
i) Accessibility easy 4 15
ii) Quality of services excellent 1 12 4 2
iii) Availability of services complete 9 10
iv) Expenses lower than pvt hospital and clinics 10 5 4
27
v) Doctors and staff behaviour proper 15 1 3
Table 17: Perception about the hospital (rural poor non-KRUPA)
Rural non-poor
Total number eligible to respond: 27
The main concerns for these sub-category respondents appear to be expenses and
behavior of the doctors and staff.
1 2 3 4 5
i) Accessibility easy 1 12 1
ii) Quality of services excellent 7 4 3
iii) Availability of services complete 7 7
iv) Expenses lower than pvt hospital and clinics 7 1 6
v) Doctors and staff behaviour proper 5 1 7 1
Table 18: Perception about the hospital (rural non-poor non-KRUPA)
28
Reasons for buying insurance:
Urban Poor Urban non-poor Rural poor Rural non-poor
(Total: 3) (Total: 25) (Total: 2) (Total: 24)
Security
coverage 3 25 2 23
As an
investment 0 19 0 15
Income tax
benefits 0 13 0 5
Other benefits 0 0 0 0
Table 19: Reasons for buying insurance (Non-KRUPA)
Security coverage is the most dominating reason for buying an insurance policy. But,
among the non-poor, investment and income tax benefits are also fairly important.
This shows that there is a real problem of awareness about the scheme. There is an urgent
need to spread more awareness about the scheme.
For those who are aware of KRUPA: Reasons for not becoming members-
UP UNP RP RNP
i. Lack of willingness to pay the membership fee: 1 2
ii. Affordability of the membership fee:
29
vi. Dissatisfaction with the coverage: 1
vii. Bad experiences with such schemes: 1
viii. Other reasons: 1
Table 20: Reasons for not becoming members (Non-KRUPA)
Among those who are aware of the scheme, the most important reason for not buying
appears to be that such a security is not a priority for them.
This calls for a need to spread a greater awareness, not just about the scheme but also
health insurance in general.
The following are their responses to the statements reflecting their perceptions about the
scheme in terms of different parameters:
The responses were recorded on a scale of 1 to 5.
Certain things that come out from the above data concerning the perceptions about
KRUPA:
30
- The fee is not a problem for most people.
- The coverage is also acceptable to most of the people from both the types.
- The exclusion criteria are troubling some of the people, especially all of those
who were already aware of the scheme.
- Most of the respondents didn’t have much of a problem with the formalities
involved.
This gives a positive sign for the scheme as such, but the exclusion criteria working as
deterring factors need to be looked into.
Note: It needs to be pointed out here that the Urban poor respondents overwhelmingly
liked the scheme and didn’t give any specific suggestions for improvements. Their main
concern is the accessibility of the service provider.
We also asked them a question about the frequency and quantum of fee payment, giving
them three options:
i. One time payment of fee
31
ii. 3 installments in 3 months (Rs. 30 each)
iii. 10 installments in 10 weeks (Rs. 9 each)
iv. 45 installments on alternate days (Rs. 2
each)
Only the rural and urban poor showed interest in any option other than the first one.
13 out of 30 urban poor respondents showed preference for the second option.
6 out of 30 rural poor respondents showed preference for the second option.
KRUPA respondents:
The sample is small, but the indication is in the direction of perception about expenses as
the most important reason for not preferring.
32
Quality of service: 1 Quality of service: 1 Quality of service: 1
Expenses: 7 Expenses: 1 Expenses: 1
Availability of services: Availability of services: Availability of services:
Behavior of doctors and Behavior of doctors and Behavior of doctors and
Staff: staff: staff:
Other reasons: Other reasons: Other reasons:
Table 23: Reasons for not preferring (Non-renewing members)
33
insured:
34
The most important reason for leaving the scheme:
The most important reason turns out to be dissatisfaction with the coverage, especially
OP coverage. The second important reason is the belief that such a scheme is not
important for them.
i) Lack of willingness to pay the membership fee:
ii) Affordability of the membership fee: 2
iii) Only one service provider:
iv) Don’t think it is important to have such healthcare security: 7
v) Already covered under some other scheme: 3
vi) Dissatisfaction with the coverage: 13
vii) Bad experiences as a member:
viii) Migrated elsewhere 2
ix) No follow-up 2
x) Didn't know about renewal 1
Table 28: Reasons for leaving the scheme (non-renewing members)
For those who joined some other scheme after leaving KRUPA:
The following are the points on which they find the chosen scheme better than KRUPA:
Number who joined some other scheme: 3
Name of the scheme Better features
Mediclaim Treatment anywhere 3
Income tax benefit 1
35
There was no instance of category 2 disease among the respondents. The overall picture
indicates that SK hospital is the most preferred destination for the respondents in this
category.
Category Preference SK hospital Others Total
1 1 5 4 9
2 5 4 9
2 1 0 0 0
2 0 0 0
3 1 7 2 9
2 7 2 9
All 1 12 6 18
2 12 6 18
Table 29: Preference of health-service providers (renewing members)
i) Security coverage 30
ii) As an investment 12
iii) Income tax benefits 5
iv) Other benefits 0
Table 31: Reasons for buying insurance (renewing members)
36
KRUPA staff 29
Relative 1
Experiences of those who availed the benefits before and after becoming KRUPA
members:
37
Here, all the respondents found it easier to avail benefits as KRUPA members than they
did when they were not KRUPA members. This was mainly due to the transaction being
cashless. But, they didn’t feel more privileged in comparison to their earlier visits as non-
KRUPA members.
1 2 3 4 5
Easier to avail services 4
Felt more privileged 4
Table 34: Experiences of those who availed the benefits before and after becoming
KRUPA members (renewing members)
1 2 3 4 5
i) Accessibility easy 12 18
ii) Quality of services excellent 2 24 3 1
iii) Availability of services complete 16 13 1
iv) Expenses lower than pvt hospital and clinics 1 14 12 3
v) Doctors and staff behaviour proper 1 27 1 1
Table 35: Perception about the hospital (IP beneficiaries)
38
5) Formalities minimal 14 16
6) Renewal easy Total: 24 9 15
Table 36: Perception about the scheme (IP beneficiaries)
1 2 3 4 5
Easy to avail benefits as members: 4 23 2 1
Satisfied with the coverage for the fee 1 26 1 2
Table 37: Experience while taking services as KRUPA member (IP beneficiaries)
Experiences of those who visited the hospital both before and after becoming members of
KRUPA:
Total number of such members: 25
When asked to compare the experiences before and after becoming members, most
respondents didn’t say they felt more privileged as KRUPA members than they did when
they visited as non-members. Almost half of the respondents also didn’t agree that it was
easier for them to avail services as KRUPA members.
1 2 3 4 5
Easier to avail services 13 11 1
Felt more privileged 6 18 1
Table 38: Experiences of those who visited the hospital both before and after
becoming members of KRUPA (IP beneficiaries)
Experiences of those who did not visit the hospital before becoming members:
Total number of such members: 5
1 2 3 4 5
More convenient to avail services in SK
hospital than at the earlier place: 3 2
39
Table 39: Experiences of those who did not visit the hospital before becoming
members (IP beneficiaries)
For those who had earlier been with some other scheme:
Only one member had earlier been with another scheme. He had been with Mediclaim
earlier. He said that Mediclaim was not easy to use and involved hassles of claim etc.
Willingness to pay extra fee for two free OP services and very limited exclusion:
20 respondents were willing to pay extra fee for these additions in the scheme. The range
of desired payment was from Rs. 20 to Rs. 110.
40
Category Preference SK hospital Others Total
1 1 3 10 13
2 3 10 13
2 1 1 1
2 1 1
3 1 9 3 12
2 9 3 12
All 1 13 13 26
2 13 13 26
Table 41: Preference of health providing facilities (donor benefited)
41
v) Doctors and staff behaviour proper 4 14
Table 43: Perception about the hospital (donor benefited)
Number of those who have bought any other insurance scheme: 1 (LIC)
This low number indicates that the people are not very well aware of the insurance
schemes or that it is not their priority. The fact that they have been initiated into KRUPA
through donors’ money and still most of them wish to continue on their own shows that
once they become aware of the benefits, they may choose to stay. The main thing is
initiation.
For those who visited both before and after becoming members:
Total number of such respondents: 2
1 2 3 4 5
Easier to avail services 2
Felt more privileged 2
Table 46: Experience of those who visited both before and after becoming members
(donor benefited)
42
Number of those who have got the membership renewed or plan to get it renewed: 26
26 out of 30 is a good score because this time they were asked whether they would pay
out of their own pockets to get the membership renewed.
Findings from schools:
We went to four schools, 2 of which are in rural areas and the other two in urban area.
2 of the schools were enrolled under KRUPA, while the other two were not enrolled.
Following are the names of the schools:
Rural
Primary girls school (Mogri) - Enrolled
Smt. C. J. Patel English Medium School ( Karamsad)- Not enrolled
Urban
B.S.W. Anand Institute of Social Work (Anand)- Enrolled
M. S. Mistry school ( V V Nagar)- Not enrolled
Findings:
Need special attention for students in terms of priority in consultation.
OP benefit: Discount on medicine should be more
For some schools hospital is not acceptable destination
Students claimed: Staff does not behave properly.
43
high and the payment is partially done by GIDC. VHCS is run on a high deficit, just to
give more benefits.
Enrolled
Tripicon Engineering Pvt. Ltd. (plot-1115, GIDC-IV)
Swiss Glas-Coat Pvt. Ltd. (GIDC-IV)
GMM pfaudler reactor Pvt. Ltd. (GIDC, Sojitra road)
Findings: The main expectations that came out of the interviews were: More OPD
benefits and group insurance. Group insurance is expected because sometimes the
employees are hired for less than a year. Thus, the premium for such employees goes
waste.
44
– Most were willing to pay extra for higher OP coverage and minimal
exclusions.
• The members who did not renew the membership:
– SK hospital is not a preferred destination for most respondents.
– The scheme is acceptable if the OP coverage is increased and exclusions
reduced, even at extra fee.
– Most people didn’t find more privileged availing services as KRUPA members
than they did before becoming members.
– The most important reasons for leaving the scheme:
• Dissatisfaction over coverage and exclusions.
• Such security is not a priority.
• Those members who got the membership renewed
– The SK hospital is the most preferred healthcare-seeking destination for most
respondents.
– Most understand the importance of such security, thus renewed in spite of not
taking benefits.
– Most were very pleased with the scheme, except on OP coverage and
exclusions. Most were willing to pay extra fee for more OP coverage and less
exclusions
– The experience while taking benefits was pleasant, but they didn’t feel more
privileged than they did while visiting as non-KRUPA patients.
• Donor benefited members
– SKH is the single most preferred destination. Reason : They got benefits as
KRUPA members.
– Only on the questions related with expenses there seems to be some concern,
otherwise the perception about hospital is good.
– Perception about the scheme: OP coverage and exclusion criteria are the main
concerns for the people
– Those who availed the services were satisfied with their experience while
availing benefits.
45
– Number of those who have got the membership renewed or plan to get it
renewed: 26
Now, keeping in mind the problems and expectations found from the field study, we
studied the other similar schemes.
Provider model:
This is the model in which KRUPA falls. The schemes under this model were studied
very closely, looking for innovative ways to improve the acceptability of KRUPA in the
community and to look for solutions to the problems discovered during the field study.
46
The suggestions coming out from the study of the schemes of this model do not require
any change in the basic design model of the scheme and SKAT.
In this model, four schemes were studied. The following are the names of these schemes,
along with some brief information about them:
47
Suggestions:
The following are some of the suggestion which if worked on, can help in
improving the acceptability of KRUPA in the community. The suggestions are
grouped as per the objective they would achieve. The first 16 suggestions came
from the study of other schemes of the provider model:
For tying up with an insurance company
Tying up with an insurance company can move some of the risk away from the
organization and place it with an insurance company. The scheme can also benefit
from the various special packages available from the companies. The following
three suggestions are concerned with benefiting from such a step.
i) The design with an insurance company as the prime insurer: Within the
insurer model, it is possible to go for a prime insurer. SKAT can consider
minimizing its risk by the use of such a design. For example, the ACCORD-
AMS-ASHWINI scheme has to be viewed at two levels. One level is the
arrangement between ACCORD/ASHWINI and the insurance company, and
the other level is the arrangement between the tribal community (AMS) and
ACCORD/ASHWINI. The premium, benefit package and administration vary
for these two levels. The following is the design:
ACCORD ASHWINI
C
P A
R R
E E
M
I
U
M
COMMUNITY
(Members of the AMS union)
48
Figure 2: The design of the ACCORD-AMS-ASHWINI health insurance
scheme.
ii) Long term and group discount from the insurance company: In the ACCORD
scheme, the members were insured in groups and for a period of five year.
This entitled them for long term and group discounts. The group and family
insurance also minimize the problem of adverse selection. This can be done by
SKAT if it chooses to go for a prime insurer.
iii) Upfront payment of premium from the NGO to the company and annual
payment by members to the NGO: ACCORD/ASHWINI insured tribals en
masse with the formal insurance company and paid their premiums upfront;
the tribals repaid this premium on an annual basis. This can be done by
KRUPA in order to insure people from very poor sections of the community.
But, this would need the involvement of a community-based organization, as
mentioned in the next point.
49
a respected organization of the tribals, making it very easy to create trust in
the population. SKAT would sooner or later need to involve a community-
based organization, like an NGO, on the basis of incentive. This would also
improve the current marketing tactics employed for the scheme. Moreover,
they could also go for tying up with some trade unions, cooperatives etc.
v) Going beyond the hospitalization coverage: All the schemes studied under this
category have tried to go beyond just the hospitalization coverage. Some have
tried to provide some primary and tertiary level care, and some have made
active attempts to go into preventive and promotive healthcare as well. For
example, the formal insurance company provides a hospitalization package,
but ASHWINI uses its resources to provide a more holistic coverage. External
resources are used for meeting the difference in the benefits package. As
ASHWINI provides comprehensive care, it provides people to live and to seek
care at the earliest when ill. This cuts down morbidity, making it a win-win
situation. Another example is the use of village health workers for providing
primary healthcare services under the Jawar health assurance scheme,
described in the following point.
For reaching out to the community with more services and for increasing the depth of
involvement
Most of the scheme we studied had a very deep involvement of the local community
in the scheme and the provider’s activities. Thy formed an important part of the lives
of the people. The steps suggested to this end are strategic in nature and would entail
some initial heavy investment on the part of the organization. Recruiting village
health volunteers and setting up Mini Health Centers are such steps. But, we need to
understand that these steps can go a very long way in getting community involvement
increased in the hospital’s and scheme’s activities.
vi) The use of Village Health Volunteers for collection of premium and for
providing primary health care: The Jawar health assurance scheme uses
village health workers for collecting premium; they are also provided with
drug kits for providing primary health care to the members. This leaves only
50
secondary and tertiary care to the hospital. This helps in a deeper penetration
into the community and makes the scheme the main part of their health-related
behavior. SKAT could tie up with a community-based institution and with
their help depute some local people as such workers. This need not be done on
one person per village basis. It can also be done on cluster basis. This can take
the scheme deeper into the community.
vii) The maintenance of a village savings account: This is an extension of the
above point. In the Jawar health assurance scheme, the collection of premium
is deposited in the village fund. This fund pays for the remuneration of the
VHW, to manage the drug kit, to meet the fuel expenses of the vehicle for the
village visit and to arrange village level meetings. The MGIMS receives co-
payments from members for providing secondary and tertiary care. This kind
of an arrangement makes it a village-level affair. The chances of villagers
enrolling en masse are improved. This method can be used by SKAT, if it is
able to partner with some community-based organization or the Panchayats.
This could help in making a village as a unit or enrolment. A village as a unit
of enrolment is very useful for reducing the chances of adverse selection. The
problem could be that since the AMUL members already get benefits through
the Tribhuvandas Foundation, it will take substantial effort and higher benefits
to get the people to join en masse. A village level fund and a nearby VHW can
do this for SKAT.
viii) The MHC pattern of spreading accessibility for the people: The 14 Mini-
Health Centres (MHCs) that support this establishment are manned by 2
Multi-purpose workers (MPWs) and provide curative and preventive care to
the 6000-10000 population in their catchment area. The MPWs work closely
with Lay First Aiders (LFAs) who are equivalent to Village Health Workers
and provide promotive health care in the villages. From our point of view, this
kind of a penetration can be very useful, not just for the scheme but also for
the hospital’s long-term share in the health-seeking preferences of the people.
The hospital already has two extension centres. They can be more properly
equipped. Moreover, smaller centres can be set up for far and wide reach.
51
For making the scheme more flexible
The present format of the scheme leaves very little room for the members to make
choice about what they want. Our field study also showed that many of them are
prepared to pay more for more services. Considering the following five steps could
help the scheme in increasing the flexibility of the scheme.
ix) Variable premium depending upon the reported family income: The SKAT has
a policy of subsidizing the premium for some members from the poor
community by using the donors’ money. This is a good way of getting them
initiated into the scheme. This can be formalized and used to make the scheme
appear more approachable for the members of the economically backward
community. An example of this type is the Medical Aid Plan of Voluntary
health Services. It takes variable premium from people depending on their
reported family income. The people are divided into 5 categories. The
members from the 3 categories of lowest income people receive subsidies
from donations. In our case, the basis of categorization can be different, but
the concept of variable premium can be tested.
x) Variable benefit package: The variable benefit packages can be used by SKAT
for ensuring that the members from the poorest sections of the society can be
given more care in cases in which the chances of their going into abject
poverty due to expenses are high. Such a variable benefit package can be used
for increasing flexibility in the scheme and providing the potential members
with option for joining the scheme for different types and levels of benefit
packages. The Medical Aid Plan of Voluntary health Services provides
variable benefits to different members, depending on their category.
xi) The concept of charging just the cost for certain services: The concept of
charging just the cost for certain services can be used for giving higher benefit
to in OP category and for some excluded categories. It would minimize the
losses, but give some benefits to the members. For example, the Medical Aid
52
Plan of Voluntary health Services charges just the cost in certain cases,
without any mark-up. This helps in ensuring that they don’t suffer losses and
at the same time, the members get a benefit.
xii) Flexibility of time period of membership: People should be allowed to buy
security for more than one year. Presently, they can wither buy for one year or
for lifetime.
xiii) Allow people to buy healthcare security for their old age during their working
life: Installment-based collection of premium from working people to provide
them insurance in their old age is a good way of attracting more long term
members.
53
diseases. Extra fee can be charged for such benefits, if they are to be made
totally free.
xvi) Special care of the poorest of the poor: The very poor sections of the society
invariably fall through the safety net. Some of the Community health
insurance schemes have initiated informal mechanisms to cover this
vulnerable section. At ACCORD, some better off people are requested to pay
extra and this is used to pay the premiums of the destitute.
54
For trying up with other hospitals for providing services:
xxii) Check the possibilities of tie up with hospitals in Khambhat, Nadiad etc. We
checked with two such hospitals. Following are the findings.
55
catchment areas membership base will be close to the potential membership base. This
would need the policy makers of SKAT to take a decision: Whether to remain within the
same catchment area and improve the services as much as possible; or to scale up the
operations and move to more distant catchment areas, again constantly improving what is
being done. The decision can be taken even before the catchment area has been tapped up
to the potential. Whatever may be the case, such a decision would involve a serious
strategic stand-taking on the part of the policymakers of KRUPA. Depending on the
decision, the future course of action would have top be decided. Presuming that the latter
decision is taken, we studied some schemes of the models 2 and 3 of the Community
Health Insurance. The purpose of studying these schemes was to bring about the pros and
cons of switching from one model to another, so that the policymakers can take informed
decisions in this matter.
The following are the point that came out from a literature study of the schemes coming
under insurer and linked models:
Parameter Provider model Insurer model Linked model
Flexibility to Very flexible Depends on the insurance
suit local needs company’s products
Premium Set by NGO, Set by NGO, Set by insurance company
considering considering and based on actuarial
affordability affordability calculations
Coverage Can be made very Can be made very Traditional policy with its
comprehensive, based comprehensive, exclusions and limitations.
on needs based on needs
Risk With the NGO With the NGO With the insurance company
Quality of care Can be better because Can be better because No difference for insured and
of closeness between of closeness between non-insured patients
NGO and provider NGO and provider
Community Minimal as the Depends on the NGO Depends on the NGO
involvement hospital is in charge
and is usually
technocratic.
Exceptions are there.
Number of Usually only one main Can be many Can be many
56
providers provider
Claims and Generally cashless Mixed Mostly reimbursements.
reimbursements
Category Name of Disease
1 Common cold, fever, dysentery, peptic ulcer
(mild), worm infection, diarrohea, cholera,
acidity, common dental problem, viral infection,
nausea, vomiting, etc.
2 Malaria, pneumonia, kala ajar, sinusitis, VD,
bronchitis, surgical excision, hepatic infection,
appendicitis, fistulaa, etc.
3 Diabetics I & II, hypertension, TB, cardiac
problem, cerebral fever, cerebral TB, goiter,
ophthalmic complication (except infection),
falaria, unbalanced hormone secretion,
orthopedic, acute VD, cancer (various type),
renal problem, acute hepatic malfunction, organ
transplant, HIV infection, etc.
ANNEXURE:
57