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Health Insurance Scheme, Gujarat
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Subject Area="Health financing." Objective="Mobilising community participation."
Details for Reform Option "Health Insurance Scheme, Gujarat"
Summary

Background: This community-based health insurance scheme was run by Navsarjan, an NGO established in 1988 for the dalit (untouchable) community. The health insurance idea was initiated by Navsarjan. Action: The organisation bought the ‘mediclaim’ policy from New India Assurance and paid the premium. They ran the scheme for a one year pilot period: coverage period was from March 17 1999 to March 16 2000. Premium charged was INR 175 per member paid by Navsarjan to GIC. New India Assurance gave a 5 per cent group discount. Covered only inpatient care. Free hospitalisation up to INR 15,000 was also included at just one hospital in Patan. Five doctors (two orthopaedic surgeons, one gynaecologist, one physician and one general surgeon) were approached in Patan town and agreed to treat members who produced a valid membership card. The doctors gave treatment on credit and were paid every three months. Results: Had only 574 members (all the Navsarjan members in Sami and Harij Talukas of Patan district), less than one per cent of the population. During the year, 57 claims were made costing INR 81,130 . Of these claims, 21 were rejected and Navsarjan bore the cost of two of them. The other 19 members had to pay for their own treatment which caused much discontentment. But by the end of the scheme most members said they were happy with it and were willing to pay the premium themselves if the scheme were restarted.

Cost Total premium paid INR 91,216.
Place Sami and Harij taluka of Patan district, North Gujarat, 1999-2000.
Time Frame Approximately three months.
Advantages

Improved access: The community had previously (particularly women with gynaecogical problems) avoided doctors because of the cost.

Challanges

Fraud: Doctors inflated bills, overprescribed medicines and advised unnecessary hospitalisation when they knew the patient had health insurance. Managerially demanding: The scheme was time consuming and expensive to run.

Prerequisites

Good communication and relationship between the doctors and members. Clear understanding of the health insurance policy by all parties.

Who needs to be consulted

The Community. Staff at the NGO (in this case Navsarjan). Medical community.

Risks

Sustainability

No. The scheme was partly subsidised by Navsarjan’s Social Security membership fund (a larger comprehensive scheme which included accidental death, maternity benefits etc and had a membership fee of INR 400 per annum and partly by HIVOS (a funding agency)). Navsarjan did not continue the scheme beyond the pilot stage because it realised that it needed a huge commitment in terms of time, money and manpower to run and they wanted to focus on their primary activity, working with dalits. However the doctors were interested in continuing the scheme and offered to subsidise the premium on behalf of the members if Navsarjan was willing to coordinate the process. But Navsarjan declined for the following reasons: (i)Although the scheme was viable, it would primarily benefit the doctors who owned the clinic, pathological lab and also drug store. (ii)The drugs prescribed were more expensive (next generation) which contravened Navsarjan’s ethical code and community health worker policy.

Chances of Replication

Navsarjan judge that this scheme is replicable but that the NGO would need to use doctors committed to their policies. Navsarjan suggests any NGO trying to run such a scheme should establish its own 20-bed hospital with its own committed doctors dedicated to their philosophy of community health.

Comments

None.

Contact

Submitted By

Clare Kitchen, Research Consultant, ECTA, New Delhi, November 2005.

Status Active
Reference Files
EPW (Akash).pdf Akash Acharya, M Kent Ranson: Health care Financing for the Poor: Community-based Health Insurance Schemes in Gujarat. Economic and Political Weekly, September 17 2005.
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