The consequences of health insurance for the informal sector : two non-governmental, non-profit schemes in Gujarat

Policy makers generally see community-based health insurance as a means of improving access to expensive medical care, particularly among the poor and preventing indebtedness secondary to medical expenidures. However, there is a paucity of empirical evidence on the impact of CBHI, and how its impact is influenced by a scheme's design, management and context. This research examined the cconornic and social impact of two CBHI schemes in Gujarat, India, and explored potential determinants of impact. A case study approach was employed. Data were collected using a variety of methodologies: a cross-sectional household survey,a review of insurance scheme utilisation data, focus group discussions, and in-depth interviews. The CBHI schemes had achieved minor successes. Both provided financial protection to those who actually used the schemes and one of the schemes was successful in including the poor. These successes, however, were overwhelmed by very low rates, of utilisation. Demand for membership in the schemes was determined in part by their strong links with larger parent organisations (a dairy co-operative and a worker's union) and by other services that were packaged with the health insurance. Factors responsible for low rates of health insurance utilisation included a lack of awareness among members of the schemes and their benefits, and perceived problems with the cost. quality and or accessibility of benefits provided. The findings support a cautious approach among those wishing, to foster CBHI in developing countries. Schemes should not be expected to contribute rapidly to broad health system goals. Consistent with past research on CBHI. this study finds that scheme design and management are of utmost importance in determining whether or not the scheme will have the desired impact. Specific areas are identified where government might intervene to optimise the impact of a CBHI scheme.