Helping members of a community-based health insurance scheme access quality inpatient care through development of a preferred provider system in rural Gujarat.

We describe and analyse the experience of piloting a preferred provider system (PPS) for rural members of Vimo SEWA, a fixed-indemnity, community-based health insurance (CBHI) scheme run by the Self-Employed Women's Association (SEWA). The objectives of the PPS were (i) to facilitate access to hospitalization by providing financial benefits at the time of service utilization; (ii) to shift the burden of compiling a claim away from members and towards Vimo SEWA staff; and (iii) to direct members to inpatient facilities of acceptable quality. The PPS was launched between August and October 2004, in 8 subdistricts covering 15,000 insured. The impact of the scheme was analysed using data from a household survey of claimants and qualitative data from in-depth interviews and focus group discussions. The PPS appears to have been successful in terms of two of the three primary objectives--it has transferred much of the burden of compiling a health Insurance claim onto Vimo SEWA staff, and it has directed members to inpatient facilities with acceptable levels of technical quality (defined in terms of structural Indicators). However, even under the PPS, user fees pose a financial barrier, as the insured have to mobilize funds to cover the costs of medicines, supplies, registration fee, etc. before receipt of cash payment from Vimo SEWA. Other barriers to the success of the PPS were the geographic Inaccessibility of some of the selected hospitals, lack of awareness about the PPS among members and a variety of administrative problems. This pilot project provides useful lessons relating to strategic purchasing by CBHI schemes and, more broadly, managed care in India. In particular, the pragmatic approach taken to assessing hospitals and identifying preferred providers is likely to be useful elsewhere.

Community-based health insurance schemes in India: a review.

There is an increasing inclination among multinational agencies--including the World Bank, World Health Organization and International Labour Organization--to advocate community-based health insurance (CBHI) schemes as part of a comprehensive solution to improving access for healthcare services in India. This paper reviews the experience of Indian CBHI schemes, their impact on health system goals, such as access to hospitalization and protection from indebtedness, and the factors--particularly scheme design and management--that may contribute to success. The CBHI schemes in India are extremely diverse in terms of their designs, sizes and target populations. While some of the schemes are run by non-governmental organization (NGO) providers, there is an increasing trend towards collaboration with the Government Insurance Company (GIC). In its partnership with NGOs, the GIC seems to have provided favourable group plans compared to the individual Mediclaim and Jan Arogya policies. We have little information on the impact of existing CBHI schemes--most importantly, in terms of access and protection from indebtedness--and even less on factors that make for a successful scheme. This review suggests that there is a demand for health insurance services among the poor. To date, there is little evidence to suggest that these schemes can include the poorest of the poor or improve access to inpatient care. Furthermore, the schemes have done little to address the issue of low/variable quality of healthcare services. Empirically derived data on the existing schemes in India are extremely limited, making this fertile ground for future research.