Chapter -1
INTRODUCTION
1.0 Introduction
1.1 Need for health care scheme
1.2 Taxonomy of health insurance
1.3 Motivation for the Study
1.4 Statement of the problem
1.5 Objectives
1.6 Hypotheses
1.7 Landscape of methodology
1.8 Scope of the Study
1.9 Limitations of the study
1.10 Organisation of thesis
Chapter One
INTRODUCTION
1.0 Introduction
The saying "health is wealth" is very much true in the present fast-paced life. If an
individual is not in the best of health, he will find it hard to do/enjoy anything else. An unhealthy
person cannot achieve much because of dealing with his sickness dominating his thoughts,
whereas an individual with a sound health will be motivated and will be able to achieve
anything. Ill-health not only gives a lot of suffering to the affected individual and his/her family,
but also leads to financial bankruptcy (D Rajasekhar et.al. 2011). The mean household
expenditure varies across the states, from the highest of ?9,196 (fNR) in Rajasthan to the lowest
of ?4,710 in Assam and in Kamataka is of ?6,686. Mean monthly consumption expenditure of
the non-poor households (HH) is ?8262 compared to ?2307 for the poor households. Nine
percent of non-poor households have become poor (impoverished) due to average Out-Of-Pocket
(OOP) expenditure of ? 1106 per month. Among both, poor and non-poor households, 21-24%
incurred catastrophic health care expenditure. OOP health payments constituted 13% of the
monthly consumption expenditure of the non-poor households in comparison to only 6% share
for the poor households (Sekher T.V et.al. 2012).
To accomplish mentioned direction, against the world average of four beds per 1,000
populations, India has 1.5 beds. To make this figure 2.5 beds, India requires ?5 lakhs crore by
2025 (R.Venugopal, 2009). Presently it has 6 lakhs doctors and 16 lakhs nurses, which cannot
fulfill the national needs. Hence our country needs another 15 lakhs doctors and 30 lakhs nurses
to come near the halfway mark at the global standards. In India, there is one doctor for every
10,000 population whereas it is 548 in the United State, 166 in the United Kingdom, 209 in
Canada and 249 in Australia on this extent our country need another 2 lakhs dental surgeons.
Beside this our country has around 60,000 doctors overseas (R.Venugopal, 2009). This is just to
give a glimpse of healthcare infrastructure in India.
The indicated commitment is needed in behalf of poverty and ill-health is intimately
related. The poor are often unable to have smooth consumption across periods of ill health and it
has been argued that 'catastrophic' health care expenses are a major entry point into poverty
across the world. In India, the mean household expenditure was ?6,671 (INR). The mean OOP
expenditure on health care was ?847. On an average, the OOP on health care was 13% of the
total household expenditure and 19% of the non-subsistence spending. Some researchers confirm
this: an extensive research programme undertaken across parts of India (Rajasthan, Gujarat and
Andhra Pradesh) and Africa (Ghana, Uganda and Kenya) found that ill health and health-related
expenses or health care finance were the most common reasons given by the poor for their own
descent into and inability to escape from poverty (Sekher T.V et.al. 2012).
To solve this problematic situation, intervention of government is essential in the form of
warranted health care for poor and farmers in India as well as in Kamataka. Because India is one
of the low-income country in the world with 26% population living below the poverty line, and
35% illiterate population with skewed health risks. But, it is an open question whether the
government should provide health care to directly empower the farmers' health status (e.g.
through vouchers) to obtain it from private providers or enter into Public-Private Partnerships
(PPP) with health providers and insurance companies. Designing and implementing large-scale
public service delivery systems is notoriously difficult, as the Indian experience illustrates: after
all, India is already supposed to have universal, free publicly provided health care. In practice the
better-off pay for private health services, leaving the poor to live and die with the corrupt, low-
quality and overburdened public hospitals. Researchers have shown that the poor spend
considerable amounts of money on health care, both in the private sector and the supposedly free
public sector. Private health care is not always high-quality, but unregulated providers tend to
offer low-quality care (Gobi .S et.al 2011).
1.1 Need for Health Care Scheme
As a result of this fact, there is an absolute need for health care scheme/insurance for the
rural poor fanners, so that they are able to overcome all the obstacles that might come their way.
With increasing awareness on health amongst farmers' and the newer generation, India is
gradually becoming health conscious. Owing to this realization, the health/medical
care/insurance sector is one of the fastest growing segments in India today. A lot of factors have
contributed to this change with the most important being the change in people's mindset about
'Health Insurance' (HI) (Kalaisigamani .J et.al. 2013). A suitable cover by the way of HI is all
that is required to cope with such situations. HI in a narrow sense would be 'an individual or
group purchasing health care coverage in advance by paying premium'. In its broader sense, "it
would be any arrangement that helps to defer, delay, reduce or ahogether avoid payment for
health care incurred by individuals and households".
The HI is attracting more and more attention of poor farmers in low and middle-income
countries as a means for improving their health care utilization and protecting households against
impoverishment from OOP expenditures. The health care financing mechanism was developed to
counteract the detrimental effects of user fees introduced in the 1980s, which now appear to
inhibit heath care utilization, particularly for marginalized populations and to sometimes lead to
catastrophic health expenditures. The World Health Organization (WHO) considers health
insurance a promising means for achieving universal health care coverage (Ernst Spaan et.al.
2012).
1.2 Taxonomy of Health Insurance
There are various types of HI available for the peoples including poor farmers in
Kamataka. National or Social Health Insurance (SHI) is based on individuals' mandatory
enrolment. Several low and middle-income countries, including the India, Philippines, Thailand
and Viet Nam are establishing SHI method. Voluntary insurance mechanisms include Private
Health Insurance (PHI), which is implemented on a large scale in developing countries like
India, Brazil, Chile, Namibia and South Africa, after-all Community Based Health Insurance
(CBHI), nowadays, this type of scheme or model is available in developing countries like India,
Democratic Republic of the Congo, Ghana, Rwanda and Senegal'. The various types of HI have
different impacts on the populations of the country as they serve. For example, PHI is said to
mainly serve the affluent segments of a population, but CBHI is often put forward as a health
financing mechanism that can especially benefit the poor farmers in Kamataka (Ernst Spaan
et.al. 2012; D Rajasekhar et.al. 2011). Countries wishing to introduce HI schemes into their
health systems should be aware of how their impact varies.
Instantly, the healthcare industry, with global revenue of over ?2.75 trillion is the largest
industry in the world. India has population of 1.21 billion as per in 2011 census experiences a
vast inequity that exists in the healthcare industry with barely 3% of the population covered by
some form of HI, either SHI or PHI. During the last 67 years, India has made considerable
'Sukumar Vellakkal (2007), "Health Insurance Schemes in India: An Economic Analysis of Demand Management under Risk Pooling and Adverse Selection", p 7-9
progress in improving its health status of its peoples. Death rate has been reduced from 40 to 9
per thousand, infant mortality rate has been reduced from 161 to 71 per thousand live births and
life expectancy has been increased from 31 to 63 years^. However, many challenges remain and
they are: life expectancy 4 years below world average, high incidence of communicable
diseases^, increasing incidence of non-communicable diseases, neglect of women's health,
considerable regional variation and threat from environment degradation. At any given point of
time 40 to 50 million of population are on medication for major sickness. About 200 million
days are lost annually.
The annual rate or range of out-patient: rural 30-152/1000, urban 9-81/1000 and for
hospitalization: rural 16-76/1000, urban 5-38/1000. As a result, in India, presently the HI exists
primarily in the form of Mediclaim policy offered to the individual or to any group, association
or corporate bodies. Although, total expenditure on health in India is nearly 6% of the entire
GDP, the government spending is less than 25% against the average spending of 30-40% in other
developing countries. Penetration of mediclaim is currently done by state-owned insurance
companies, covering only about 2.5 million people i.e less than 0.50% of the country's
population'*(P.K. Gupta, 2011).
1.3 Motivation for the Study
Out-of-pocket payments are the principal source of health care finance in most of the
states of India and the Kamataka is no exception. This evidence has important consequences for
household living standards. In most of the developing countries, including India, the poor
peoples' lion's share of health spending is made by OOP. This leads to impoverishment and low
^District wise health profile of TFR, IMR, CBR and CDR in Kamataka described in the chapter three. 'A detailed estimation of WTO on communicable diseases mentioned in chapter three. Coverage under VPHI in India 2009-10 to 2011 -12 is indicated in the subsequent chapter
access to health care facility, especially for weaker segments of the population. The only solution
for this is Micro Health Insurance (MHI) or CBHIs, like Yeshasvini Health Scheme (YHS) has
the potential to reduce the severe consequences of unforeseen illness of farmers.
However, in order to make use of the scarce resources available and build systems
offering value to the poor farmers, it is important to have a detailed and evidence based
understanding of the impact of Yeshasvini on the health and financial status of farmers.
In this way, Kamataka state has implemented this YHS for rural farmers; it is the first in
the developing world like India. YHS is attracting many researchers to investigate the aspects
important for the successful implementation of YHS as CBHI. It does so through a set of
controlled randomized trials through which YHS is implemented in all over Kamataka state,
India. And rigorous longitudinal research is used to identify causal effects of YHS on equitable
access to healthcare infrastructure and financial protection.
Providing HI or health care security for farmers continues to be one of the most important
unresolved policy issues for the world. Most of rural and informal sector workers in the world do
not have any form of HI. And in most developing countries, the rural and informal sectors
constitute the bulk of the population. In India, an estimate suggests that 90% of India's families
earn their livelihood from the unorganized sector, contributing 40% of the nation's GDP.
However, they are poor, most of them are not in employer-employee relationships, they do not
have any form of insurance or social security (e.g. maternity benefits, retirement, health
insurance, etc.,), nor do they have representative organizations that might help them fight for
these benefits.
To such a great extent, researches are essential to provide such benefits for the informal
rural farmers of Kamataka in particularly vulnerable to the lack of access to health care security.
Studies show that the poor spend a greater percentage of their budget on health related
expenditures (this varies between 6-8% in various studies). The burden of surgical treatment is
particularly devastating for major health issues and particularly when they seek "in-patient" care
or hospitalization. Further, the high incidence of morbidity cuts into their budget in two different
ways, i.e. they need to spend large amounts of money for surgical treatment and are unable to
earn money while under treatment. In fact, healthcare costs are one of the primary reasons for
rural indebtedness and poverty of farmers. It is estimated that at least 24% of all Indians
hospitalized fall below the poverty line because they are hospitalized and that OOP spending on
hospital care rises by 2% of the proportion.
Moreover, there is the issue of accessibility given that a majority of farmers' households
reside in remote rural areas, where there is no government or private medical facilities are
available. Obtaining treatment at a town or district level hospital involves travel costs, which are
not insignificant. Thus for many, simply accessing health care is by itself, an expensive
proposition.
However, a common perception is that the farmers are too poor to buy HI. While it might
be true for the poorest of the poor who struggle for survival every day, it need not be true for
those living close to the poverty line. Moreover, there is substantial evidence that if provided
with the opportunity, the farmer would be willing to pay for HI or health care schemes. A recent
study by Cumber and Kulkami (2000) suggest that the rural respondents in Gujarat were willing
to pay an annual premium of ?80 and ?95 for coverage of hospitalization, chronic ailment and
specialist consultation and an additional 16%, if there was coverage of transport costs, medicine
costs and diagnostic charges. However, a large number of the existing schemes for poor people
still involve part or full subsidies by the governments of various countries.
There are several obstacles stand in the way of providing HI to the rural farmers and
informal sectors' rural workers (Gerard La Forgia et.al. 2012; Ernst Spaan et.al. 2012). Thus, the
above factors motivate the systematic study of the impact of YHS in Kamataka. Due to such
importance this case study is focused on following areas; burden of diseases, health care
expenditure by OOP and by the government, taxonomy of HI and its development, key design
features of government sponsored HI schemes and Kamataka's health care sector, Yeshasvini
scheme, its design and coverage features, its potentials to contribute for universal coverage and
its role within Kamataka's health care finance and delivery system etc., are the area of subjects
of this research case study.
1.4 Statement of the Problem
The impact of HI in low and middle income countries has unfortunately been
documented only partially. Previous reviews have evaluated the performance of CBHIs in terms
of enrolment, financial management and sustainability. A recent review provides an overview of
the scope and origin of CBHI in low and middle income countries, with a particular focus on
India, China, Ghana, Mali, Rwanda and Senegal and also assesses CBHIs performance in terms
of population coverage, range of services included and reimbursement rate. HI is also known to
have effects on domains beyond those reported in existing reviews, such as social inclusion.
Furthermore, most reviews are available on the rapid development of HI in low and middle
income countries are somewhat outdated. No systematic reviews are available on the impact of
YHS. This limits to the direct comparison with other health care schemes operating in Kamataka.
In this way this research is carried out to make the systematic review regarding to the impact of
YHS on, enrolled members in YHS, YHS hospitalized and non-YHS cooperative members, in
terms of their health and financial status.
1.5 Objectives
1) To analyze the health insurance schemes of farmers in Kamataka.
2) To study the functioning of the prominent Yeshasvini health care scheme as a
community based health insurance in terms of technical and organizational
characteristics.
3) To assess the Yeshasvini health care scheme that is affordable, responsive and
inclusive which is designed to promote health care facilities of farmers in
Kamataka.
4) To examine the impact of Yeshasvini health care scheme in Shivamogga district
of Kamataka.
5) To identify emerging issues, opportunities, potential challenges and to
recommend policy measures for its expanding coverage and improving the
efficiency and effectiveness of Yeshasvini scheme.
1.6 Hypotheses
In order to achieve the above objectives, the following hypotheses are formed and tested
in the study.
1) Health Insurance lowers and/or avoids the cost of treatment at the point of
hospitalisation for rural farmers' in Kamataka.
2) The Yeshasvini health scheme is successively operating compared to SHI and
PHI with regard to farmers' health care schemes.
3) The YHS has influenced positively on the health status of mral farmers in
Kamataka.
4) YHS explicitly state that the health scheme was developed to prevent the rural
individual farmer from bearing the financial burden of hospitalisation.
5) One of the most active health care organization in Kamataka is Yeshasvini
Cooperative Farmers Health Care Trust, used as community health insurance as a
measure to increase solidarity among its members - "each for all and all for each".
1.7 Landscape of Methodology
For any scientific study the adoption of sound methodology occupies an important place.
The present study is an analytical research based on statistical methods applied to quantitative
and qualitative data. And it has concentrated on analyzing data in depth and examining
relationship from various angles by bringing in as many relevant variables as possible in the
analysis. In addition, diagnostic approach is applied wherever necessary.
This research work, being a case study, has adopted simple random sampling technique
to collect the primary data of samples. The primary study is restricted to the Shivamogga district.
On the basis of robust on the members of YHS via membership with co-operative societies in the
two taluks of Shivamogga district viz. Bhadravathi and Shikaripura were rationally selected on
the basis of geographical profile.
The main reason for this area selection is, its geographical situation, which means one's
(viz. Bhadravathi) agriculture depends more on irrigational facilities and less on rain. Viz.
another one (Shikaripura) is more on rain and less on irrigational facilities for their cultivation as
agriculture is the main source for their revenue. In the both taluk, the samples are selected
randomly on the basis of their membership of farmers with co-operative societies and the
hospitalisation in the scheme and enrollment with YHS. This selection is based on the study of
10
THE STUDY AREA
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11
A. Agarwal's observation. According to Agarwal (2009) 'the success of the any
community based health insurance is based on collection of the premium via their enrollment by
its members and remarkably considered this, the regular payment of the annual premium for their
health security, their financial status is very much important along with their educational status,
for their awareness on the health schemes'.
Thus, simple random sampling procedure is adopted to select the YHS
members/respondents in the category of; YHS Enrolled (YHS E) members (however not
hospitalized); YHS Hospitalized (YHS H) members and Non-YHS Co-operative Member
(NYCM) households (they remained as only member of co-operative society). Altogether, 180
samples from two taluks were selected randomly picking 90 sample farmers from each taluk, in
this 30 each from membership in co-operative societies, hospitalisation and non-YHS co
operative members. The central part of the samples, are co-operative societies members only.
Along with this, during the time of selection, researcher has concentrated favorably of the
households belonging to those who are not economically stable to get hospitalisation facilities by
the private health care providers.
The fundamental and rational criteria for the random selection for the sample is the
minimum basic knowledge and mainly interested cooperative members on YHS and the chart 1.1
shows that the method of selection of sample and chart 1.2 shows the landscape of methodology
in the area of study.
12
Chart 1.1: Flow Diagram of the Selection of Samples in the Study Area
Bhadravathi
YHS Enrolled
30
'S
Shivamogga Dist. Total Samples 180
JL
Shikaripura
o
YHS Hospital isation
30
/ v
Non-YHS Co-Ope rative
Mem. 30
J V. y V.
YHS EnroUed
30
y V.
YHS Hospital isation
30
Non-YHS Co-Opera tive
Mem. 30
J \
This case study depends on both primary and secondary data for the analysis. The
secondary data are captured and collected from the reports, books, national and international
journals and articles, national and international conferences' edited volumes, brochures and
leaflets, and also the data taken from concerned health care schemes' reports and their volumes,
etc., unpublished and published sources by various government agencies; whereas the primary
data are collected by interviewing, FGDs with the farmer members of co-operative society and
staff and simple random sampling techniques as highlighted above. For the simple random
sampling purpose pre-tested questionnaire was prepared and used.
13
Chart 1.2: Landscape of Methodology
METHODOLOGY I
£ Review of YHS documents, records, registers, leaflets,
reports by consulting dept. of cooperative societies,
Shivamogga and Bangalore
1 Broad approach for
primary data collection
Selection of taluks and villages
a) Qualitative: FGD b) Quantitative: Households (HH)
survey schedule
I Data collection
T Cross checking and
validation
Analvsis
Key gaps and follow up of recommendation
14
Furthermore, to know the trends in the membership at the co-operative societies, 8
villages have been selected from the two taluks of the study area. First, in the each study area
randomly two hoblies have been selected. In the each hoblies four villages were chosen for the
selection for co-operative societies.
1.7.1 Definitions of sample groups:
• YHS E: are those who may not have enrolled in the previous YHS year, however,
according to survey period of 2011-12 they were enrolled or renewed in the YHS.
• Likewise, YHS H: thirty HH are taken from the 2011-12 Yeshasvini year hospitalized
household and also,
• NYCM are from the respected Yeshasvini year. They may have got enrolled in the
previous year, but in 2011-12 they have not renewed or enrolled in YHS, yet remained
only as members of cooperative societies.
1.7.2 Analytical Techniques
The information/data collected from both sources are analyzed with the help of
conventional tabular analysis, charts, graphs and suitable diagrams and have been used in
interpretation. Simple statistical tools like CAGR method, measures of central tendency,
percentages and averages has been used in the discussion and interpretation of the data gathered.
1.7.3 Calculating Percent (Straight-Line) Growth Rates
The percent change from one period to another is calculated from the following formula:
( 'Present— 'Past/
V r Past
PcR ^^"O N
Where:
PctR = Percent Rate
V Present = Present or Future Value
V Past - Past or Present Value
The annual percentage growth rate is simply the percent growth divided by A', the
number of years.
1.7.4 Compound Annual Growth Rate
CAGR is a useful measure of the growth of health care expenditure or investment over
multiple time periods by government or OOP, especially if the value of health care outlay has
fluctuated widely during the time period in question.
CAGR is in outlay of specific term for the geometric progression ratio that provides rate
of outlay over the time period. CAGR is not an accounting term, but it is often used to describe
some element of the HI sector.
1
(tn-to)
CAGR (to,tn) = ( V ( t n ) / V (to)) - 1
Where:
• V(to): (to): the start of expenditure, (or initial value)
• V(t„): the last year of expenditure observed
16
• to - the first year of observations.
• tn - the last year of observations.
Actual or normalized values are used for calculation as long as they retain the
same mathematical proportion.
1.7.4.1 Verification:
The formula to check CAGR is:
(tn-to) V(t„) = V(to)X(l+CAGR)
1.8 Scope of the Study
The present study aims at analyzing the impact of YHS on farmers and peasants of
cooperative society. The study deals with the contribution of farmer members of co-operative
society to YHS financial status and OOP expenditure. In view of the difficulties involved in
covering the entire state a unit has been selected. In order to study the objectives and achieve
greater accuracy, Shivamogga district of Kamataka has been purposefully selected as unit of
study. In a nutshell, the study aims at evaluating the impact of YHS on farmers through
cooperative society in Shivamogga district. This study mainly relates to health scheme of the
farmers in Kamataka, specifically Yeshasvini health care scheme of Kamataka and also the
health care expenditure of Gol as well as GoK and diseases pattem in the states and country. It
analyses the level of awareness, progress, achievements and impact of the YHS in Shivamogga
district.
17
1.9 Limitations of the Study
At this juncture, it is essential to mention the limitations to which a study like this is
subjected to. As stated earlier in the scope of the study, the study pertains only to analyse the
broader areas of impact of YHS on selected sample farmers of co-operative societies in
Shivamogga district for a specific period (2011-12) and hence excludes a deeper enquiry into the
other aspects of CBHI. The study does not cover any districts other than Shivamogga district for
primary data. Further, this present case study is beset with certain limitations, they are
enumerated here:
1. At various stages, the basic objective of the study suffered due to inadequacy of
time series data from related cooperative departments and co-operative societies.
There has also been a problem of sufficient homogenous data from different
sources (Like ILO, NABARD, researchers, WHO, PHFI, MoHFW, many
government departments including planning department of state and planning
commission of country, etc,.). For example, the time series used for different
variables, the averages are used at certain occasions. Therefore, the trends, growth
rates and estimated regression coefficients may deviate from the true ones.
2. The field study is covered only to Yeshasvini health care scheme, along with
other schemes which are supporting to farmers' health care status and this does
not cover the private and public insurance companies for deeper study of health
care products and users.
3. Researcher faced by some major constraints of various resources like time and
money. So the researcher forced himself to select a cluster of only two taluks for
18
the case study. Hence, results are largely applicable to those areas where similar
conditions prevail, with the problem of various resources like time.
4. The interview method of data collection requires the respondents to recall from
their memories about their hospitalization. Hence, the findings may be subjected
to memory lapses of the respondents.
5. Hardly, very few studies have been carried out and published on the Yeshasvini
health care scheme of Kamataka. Hence, the study has been done on the basis of
data collected from primary source and availed secondary sources also.
1.10 Organisation of Thesis
This study has been presented in six chapters as indicated below:
Chapter I: Introduction
Chapter I, deals with theme, nature, motivation for the study, statement of the problem
and importance of the present study. The objectives of the study, hypotheses to be tested are also
specified. The scope and limitations of the study are presented at the end.
Chapter II: Concepts and Review of Literature
Chapter II, describes comprehensively a review of the relevant research work done in the
past related to the present study.
Chapter III: Health Insurance Sector in Karnataka - A Critical Analysis
Chapter III, presented in two parts namely, Health Insurance Sector - A Glimpse and
Health Insurance Sector in Kamataka. Comprehensively, this chapter provided the critical
analytical look inside of health care and insurance sector in Kamataka, which is captured and
19
collected by secondary data. The major analysis relates to the genesis and growth process of
health care expenditure by the government and private OOP of people, taxonomy, development
of HI, key design features of government sponsored HI schemes and Kamataka's health care and
health insurance sector along with India and world.
Chapter IV: Benchmark Information of Yeshasvini Health Scheme in Karnataka
Chapter IV, presented in two parts:
Part-I: Devoted for a brief picture relates to socio-economic status of farmers in the study
area of Shivamogga district of Karnataka state, India, as they supported information for the
present study through a brief picture of cooperative society movement and its status in state and
Shivamogga district.
Part-II: Presented the information about the theoretical background of the YHS and also
this chapter analyzed the YHS in Karnataka, with special concentration on the study area on the
basis of data captured by secondary source.
Chapter V: Analysis and Interpretation of Results
Chapter V, discusses the results of the study and it devoted for the results on ethnics of
respondents and their health status, chronicle illness and deceases and other related to the OOP
expenditure of the farmers in Shivamogga district of Karnataka.
Chapter VI: Key Gaps, Recommendations and Conclusion
Chapter VI, provides summary of the whole study and also suggest the recommendations
based on the findings of the study. At the end, bibliographies have been listed related to the
present study.
20
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