An EC-FP7 Action -Research Project · · 2016-06-09Exit Interview – Medical Expenditures ......
-
Upload
phungthuan -
Category
Documents
-
view
215 -
download
1
Transcript of An EC-FP7 Action -Research Project · · 2016-06-09Exit Interview – Medical Expenditures ......
Developing efficient and responsive community based micro health insurance in India
Developing Efficient & Responsive Community Based Micro Health
Insurance in India:
An EC-FP7 Action-Research Project
Pradeep Panda, PhDSenior Researcher, Micro Insurance Academy
&Conor Doyle, M.Sc, Sachin Shinde,M.S., Shikha Dixit, PhD
Researchers, Micro Insurance Academy
August 18th, Delhi Seminar Series, 3ie, Global Development Network
Developing efficient and responsive community based micro health insurance in India
Project Overview
• The EC-FP7 project is a five year researchproject on the effectiveness of CommunityBased Health Insurance (CBHI) schemes
• Comprises three separate Randomized ControlTrials (RCTs)
• Each trial will establish an independent,community-based and community-run CBHIscheme• Performance of the three schemes will becritically evaluated
Developing efficient and responsive community based micro health insurance in India
Research & implementation sites
Uttar Pradesh Bihar
Kanpur Dehat
PratapgarhVaishali
Source: www.MapsofIndia.com
Developing efficient and responsive community based micro health insurance in India
Core Hypotheses (1)
1. Membership in a CBHI scheme causes a decrease in thehousehold Out-of-Pocket Healthcare Spending (OOPS).
“With the replacement of point-of-service user fees with prepaymentfor insurance, members' OOPS on healthcare decrease andbecome more predictable and manageable”
2. Insured households are less likely to rely on welfare-threatening health financing strategies than uninsured households.
“Reducing the risk of unexpected high health care costs will result inreduced risk of households that are obliged to borrow, sellassets or liquidate savings to finance their unexpectedhealthcare needs”
Developing efficient and responsive community based micro health insurance in India
Core Hypotheses (2)
3. Households covered by CBHI face less financial exposure tohealth care expenditure.
Financial Exposure Index = (A x B) / CA = % of cases / insureds incurring expenditure above the CBHI capB = Average OOPS on cases incurring expenditure above the CBHI
capC = Income per capita in insured cohort
4. Insured households have a lower risk that their TotalHealthcare Expenditure (for which they are liable) will be“catastrophic”.
“CBHI schemes reduce the instances of sudden illness forcingpeople to expend a catastrophically high percentage of theirincome/assets to finance health care.”
Developing efficient and responsive community based micro health insurance in India
Core Hypotheses (3)
5. Utilization of available healthcare is increased bymembership in the CBHI (for the benefit types whichare covered by the insurance package).
“Through prepayment, CBHIs lessen the financial barriers to
health care utilization, leading members to seek more
care from health providers”
6. Increase in solvent demand for healthcare due to CBHI will increase the quantity of services provided.
“The increase in solvent demand would in turn have animpact on the quantity of health care available to thesecommunities.”
Developing efficient and responsive community based micro health insurance in India
Core Hypotheses (4)
7. Community based health insurance schemes (CBHI) would improve the physical accessibility of health care facilities.
“Increase in demand for health care may lead people to adopt faster modes of transportation or development of new health facilities”
Developing efficient and responsive community based micro health insurance in India
Ongoing Research
Key Hypotheses
Quantitative(Surveys)
Qualitative (Interviews & Group
Discussions)
Peer reviewed articles on impact of CBHI
Roll-out of insurance to 29,880 persons by 2014
Spatial(Mapping)
Developing efficient and responsive community based micro health insurance in India
• Our partners have been organizing SHG activities for between 1,000 and 1,500 members at each of our three sites.
• These members are scattered over 15, 34 and 42 villages.
• The SHG members will be encouraged to join a community based health insurance scheme.
• Community Based Health Insurance is operated by and for communities, not for individuals at random, (for reasons of rating, inclusion etc).
• We also need to generate a control group to the insured cohort.
• Our solution is the Step-Wedge Cluster RCT........
Methodology: Step-Wedge RCT
Developing efficient and responsive community based micro health insurance in India
First: Revenue villages are grouped into clusters.Each cluster is geographically contiguous androughly equal in numbers of SHG members.
Methodology: Clustering
Developing efficient and responsive community based micro health insurance in India
Methodology: Random SelectionSecond: Clusters of villages are randomly assignedto treatment (insurance) or control groups:
Developing efficient and responsive community based micro health insurance in India
• Third: Insurance is implemented using a “Step-wedge” design:
• 1/3 of villages are selected this year• 1/3 join next year• 1/3 the year after that
• This design is used to encourage community acceptance and enthusiasm
• Over 24 months, the entire community is offered the chance to join the scheme.
Methodology: Step-Wedge Implementation
Developing efficient and responsive community based micro health insurance in India
1. Household Survey – Healthcare Seeking Behaviour– Medical Expenditure– Financing of Medical Expenditure – Other details....
2. Exit Interview – Medical Expenditures– Financing of Medical Expenditure
3. Income Survey
4. Insurance Understanding Survey
Quantitative Tools
Developing efficient and responsive community based micro health insurance in India
Income Survey (10%)
Insurance Understanding
(20%)
HH survey (100%)
Income Survey (10%)
Insurance Understanding
(20%)
HH survey (100%)
4000 SHG Members 1200 Non-SHG Members
5200 HH Surveys over 3 Sites
Exit Interviews
Sampling Methodology
Developing efficient and responsive community based micro health insurance in India
Tool Data Type Obs Vars
HH Survey
By Health Event: health seekingbehaviour, spending andfinancing patterns
12248 311
By Individual: Socio-economicstatus, and current health status
29880 94
By Household: Perceptions ofhealthcare availability,household spending, assets, andstatus
5214 411
Exit Intervie
w
Medical Expenditures, Financingof Medical Expenditure
1664 85
Income Survey
Household income levels, bysource
566 60
Insurance Survey
Understanding of basicinsurance concepts among SHG
1013 13
Quantitative Data Output
Developing efficient and responsive community based micro health insurance in India
Qualitative InvestigationFocus on FOUR Areas:• Healthcare: Health and illness, health
seeking behavior, and healthcare cost• Social capital: Socio-economic structure of
the village, trust and cooperation, rules and norms of the day to day village life, and issues of conflict, etc.
• Risk protection: Perceived risks, strategies to manage risks, interlinks between social capital and risk management
• Impact Assessment of awareness campaign and CHAT tool
Developing efficient and responsive community based micro health insurance in India
Tools of investigation
• Focus group discussion with the SHG members
• Focus group discussion with the Head of SHG households
• Key Informant interviews with village leaders
• Key informant interviews with various healthcare providers
• Case studies
Developing efficient and responsive community based micro health insurance in India
Qualitative Data Output
Sr. No.
InterventionsPlanned (Completed)
NIDAN BAIF SB
1 FGD - Healthcare 36 (36) 36 (32) 36 (36)
2 FGD - Social Cap. & Risk Protection
24 (24) 24 (24) 24(24)
3 KII - Healthcare 30 (36) 30 (25) 30 (30)
4 KII - Social Cap. & Risk Protection 6 (6) 6 (6) 6 (6)
5. Data Collection: Impact assessment for awareness
Upcoming Upcoming Upcoming
Developing efficient and responsive community based micro health insurance in India
Qualitative Data Analysis
Analysis of Healthcare data:
• All the FGDs and KIIs are transcribed, thentranslated from Hindi into English.
• Coding work with NVivo (version 8) inprogress.
• Next steps: Picking up the themes foranalysis, extracting data and developingmodels
• Data collection after the awarenesscampaign and CHAT process
Developing efficient and responsive community based micro health insurance in India
Spatial Research
Overview • Spatial research analyzes geographical attributes using
various mapping tools. • Baseline spatial research will analyze physical access
to health among target communities. • Following waves of spatial data collection will analyze
affect of CBHI on parameters associated with accessibility and utilization.
Hypothesis
• Accessibility is a major factor affecting the utilization of health care facilities. (Location of a facility and its distance from the community governs its utilization.)
Developing efficient and responsive community based micro health insurance in India
Goals & Data Goals• To analyze physical access to health care among the
target communities.• To identify areas characterized by shortage of health
care facilities.• To analyze how introduction of CBHI affects the
parameters associated with accessibility and utilization of health care facilities.
Data• Block Level Data on Villages – smallest geographical
unit of analysis.• Existing Road Network – for conducting network
analysis. • Health Care Facilities – number, type, range of
services and facility size.
Developing efficient and responsive community based micro health insurance in India
Tools
1. GPS Mapping – Global Positioning System(GPS) mapping will be utilized to giveprecise locations of the healthcare facilities,villages, etc.
2. Remote Sensing – Satellite Imagery will beused for precise mapping of access routes,etc.
3. Provider Survey Tool – captures supplyside details at local providers i.e. Servicesoffered, physical infrastructure, facility staff,costs & charges
4. Geographical Information System – GISsynthesizes GPS, Remote sensing andProvider survey data
Developing efficient and responsive community based micro health insurance in India
Measuring Impact
LocationSupply
GPS
HCP Tool
Availability
Accessibility
RoadRail
GPSMapsSatellite data
Data synthesis
(Integration of RS & Quantitative data in the GIS platform)
Input Tools OutputSpatial Analysis
Village wise Health care Index
Developing efficient and responsive community based micro health insurance in India
Household mapping & listing
Unused land *Target Household
Household Mapping
èSpatial Mapping helped in developing sampling framesfor survey.
Developing efficient and responsive community based micro health insurance in India
Mapping helped in randomization
èClusters form unit ofrandomization. village polygons mapshelped in demarcation of clusters.
Before looking at village polygons
After looking at village polygons
Developing efficient and responsive community based micro health insurance in India
Urbancity VariableDistance from urban centresDistance from metalled roads
Buffer distance 2 km
GoodAverageBad
èSpatial mapping helped in generating access variable (urbancity). This helped in ensuring treatment & control similarity in terms of access to metalled roads and town.
Buffer distance 1 km
Developing efficient and responsive community based micro health insurance in India
Health Care Supply –Rasulabad Site
Supply mapclearly depicted implementation challenges.
Developing efficient and responsive community based micro health insurance in India
Health Care Supply- Mahua-Vaishali
Provider mapdepicts large number of local medical practitioners.
Developing efficient and responsive community based micro health insurance in India
Distribution of Population & Health Care Supply
Mahua Block-District Vaishali
Provider map overlaid on populationdistribution mapgives insights about health supply.
Developing efficient and responsive community based micro health insurance in India
Research Challenges
• Villages are remote - access is difficult
• Participation: Unavailability and / or unwillingness ofthe participants at some locations
• Some external researchers are unfamiliar with usingthe tools effectively. This requires us to trainresearchers in using tools and applying our methods.
• Inadequacy of data in some qualitative questions /Inaccuracy of data in some quantitative questions.
• Monitoring research and standardizing proceduresacross three very separate sites.
Developing efficient and responsive community based micro health insurance in India
Implementation Challenges
• Generating support among our NGO partners for therandomization of insurance access
• Explaining research needs to implementers /Explaining implementation needs to researchers.
• Integrating the timetables for research &implementation procedures – each team requiresinputs from the other
Developing efficient and responsive community based micro health insurance in India
• Experimental design (RCT) allows for robust assessment of results
• Implementation program designed to optimise validity of impact assessment
• Replication of trials allows for more confidence in generalisability of findings
• Multiple evaluation methodologies (quali, quanti, spatial) capture both the “size and “source” of impact
Distinctive Elements of Project