Group health insurance choices in rural India

1. Group health insurance choices in rural India Marta Quintussi Cologne Graduate School in Management, Economics and Social Sciences (Joint work with Ralf Radermacher, Pradeep Panda and Christina May )

2. Research objectives • In India ill-health still has hard financial consequences on the livelihoods of resource poor families, especially in rural areas (Krishna 2004, Van Doorslaer et al 2006, Vaishavi and Dash 2009, Shrahrawat et al 2011, Binnendijk et al 2012, Quintussi et al 2012); • Health costs are paid OOP, forcing HHs to rely on damaging coping strategies to finance healthcare (Binnendijk et al 2012, Quintussi et al 2012); • In the absence of an inclusive social insurance scheme, community based pre-financing mechanisms could represent a safety net against catastrophic effects of ill-health. • Further information is needed toset up an efficient and responsive community-based insurance scheme. • Our paper aims at: • Understanding preferences for health insurance of communities in rural India • observing the selection process used by resource-poor and (mostly) less educated individuals with inexperience with insurance • individuating the factors influencing the choice of health insurance packages • observing preference transitivity between individual and group choices

3. Data • FP7 projectimplementing RCT of CBHI in three sites in rural India: baseline HH survey • Socio-economiccharacteristics • Healthstatus (self-assessed) • Healthexpenditures and financingstrategies Threediscretechoiceexperiments (1st year): • Individual and group preferences for health packages Evaluation survey (subsample 20%) • Self –reportedreasons for choice • Evaluation of CHAT tool Qualitative interviews withrandomlyselected CHAT participants and facilitators

4. Data analysis 1)Descriptive analysis of data 2)We model individual choices using multinomial logistic regression (adjusted s.e. for SHG level clustering):

5. Descriptive statistics

6. CHAT tool • Revised version of the CHAT (Choosing Health plans All Together) decision tool; • Game-like exercise facilitating group discussion and presenting different insurance options within a limited budget; • Pre-determined benefits (benefits workshops) with representatives from communities; • Exercises have been run after an insurance awareness campaign; CHAT board (old version) New version CHAT board

7. 1st trial – Pratapgarh (UP)

8. 1st trial - choices Number of CHAT participants: 510

9. Determinants of Individual choices • Package4 reference category • Package1 : ↓ chronic ill persons; • Package2: ↑ proportion of children; n. hospitalizations; n. pregnancies; ability to self-finance health exp. ↓choice eldest member; • Package3: ↑ n. hospitalizations ↓ choice of most educated & eldest members. • No effect of possessing RSBY card

10. Self-reported reasons CHAT1: • Most of respondents (63%) choosing package4 reported to have been influenced by SHG members (leader or most educated) or other women from the village for the choice of the individual package; • 30% reported wanting to buy the best package with the most benefits; • A main part of individuals choosing other packages were also influenced by other women´s choices or have chosen the package they thought to be the best. • Only few reported that the price was the main issue in choosing the package (probably because packages are all quite affordable, compared to the other trials) CHAT2: • 75% of respondents reported to have been influenced by other SHG members; • 50% of individuals choosing the cheapest package reported that the price was the main factor, while the rest reported to have been influenced by other members;

11. Preference transitivity between individual and group choices • The number of benefits, the coverage level and value for the money have played an important role in choosing the package. • In the group sessions individual and group preferences are gradually aligned and many people are willing to choose more expensive and more inclusive packages. • In CHAT2 all SHGs choose the same group package (n.4) and thus the community package captures the totality of group preferences (positive for willingness to enroll in CBHI). • In general, the number of benefits included in the package chosen for the group exceeds significantly the number of benefits included in the package chosen for the own household (Wilcoxon signed-ranks test).

12. Findings qualitative interviews • Individuals weightened both cost and benefits when making choices (package4 contains the same benefits of p2 but coverage is higher and price difference is little); • The premium was not the fundamental factor influencing the choice, since all packages were quite affordable and prices differences not huge; • The opinion of most educated SHG members (especially those with administrative positions) was listened to by less educated women. However, the facilitator reports that this was not widely observable; • Each one´s opinion was taken into account for the group choice; • In general respondents expressed satisfaction with the final group choice and with the community package. • However, some expressed some dissatisfaction with the benefits included in the packages (only cesarean delivery), but no one was dissatisfied with the choices. • Despite choosing package4 in CHAT sessions, some individuals decided not to enroll, due to difficulties with paying the premium. (more insights on enrolment in the afternoon session)

13. 2nd trial - Kanpur Dehat (UP)

14. 2nd trial - choices Number of CHAT participants: 332

15. Reported reasons for choices • Individual choices: • 50% of respondents reported the cheaper price was the main reason for choosing package1; • 50% reported having consulted other SHG members and other women in the village for orientation on the best package to choose; • Group choices (package1 chosen unanimously): • The main reported reason for choosing this package was the cheap price of the package • The second main reason was that other SHG members liked that package • Few reported having asked NGO staff for orientation • No preference transitivity between individual and group sessions • All packages contain the same benefits (with different coverage levels), choices are based on price.

16. Findings qualitative interviews • Despite final choices are concentrated on one single package, discussions and deliberations took place before the official choice was made; • During pre-discussions some individuals were willing to choose more expensive packages but changed their mind after considering the lower ability to pay of other individuals in the group (even for individual choices); • Medical history of use of healthcare (mostly outpatient, no perceived need for high coverage of hospital costs) was taken into account to choose the package; • There was no dominant opinion in the group, every single opinion was listened to (in particular the less wealthy members); • Solidarity within the SHG made them choose the cheapest package; • It also emerged that some of participants had no experience with insurance and decided to try the CBHI scheme for one year buying the cheapest package possible;

17. 3rd Trial - CHAT board

18. 3rd trial - choices Number of CHAT participants=659

19. Determinants of Individual choices • Package2 reference category • Package1 : ↓ women autonomy & n. hospitalizations • Package3 : ↑ number HH members • Package4 : ↑ suffering chronic; ↓ choice of most educated; n. pregnancies; proportion of health exp.; women autonomy; • Package5 : ↑non-health expenditures; proportion of children; • Package6 : ↑choice eldest & most educated member; n. pregnancies ; ability of self-financing health exp. ↓proportion of elderly; foregone healthcare • No effect of possessing RSBY card

20. Self-reported reasons CHAT1: • Respondents chose package2 mostly for the cheap price (36%) and (44%) reported to have been influenced by SHG members (leader or most educated) or other women of the village in the choice; • Respondents choosing package1 have been mostly influenced by the price (67%); • The few individuals choosing more expensive packages reported wanting to buy the best package with the most benefits; CHAT2: • Choices concentrate now on cheaper packages, affordable for the most of members; • 72% of respondents choosing package2 resported to have been influenced by other SHG members; 17% reported that the price was the main factor; • Individuals choosing other packages looked mostly at the price and have been influenced by other SHG members;

21. Preference transitivity between individual and group choices • Size of benefits, value for the money and capacity of upfront contribution have played an important role in choosing the package. • Some individuals opted for higher cost packages for their own family, because of their high capacity of upfront contribution. • However, in the group decision (chat1 and chat2) they have shown willingness to align individual and group preferences. • In general, the number of benefits included in the choice for the group exceeds significantly the number of benefits included in the individual choice (Wilcoxon signed-ranks test).

22. Findings qualitative interviews • Individuals weightned both cost and benefits when making choices (package2 contains more benefits for cheap price); • The premium was the fundamental factor influencing the choice; • The opinion of other SHG members was listened to, especially the one from the leader and from trusted members; • However, each one´s opinion was taken into account for the group choice; • Whithin the household, fathers-in-law often influence women´s choices; • Possessing other insurances played a role in the decision process: individuals tried to find the package with less overlapping and with the best complementary benefits; • In general respondents expressed satisfaction with the final group choice and with the community package. • However, for some the price was still to high and were not able to enrol;

23. CHAT evaluation 1st trial: • 66% of respondents reported that the staff was able to explain benefits options in a good or very good way; • Few respondents have had problems with discussing with the family (because too busy or against insurance scheme • 16% report that CHAT was the least convincing activity within the project (because not repeated or some would have liked to include men in the choice process); 2nd trial: • 67% of respondents reported that the staff was able to explain benefits options in a good or very good way; • Few respondents have had problems with discussing with the family (because too busy or did not understand insurance options) • 17% report that CHAT was the least convincing activity within the project (because not repeated or some would have liked to include men in the choice process, that examples were not completely clear and no one-on-one interaction with the staff); 3rd trial: • 68% of respondents reported that the staff was able to explain benefits options in a good or very good way; • 12% of respondents have had problems with discussing with the family (too busy or not interested); • Only 4% report that CHAT was the least convincing activity within the project (because not repeated or not clear);

24. Concluding remarks • Despite inxperience with insurance, participants showed interest and willingness to participate in the choice of the community insurance package; • During this first year some participants needed the support of other SHG members (more educated and experienced) for making their choice; • The premium was a determinant factor for the choice, both because of low ability to pay and also inexperience with insurance (1st year trial). • However, individuals showed their ability of thinking in terms of „value for money“ and trading in terms of number of benefits, coverage and premium. • In group choices solidarity with less-wealthy members played an important role for decisions; • Most of individuals gave a positive feedback on CHAT tool and the way information were transmitted by facilitators; • This first year experience will hopefully bring more awareness for CHAT exercises in the following years of CBHI scheme (Further insights on determinants for enrolment in the afternoon session)

25. Thank you for your attention! quintussi@wiso.uni-koeln.de