Improving the Distributional Impact of an Indian Community-Based Health Insurance Scheme Among its Rural Membership: Cluster-Randomised Controlled Trial

Abstract

Background: Community-based health insurance (CBHI) is often cited as a means of improving access and financial protection in developing countries, but such schemes may not benefit the poorest. We evaluate alternative strategies for improving the uptake of benefits of a CBHI scheme by its poorest members.

Methods: The trial was nested within the Vimo SEWA CBHI scheme in rural India. 16 rural sub-districts were allocated at random to four groups: after-sales service with supportive supervision; prospective reimbursement; both packages; and neither. We assessed socio-economic status (SES) of those seeking reimbursement for health care costs at baseline (713 claimants) and two years later (1,440 claimants). The primary outcome was mean SES of claimants relative to members living in the same sub-district. Secondary outcomes were enrolment rates in Vimo SEWA, mean SES of the insured relative to the general rural population, and rate of claim submission. Analysis was by mixed effects regression, accounting for the sub-district-level randomisation.

Findings: Between 2003 and 2005, the mean SES of SEWA Insurance members (relative to the rural population of Gujarat) increased significantly. Rates of claims also increased significantly, on average by 21.6 per 1000 members (P<0.001). However, differences between the intervention groups and the standard scheme were not significant. There was no systematic effect of time or interventions on the SES of claimants relative to members in the same sub-district.

Interpretation: Neither intervention was sufficient to ensure that the poorer members in each sub-district were able to enjoy the greater share of the scheme benefits. Claim submission increased as a result of interventions that appear to have strengthened awareness of, and trust in, a CBHI scheme.

Keywords: insurance, Inida, financing