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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 6  |  Issue : 2  |  Page : 178-183

Health insurance coverage and its sociodemographic determinants among urban and rural residents of Haryana


1 Department of Community Medicine, ESIC Medical College and Hospital, Faridabad, Haryana, India
2 Department of Community Medicine, SHKM GMC, Mewat, Haryana, India

Date of Submission16-Oct-2020
Date of Decision05-Feb-2021
Date of Acceptance16-Mar-2021
Date of Web Publication08-Jan-2022

Correspondence Address:
Dr. Mitasha Singh
Department of Community Medicine, ESIC Medical College and Hospital, Faridabad - 121 001, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/bjhs.bjhs_106_20

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  Abstract 


BACKGROUND: The National Family Health Survey 4 data state that health insurance (HI) coverage is 28.2% in urban areas, 29.0% in rural areas, and overall 28.7% in India. To achieve universal health coverage and to reduce out-of-pocket expenditure, it is prudent to enhance coverage of HI, especially among middle and low socioeconomic status (SES) strata.
OBJECTIVES: The objectives of this study were to estimate HI coverage among rural and urban households and compare the sociodemographic determinants of HI.
METHODOLOGY: A community-based, cross-sectional study was conducted in 179 rural and 193 urban households. The tool was a structured questionnaire administered to all consented participants.
RESULTS: Awareness about any type of HI scheme was almost equal in rural and urban areas (74.9% and 74.6%, respectively) whereas coverage was much better in urban (58.0%) than rural areas (38.5%). TPA/private schemes were mostly availed by rural while the majority in urban areas availed employer-based or public sector HI schemes. The main reason for availing HI as quoted by rural families was tax gains (66.7%) and to cover medical expenses (46.4%) or compulsion from employer (41.1%) by urban families. HI coverage was observed to be better among urban families having dependents (children or elderly) as compared to rural and rural Hindus as compared to urban. HI coverage was significantly higher among upper- and upper-middle-class strata (as per BG Prasad classification) rural households than urban (P = 0.005 and 0.008, respectively). However, lower-middle and lower classes in urban areas have better coverage (P = 0.028 and 0.076, respectively).
CONCLUSION: HI awareness among the rural as well as the urban population is quite good. There is a need to bridge the gap between awareness and coverage of HI by motivating middle and low SES strata and introducing affordable and acceptable HI schemes for them.

Keywords: Insurance, out-of-pocket expenditure, social security, universal health coverage


How to cite this article:
Goyal P, Narang S, Singh A, Singh M, Goswami S. Health insurance coverage and its sociodemographic determinants among urban and rural residents of Haryana. BLDE Univ J Health Sci 2021;6:178-83

How to cite this URL:
Goyal P, Narang S, Singh A, Singh M, Goswami S. Health insurance coverage and its sociodemographic determinants among urban and rural residents of Haryana. BLDE Univ J Health Sci [serial online] 2021 [cited 2022 Jul 2];6:178-83. Available from: https://www.bldeujournalhs.in/text.asp?2021/6/2/178/335316




  Introduction Top


The concept of health insurance (HI) was introduced by Hugh the Elder Chamberlen in the year 1694. HI is now rapidly emerging as a tool to manage the financial needs of people to seek health services. In 1991, the Government of India reformed economic policy and liberalized the insurance process and this paved the way for the privatization of the insurance sector in the country. The Insurance Regulatory and Development Authority Bill, passed in the Indian parliament, is the important beginning of changes having significant implications for the health sector.[1]

The World Health Organization data state that the public sector in India spent just 1.46% of gross domestic product on health care, ranking 187th among 194 countries. In the present scenario, spending on health care accounts for approximately 72.2% of out-of-pocket spending.[2] High OOP is one of the major reasons for inequitable access to health care in India. To achieve the ambitious goal of universal health coverage (UHC), it is imperative to motivate people to avail HI. India has enormous unmet needs for health care and a huge population of uninsured residents. Even among the growing number of middle classes, for whom HI would be a worthwhile investment, only a few Indian consumers comprehend the value of an insurance plan.

The Indian middle class is also growing rapidly, and the rising prosperity of many Indian households is prompting demand for high-quality medical care and increasing private sector participation.[3] Health scheme coverage in urban households was 28.2% and 29.0% in rural areas as per the National Family Health Survey 4 (NFHS-4).[4] HI in India is provided through the Central Government Health Scheme, Employee State Insurance (ESI) Scheme, and Private HI. In India, many studies have been conducted to determine the HI coverage in rural or urban areas, but none has compared the two. Hence, the present study was conducted among urban and rural residents of Haryana.


  Methodology Top


This was a community-based cross-sectional study. It was conducted in the field practice areas of urban and rural health training centers attached to the Department of Community Medicine, ESIC Medical College and Hospital, Faridabad, Haryana.

One hundred and seventy-nine households from rural and 193 from urban areas were selected through simple random sampling participated in the study. After obtaining written informed consent, the head of the household or in his absence any responsible adult was considered as a respondent. Only those who were residing in the field practice area for the past 5 years were included in the study. Eligible participants who did not consent and/or comprehend the questions were excluded. The required sample size was calculated based on NFHS-4 data stating an overall coverage of HI in India as 28.7%.[4] Taking an absolute precision of 5%, at a 95% confidence interval, the minimum sample size was calculated using Epi Info version 7 as 315. Accounting for a nonresponse rate of 10%, the required sample size was calculated to be 347, but the study enrolled 372 households (179 rural and 193 urban).

A self-designed, structured, closed-ended interview schedule in the vernacular language (Hindi) was used for data collection. Undergraduate medical students posted in the department were trained in administering the interview schedule. House-to-house visits were made by these interviewers up to a maximum of two visits. Information about sociodemographic factors, awareness, and utilization of HI schemes was collected. A participant was considered aware of any HI scheme if she/he knew the name of the particular scheme launched by the government or private sector. If the participant was availing or had availed benefit from any of the HI schemes, it was classified as utilizing the HI schemes.

Anonymity and confidentiality of all the study participants were maintained. The study was approved by the Institutional Ethics Committee.

All the filled pro forma were checked for completeness and coherence before data entry. Data were entered in SPSS version 21 (IBM SPSS software version 21.0. IBM Corp., Armonk, NY, USA). Participants' demographic and socioeconomic characteristics are described with proportions or means wherever applicable. P < 0.05 was considered statistically significant.


  Results Top


In the present study, families from rural and urban areas were considered as study units.

Sociodemographic profile

The majority of the families in both rural and urban areas had 6–10 family members (69.3% and 67.4%, respectively). More than 95% of families in urban as well as rural areas had both unmarried adults and married couples. Rural families (16.8%) had more widow/separated adults as compared to urban families (13.9%). As per BG Prasad classification, maximum (31.3%) families in rural areas belonged to upper-middle-class socioeconomic strata as compared to urban families where lower-class socioeconomic strata (37.8%) dominated [Table 1].
Table 1: Sociodemographic profile of households (n=372)

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HI awareness and coverage

In the present study, awareness about any type of HI scheme was almost equal in rural and urban areas (74.9%, 74.6%). HI coverage was much better in urban areas (58.0%) as compared to rural areas (38.5%) [Figure 1].
Figure 1: Awareness regarding health insurance schemes and the proportion availed among urban and rural households

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Health insurance schemes availed and utilized

The majority in both rural (95.7%) and urban (88.4%) areas opted for HI schemes providing coverage to the entire family rather than the individual. In rural areas maximum availed TPA/private schemes while urban households were mostly covered by employer-based or government-based HI schemes [Figure 2]. Not all those who availed/enrolled in a scheme utilized it. Non-utilization of any scheme was higher in rural areas (53.6%) as compared to urban (29.5%). Urban families in the majority had utilized the ESI Scheme (73.2%) while TPA/private schemes by most of the rural families [Figure 3].
Figure 2: Health insurance schemes availed by households availing these schemes

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Figure 3: Health insurance schemes utilized by households availing these schemes

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Reasons for availing health insurance and its perceived benefits

Tax gains were quoted as the main reason for availing any scheme by rural families (66.7%) whereas most of the urban families availed HI to cover medical expenses (46.4%) or due to compulsion from employer (41.1%). Surprisingly, about one-fourth of the urban population was not sure about the benefits (25.9%) of HI. The most common perception regarding the benefits of HI was a reduction of out-of-pocket expenditure (57.0%) among urban and health care during a crisis (33%) among rural households [Table 2].
Table 2: Reasons for availing and perceived benefits about health insurance among urban and rural families

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Sociodemographic determinants of health insurance

HI coverage was better in rural families having members >5 whereas in urban areas small families (<5 members) were in an advantageous state, although a statistically insignificant trend was observed. Coverage was more among urban households having dependents (children/elderly) than rural. Religion-wise, rural Hindus had better coverage. HI coverage was significantly higher among upper- and upper-middle-class strata (as per BG Prasad classification) rural households than urban (P = 0.005 and 0.008, respectively). However, lower-middle and lower classes in urban areas have better coverage (P = 0.028 and 0.076, respectively) [Table 3].
Table 3: Sociodemographic determinants of availing health insurance in rural and urban areas

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  Discussion Top


UHC is focused on meeting both the preventive and curative health-care needs of the population. The private health-care delivery system has developed rapidly but provides most of the curative services only. The public health system lags due to its low capacity in terms of infrastructure and workforce.[5] The aim of the policymakers is to provide HI to a population to achieve the major part of UHC by reducing their OOP expenditure even if they utilize public or private health system. This analysis provides evidence from households of both urban and rural areas of Haryana on awareness of HI, availing, and utilizing HI schemes and their perceptions about it.

In the current study, upper-middle-class households dominated in rural areas as compared to urban regions where the lower class was in majority. Contrastingly similar studies conducted by Netra et al., Bawaand Ruchita, and Madhukumar et al., in rural areas, the most reported number of families is belonging to lower and lower-middle socioeconomic classes.[6],[7],[8] Better socioeconomic status (SES) scale enjoyed by the rural population in the present study may be attributed to high per capita income and prosperity in the state of Haryana.[9]

In the present study, awareness about any type of HI scheme was almost equal in rural and urban areas (74.9% and 74.6%, respectively). The results are in accordance with studies conducted in rural areas of South India by Indumathi et al. (75.7%) and Holyachi et al. (75%).[10],[11] Reshmi et al. from rural Mangalore and Yellaiah et al. in Hyderabad reported the awareness about HI as 64% and 66.5%, respectively, which was lower as compared to our study,[12],[13] while Kusuma et al. from urban clusters of Delhi reported that more than half (56%) of the participants had no knowledge of HI.[14]

However, HI coverage is much lower than its awareness in both rural and urban areas. This may be attributed to low SES and no willingness to devote time for procedures of availing the same by the study participants. The findings were comparable to the studies conducted by Madhukumar et al., Indumathi et al., and Choudhary et al. in rural areas and Reshmi et al. in urban areas.[8],[10],[15],[16] Baisil et al. reported 57% of patients attending rural health centers of Mangalore using HI scheme.[17] Around 50% enrollment was reported by Mahmood et al. in their study from households of Bangladesh.[18]

Both rural and urban households availed schemes in the majority for families. Observations from rural areas are contrary to that of Netra et al.,[6] where the majority availed public or employer-based insurance schemes covering individuals and not their family members. Less than half of the households with dependent elderly (both in rural and urban) availed HI schemes. Similar findings were reported by Dror et al. in their meta-analysis on factors affecting uptake of community HI schemes. The results of meta-analysis approve a positive association of SES with enrollment in HI schemes.[19] The current study shows an increasing trend in acceptance of insurance schemes from lower to upper-middle class which reduces again in the upper class of rural areas. In urban areas, as the SES decreased from upper middle to lower middle, the acceptance of HI scheme increased. Both the upper and lower classes remained outliers with low acceptance. Contrary to the current findings, Mahmood et al. in their study from Bangladesh reported that a higher proportion of households from the highest socioeconomic quintile were enrolled in the HI schemes. Households with members 5–10 were the major beneficiaries of HI schemes both in rural and urban areas. In a similar study from Bangladesh, the major enrollees of HI schemes were households with 4–6 members.[18]

Not all those who availed/enrolled in a scheme utilized it. Nonutilization of any scheme was higher in rural areas as compared to urban. The reasons could be the accessibility of ESI dispensary as well as hospital to urban residents covered under the scheme. Another way round it could be due to the better health status of rural residents as compared to urban ones. The majority of the population from urban areas in our study were migrants and industrial workers with general health status poorer as compared to residents of rural areas.

The most common perception regarding the benefits of HI was the reduction of out-of-pocket expenditure among urban residents while the availability of health care during a crisis was perceived as a benefit by rural households. Reshmi et al., and Indumati et al., have almost similar findings in their studies in urban and rural areas, respectively.[8],[15] Urban residents in the current study are majorly factory workers who are prone to injuries and accidents, hence insurance cover during a crisis is a benefit for them.

Limitation

The percentage of people using ESI is high in urban areas and hence may not be representative of the general urban population. This is because the study was conducted in the industrial township area which is also the field practice area. ESI Scheme is better utilized in urban because the slums catered by the health center of the institute have a substantial number of persons insured under the ESI Scheme.


  Conclusion and Recommendations Top


As far as awareness is concerned, the state of Haryana has attained a respectable level. Enrollment in the HI schemes is low and utilization is again lower. The upper and lower classes are the ones who are least in number to avail the schemes. The aim should be complete coverage of the population with HI schemes. It is high time for the public and private sector to tap the middle and low SES strata as they are ready to pay a reasonable amount as a premium to cover expenses in case of any medical adversities.

Acknowledgments

We would like to thank the undergraduate students posted in our department who helped us in collection of data. We would also extend our gratitude to Mr. Jefin Joseph and Dr. Prabhat Ranjan who helped us in data collection.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Crawford S, Sachdev R. Global Analysis of Health Insurance in India- EY. Oxford Economics; 2018. Available from: https://www.ey.com/Publication/vwLUAssets/EY-global-analysis-of-health-insurance-in-india/$F. [Last accessed on 2020 Feb 10].  Back to cited text no. 3
    
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Prinja S, Chauhan AS, Karan A, Kaur G, Kumar R. Impact of publicly financed health insurance schemes on healthcare utilization and financial risk protection in India: A systematic review. PLoS One 2017;12:e0170996.  Back to cited text no. 5
    
6.
Netra G, Rao BA. A study on awareness, coverage and willingness to avail health insurance among the residents of a rural area in Central Karnataka. Natl J Community Med 2019;10:190-6.  Back to cited text no. 6
    
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Bawa SK, Ruchita M. Awareness and willingness to pay for health insurance: An empirical study with reference to Punjab India. Int J Humanit Soc Sci 2011;1:100-8.  Back to cited text no. 7
    
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Madhukumar S, Sudeepa D, Gaikwad V. Awareness and perception regarding health insurence in banglore rural population. Int J Med Public Health 2012;2:18-22.  Back to cited text no. 8
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Reshmi B, Sreekumaran Nair N, Sabu KM, Unnikrishnan B. Awareness of health insurance in a South Indian population – A community-based study. Health Popul Perspect Issues 2007;30:177-88.  Back to cited text no. 12
    
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Baisil S, Sathyanath S, Kundapur R. Types of health insurance and its utilization in a primary, secondary and tertiary care setting in coastal Karnataka. Int J Community Med Public Health 2017;4:1758-61.  Back to cited text no. 17
    
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