Introduction
"Health insurance" implies a system that covers the whole or part of a person's health risk incurring medical expenses. 1 Government health insurance schemes, such as the Central Government Health Scheme (CGHS) and the Employees State Insurance Scheme (ESIS), are available for people working in the public sector.2 Private insurance companies provide medical care insurance through individual subscriptions.
Public health spending in India has been at a dismal low over the past few decades; it is about one percent (1.2%) of the country's GDP, with about 70% of health expenses met as out-of-pocket expenditure by the patients.3 Over 63 million people in India face financial stressyearly due to healthcare spending alone.4 In 2008, India launched the Rashtriya Swasthya Bima Yojana (RSBY) for below-the-poverty-line familiesto reduce catastrophic healthcare expenditures arising from health status involving hospitalization.5 With the launch of Ayushman Bharat, health insurance has come to the forefront of government health policy in India.6 With low government spending, health insurance is being proposed as a way out.
Previous studies have shown that awareness about health insurance among the Indian population is low, and health insurance coverage is still inadequate. With increased awareness about various insurance schemes over the past few years, there is an anticipated change in public perception of India's health insurance. Hence, we conducted this study to assess the awareness, perception and utilization of health insurance policy among patients attending the outpatient department (OPD) of a tertiary care hospital in Lucknow.
Materials and Methods
A hospital-based descriptive cross-sectional study was conducted in the general OPD section at the tertiary care teaching hospital in Lucknow, Uttar Pradesh, from October 2020 to January 2021. Patients aged 18 years and above were registered at general OPD and willing to participate in the study. Non-responsive and seriously ill patients were excluded from the study.
Sample size
The sample size was calculated to be345 using the W. Daniel formula,7taking a two-sided 95% confidence level, five percent of absolute error, and prevalence (34%) of individuals covered under any health insurance in the year 2016-17.7
Questionnaire design and validation
A pretested and validated (Cronbach's alpha: 0.78, suggesting acceptable interviewing tool)8 semi-structured questionnaire was developed following the variables used in "Pre-launch Report of Insurance Campaign".1 All the variables were entered in an Microsoft Excel sheet and coded numerically as 0, 1, 2 and so on as required.
The questionnaire consisted of two sections, biosocial characteristics of the participants and questions about awareness, perception, and possession of any health insurance scheme.
Ethical committee approval
Necessary permission was obtained from the relevant department and informed consent was obtained from each participant.
Sampling procedure
A convenient sampling technique was used to recruit study participants. Patients were interviewed at the registration counter after their registration. A total of 345 patients fulfilling the inclusion and exclusion criteria were personally interviewed.
Data processing and analysis
Data were processed and analyzed using SPSS 26. Descriptive statistics were represented as the frequency with percentages (categorical data). Findings were also presented through graphs. Association between categorical variables was tested using a Chi-Square test. Predictors for the outcome variables were analyzed using binary logistic regression.
Results
Table 1
Distribution of study participants based on socio-demographic profile and by their health insurance status (N=345)
Out of the 345 participants, about one-third (116, 33.6%) were covered under at least one health insurance policy. Table 1 shows the socio-demographic characteristics of the study participants. The mean age (in years) ± SD (range) of the insured participants was 44 ± 14 (19 — 70), while for uninsured participants, it was 35 ± 12 (18-76). The majority of the insured participants were professionals (62.9%), while the majority of the uninsured participants were unemployed (44.1%). Total annual health expenditure for insured participants was up to 10% of their total yearly income (100.0%), while in more than one-third of uninsured participants, it was more than ten percent of their total annual income (39.3%). (Table 1)
Table 2
Distribution of the participants based on the awareness about health insurance and source of information (N=345)
Three-fourths of the uninsured participants (76.4%) were aware of health insurance. The commonest source of information was the newspaper among two-thirds (66.4%) of the insured participants, while among the uninsured participants, the newspaper was the source of information in only about one-third (39.7%). (Table 2)
Table 3
Health insurance coverage, type of health insurance policy held and the reasons for not having health insurance. (N=345)
Out of the participants who acquired health insurance, most of them were covered with private health insurance companies (46.6%), while the most commonly acquired government health insurance scheme was Ayushman Bharat (42.8%). The most frequent reason reported for not having health insurance was lack of knowledge about terms, conditions and benefits (64.2%). (Table 3)
Table 4
Type of health insurance policy, duration, and benefits availed by the insured participants (N=116)
Majority of the participants insured by private insurers had cashless benefits. And had a cover of more than five lakhs. Emergency services were covered for all the participants under government funded policies. About one-fourth (26.1%) of the participants bear catastrophic health expenditure of more than ten percent of their total monthly income. Other characteristics of the health insurance held are presented in the table. (Table 4)
Table 5
Distribution of the participants based on the health insurance held and perception about the importance of health insurance (N=345)
Among the insured participants, about three percent (2.6%) were indecisive if the health insurance was essential, while about two-thirds (65.1%) of the uninsured participants felt health insurance essential. (Table 5)
Table 6
Predictors of uptake of health insurance policy# (N=345)
Univariate analysis followed by multivariate binary logistic regression analysis was used for variables to compute the predictors of acquiring a health insurance policy. For obtaining a health insurance policy, the model predicts that respondents with advancing age were 1.004 times more likely to acquire government health insurance policies. Similarly, male gender and individual having a larger family size were more likely to acquire government health insurance policies. Conversely, individuals who follow religion other than hindu and belonged to lower socio-economic status were less likely to opt for government health insurance policies. Occupation and felt need for acquire health insurance policies were found to have similar impact for acquiring government or private health insurance policies. (Table 6)
Discussion
Coverage of health insurance
Only one-third (32.8%) of the participants were covered under any health insurance scheme in the present study. At the same time, Prinja S et al. (2019) found relatively low health insurance coverage (10.0%) in Uttar Pradesh.9 Whereas, Baisil S et al. in their study conducted in Karnataka, found a higher (57%) proportion of the participants were insured, which can be due to the different study settings and population with varied awareness and perception on health insurance.4 In the present study, more than half (53.4%) participants were covered under the private health insurance policies, similar findings were revealed by Kala P et al. where 56.8 percent of the participants were covered under the private health insurance policies.10
Awareness regarding health insurance and source of information.
The majority of the participants (84.3%) had heard about the existence of insurance for health, similar findings were observed by Kusuma Y et al. where 98.2 percent of the participants had heard about the same.11 The major source of information was a newspaper (48.7%). Similar findings were revealed in a report published by Sinha A et al.1 The most frequent reason reported for not having health insurance was lack of knowledge about the person or place to approach for acquiring health policy (64.2%), low income resulting in an inability to pay the premium (18.8%) and lack of felt need (15.7%). Madhukumar S et al.showed that the major barrier for the subscription of health policy was low income (43%) and no felt need (29%).12 About one-fourth (26.1%) of the participants bear catastrophic health expenditure (more than 10 percent of the annual income), similar to the findings of Prinja S et al.9 All the dependents were covered under health insurance in less than two-thirds (61.2%) of the participants, similar to the results showed by Garge S et al. where half of the respondents (47.1%), had all the family members covered under the health insurance.13
Benefits availed by the insured participants
More than three-fourths (79.3%) of the insured participants did not know the terms and conditions of the health polity they held. In contrast, Kala P et al. showed that about half (55.0%) of the participants did not know about the terms and condition of the health insurance policy they held.10 In the present study, OPD consultations were covered under only one-third (36.2%) of the participants, similar to the findings of Baisil S et al. showed that only 34.9 percent of patients used it for outpatient care.4 We found that 8.6 percent of the participants used it once a year during the past financial year and 6.9 percent have used it twice, while Baisil S et al. showed that about one-fourth (28%) of the patients used it once a year and a less than one-fourth (22%) utilised it twice in a year.4
Predictors of uptake of health insurance policy
The association of socio-demographic factors with possession of a health insurance policy found that the respondents employed under the unorganised sector and professionals were more likely to have health insurance policy than the unemployed. Also, individuals with middle and higher socio-economic status were more likely to have health insurance policies. These findings parallel with the results observed by Goud B et al.14
Conclusion
The present study revealed that various factors such as age, occupation, education, family size impact the acquisition of health insurance policies. People with higher socio-economic status, who can pay for the premium, were likely to acquire private health insurance policies. Whereas, individuals with advancing age, having more dependents to take care of, were more likely to acquire government health insurance policies. Inadequate knowledge regarding health insurance among health care seekers is a major roadblock in the government's ambitious project of Ayushman Bharat and other health insurance schemes. Rolling out such an insurance scheme is unlikely to yield intended benefits unless emphasis is given to educating the people regarding their rights and the benefits of such schemes.
Strengths and Limitations
Participants were selected randomly. The participants underwent an informative session wherein they were briefed about the problem statement and how they could make a recuperative contribution by answering honestly to the questions. However, there were a few limitations of the study: we did not include gynaecology and obstetrics patients, as they presented in a dedicated OPD for such patients. Also, the study was conducted at a single centre, and education and other socio-demographic factors vary hugely across various geographical regions of the country and the globe.
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