Introduction:
Healthcare financing is an important part of wider efforts to safeguard health. Since independence, the health care system in India has been expanded and modernized considerably. (1) There is substantial indication that the level of health care spending in India is 6 per cent of its total GDP which is significantly higher than in many other developing countries. Even though the economic input is increasing, the people of rural area are not reaping the benefits of it due to failure at various levels. (2)
Many families in India are pushed below the poverty line each year because of raising healthcare costs. In spite of various government schemes, NSSO (National sample survey office) figures the insurance coverage as 18.1% for urban population and 14.1% for rural population. Yet, it is still a long way to go to ensure access to affordable healthcare to 1.2 billion people. (3) Its worth to health insure to manage the ever rising healthcare costs. On an average, 10% Indians are covered under different types of health insurance schemes, mostly inadequate. (4) This low coverage might be because of lack of awareness about health insurance or might be because of lack of financial literacy. The aim of the present study is to investigate the awareness, and utilization of health insurance in the selected population of State of Sikkim.
Methods
A cross-sectional descriptive study was carried out in northeastern region (NER) of India, which is considered as one of the backward regions of the country. Sample unit was revisiting Central Referral Hospital Manipal, Gangtok Sikkim. The study was conducted among 1500 Out-patients revisiting the various outpatient departments of the hospital. Purposing sampling method was used. Consent was taken from the willing participants. The study was carried out during the period of July 2016 to December 2016 and Survey has been done to know the Awareness, enrolment and utilization of health insurance by using validated Questionnaire containing 14 questions.
About Sampling unit
Tadong, Gangtok is the most significant urban area in the mostly rural state. The Central Referral Hospital (CRH), Tadong, is a 500 bed Tertiary Care Hospital. The hospital has 22 specialties, 12 operation theatres and all state of art equipment. The hospital caters to the health of North Eastern part of the country. Health care delivery is in a fine balance due to the increasing expectations of the customer and the cost of continuous technological advances in the field of medicine. (5)
Sample size was based on data collection period of 3 months and willingness of the patients to participate in the study. Study was explained and consents were taken from willing participants. Sample size was rounded up to 1500 samples of an average of 140 to 150 outpatients per day. Participants were explained about the study in local language and all the information was collected through personal interviews.
Data colleting tool: Survey was conducted using the semi structured validated questionnaire containing 14 questions. Part 1 contained Socio-Demographic profile of respondents and Part 2 – questions related to Awareness and utilization of health insurance. Insurance scheme specific questions were included to know the high and low preferred schemes. The hospital falls in the network of six health insurance schemes namely: Jana raksha scheme, Aarogya raksha, Aarogya bhagya, Swasthya surakshya yojana, Rashtriya Swasthya bima yojana and Janashree bima yojana.
Socio economic analysis was done based on Revised Kuppuswamy and B G Prasad socio-economic scales for 2016. (6) Economic class is categorized as class I (upper), class II (upper middle), class III (lower middle), class IV (upper lower), and class V (lower).
Data analysis: Data was entered into Excel 2007 and facts were analyzed for frequencies and percentage and SPSS Ver.20 is used to test the significance. Respondents’ response frequencies and percentage of each parameter was analyzed and discussed.
Results
For socio economic status of the respondents, age, gender, marital status, family type, literacy, occupation, income and department visited were considered and analyzed.
| Table 1: Socio economic Information |
| Parameters |
Variables |
Frequency |
Percentage |
Age group |
20-29 years |
512 |
34.1 |
30-39 years |
524 |
34.9 |
40-49 years |
309 |
20.6 |
50-59 years |
155 |
10.3 |
Gender |
Male |
488 |
32.5 |
Female |
1012 |
67.5 |
Marital Status |
Married |
901 |
60.1 |
Single |
599 |
39.9 |
Family Type |
Joint family |
359 |
23.9 |
Extended family |
781 |
52.1 |
Nuclear family |
360 |
24.0 |
Literacy |
Illiterate |
100 |
6.7 |
Literate |
1400 |
93.3 |
Occupation |
Government employees |
369 |
24.6 |
Private sector employees |
261 |
17.4 |
Self employed |
89 |
5.9 |
Business |
148 |
9.9 |
Agriculturist |
152 |
10.1 |
Students & house wives |
481 |
32.1 |
Income group |
Class I |
150 |
10.0 |
Class II |
256 |
17.1 |
Class III |
723 |
48.2 |
Class IV |
244 |
16.3 |
Class V |
127 |
8.5 |
Out Patient Department visited |
Medicine |
547 |
36.5 |
Orthopedics |
178 |
11.9 |
Dental clinic |
98 |
6.5 |
Dermatology |
205 |
13.7 |
Obstetrics and gynecology |
271 |
18.1 |
ENT |
122 |
8.1 |
Urology |
19 |
1.3 |
Gastroenterology |
56 |
3.7 |
Cardiology |
4 |
.3 |
The analysis revealed (Table 1) that were nearly equal number of participants from age group of 20 -29 (34.1%) and 30 -39 (34.9%) most were women (67.5%), married (60.1%), extended family (52.1%), literate (93.3%) and class III income group (48.2%). Women and student participants were more (32.1%) and 24.6% were working in government sectors. And majority of the participants (36.5%) were from medicine OPD.
| Table 2: Awareness of Health Insurance |
| Parameter |
Variables |
Mean |
SD |
Sig. (p) |
Yes |
No |
Frequency |
Percent |
Frequency |
Percent |
Awareness of health insurance |
1159 |
77.3 |
341 |
22.7 |
1.23 |
.419 |
.000** |
Awareness of types of health insurance schemes |
675 |
45.0 |
825 |
55.0 |
3.03 |
1.833 |
.000** |
Enrolment for the scheme |
570 |
38.0 |
930 |
62.0 |
1.62 |
.486 |
.000** |
| ** significant at 0.01 level |
The result showed (Table 2), 77.3% of the participants were aware of health insurance and 45% were aware of various types of health insurance schemes and 38% of the participants were enrolled in health insurance schemes. And t-test showed the findings as highly significant.
Highest enrolment of 34.4% for Sikkim Manipal Swasthya Suraksha Yojana and least enrolment of 2.8% for Jana suraksha scheme was found.
| Table 3: Reasons for non-enrolment |
| Reasons |
Frequency |
Percent |
Mean |
SD |
Sig. (p) |
Not aware of schemes |
464 |
49.9 |
1.471 |
1.38 |
.000** |
Did not feel worthy |
107 |
11.5 |
Not a regular patient |
117 |
12.6 |
No returns for investment |
32 |
3.4 |
Insurance coverage is not there where I work |
210 |
22.6 |
| **Significant at 0.01 level |
Out of 570 participants (Table 3) who were not covered under any type of health insurance 49.9% were not aware of any type of health insurance schemes and in these group 49.9% participants were said that they were not aware of the health insurance schemes.
| Table 4: Showing results of other parameters considered |
| Who is the beneficiary? |
Frequency |
Percent |
1. |
I am one of the beneficiary |
17 |
3.0 |
2. |
Only myself |
123 |
21.6 |
3. |
Only wife |
6 |
1.1 |
4. |
Myself and my wife |
58 |
10.2 |
5. |
Parents are included |
298 |
52.3 |
6. |
Other family members are also included |
68 |
11.9 |
What is the reason for purchase? |
1. |
Wanted health security |
106 |
18.6 |
2. |
Passive membership |
31 |
5.4 |
3. |
Family is covered |
72 |
12.6 |
4. |
Can't say |
302 |
53.0 |
5. |
Other reasons |
59 |
10.4 |
Who influenced you for enrolment? |
1. |
Agents |
213 |
37.4 |
2. |
Family |
174 |
30.5 |
3. |
Neighbors |
131 |
23.0 |
4. |
Colleagues and friends |
35 |
6.1 |
5. |
Media |
17 |
3 |
How many times you utilize in a year? |
1. |
Once |
22 |
3.9 |
2. |
Two times |
75 |
13.2 |
3. |
Three times |
95 |
16.7 |
4. |
Four times |
137 |
24.0 |
5. |
Five times |
98 |
17.2 |
6, |
More than five times |
143 |
25.1 |
What are the benefits of health insurance? |
1. |
OOP expenses are minimum |
263 |
46.1 |
2. |
Emergency healthcare services included |
128 |
22.5 |
3. |
Access to better healthcare services and facilities |
74 |
13.0 |
4. |
Minimal premium |
31 |
5.4 |
5. |
Can't say |
74 |
13.0 |
Most people (52.3%) purchased schemes that covered their families and parents (table 4). Six (1.1%) opted schemes that covered only their wives; 53% were not sure what made them purchase the policy; 18.6% to secure health; 37.4% were influenced by agents to purchase health insurance policy and only 3% were influenced by media.
Regarding utilization of health insurance benefits (Table 4), 25.1% utilized it more than 5 times in a year and 3.9 % utilized it once. Concerning benefits (Table 4), 46.1% said out of pocket expenses are minimum for health care and 5.4% said they need to pay minimum premium and benefit is more.
| Table 5: Overall satisfaction with health insurance scheme |
| Levels of satisfaction |
Frequency |
Percent |
Mean |
SD |
Sig. (p) |
Very satisfied |
156 |
27.4 |
.80 |
1.162 |
.000** |
Satisfied |
250 |
43.9 |
Can't say |
120 |
21.1 |
Somewhat satisfied |
41 |
7.2 |
Not satisfied |
3 |
.5 |
| **Significant at 0.01 level |
Overall satisfaction result showed (Table 5) maximum people who enrolled for health insurance schemes were satisfied (43.9%) and highly satisfied (27.4%). Test of significance showed the result to be highly significant.
| Table 6: Correlating socioeconomic parameters with enrollees and non-enrollees |
Parameter |
Enrollees |
Non-enrollees |
Pearson correlation ‘p’ |
Frequency |
Percent |
Frequency |
Percent |
Education |
Literates |
567 |
99.5 |
833 |
89.6 |
.000** |
Illiterates |
3 |
.5 |
97 |
10.4 |
Family type |
Nuclear |
149 |
26.1 |
211 |
22.7 |
.049* |
Extended |
298 |
52.3 |
483 |
51.9 |
Joint |
123 |
21.6 |
236 |
25.4 |
Economic status |
class I |
15 |
2.6 |
135 |
14.5 |
.000** |
class II |
71 |
12.5 |
185 |
19.9 |
class III |
260 |
45.6 |
463 |
49.8 |
class IV |
183 |
32.1 |
61 |
6.6 |
class V |
41 |
7.2 |
86 |
9.2 |
| **Correlation is significant at the 0.01 level; *Correlation is significant at the 0.05 level |
Table 5 shows in literates group 99.5 % of participants are covered under insurance and in non – enrollees group 89.9 % were literates. Significance test showed both the finding as significant. Maximum enrollees and non-enrollees were from extended family type. The socio economic results showed maximum enrollees (total of 77.7%) belonged to class III and class IV and finding showed significant at .01 level.
Discussion
Studies based on the socio-economic parameters allows better understanding of the awareness of health insurance among various categories of people. Awareness and reasons for non-enrolment are the important factors to be considered for health insurance enrolment and hence the significance test was done to know the significance and both results showed significance at 0.01 level. Of the few Indian studies related to health insurance awareness majority of them were carried out in the urban areas. A study carried out at Jaipur city of Rajasthan revealed 43.4% were aware of health insurance. (7) Another study carried out at a tertiary care hospital in coastal Karnataka found that only 38% were aware of health insurance. (8) Our study showed, 22.7% of participants were not aware of health insurance and 55% were not aware of the different types of health insurance schemes. Many participants did understand the concept of health insurance although those insured (64.1%) seem better in this regard. Many opined that health insurance brings down their out of pocket expenses towards health. Many of the interviewed participants, perceived life insurance as only the form of insurance. When questioned on views on various aspects of health insurance, a fairly large proportion (49.9%) of uninsured participants did not give any answer. This may be due to lack of knowledge and interest in purchasing health insurance. Majority (34.4%) of the study participants were enrolled under Sikkim Manipal Swasthya Suraksha Yojana. Most of them (53%) were not clear why they have enrolled in the scheme. Insurance agents played major source of information for enrollment (table 6) as well as friends, relatives, media contributed for enrollment. The study results showed higher proportion of insured as well as uninsured participants live in extended families (table 6) in contrast to the study by suwarna et al., (9) at Bangalore where it showed the enrolment of nuclear family were more. Hence it is clear that the rate of enrolment may not depend on the type of family. An important finding of the current study is that education and economic status seldom influence peoples’ enrollment in health insurance schemes. The study supports this statement as 89.6% of literates were from non-enrollees group and 77.7% were from class III and IV categories hence indicating the need for financial education for people and their families to take up better financial investment decision and increase their health security. (10) Financial literacy to create the awareness and benefits of health insurance among the people of the selected region is important.
The success of a health insurance program depends on the impact of awareness programs. Rate of enrolment is one of the indicators for success of these awareness programs. This study, showed that 11.5 % participants opined purchasing health insurance is not worth and 3.4% opined there is no returns for money they pay as premium. With awareness program, it is better to have a good insight into perception of people about health insurance and educating them about various types and features of health insurance. It is suggested that the issues related financial literacy can be taken up by insurance companies or the organizers by conducting more and more awareness programs in identified regions of low and moderate enrolment across the country and open up counseling counters at empaneled hospitals.
Limitation
Study is conducted in one healthcare setting in selected region hence results cannot be generalized.
Acknowledgement
We thank Hospital Authorities, Central Referral Hospital Manipal, Gangtok Sikkim for approval and support to carry out the study.
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