Workshop on Community Based Health Insurance Kerala – India Wayanad, 19-23 July, 2004

With the support of the CDS – UdeM Action Research Initiative Access to Health Care and Basic Minimum Services in Kerala, India

Final Report 26-08-2004

Executive summary

Background & Objectives

As part of a broader action research project aiming at reducing social exclusion and improving access to basic services, the Centre for Development Studies and the University of Montreal are supporting the development of a community based health insurance (CBHI) in the district of Wayanad. The idea of the CBHI originally emerged during discussions with community representatives and women engaged in self help groups. The basic idea is to draw on their existing networks to extend their income generating activities to health related activities. A feasibility study has demonstrated that the context is extremely favourable to the implementation of a CBHI and meets the most important preconditions, which are necessary for the success of such an intervention. The household surveys and the discussions conducted with the women indicated a strong demand for heath insurance and that families were willing to contribute additional funds to their weekly group savings towards developing a community insurance scheme. With the support of the CDS-UdeM project and the active involvement of a local NGO named Women Welfare Association (WWA), population participating in SHGs, or other groups have come together to form voluntary organizations that will manage the CBHIs and promote health among the communities. Four organizations have already been constituted (called SNEHA) one for each of the four Panchayats where the CBHIs will be initiated (Kottathara, Meenangadi, Ambalavayal and Muppainad).

i) to complement the field work and the feasibility study that has been recently done, by further exploring all the possible options related to aspects such as membership, exclusion, benefits, organization of the scheme, working as an insurer or an agent, relation to providers, cost containment, control of asymmetry of information, collecting, pooling and allocation procedures, information systems, staff, training, choice of the providers to contract with, etc. ; ii) to make the key decisions regarding the scheme and then, be able to initiate its implementation soon after the workshop.

Process

The workshop was held on July 19-22, 2004, at M S Swaminathan Foundation, located in Wayanad district. Participants included representatives from the 4 SNEHAs, representatives from WWA, experts, and the research team.

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There was a full agenda, which was covered by the end of the workshop. All of the presenters, community representatives and experts who had been invited to attend were present. The workshop was a success, and participation greatly exceeded the organizers’ expectations.

Outcomes

The representatives of the SNEHAs acquired a better understanding of CBHI, including the principal characteristics of the schemes, the main options available for Wayanad, practical aspects related to the design of the scheme, and challenges to be encountered in the field. Importantly, they are now in a better position to understand the two possible models (intermediary model vs Insurer model) with the management and training requirements under the two. They noted the importance that the model selection would have on the design of the scheme, and their power of negotiation with insurance companies in the second model.

There was an important equalisation of information between the representatives of the SNEHAs from Meenangadi, from Ambalavayal and Muppainad and those from Kottathara, because prior to the workshop there had until now been few opportunities for exchange and discussion with the project team in the three other Panchayats.

Clear choices were expressed by the participants in terms of membership, criteria for inclusion and exclusion of the scheme, and the risks that should be covered.

The intricacies of the relationship between providers and organisations such as SNEHA became evident to the SNEHA. The need to think of it as a relational contract was understood. The issues to be focused in the dealings were made explicit: controlling drug cost; defining and ensuring quality; prevent malpractice and unnecessary procedures.

There is now a legal entity, SNEHA, duly formed by people’s participation, which is our interlocutor. The people have acted to go forward on the CBHI. The CDS-UdeM project team could also be better focused. Rather than drawing only on the strengths of the SHG networks, now we can focus on SNEHA, which draws on the strengths of numerous networks. SNEHA could also look up to CDS_UdeM team, Gram Panchayats, Insurance companies, and experts (especially Dr Devadasan and Dr Unnikrishnan). A few more steps together with all of them should see SNEHA initiating CBHI in Wayanad.

Evaluation of the workshop by SNEHA indicated that they required more clarification on CBHI. Especially on those factors related to the implementation of CBHI, which they are supposed to transfer to the community (premium etc).

The next steps to be taken have been crystallized, and the research team will now proceed to work with the community to design the scheme.

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Table of Content

I. Background ...... 1 II. Objectives of the workshop ...... 2 III. Agenda: see Appendix 4 ...... 2 IV. Process – Attendance ...... 2 V. Content – outcomes ...... 3 VI. Outcomes...... 11 VII. Next Steps...... 13 VIII. Conclusions...... 15

List of Appendixes

Appendix 1 : By Law of the organizations

Appendix 2 : Dr Devadasan's feasibility report

Appendix 3 : Guiding principles for the scheme

Appendix 4 : Workshop agenda

Appendix 5 : List of participants

Appendix 6 : Presentation by Dr. Narayana, “Overview of the CDS_UdeM project”

Appendix 7 : Presentation by Dr Bart Criel, “Challenges in the development of Community Based Health insurance: lessons from international experience”

Appendix 8 : Presentation by Dr Deepti Chirmulay, “CBHI movement in India”

Appendix 9 : Presentation by D. Narayana “Health condition and preferences for health insurance. Preliminary results of the Baseline survey”

Appendix 10 : Presentation by Dr N. Devadasan, “Community health insurance in Wayanad. A feasibility study”

Appendix 11 : Presentation by Dr Deepti Chirmulay, “Health Insurance in Maharastra”

Appendix 12 : Presentation by Dr Unnikrishananand and D. Narayana, “Health insurance plans in India”

Appendix 13 : Presentation by Dr Bart Criel, “The relationship between community based health insurance and health care providers”

I. Background

Although Kerala is known for its achievements in health, poor and vulnerable populations are often excluded from accessing fair quality health care. High economic costs of health care often preclude those who do not have the ability to pay and the highly developed for-profit private health care system deters many who do not have the capacity to pay for accessing quality care. The India MAPHealth1 study found that 10% of households spend more than their annual income on health care. Clear inequalities exist as the burden of health care is three times higher for the poorest (14.4% of their income) than for the wealthiest (4.4% of their income). In addition, Kerala faces a particular challenge due to its ageing population and shift from communicable diseases to chronic disease, both of which will generate additional financial burdens.

A feasibility study has demonstrated that the context is extremely favourable to the implementation of a CBHI and meets the most important preconditions, which are necessary for the success of such an intervention. The household surveys and the discussions conducted with the women indicated a strong demand for heath insurance and that families were willing to contribute additional funds to their weekly group savings towards developing a community insurance scheme. In fact, they had been thinking of proceeding towards achieving this goal.

With the support of the CDS-UdeM project and the active involvement of a local NGO named Women Welfare Association (WWA), population participating in SHGs, or other groups have come together to form voluntary organizations that will manage the CBHIs and promote health among the communities. Four organizations have already been constituted (called SNEHA, which means friendship) one for each of the four Panchayats where the CBHIs will be initiated (see By Law of the organizations in Appendix 1). Although each organization is independent, they will work closely together and share some resources and activities. This will allow enlarging the pool, increasing the financial sustainability of the schemes and reducing fixed costs. There are about 750 SHG in the four Panchayats corresponding to 40 000 to 50 000 potential enrollees to the CBHI (some basic population data regarding the four Panchayats are presented in Table 1, p.7). Both WWA and the CDS_UdeM project are committed to support the SNEHAs for the implementation of the scheme.

1 MAPHealth is a multi-country project coordinated by the principal investigators of the CDS-UDeM action research project, which evaluated the effects of macro-economic and sectoral reforms on health systems in eight countries.

II. Objectives of the workshop

The workshop focused on the practical aspects related to the implementation of the Wayanad Health Insurance Scheme. The workshop aimed to unite representatives of each of the four participating community organizations, Indian and international experts of CBHI, representatives of some public sector insurance companies, and the CDS-UdeM project team in order to meet the two following objectives: i. to complement the field work and the feasibility study that has been recently done, by further exploring all the possible options related to aspects such as membership, exclusion, benefits, organization of the scheme, working as an insurer or an agent, relation to providers, cost containment, control of asymmetry of information, collecting, pooling and allocation procedures, information systems, staff, training, choice of the providers to contract with, etc. ; ii. to make the key decisions regarding the scheme and then, be able to initiate its implementation soon after the workshop. The workshop aimed essentially to continue the feasibility analysis done by Dr Devadasan and to answer all the remaining questions regarding the development and the implementation of the insurance. Two background documents were used as a basis for the identification of the points to be discussed and the decisions to be made: Dr Devadasan's report (Appendix 2) and the document suggesting some guiding principles for the scheme (Appendix 3).

III. Agenda: see Appendix 4

IV. Process – Attendance

The workshop was held on July 19-22, 2004, at M S Swaminathan Foundation, located in Wayanad district.

Given the background of the participants and the objectives of the workshop, it was decided to limit formal presentations and pursue outcome – oriented "working sessions", addressing precise and practical questions, and assessing alternatives raised in the feasibility report. There was a full agenda, which was covered by the end of the workshop. All of the presenters, community representatives and experts who had been invited to attend were present. The workshop was a success, and participation greatly exceeded the organizers’ expectations. There were about 30 participants in all, including: - 17 representatives from the 4 SNEHAs (3*4 + 1*5; all members of the executive committee of the SNEHAs) & representatives from WWA (Anthony Kunnath, and Apsara); - 5 experts : Dr Bart Criel (Institute of Tropical Medicine, Antwerp), Dr Deepti Chirmulay and Jitendra Sawkar (Basic Health Programme, GTZ, Maharastra), Dr Unnikrishnan (United India Insurance), Dr Rajesh (Bangalore). - Team members (DN, SH, Devadasan, SA, SS, HCK, translator).

The list of participants is presented in Appendix 5.

V. Content – outcomes

Day 1 – session 1: Chair: Mr Anthony Kunnath

Process: - Welcome address (Dr Narayana). Presentation of participants, and of the workshop objectives. Discussion and agreement on expectations, objectives, timetable. - Dr Narayana: Presentation of the CDS_UdeM project (Appendix 6). This short presentation exposed the history of the project and the constitution of the SNEHAs. The principal characteristics of the populations from the 4 Panchayats were also presented. The total population consists of over 100 000 individuals and 750 SHGs. If 50% of women who participate in SHGs insured themselves and their families, there would be about 4500 families insured (based on an average of 12 women per SHG) and 22 500 individuals covered (based on an average of 5 persons per family), translating to one in five inhabitants covered by the CBHIs. This would be an impressive coverage for a CBHI to begin activities. The insurance pool would be sufficiently large to assure the financial security of the CBHI.

Table 1: Population Characteristics of the four Panchayats, Wayanad District, Kerala.

Meenan- Ambala- Mup- Characteristics Kottathara Total gadi vayal painad Total Households: 7 217 7 607 4 955 3 360 23 139 Total population 32 054 34 345 24 033 16 613 107 045 Total 0-6 age group 3 958 4 245 3 197 2 300 13 700 SC population (%) 3% 3% 6% 3% ST population (%) 22% 14% 4% 28% Literate (%) 86% 87% 85% 84% Total Workforce 13 311 13 980 9 282 6 562 43 135 Main Workers 8 980 10 226 7 082 4 696 30 984 Cultivators 1 745 2 126 527 1 412 5 810 Agrl. Labour 1 920 3 089 763 1 435 7 207 HH Industry 100 103 40 54 297 Other workers 5 215 4 908 5 752 1 795 17 670 No. of wards 15 16 12 10 53 No. of SHGs (apprx.) 190 210 150 200 750

- Dr Bart Criel’s presentation was about “challenges in the development of Community Based Health insurance: lessons from international experience (Appendix 7). The size of CBHIs and asymmetrical information are common challenges encountered. Dr. Criel expanded on the role of communities and professionals in managing CBHIs and executing different managerial functions. Experience has demonstrated that these functions may not necessarily need to be performed by the same actors responsible for the scheme; communities should consider the possibility of delegating certain technical roles to professionals with the necessary skills. The principal functions of CBHI are the following : i) information and mobilisation of communities; ii) premium collection & basic financial management; iii) risk management; iv) relationship with providers; v)

monitoring, evaluation & control; vi) voicing people’s demands and interests. There was a discussion on the role that communities and professionals could assume. Among other issues, Dr Criel mentioned that it is important to involve providers to identify their expectations and fears. He also summarized the advantages and disadvantages of CBHIs (more details in the presentation, Appendix 7) and pointed out that subsidies are unavoidable if a scheme wants to include those who cannot afford to pay the premiums. Some subsidies are also often needed to support management and monitoring functions. From the demand side, there are three kinds of obstacles that are usually encountered: poor quality of care and/or lack of trust to the organization and/or inability to pay for the premiums. During the discussion, some participants asked Dr Criel to share some of his experiences in Africa. From his experience, some schemes have been successful – mainly due to the presence of quality of care and trust of the organizers. Other exchanges with the audience led to a specification of the notion of CBHI, it’s implementation, and the principal factors that determine their performance.

Achievements: Important clarifications were made. We could see by the discussions that took place, and the reactions of the audience to the presentations, that the representatives of the SNEHAs had acquired a better understanding of CBHI, including the practical aspects related to the design of the scheme, and challenges to be encountered in the field.

Day 1 – session 2: Chair: Ms Smitha Aravind

Process: - Presentation by Dr Deepti Chirmulay. This presentation provided an overview of the emergence and evolution of the CBHI movement in India (Appendix 8). CBHI emerged due to the absence of social protection, and vulnerability of households to catastrophic expenditures. Poor households do not benefit from social protection, and the first CBHIs focussed on covering poor families and persons working in the informal sector. External partners supported many of these CBHIs. Dr Chirmulay demonstrated the diversity of these CBHI, which are distinguished by the population covered, conditions for eligibility and membership, benefits offered to members, procedures for collecting premiums, linkages with insurers, modalities of distribution of benefits (cashless systems vs reimbursement of payments), etc. Most CBHIs focus on reimbursing hospital costs. Certain CBHIs also offer regular health check ups, say once in two years, , discounts on certain services or other advantages. A discussion ensued on various aspects of insurance. Some suggested immediately extending CBHI to all the Panchayats in the district. There was a greater preference to begin the scheme in the 4 Panchayats as a pilot, before considering the extension of CBHI to other Panchayats. The possibility of covering out patient services (ambulatory care) was also discussed and to what extent CBHI can offer effective financial protection against catastrophic health expenditures. - Presentation by D. Narayana “Health condition and preferences for health insurance. Preliminary results of the Baseline survey” (Appendix 9). Results of the study, based on the responses of close to the 3360 household in Kotthatara Panchayat demonstrated that women and persons who from poor households have a lower perceived health compared to men and persons living in non poor households (p<.001). There were a higher percentage of poor households, female-headed households, and tribal populations from the Paniya group who faced difficulties in securing health care for an ill child, adult or elderly person because of financial reasons. One in five households had to pawn assets to care for certain members of the family over the past year, and one in six

had to borrow money from a SHG. Two percent of households reported the extreme coping strategy of selling land to care for a family member (4% among backward castes). Table 2 : Household coping strategies used to pay for health care of household members, by social characteristics Items Loan from Loan from Savings Sold food Sold land pawned friend SHG withdrawn stocks

BPL status BPL 20% 12% 19% 1% 9% 2% APL 21% 14% 14% 1% 16% 3% Caste/tribe Paniyas 6% 4% 4% 1% 2% 1% Other ST & SC 18% 12% 20% 1% 15% 2% OBC 27% 17% 17% 2% 15% 4% FC 21% 14% 17% 1% 12% 1% Sex of head of household Male 21% 14% 17% 1% 13% 2% Female 19% 10% 13% 1% 11% 3% Total 21% 13% 16% 1% 13% 2%

- The survey confirms the results of the feasibility study on community readiness for a CBHI. Almost everybody in Kottathara sees insurance as very or somewhat important (99%). Insurance is very important for 47% of the BPL households (35% among APL) and is more valued in families where somebody already has health insurance (48% vs 40%). In terms of benefits, there is a strong desire for covering medication costs (95%) and hospitalization costs (88%). - Presentation by Dr N. Devadasan. “Community health insurance in Wayanad. A feasibility study” Appendix 10). The presentation was based on discussions with women representatives of the SNEHAS, permitting a reanalysis of the fundamental aspects of implementing CBHI, given the concrete realities of the SNEHAs. Adopting a pedagogic approach, Dr Devadasan introduced the possible actors that could be involved in the CBHI for Wayanad : the SNEHAs, women’s groups, governmental institutions, insurance companies, and hospitals. The possible roles of each of these actors, and eventual inter- relations – in terms of costs of services and/or financial flux – were discussed with the representatives of the SNEHAs (Figure 1). The two possible options for managing risks in Wayanad (intermediary model vs insurance model) were explained and discussed. In the case of the « insurance model” the CBHI takes the role of the insurer, collects money from the community and purchases health care for its members. In the case of the intermediary model, the CBHI sub-contracts management of risk to an insurance company. This model is the most frequent model adopted in India.

- Wrap up by Dr Jitendra Sawkar. The wrap up by Jitendra Sawkar emphasized the following points: 1. CBHI is achievable, but understanding the ‘needs’ of the community is a must. 2. CBHI is a ‘go- between’ client and provider and can play an important role.

3. There could always be a dualism in CBHI: community partnership vs. community management. The advantage of community participation is transparency but the disadvantage is the lack of professional expertise. 4. Two models of insurance- insurer vs. intermediary- has been introduced for further discussion. 5. One important issue in whatever model of insurance is the involvement of all the members. After the initial enthusiasm, CBHI can quickly turn into one where a divide between the executive and member could come about.

Achievements: The workshop participants were satisfied with the outcomes of the first day, which permitted a global overview of the principal characteristics of the schemes and the main options available for Wayanad. The level of information absorbed by the representatives of the SNEHAs from Meenangadi, from Ambalavayal and Muppainad was a considerable feat because contrary to those from Kottathara, there had until now been few opportunities for exchange and discussion with the project team. It was clear, however, that a number of specific points would require clarification over the following days.

Day 2 – sessions 1 & 2

Process: Animated by Dr Devadasan, the day’s activities were devoted to detailed discussions on operationalization of the scheme. The discussion of the morning session explored membership and conditions of eligibility, benefits, and premiums. Discussions on benefits were further pursued during the afternoon session. Each option was discussed at length, including the advantages and inconveniences of each. The session on « issues related to financing and management », initially scheduled for the afternoon, was put off until the following day in order to complete discussions on the design of the scheme.

Achievements: This day provided the opportunity to capitalize on the work of the previous day. The project team and resource persons took a ‘backseat’, encouraging instead the appropriation of the workshop, and discussions by the representatives of SNEHA. Clear choices were expressed by the participants in terms of membership, criteria for inclusion and exclusion of the scheme, and the risks that should be covered. The project team was extremely satisfied with the day’s outcomes; these outcomes are detailed in section 5 « outcomes ».

Day 3 – session 1

Process: Presentation by Dr Deepti Chirmulay and Dr Jitendra Sawkar. Mr Sawkar began by presenting two videos and the Basic Health Programme in Maharastra. The presentation then dealt with four CBHI's in Maharastra (Appendix 11) and ended with the discussion of management issues and capacity building. Table 3 reproduces the principal characteristics of the four schemes presented. Discussions re-examined benefits that the women could extract from participation in a CBHI. These benefits are principally of three orders: (i) removing economic barriers to access and promoting financial protection of the household when faced with an episode of illness; (ii) sense of security and knowledge that household members do not have to worry that they will be able to access care when in need; (iii) the possibility, depending on the scheme, of benefiting from health promotion and prevention activities (BAIF offers their members a free health check up every two years, and the opportunity for rebates for certain health care services).

Table 3: CBHI schemes in Maharastra

BAIF CHAITANYA BUCCS HMF

Organization NGO NGO Credit Cooperative NGO Integrated Women’s Charitable initiatives Health & women’s development empowerment empowerment CBHI since 2000 2003 2003 2004 Membership Indv. Woman SHG Woman SHG Family / individuals Individual woman SHG member member member # Members 872 276 7500 850 Insurance Policy Janashree + Rural women’s Janashree + Rural women’s Janashree + Rural Janaarogya – including package package with family rider / women’s package maternity Universal HI including maternity Additional benefits Health check up every -- Spectacles for school children, Bharat Vaidya (CHV) for two years, nature cure maternity support for insured first contact care, discount, investigations families – (Not implemented) concession in discount Parallel activity of ambulance diagnostics and hospital (shikshan sahayog for body transport, health (shikshan sahayog scholarships) camps scholarships) Premium Rs. 225 (125) 150 250 (150) / 365 / 548 / 730 250 (150) Hospitalization 5000 5000 5000 / 15000- 30000 5000 Coverage Provider link Discounts / package -- Trying to establish cashless -- rates in private system Control Black listed fraudulent -- List of hospitals & pharmacies -- Claims – 40 13 105 12 processed – 37 13 105 12 settled + 30 + 49 + 12 + rejected 3 20 0

The presentation explained the operation of the health schemes in the four settings in Maharastra. The issues covered were, health insurance promotion, premium collection, claim disbursement, claim review, forwarding claim papers to the company, and settlement. For each activity the management and training needs were also explained. - Presentation by Dr Unnikrishananand D. Narayana: “Health insurance plans in India”. (Appendix 12) This presentation aimed to introduce to the representatives of the SNEHAs the different health insurance plans offered by governmental insurance companies. The three main plans presented and discussed were MEDICLAIM, Universal Health Insurance Plan, and Rural women’s package. These plans target different clients, and offer various coverage plans (for more details, consult Appendix 11). Government, and the four public sector insurance companies established these plans, but insurers can propose modifications to their plans based on their negotiations with organised groups. They will need, therefore, to obtain agreement by the Insurance Regulatory and Development Authority (IRDA). Plans can also be rearranged as a function of roles of the various actors : if a CBHI assures screening of claims, and of the quality, the costs of the insurance policy can be lowered. Also, premiums can be lowered if they are paid in one day. Dr Unnikrishanan also mentioned that there are some kinds of subsidies to health insurance. There is a cross subsidy from other portfolios. In the next year, all the policies will be detariffed which means that the cost for health policies may come down.

One of the important clarifications made during the presentation was regarding the Universal Health Insurance Plan. Till last year, it was available for every body. Following the budget proposals this year, the plan is available only for the BPL households.

Achievements: The presentations were extremely instructive and allowed the representatives of the SNEHAs to hear about different schemes. The women were now in a better position to understand the two possible models (intermediary model vs Insurer model) with the management and training requirements under the two. They noted the importance that the model selection would have on the design of the scheme, and their power of negotiation with insurance companies in the second model.

Day 3 – session 2: discussion with providers.

Process: - Presentation by Dr Bart Criel “the relationship between community based health insurance and health care providers” (Appendix 13). Dr Criel began by presenting the contractual relationships between CBHI and providers. Contracts are a relatively new tool, but are being increasingly used. They can take different forms. Relational contracts, contracts embedded in a process of dialogue and concertation, seem more appropriate in health care. The second part of the presentation dealt with quality of care and the capacity of CBHIs to contribute to quality of care. CBHIs not only allow for better access to care, they can be levers to improve the quality of care. - Discussion with providers (Dr Rajesree, Medical Officer, PHC, Kottathara; + Dr Jitendranath, Secretary, Indian Medical Association, Wayanad; Dr Rajeev; Mr Girish, representative from Leo Hospital, Kalpetta.)

- Dr Jitendranath was the main speaker. He introduced a number of issues. The first issue was about quality. His question was: “What is quality? Good infrastructure facilities, smiling doctors, or something else?” SNEHA has to decide what quality they want. Whatever they decide it should be satisfactory to their members. Secondly, cost of care has to be controlled. Drugs is one of the major cost components. But how to control the cost of drugs? The solution suggested in the feasibility study that generic drugs should be prescribed is no solution at all, as in the Kerala situation generic drugs could cost more than branded drugs. It is important for SNEHA to make lists of drugs and insist that only those will be reimbursed. Thirdly, the same procedure costs varying rates in different facilities- is it possible to think of flat rates? It was responded to differently by different providers. Dr Rajasree said it is not feasible. Girish said it is owing to difference in quality. Fourthly, how to control unnecessary treatment and malpractice? The suggestion that preauthorization by doctors from a panel was ruled out by the providers. Dr Rajasree also said it would not be tolerated. Telephonic consent from a panel was also discussed but no opinions were expressed. It was, however, mentioned that IMA’s cooperation and support would be forthcoming for any such move. The general view is that any action/process leading to additional administrative burden on the providers will be difficult to accept.

Achievements: The intricacies of the relationship between providers and organisations such as SNEHA became evident to the SNEHA. The need to think of it as a relational contract was understood. The issues to be focused in the dealings were made explicit: controlling drug cost; defining and ensuring quality; prevent malpractice and unnecessary procedures.

Wrap up: Bart Criel 1. The different schemes in Maharastra share some similarities but differ in terms of benefits and management. It is alright to design schemes which are different. 2. There is a benefit to everybody who joins health insurance: the unfortunate who fall ill get financial protection against catastrophic health expenditure, others feel secure as there is no tension about high health expenditure and lack of access. 3. The different health plans offered by the public sector companies show a certain social concern, rarely seen elsewhere. The project could capitalise on it. 4. The discussion between SNEHA and the providers has raised important problems and issues. It is a good beginning, which should lead to a contract which is mutually beneficial. It could happen through dialogue and discussion.

Day 4 – session 1

- Open discussion on the functioning of the SNEHAS and how the organizations will work together. The participants discussed the advantages and disadvantages associated with bringing together the four organisations, and putting into place common resources and activities. Following the debate, a consensus was reached that it would be advantageous for the SNEHAs to work closely together, and to implement a coordination structure. This structure would be constituted by one Executive committee composed of 8 members; 2 from each SNEHA. The executive committee will meet once a month. There was agreement that the SNEHAs should have a central meeting place / office. The division of individual and collective responsibilities are as follows :

Table 4: Collective and individual responsibilities of the SNEHAs

Collective Individual Pooling risks Promotion of schemes in the communities Negotiations with insurers and providers Enrolment Scrutiny of claims Premium collection Quality control Claim collection Pooling risks Other activities Strategic thinking

- Open discussion on the insurer and intermediary model, with a debate on the advantages and limitations of each of the models. Neither of the models was clearly the preferred choice. The decision on the model was put off. - The issue of providers- public, private, or both- was also discussed. The opinion was divided among the SNEHA: some wanting public providers and others not wanting them. It was agreed that there is little leverage with the public as of now. It was clarified that the District Medical Officer was invited for the workshop. She showed hardly any interest and said she is not available during the week.

Day 4 – session 2:

- Summary of the discussions and achievements by Dr Slim Haddad. (see section 5). - What is next: discussion animated by Dr Narayana (see section 6). - Closing ceremony.

VI. Outcomes

Process Slim Haddad summarised the proceedings of the workshop. He reminded the participants the objectives of the workshop. There were three objectives: 1. A fair understanding of the key issues in CBHI; 2. Make decisions and agree upon guiding principles; and 3. Work out processes for the implementation of the scheme. As regards the key issues in CBHI, our understanding is that,

There is no one best way – there is no blueprint. Different schemes have evolved in different settings. Each scheme has to be developed according to the local situation. The role of the community- There are a variety of functions ranging from community awareness to processing claims. And these need to be distributed between the community and professional(s). A single expert cannot provide expertise for multiple tasks. Multiple benefits of CBHI – it increases access, helps protect against CHE and also an opportunity for promoting health. It can also help empower the community to negotiate with the providers and the insurance company. There are huge variations in hospitalizations, treatment, and quality of care and so costs of care can vary from hospital to hospital for a given condition. Which means that the CBHI needs to ensure that they are getting good quality care. A CBHI is like a chapathi – and everybody tries to get a share of the chapathi. We should try and see that everybody gets a fair share – so that there is no tension and it is sustainable.

Regarding the decisions made and guiding principles agreed upon, the following classification is useful: Decisions made – clear guidelines. Consensus on general principles, needs operationalisation. Options presented / identified. Decisions pending. Limited discussion – not discussed.

Table 4: review of discussions Decision made Consensus Options Limited discussion presented Eligibility criteria Only SHG members can become members Family is the unit of the enrolment No group membership: IP + health check ups members are free to join or not to join. IP care + some OP No medicines for chronic procedures diseases. But can be reviewed after two years. Exclusions needed (Cases No preexisting hea;th Renewal of policy referred to Kozhikode will problems. not be covered) Which diseases need to be excluded Benefit package is flexible No referrals and will evolve over time. Eligibility to benefits: Waiting time, 1 to 6 months Every family will pay a flat Cashless system rate Premium should be Collection time affordable and around Rs 200 per year per family. No co-payments Ceilings: Upper limit is The amount of Review of claims acceptable upper limit Creating awareness by Payment of Quality of care SNEHA providers: Fee for Control of moral hazard service or flat Control of cost rate Control of fraud Training needs An informal organization of Functions of SNEHA Model of CBHI The Way SNEHA will SNEHAs that will come work, management, together. Executive MIS, training, capacity committee with 2 members building from each SNEHA. Financial sustainability

VII. Next Steps

Functions to be done How? Date to be done

1. Discussions of the workshop Not all areas can be covered by August 1, 2004- to be reached to the level of Sneha. CDS help needed. Muppainad. the Panchayat. Feedback to Help will be there. (to be decided members. Community animators can be in consultation 2. Some initial expenses- who trained. They take it to people. with Smitha) will meet? CDS will meet the Sneha executives will also cost. participate. Community leaders may also be invited. 3. Premium to be decided * Awareness of premium Initiate negotiations: call company computations reps to conduct it. Sneha should do the needful. (*) 4. 4. To bring together 4 Nominate 2 from each. First meeting Sneha’s who will take the to be participated by CDS. Work out initiative? functions

5. 5. Decide scheme details- Simultaneously with negotiations. benefits, premium, collection, claims 6. 6. Design of the scheme

(Executive committee of 4 Sneha’s becomes the interlocutor with CDS)

Implementation of the schemes: main tasks and time schedule

Date and Week number (starting date: Monday, July, 25th) 25-07 04-08 14-08 24-08 03-09 13-09 … … Task 1 2 3 4 5 6 … n n+1 …

Workshop report (draft) SH

Finalization - translation of DN Workshop report

Meetings in 4 Panchayats SA

Constitution + first meeting of SA Executive committee Preparation of TOR for Insurance EC* + SA + DN companies EC with the Contact Insurance companies - support of project distribution of TORs to companies team

EC with the Collect / analyze offers made by support of companies project team EC with the Negotiations with companies support of project team EC : Executive Committee of the federation of SNEHAs

VIII. Conclusions

From the perspective of CDS_UdeM project, the decisions taken and the issues discussed in the workshop is a definite stage in the progress of the project. It can be considered an achievement. Unlike the situation that existed when we began the project, now there is a legal entity, SNEHA, duly formed by people’s participation, which is our interlocutor. The people have acted to go forward on the CBHI.

The CDS-UdeM project team could also be better focused. Rather than drawing only on the strengths of the SHG networks, now we can focus on SNEHA, which draws on the strengths of numerous networks.

SNEHA could also look up to CDS_UdeM team, Gram Panchayats, Insurance companies, and experts. Dr Devadasan has volunteered to come whenever invited. Dr Unnikrishnan has agreed to make his services available. A few more steps together with all of them should see SNEHA initiating CBHI in Wayanad.

It is gratifying to note that the participants have evaluated the workshop favourably (see below).

Evaluation of the workshop by participants from SNEHAs

Very Invalid Very Good Good Average Bad Total Bad / NR Organizing 16 100% 0 0% 0 0% 0 0% 0 16 Resource 10 62.5% 6 37.5% 0 0% 0 0% 0 16 Persons

Presentation 8 50% 7 43.75% 1 6.25% 0 0% 0 16

Timing 10 62.5% 5 31. 5% 0 0% 0 0% 1 16 Travel 12 75 % 4 25% 0 0% 0 0% 0 16 facilities Food 0 0 5 31.25 10 62.5% 0 0% 1 16

Important suggestions and comments made by the participants: 1. Most of the participants have expressed their view that they need more clarification on the subject. Especially on those factors related to the implementation of CBHI which they are supposed to transfer to the community (premium etc). 2. Considering the importance of the subject they would have liked to extend the duration of the workshop.