Four Week Cross Cultural Study Period

The project “Strengthening Micro Health Insurance Units for the Poor in India” is focused on providing support to what we believe is the most promising factor for widespread extension of health insurance among the poor in India. The project has thus conducted a household survey at seven locations all over India, where micro health insurance schemes are already in place. With 350 insured households and 350 uninsured households interviewed at each location, this is the largest comparative survey on micro health insurance in India ever undertaken. We recognize financial support from the German Technical Cooperation (GTZ) that enabled us to enlarge the survey, in addition of course to the main funding by EU/ECCP.

A Major Effort in Capacity Building

The data gathered through the interviews of these 4,900 households has been analyzed with the participation of several international experts as well as 31 post-graduate students from India, Germany, the Netherlands and other places. By including post-graduate students in the analysis we intend to build capacity in the field of micro health insurance among decision makers of tomorrow. This capacity is needed in order to fuel the sector with skilled professionals and thus ensure sustainable development. All students received some preparation upfront before meeting for a four week cross cultural study period in November/December 2005 in India.
The cross-cultural study group was conducted in close collaboration with the Biral Institue of Management Technology (BIMTECH). Working groups of three students each were formed. An Indian, a German and a Dutch student have been working on a meta topic assigned to them together. National and international experts on micro insurance lectured during the study period on the current thinking regarding the development of the Indian health insurance market for the poor.

Week 1 – Getting an overview and deepen statistical knowledge

After a warm and hearty welcome of the Indian students to their European fellows the official part of the study period started. The opening ceremony took place at the Federation of Indian Chambers of Commerce and Industry (FICCI) the day after the European students arrived in India.

The first week served the purpose of giving students orientation and a good overview about the topic and to show them linkages of their respective topic to those of other students. Additionally, the basic tools for the analysis of the huge data-set were constructed. The lectures were hold by many prominent experts coming from Harvard University, National Institute of Health (USA), Tel Aviv University, and the Institute of Economic Growth in Delhi amongst others. Giving students orientation for their topics was the priority of the first day. Ruth Koren, professor of medical science at the University of Tel Aviv, introduced the students to their meta topics and related these topics to the topics of other students. A helpful exercise for not getting lost the first day! Other lectures during this week covered aspects like:

How to define a benefit package?

If an insurance product is not designed in a way that it meets the clients' demand nobody would buy it. Therefore, it is recommendable to involve the clients directly at the stage of benefit package design. A methodology for this was developed in the United States and was adapted to the Indian context by this project in collaboration with one of the inventors of this methodology, Dr. Marion Danis. Marion is head of the Section on Ethics and Health Policy and Chief of the Bioethics Consultation Service in the Department of Clinical Bioethics at the National Institutes of Health (USA). Marion Danis focused much of her effort on the development of decision tools to let the public participate in allocation resources for health care. Marion introduced the idea of the tool called CHAT: Choosing Health Plans All Together. CHAT has the character of a game and before applying it in the field it was tested with participants of the study group. The objective of CHAT is to develop an imaginary health insurance plan. Throughout the exercise, players make tradeoffs between competing needs for limited resources. The game was conducted once with a cross cultural group of the students and once with Indian students only, before it was applied in the field. A big fun for all participating!

What does health insurance mean in the context of a health system? An introduction to National Health Accounts

Prof. Peter Berman, Lead Economist Health, Nutrition, Population World Bank & Harvard University lectured on what he basically invented: National Health Accounts. National Health Accounts are a descriptive accounting of all sources of funding and spending for health in a country during a year, regardless of the origin, destination, or object of the expenditure. It can help to answer key questions like how large the health system is and its part in the economy, but also how health care is financed and who pays for it. A lot more information can be drawn from National Health Accounts as the students experienced themselves during a case study. The students learned how National Health Accounts can support the decision making of politicians and how important this information is to evaluate financial situations of health systems.

MHI in the context of the Indian health system

Indrani Gupta is a health economist and an associate professor at the Health Policy Research Unit of the Institute of Economic Growth in Delhi. Her main fields of research are health insurance, health financing and demand for health care. She focused during her lecture on micro health insurance in the context of the Indian health system.

Refreshing the Tool Kit: Statistics & SPSS

Having a data file for analysis containing five million cells it is important not to lose oversight. Trea Laske-Aldershof gave an introduction to SPSS, the statistical software that is used to analyse the collected data. She gave necessary working tools to the students during four intensive lectures. Trea Laske-Aldershof is assistant professor of health economics at the Institute of Health Policy and Management ant the Erasmus University Medical Center in Rotterdam.

The students furthermore heard a lecture concerning the Indian health insurance scenario by Dharmendra Kumar (Dean of the Insurance department at BIMTECH), an Introduction to micro health insurance by David Dror and Ralf Radermacher, an introduction to regulation of micro insurance by Olga von Putten and a presentation about information systems for micro insurance units by Iddo Dror and Hugo von Putten.

Week 2 – Preparation of Field Work

Checking the dataset and defining information to be collected during the field work were the core activities of the second week. Key informant interviews had to be designed and a further questionnaire for the management of the micro health insurance units was developed.
But still time was kept for extending the students' background with interesting acticities like the lecture of Marc Socquet, ILO, and the attendance of FICCI’s 10th Flagship Insurance Conference – India’s prime conference on insurance.

Marc Socquet works for ILO as senior specialist on social protection and informal economy as well as coordinator for the STEP programme in Asia. He focused on the financial challenges of Micro Health Insurances during his lecture. To estimate the contributory capacity of the clients, the Micro Health Insurance Schemes have to know about their ability to pay. Furthermore, Marc Socquet described the structural trends of the movement of Micro Health Insurance: The development from In Home Micro Health Insurance to a Partner Agent Model to the final State Level Model. He was happy to answer the various questions of the students and supported the following discussion.

Bringing the students in touch with the Indian insurance reality was the intention of spending one day at FICCI’s 10th Flagship Insurance Conference. A special session was dedicated to micro insurance. A nice alternation to data work and an important opportunity to get in touch with some working in the insurance busisness.

Week 3 – Field Work

Six Micro Health Insurance Schemes were visited by students. BAIF and UPLIFT around Pune have welcomed students as well as Karuna Trust and Yeshasvini Trust in Karnataka. A group of students visited VHS in Chennai and a further group travelled to Madurai to visit DHAN. It was a great possibility for the students to get a close look at the functioning of micro health insurances. The students enjoyed the contact with insured and uninsured interviewees and received much information from their interviews but also about the method of qualitative research.

UpLift

Uplift is all about self-management and empowerment of women. Covering urban communities in Pune, the mainly female members of Uplift recruit new members among their neighbours and friends. In frequent meetings members learn about how insurance functions. All the participating women are involved in the decision-making process of the insurer. That way decision-making is always a democratic process, which is considered fair by all the members of the system. During our field research, Uplift members revealed an astonishing understanding of insurance principles. They were very proud of being part of this system and very co-operative in providing information to us.

DHAN

A group of eight Dutch, Indian and German students travelled to Madurai to visit the Kalanijum Hospital which is placed in a remote area. The students conducted interviews with insured and uninsured women. The insured women are members of SHGs organized by the Kalanijum Hospital. The members experience the community as trustful. They enjoy being the decision maker in the scheme. Most of the women joined the SHG to uplift their living condition and to support their own development.
All women, who are members of the SHG, seem to feel empowered, especially those who participate actively. Even if the insurance principle is not understood by each member, the women know how to proceed in case of illness, which makes them feel more comfortable and safer.
The students gained much interesting information from the interviews. However, almost every interview turned out to be a focus group discussion.

Yeshasvini

The fieldtrip lead three students from India and Germany to Yeshasvini Trust, a health insurance scheme for farmers in the state of Karnataka, where they could conduct interviews with the management and members of the Yeshasvini Health Insurance Scheme. With approx. 1.4 million individuals insured by this scheme, it is a good example to examine the potential and current shortcomings of micro health insurance schemes and to analyse potential for financial stabilisation measures. First, the students visited the central administration of Yeshasvini in Bangalore and after that they were invited to Bijapur District (Northern Karnataka) where they were able to hear from officials “on the ground” about operational inefficiencies of the scheme and to identify together the options for improvements. Two major results of the fieldwork were achieved: The students' understanding of the structure and operational processes of Yeshasvini has been greatly enhanced. "We are now much more aware of the underlying reasons for financial instabilities and operational inefficiencies and could identify possible entry points for stabilisation and support." the three students stated.

Week 4 – Consolidation of the data analysis

Consolidation was in the centre of interest in the fourth week. Using the new findings from the field work to get a new angle data analysis led to new and better results. The students presented their interesting and partly surprising results at the end of week. The work done was discussed with the group and all students went home with a challenging and exciting work order for the weeks to come. But before that, the results were discussed with some of the micro insurance partners in a panel discussion. The partners presented their schemes to the group and the students took the opportunity and discussed their impression with our partners. Three guests participated in a panel discussion facilitated by Prof. David Dror at BIMTECH. Deepak Mendiratta, Chief of Health Plans and Health Insurance Administration at Max Healthcare Institute and two representatives of partner micro health insurance schemes were at the student’s disposal to answer questions and discuss current challenges of micro health insurance schemes. Arbind Singh is Executive Director of the micro insurance scheme “Nidan”. He is a social activist mostly working on livelihood security, collective enterprises and social security with families of working poor in Bihar. The second representative was F.X. Hay from “UpLift” in Pune. He works as Microfinance and micro insurance program manager in India for the French NGO “Inter Aide” since 2000.

Overall, the study period was a huge success. The students had the opportunity to deepen their knowledge regarding micro health insurance units in India as well as to strengthen their intercultural competences. For all students, it has been a remarkable experience to get in touch with Indian reality.