Health Burden on Urban Poor and Experiences from Basti-level Health Funds

Transcription

1 Health Burden on Urban Poor and Experiences from Basti-level Health Funds Workshop on: URBAN MICROFINANCE IN INDIA: LOOKING AHEAD Session: Urban Poor and Health: Looking for Solutions in Microfinance January 21, 2008; Ahmedabad Dr. Siddharth Agarwal, Dr. Sanjeev Kumar, Aastha Sindhwani Urban Health Resource Centre, New Delhi, India

2 Outline of the Presentation Burden of Health Care on the Poor Barriers of Urban Poor to Health Care Poor Public Health Sector Performance High Cost forces Poor to Borrow Cost of Treatment Ways of Reducing Financial Burden on Poor Health Insurance Community Health Funds/Risk Pooling Linkages with Public Providers Challenges in Promoting Community Health Funds Suggestions for Improving Health Access to Urban Poor

3 Burden of Health Care on the Poor

4 Poor Face Higher Health Burden Health status-an important dimension of poverty and vulnerability. A healthy body is the primary productive asset for the poor 1. A person from poorest quintile of the population, despite more health problems, is 6 times less likely to access hospitalization than a person from richest quintile 2. Better health of the poor improves their productivity facilitating increased earning and minimizing risk of falling deeper into poverty. 1-WHO 1999; 2-Deogaonkar, 2004

5 Why Urban Poor? All India Urban areas Large cities Slums Urban population million 1. India is expected to be approximately 40% (550 million) urban by Urban poor estimated at million; projected to increase to 202 million by Estimated annual births among urban poor>2 million 4. 1-Projections for 2007 by Technical Group on Population Projections 2-Census, 2001 population, Projections, Planning Commission, Poverty Estimates for and National Population Policy, 2000; State of World s Cities, 2006/07 4-Based on CBR 22.5 for urban poor population and 100 million urban poor population

6 Poor Maternal Health Conditions Percentage (%) Complete ANC Institutional Deliveries Rural Average Urban Average Urban Poor Urban Non-poor Source: Re-analysis of NFHS-3( ) by Wealth Index;UHRC,08

7 Immunization Status of Urban Poor Similar to Rural Areas Percentage(%) Complete Immunisation Rural Average Urban Average Urban Poor Urban Non-poor Source: Re-analysis of NFHS-3( ) by Wealth Index;UHRC,08

8 Poor Child Survival among the Urban Poor Percentage(%) Infant Mortality Under-5 Mortality Rural Average Urban Average Urban Poor Urban Non-poor Source: Re-analysis of NFHS-3( ) by Wealth Index;UHRC,08

9 Childhood Under-nutrition among Urban poor Nutritional Status Rural Average Urban Average Urban Poor Urban non-poor Under nutrition will amount to a loss of $114 billion between (AED, 2003) Source: Re-analysis of NFHS-3( ) by Wealth Index;UHRC,08

10 Barriers of Urban Poor to Health Care

11 Barriers to Access 1 Lack of financial resources Poor responsiveness to needs in the Public Health System Health Facilities far-off Barriers to Access Lack of information on availability and location of services High Cost in Private Sector 1-India Health Report, 2003 Lack of transportation

12 Invisible and Uncounted Poverty Clusters/slums 452 listed slums (population 820,139) 780 slums (Total) City Slums on official List Unlisted Slums Agra Dehradun Bally Jamshedpur Total unlisted slums (population 510,397) Urban poor face social exclusion, illegality, many overlooked by official enumeration systems, poor access to public services According to NSSO 58 th Round (2002) 49.4% slums are non-notified in India 12

13 Weak Public Health Services Inadequate Public Health Centers (UFWC &UHP caters to1/4 urban popln, Irregular OPD) Poorly maintained, insufficient space, unclean surroundings Shortage of medical and para-medical staff Impolite behavior and corrupt practices Unsuitable timings for urban poor: evening OPD rare Only 38% urban cases are treated in govt hospitals /centres 1 1-NSS Data,

14 77% Public Subsidy for Curative Care Goes to Richest 3 Quintiles Source-Ajay Mahal et al,2001

15 High Cost in Private Sector Forces Poor to Borrow Poor spend disproportionately higher percentage of their income on health services than the rich 1. About 31% of urban poor do not avail treatment for financial reasons 2 Source-NCAER, 2000 The poor forced to resort to high interest loans. 1-India Health Report, 2003; 2-NSS data,

16 Cost of Treatment: Direct and Indirect Health Facility Cost of transport Doctor s consultation fee Cost of hospital admission Loss of wages Cost of medicines

17 Ways of Reducing Financial Burden

18 I. Health Insurance Organizatio ns Location and year of initiation Insurer Provider Premium Benefit Package Yeshasvini Bangalore, 2003 Yeshasvini Trust Private hospitals Rs 120 per person per year Cover for surgeries upto maximum of Rs. 200,000 per patient per year DHAN Kadamalai block, Theni District, 2000 KKVS- the SHG Federation 6 empanelle d hospitals Rs 150 for a family Hospitalization Expenses up to a maximum of Rs 10,000. Some Exclusions

19 Health Insurance Organizatio ns SEWA Kudumbashree Location and year of initiation 11 districts of Gujarat, 1992 Kerala Insurer Provider Premium Benefit Package ICCI- Lombard ICCI Lombard Public and Private Hospitals Empanelled hospitals Rs 85 per person per year Rs 399/family/ year, Rs 366 subsidised by government Hospitalisation expenses upto Rs 2000 Per patient per year Hospitalisation up to max of Rs 30,000/ family/year. No exclusions. Personal accidents up to Rs 100,000; loss of 50 / patient day for a week

20 II. Community Health Funds How Community Groups were Formed? Active and socially committed women from program slums were organized into groups Capacity of these groups was built through training sessions with help of local NGOs Inputs were provided to build institutional, program (providing knowledge on healthcare), linkages and financial capacity. There are 96 such groups in Agra and 90 groups in Indore

21 Promoting Health Funds Women in slums realizing the importance of ready source of money, started health funds Women contribute Rs.10 to100, monthly to the health fund Rules, regulations and all financial transactions are documented Groups being encouraged to have bank accounts

22 Outcomes: Agra 84 groups representing 1,32,400 slum population have collected a sum of Rs.2,96,108 between Feb,06- Dec, of these groups have a bank account. Groups have given out 319 health loans amounting to loans were for maternal and child health, 92 for other health needs. Groups also give loans for purposes such as education, household problems.

23 Total Amount Collected in Agra and Sources Contributio n by members Donatio ns Renting of sitting mats and dholak Interest on health loans Interest on personal loans Fine or penalty Other sources Total Rs.6500 is available with the federation group Creative ways to increase health fund, besides monthly contribution and interest Renting out dholaks or sitting mats in times of weddings or other ceremonies that occur in the basti. Rent charged varies from Rs.20 to Rs.50. Purchasing utensils and tents from their fund money and renting them out at rates lower than what the basti residents may get in the market. Organizing prayer ceremonies and using offerings as donations to the fund.

24 Outcomes: Indore In Indore 15 groups, 50,000 representing slum have health funds amounting Rs SHG also disburse health loans. 200 maternal-child health loans; 300 general health loans disbursed between Jan - Dec No Interest if money returned within first month and thereafter, 2% interest is taken; no interest charged form very poor families.

25 Other Community Health Funds Swyam Shikshan Prayaog and Uplift India Association help manage health funds in 30,000 popln of Pune slums and provide subsidized healthcare. Mahila Milan in Mumbai slums have helped women groups generate and utilise collective savings for diverse needs.

26 III. Subsidized Health Services by Private Providers a. OPD, Diagnostic, Hospital Services in Indore Free transport brings women for ANC to hospital on fixed date each month ANC card accredited for Govt benefits (JSY) Subsidized diagnostics services eg Rs 90/-for Ultrasound, Rs 2000 for normal delivery Services Provided: Free ANC by Qualified Obstetricians Referral for delivery, high risk cases and diagnostics to the Main Hospital Private Hospital 5 Slum Clusters (20,000 urban poor popln) Social Mobilization by CBO Promotes optimal behaviors among urban poor Identifies and mobilizes pregnant women to avail services Facilitate linkage between community and private hospitals Govt: Maternity benefit (1000 INR); IFA, TT, contraceptives for post partum women

27 b. Outreach Services to Slums by Private Doctors in Indore Socially Committed Private Doctor [honorarium collected by community] - Each Dr covers around 4-5 slums - 30 pregnant women examined per camp - Each slum covered on alternate Months 2 nd tier Govt./Private Facility Referral from slums Services Provided: ANC, Referral for delivery, high risk cases and diagnostics 110 ANC Camps have been conducted between Jan - Dec pregnant women benefited. 15 Slum Clusters (30,000 popn) Social Mobilization by CBO Supports community mobilization Supports outreach clinics Builds linkage between community, and private doctors Under the govt. immunization scheme there is provision of Rs for 4 camps to be held in a slum per month

28 Challenges in Promoting Community Health Funds

29 Challenges in Promoting Basti Level Health Funds Hesitation/reluctance and refusal by some members to contribute to health fund : Perception that health fund is equivalent to saving at home Extreme poverty Fear of pilferage by NGO staff or other members Not easily able to link health problems economic to loss Difference of opinion among group members due to social factors. Deviation of focus from health activities to increasing money in the health fund and thinking of livelihood options at a premature stage. Weak record keeping due to most women being illiterate. Weak and incomplete rules causing conflicts.

30 Suggestions For Improving Health Access to Urban Poor

31 Suggestions PUBLIC SECTOR Strengthening public health services for meeting demands of the urban poor. Government Policy/provisions to stimulate and strengthen CBOs. A Comprehensive Health Insurance scheme for urban poor. PRIVATE SECOR Socially responsible private sector to provide subsidized care to complement public sector. Private hospitals can cross subsidize free wards. Broadening target group can cross subsidize insurance premium for the poor. Corporate Social Responsibility eg TSFIF in Jamshedpur slums

32 Suggestions continued COMMUNITY HEALTH FUNDS/RISK POOLING Funds should reach a substantial population. Focused effort to reach the poorest. Health fund promotion should look into social and economic factors. Stimulate and encourage groups to determine affordable interest rates. Should be managed by community members to foster sense of ownership Information about services and facilitation at hospitals key to success By-laws SHG fund should have a clause to disbursing loan for health needs INSURANCE SCHEMES Health Insurance should cover most common health conditions and minimize exclusions. Affordable Premium for urban poor. Administrative load of the scheme on the community and paper work should be minimised. Counselling of the community about the long term benefits. Information dissemination and facilitating access through coordination with CBO/NGO.

33 Believing in people before they have proved themselves is the key to motivating and enabling people to actualize their potential -John C. Maxwell (adapted)