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|Title:||Gender Analysis Of Publicly Funded Health Insurance Schmes : A Study Of Chief Ministers Comprehensive Health Insurance Scheme Of Tamil Nadu|
Chief Ministers Comprehensive Health Insurance Scheme Of Tamil Nadu
Publicly Funded Health Insurance Schemes
|Abstract:||The WHO estimates that around 800 million are spending 10% of their household budget on out of pocket health expenses and above 100 million is being pushed to extreme poverty each year due to health care costs (WHO 2017). The National Health Accounts of India points out that 69.1% of all healthcare expenditures were borne by the households (Government of India 2016b). In response to these growing health insecurities across the world, there is a wave of initiatives under the umbrella of ‘Universal Health Coverage (UHC).’ However, the relationship between Universal Health Coverage and Gender Equity remains a less understood. Even though India has been the experimental ground since 2007 for several Publicly Funded Health Insurance Schemes (PFHIS), the study of gender dimensions in such schemes has not received its due attention. The literature review revealed that not only the schemes but research on PFHIS might themselves carry gender-based assumptions that obscure the realities of women. Acknowledging that there is a need to go beyond the unitary household model, this thesis aimed to study the Chief Minister’s Comprehensive Health Insurance Scheme (CMCHIS) of Tamil Nadu with a gender lens. Based on the theories of equity, social relations and access to health care, the study was formulated to include a mixed methods design involving secondary data as well as primary data collected from one urban and one rural low-income location in two districts of Tamil Nadu. Initially, the data from Tamil Nadu Central sample of NSSO 71st Round (3917 households) was disaggregated. Findings revealed that women had equal rates of hospitalization and membership in PFHIS, but health expenditures were low for women than men. Next, the official data on the CMCHIS scheme on empanelment of hospitals, enrollment, and claims (totaling 924362) were disaggregated. These analyses revealed geographical inequities, the lower share of insurance claims from women and marginalized social groups and the dominance of the private sector. Surprisingly, the enrollment rates quoted by the Government of Tamil Nadu were found to be much higher than the NSSO rates. The primary study employed a survey of 1176 households (4464 individuals), 33 in- depth interviews with women, 16 of men and 14 stakeholders. The study found that only 30% of sample households were enrolled, with the urban site showing poorer rates than rural. Among those who were hospitalized in a reference period of three years, 45.68% were enrolled, and 54.32% were unenrolled in the CMCHIS scheme. The barriers related to enrollment were lack of awareness on the scheme (especially among women and rural), geographical location (sector), implementation gaps in Information Education and Communication (IEC), targeting (documentary evidence) and enrollment methods (kiosk and distribution of card). Among those who were enrolled, 37.84% utilized the CMCHIS, and 62.16% did not utilize. The barriers to the utilization of the scheme were lack of awareness scheme entitlements, type of morbidity, type of facility, lack of transparency, narrow design of scheme, the fraudulent behavior of providers, out of pocket expenditures and lack of willingness from patients. Finally, even among the 17.28% of all hospitalized person who utilized CMCHIS, the study showed inadequate financial protection. A key contribution of the study was in unearthing the perversions caused by insurance based market mechanisms in public healthcare systems on which the poor, women and marginalized groups depend. Gender relations as a factor emerged at all levels of these processes. Using Kabeer’s framework on institutional ideologies, the study culled out the gender- specific, intensified and imposed barriers, which were found to be pervasive across all institutions- household, community, health systems and health organized under the State and the market. The CMCHIS policy was based on assumptions on gender relations and was seen to accentuate or impose new forms of barriers to access healthcare. In the light of increasing emphasis on additional and expanded insurance coverage, the study provides evidence that such an approach would neither result in effective financial risk protection nor improve healthcare. It calls for addressing social determinants of health (not healthcare) and strengthening health systems based on a right to health approach which will ensure gender and health equity.|
|Appears in Collections:||Ph.D.|
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