Understanding CBHI hospitalisation patterns: a comparison of insured and uninsured women in Gujarat, India

Abstract

BackgroundCommunity-based health insurance has been associated with increased hospitalisation in low-income settings, but with limited analysis of the illnesses for which claims are submitted. A review of claims submitted to VimoSEWA, an inpatient insurance scheme in Gujarat, India, found that fever, diarrhoea and hysterectomy, the latter at a mean age of 37 years, were the leading reasons for claims by adult women. We compared the morbidity, outpatient treatment-seeking and hospitalisation patterns of VimoSEWA-insured women with uninsured women.MethodsWe utilised data from a cross-sectional survey of 1,934 insured and uninsured women in Gujarat, India. Multivariable logistic regression identified predictors of insurance coverage and the association of insurance with hospitalisation. Self-reported data on morbidity, outpatient care and hospitalisation were compared between insured and uninsured women.ResultsAge, marital status and occupation of adult women were associated with insurance status. Reported recent morbidity, type of illness and outpatient treatment were similar among insured and uninsured women. Multivariable analysis revealed strong evidence of a higher odds of hospitalisation amongst the insured (OR = 2.7; 95% ci. 1.6, 4.7). The leading reason for hospitalisation for uninsured and insured women was hysterectomy, at a similar mean age of 36, followed by common ailments such as fever and diarrhoea. Insured women appeared to have a higher probability of being hospitalised than uninsured women for all causes, rather than specifically for fever, diarrhoea or hysterectomy. Length of stay was similar while choice of hospital differed between insured and uninsured women.ConclusionsDespite similar reported morbidity patterns and initial treatment-seeking behaviour, VimoSEWA members were more likely to be hospitalised. The data did not provide strong evidence that inpatient hospitalisation replaced outpatient treatment for common illnesses or that insurance was the primary inducement for hysterectomy in the population. Rather, it appears that VimoSEWA members behaved differently in deciding if, and where, to be hospitalised for any condition. Further research is required to explore this decision-making process and roles, if any, played by adverse selection and moral hazard. Lastly, these hospitalisation patterns raise concerns regarding population health needs and access to quality preventive and outpatient services.

Predictors of hysterectomy among married women 15–49 years in India

“…The linkage between health insurance and hysterectomy is not just restricted to Andhra Pradesh and Telangana. Studies conducted in Gujarat also find hysterectomy to be a leading reason of health insurance claims [ 20 , 41 ]. Our analysis that included 21 Indian states and Union Territories also found household health insurance to be a crucial factor that influenced hysterectomy in that women belonging to households covered under insurance sought hysterectomy more than uninsured women.…”

Incidence and determinants of hysterectomy in a low-income setting in Gujarat, India

“…SEWA, a trade union of over 1.5 million women workers in the informal economy, works towards members’ full employment and self-reliance. It operates a voluntary health insurance scheme (VimoSEWA) that offers coverage for hospitalizations that exceed 24 h. Previous research based at SEWA identified hysterectomy as a leading reason for hospitalization and insurance claims, indicated that it occurred at an average age of 36 and suggested that care provided to women for gynaecological ailments and surgery was of poor quality ( Ranson and John 2001 ; Desai et al 2014 ).…”

“…Analyses of facility and insurance data suggest that hysterectomy is correlated with profit incentives under the national health insurance scheme and unregulated private health care ( Jain and Kataria 2012 ; OXFAM 2013 ). Research in Gujarat identified hysterectomy as the leading reason for hospitalization in the prior 6 months among both insured and uninsured women, but the cross-sectional nature of the data prevented comparison with other settings or conclusive findings related to predictors associated with the procedure ( Desai et al 2014 ). A recent study in rural Andhra Pradesh found that hysterectomy, conducted at an average age of 29 years, also included removal of both ovaries (and thereby induced premature menopause) in 59% of cases ( Kameswari and Vinjamuri 2013 ).…”

The Social Life of Health Insurance in Low‐ to Middle‐income Countries: An Anthropological Research Agenda

“…With insurance, private providers found it more lucrative to hospitalize patients with simple ailments who had previously been treated in outpatient care. The lack of an overall vision for the health system thus compartmentalized care into secondary and tertiary level facilities rather than strengthening primary care (Desai et al ). Also relegated to the background were preventive and promotive health care at the very time when non‐communicable diseases (NCDs), linked to health and nutritional transition, have been recognized as rising public health threats.…”