Health Insurance Needs, Awareness and Assessment in the

Bahraich District, Uttar Pradesh

JANUARY 2008

This publication was produced for review by the United States Agency for International

Development. It was prepared by Constella Futures, New Delhi

ITAP is a three-year project funded by United States Agency for International Development

under Contract No. GPO-1-01-0400015-00 beginning April 1, 2005_ The project is being

implemented by Constella Futures in partnership with Bearing Point, Sibley International, Johns

Hopkins University, QED, Urban Institute and Association of Reproductive Health Professionals

(ARHP).

For further information contact:

Constella Futures

1 D-11, Parkwood Estates

Rao Tula RamMarg

New Delhi 1100 022

Health Insurance Needs, Awareness and Assessment in the

Bahraich District, Uttar Pradesh

JANUARY 2008

The authors' views expreseed in this publication do not necessarily reflect the views of the

United States Agency for International Development or the United States Government

Contents

List of Tables List of Figures List of Abbreviations Executive Summary Chapter 1: Background and Methodology .......................................................... 1.4 1.1 Introduction... 1 1.2 Objectives of the Study ................................. 1 1.3 Study Design and Methodology ....................................................................... 1

1.3.1 Sampling and Sample 1 1.3.2 Study techniques ................................................................................. 2 1.3.3 Development of the Brief Field Guide/Manual for Data Collection ................... 2 1.3.4 Pre-testing ..................................................... 2

1.4 Research Team Composition ......................................................................... 2 1.5 Training of Field Teams.. 3

1.5.1 Training for household listing ................................................................... 3 1.5.2 Training for household 3 1.5.3 Training for facility mapping .................................................................... 3

1.6 Field Work: Quality Control Mechanism ............................................................ 4 1.7 Data Processing and Entry ............................................................................ 4 1.8 Analysis and Report Writing. 4 Chapter 2: Household Characteristics ................................................................ 5-16 2.1 Socio-economic Profile of the Household...- 5

2. 1.1 Type of Dwelling . .............................................................................. 6 2.1.2 Access to Household Amenities 6 2.1.3 Household Asset Ownership ................................................................... 8 2.1.4 Ownership of Agricultural Land and Livestock 9

2.2. Occupation/Main Source of Income ................................................................. 10 2.3 Incomes and Expenditures ............................................................................. 11

2.3.1 Income ....................................... ...................... ............................... 11 2.3.2 Expenditure Pattern .............................................................................. 14

2.4 Savings and Debts . . . ....................................................................... 0 .......... 15 2.4.1 Saving Pattern ....................................................................................... 15 2.4.2 Debts ...................................................................................................... 16

Chapter 3: Health Insurance ............................................................................. 17-25 3.1 Knowledge about Health Insurance and its 17 3.2 Awareness about insurance.-............ 18 3.3 Awareness about types of insurance products ................................... 18 3.4 Knowledge and familiarization about formal and informal social security mechanism. 19 3.5 Health Insurance . 20

3.6 Willingness to pay ............................................................ 21 3.7 Preferences for Type of Policy ............... ................. 23 3.8 Preferences for Payment of 24 Chapter 4: Morbidity ............................................ ....... ............................ 26-39 4.1 Illness without Hospitalization ................................................................... 26

4.1.1 Types of Illnesses............. 26 4.1.2 Treatment Preferences .................................................................... 27

4.2 Illness with Hospitalization ....................................................................... 30 4.2.1 Types of Illnesses... 30 4.2.2 Treatment Preferences .................................................................... 31

4.3 Chronic Illnesses 35 4.3.1 Types of Illnesses 35 4.3.2 Treatment Preferences .................................................................... 37

4.4 Opinion about Evening OPID Services ....................................................... 38 Chapter 5: Social Capital ............................................................................ 40-46 5.1 Groups and Networks..................._ 40 5.2 Trust and Solidarity ................................................................................ 40 5.3 Collective Action and Cooperation ........................................................... .. 42 5.4 Information and Communication ................................................................ 43 5.5 Social Cohesion and Inclusion......__- 44 Chapter 6: Further Analysis on Health Insurance and Health Seeking Behaviour 47-49 Annexure I - Fact Sheet ............................................................................. 50-52 Annexure 2 - Further Analysis - Tables Annexure 3 - Household Survey Schedule .................. !, ................................. 63-90

Acknowledgement

ITAP would like to acknowledge with sincere thanks the contribution made by Sambodhi in

producing this resort

List of Abbreviations

BPL Below Poverty Line

CHC Community Health Center HH Household MPCE Monthly per capita expenditure

MPCI Monthly per capita income

OBC Other Backward Caste

OPD Out-Patient Department '

PHC Primary Health Center

PRI Panchayati Raj Institution .

SC Schedule Caste

SHG Self-Help Group

ST Schedule Tribe

UPHSDP Uttar Pradesh Health Systems Development Project

ZP . Zila Panchayat

e

List of Tables

Table 2.1: Socio-demographic profile of respondents

Table 2.2: Type of dwelling owned _ _

Table 2.3: Access to basic household amenities

Table 2.4: Ownership of household assets

Table 2.5: Ownership of agriculture land

Table 2.6: Ownership of Livestock Table 2.7: Occupation and Source of Income

Table 2.8: Average monthly income and expenditure by land holding pattern

Table 2.9: Average monthly expenditure (in Rs.)

Table 2.10: Ownership of ration card

Table 2.11: Savings account Table 2.12: Debt details

Table 3.1: Awareness and Perception regarding "BIMA

Table 3.2: Perception about Insurance Table 3.3 Knowledge of products provided by government or available in market Table 3.4: Familiarization with Social Security Measures/ Means of Insurance Table 3.5: Awareness / Participation in Social Security/ Means of Insurance Table 3.6: Willingness to pay - Amount & Periodicity of Premium

Table 3.7: Insurance Products - Preferred Features

Table 3.8: Preference for Type of Insurance Products

Table 3.9: Preference for Type of Insurance Products Table 4.1: Morbidity Pattern due to illness in last 2 months

Table 4.2: Extent of Severity of Disease .

Table 4.3: Type of Health Facility Visited

Table 4.4: Type of facility visited vis-a-vis type of illness -

Table 4.5: Self treatment seeking behaviour

Table 4.6: Means of payment for treatment

Table 4.7: Reason for not seeking care Table 4.8: Morbidity pattern

due to illness with hospitalization

Table 4.9: Extent of Severity of Disease Table 4.10: Type of Health Facility Visited Table 4.11: Type of facility visited for hospitalization vis-vis type of illness Table 4.12: Preference for another health facility consulted

Table 4.13: Type of alternate facility visited for hospitalization vis-a-vis type of illness

Table 4.14: Preference for other health facility visited Table 4.15: Means of payment for treatment

Table 4.16: Means of payment for hospitalization vis-a-vis type of illness Table

4.17: Morbidity pattern due to chronic illness Table 4.18: Treatment seeking behaviour Table 4.19: Treatment vis-a-vis type of chronic illness

Table 4.20: Nearest Health Facility for treatment of chronic illness Table 4.21: Average distance of Nearest Health Facility for treatment of chronic illness

Table 4.22: Opinion about evening OPD services

Table 5.1: Similarities within groups Table 5.2: Trust and Solidarity .

Table 5.3: Trust on institutions

Table 5.4: Community participation and cooperation

Table 5.5: Contribution in terms of time and money

Table 5.6: Source of information about health insurance

Table 5.7: Existence of social or economic differences

Table 5.8: Difference within the community List of Figures

Figure 2.1: Sample size distribution by caste

Figure 2.2: Type of dwelling

Figure 2.3: Basic household amenities

Figure 2.4: Ownership of household assets

Figure 2.5: Amount of agricultural land

Figure 2.6: Main source of income Figure 2.7: Reasons for debt

Figure 3.1: Awareness and Perception regarding "BIMA"

Figure 3.2: Knowledge of products provided by government or available in market

Figure 3.3: Familiarization with Social Security Measures/ Means of Insurance

Figure 3.4: Willingness to pay - Periodicity of Premium

Figure 3.5: Willingness to pay -Amount of Premium (in Rs.)

Figure 3.6: Preferred features in insurance products

Figure 3.7: Willingness to pay - Amount of Premium (in Rs.)

Figure 3.8: Preference for Type of Insurance Products

Figure 3.9: Preference to pay the premium

Figure 4.1: Morbidity Pattern due to illness '

Figure 4.2: Type of Health Facility Visited

Figure 4.3: Type of Health Facility Visited

Figure 4.4: Reasons for not taking treatment

Figure 4.5: Nearest Health Facility for treatment of chronic illness

Figure 4.6: Opinion about evening OPD service

Figure 5.1: Community cooperation to solve the problem

Figure 5.2: Source of information about health insurance

Figure 5.3: Existence of social and economic differences

Figure 5.4: Differences that cause problem within the community

Executive Summary

Health insurance is an emerging social security instrument for the rural poor, for whom, chronic

health problems, arising due to prevalence of diseases and inaccessibility to an affordable

health care system, is a major threat to their income earning capacity. In order to finance the

health care provisions of rural poor, the Uttar Pradesh Health Systems Development Project

(UPHSDP), funded by World Bank, is planning to provide health insurance coverage to about

8.3 takh population living below the poverty line (BPL) in Bahraich. Preparatory to the exercise,

a Health Insurance Need, Awareness and Assessment survey was conducted in Bahraich

district of U.P. The specific objective of the survey was to assess the experience of households

with illness and health care utilization and the associated financial risks, including informal risk

sharing mechanisms, perceptions about financial risks, demand for protection from these risks,

and knowledge of health insurance and risk pooling mechanisms. The study also made an

attempt to analyze social capital in the target populations, especially levels of institutional trust.

The study followed a two stage cluster design wherein at the first stage around 280 villages

were selected from total list of villages in the district using scheduled caste/scheduled tribe as criteria. At the second stage, 4 households from the hospitalization category and 6 households from the non-hospitalization category were taken from selected villages. Thus in all 2800 household were covered for the survey, out of which around 2662 interviews were completed for the assignment.

Socio-Economic Profile

Most of the respondents (69l) interviewed were Hindus and around one-third (30%) were

Muslims_ The caste desegregated data showed that around 53% of the respondents were from

OBC category and around 27% belonged to General category. Around 91 % of the interviewed

respondents were living in their own houses; the majority of whom (59%) were residing in

Kuccha houses.

The major source of bathing water is a hand pump inside the house, which is ithe key source of drinking water too. The main source of lighting was kerosene (96l0) and the majority of

households reported using firewood (88%) for cooking.

The occupation profile of the households suggested that around 77% of the households have

land, out of which, almost 44% own less than 1 acre of land More than threefourths of the

surveyed households reported ownership of livestock. Around 44% of the respondents reported

agriculture as the primary source of occupation followed by 36% of who reported being involved

in wage labour (non-farm). Agriculture also featured as a secondary source of income in around

29% of cases,

Income, Expenditure and Debt Pattern

The average monthly household income among sarripled households is Rs 2,827. Thus the

monthly per capita income (MPCI) as whole is Rs. 579.4, considering an average

family size of 4.88 persons. The average monthly household expenditure is Rs 2,229 or monthly

per capita expenditure (MPCE) works out to be Rs. 456.76 cqnsidering a family size of 4.88

persons, which signifies expenditure to income ratio of 79 percent.

Analysis of the expenditure pattern clearly signifies expenditure on food items to be almost 57

per cent of the total expenditure among sample households. Out of non-food items, Medical

expenses formed around eight percent of total expenditure whereas educational expenses

constituted around four percent of total consumer expenditure among sampled households.

Analysis of financial inclusion data reveal that only around one-third (30%) of the household

have a savings account, out of which majority i.e. 93 percent have an account in the bank.

Need, Awareness and Preference for Health Insurance

Around 38 percent of the respondents reported that they have ever heard of "BIMA" (Insurance)

and have seen someone buying or taking some kind of insurance instrument, highlighting the

first level of awareness about the "BIMA". The study further tried to deconstruct the notion

respondents have about insurance and found out that around 29 percent of the respondents

reported insurance as the payout which is received by the family after the death of the insured.

The study at next stage made an attempt to assess the awareness about different kinds of

insurance products. Out of all types of insurance, awareness for Life insurance (38 percent) is

by far, the highest followed by vehicle insurance (15%) and property insurance (10%).

An attempt was made to ascertain the willingness to pay for health insurance which covers

health expenditure up to Rs. 75,000 per year. Findings reveal that fifty six percent of the

respondents are willing to pay a premium of Rs.100-250 a year and another 23 percent reported

a premium of Rs. 250-500 a year, significantly highlighting the comparatively low ability to pay

and hence the need of an appropriately crafted/subsidised policy. When probed about the timing

of premium instalment payments, around 42 percent reported the half year cycle as preferred

timing and a similar percentage reported to be comfortable with an annual payment cycle.

The study further tried to seek preference among term policy and endowment policy. In an

endowment policy, the sum assured is payable even if the insured survives the policy term.

Combining risk cover with financial savings, the endowment policy has emerged as the most

popular policy. Findings indicate that around 91 percent of the respondents preferred health

insurance with partial money back even though it is at a higher cost than normal health policy

which is at a lower cost.

The study further tried to identify whether there was preference for a policy which covers all

expenses over a policy which covers the big expenses. Around 90 percent of the

respondents specified clearly that they would rather prefer a policy of Rs. 300 that covers all

expenses than a Rs. 200 policy which covers only big experises. .

Besides analyzing preference for policy type and the premium amount to be paid, the study

also sought to find out the preferred place for depositing the premium. Bank (39%), Post office

(27%) and insurance agent (23%) were named as most convenient places to deposit the

premium_ Besides being convenient places to deposit the premium, Bank (40%), Post office

(28%) and insurance agent (22%) were also considered the most trusted place for depositing

the premium payment.

Morbidity Trend

One of the key objectives of the study is to ascertain the morbidity pattern at the household level

and its burden on the household in terms of expense and opportunity lost. Findings reveal that

as many as 89 percent of the HH surveyed were affected by morbidity due to illness during two

months preceding the survey. The key reason was cold/fever which accounted for 57 percent of

the morbidity at the household level. Other ailments mentioned were cold/cough (10%) and

stomach ache (6%)

Looking at the treatment seeking behaviour, it was evident that in around forty six percent of the

cases, treatment was sought from an unqualified doctor. Drug store (18%) and Private Doctor-

MBBS (14%) were other key facilities visited for treatment. The accessibility analysis clearly

showed that they had gone to facility they desired and only in five percent of the cases they

suggested that they would have preferred some other facility.

One of the key objectives of the study is to examine the burden of treatment on the household

and mode of payment for this. Findings reveal that in majority of the cases the household paid

from its own money and in only around ten percent of the cases the households reported

borrowing from a friend to pay for the illness

Morbidity with Hospitalization

In order to assess the morbidity pattern with hospitalization in households, responses were

sought about any hospitalized case during last one year. Findings reveal that on an average

around nine percent of the HH surveyed were affected by illness/injury with hospitalization.

Further, in around sixteen percent of the cases the household reported that the member was

hospitalized for delivery. Japanese Encephalitis, Cholera (6 % each), Ulcer and stone

operations (5% each) were the major causes for hospitalization.

Looking at the treatment seeking behaviour, it was evident that in around one-third of the cases,

the patient was admitted to district government hospitaIs/CHCs followed by private nursing

homes. Government medical college (18%) and Government PHC/Sub centre (14%) were other

facilities used for hospitalization.

1n more three-fourth of the cases, the household didn't consult any other facility. In only in 5-6

percent of cases, private practioners, both allopathic and Ayurvedic, were consulted for a

second opinion.

Chronic illness

In order to assess the morbidity pattern due to chronic illnesses in the household, responses

were sought about any chronic illness that developed during the last one year.. Findings reveal

that as high a number as 29 percent of the HH surveyed were affected by chronic illnesses

requiring hospitalization.

In order to ascertain accessibility and availability of the treatment facility, the study probed about

the nearest health facility available for treatment. Government PHC or Sub centre was reported

as the nearest health facility in around forty seven percent of the cases. District Hospital was

reported as the nearest health facility in around 18 percent of the cases.

The Government PHC or Sub centre was an average distance of 6km away signifying that in

almost half the cases, one has to travel a minimum of six km to avail of the health facility for

treatment. The average distance for second nearest health facility i.e. District government

hospital, was observed to be around 16 km.

Social Capital: Construct and Dimension

One of the key objectives of the study was to examine the associations of various dimensions

of social capital with each other and with contextual and individual determinants.

On analyzing opinions on trust and solidarity, around 66 percent of the respondent were of the

opinion that one has to be careful while dealing with people, thereby highlighting the status of

trust between community members. When asked about the helpful attitude of neighbours, nearly

three fourth (75%) of the respondents were in complete agreement of the fact that most people

in the neighbourhood are willing to help in times of need. This clearly highlights that though trust

may be low in case of stranger in case of neighbour the trust is there. ,

The present study also tries to ascertain the trust community members have in institutions.

Around 61 percent of the community members showed strong trust in Panchayati Raj officials

while nearly 65 percent of the respondents confirmed having strong trust in local ZP/State

government officials.

Chapter I

Background and Research Methodology

1.1 Introduction

Health insurance is an emerging social security instrument for the rural poor, for whom a multitude of health problems, and inaccessibility to an affordable health care system, constitute a major threat to their income earning capacity. In order to finance the health care provisions of rural poor, the Uttar Pradesh Health Systems Development Project (UPHSDP), funded by World Bank, is going to implement a pilot community health insurance scheme in the Bahraich district of Uttar Pradesh. The project aims to provide health insurance coverage to about 8.3 lakh population living below the poverty tine (BPL).

The health insurance scheme will be designed based on information collected from the study. The study intends to conduct a survey of households in the Bahraich district to examine the level of awareness of insurance, prior experiences with health insurance, health expenditures, preferences and needs as well as social networks and institutional trust. The study also proposes to compile demographic as well as disease profile data on the districts and collect information on health care institutions in the Bahraich district.

1.2 Objective of the Study

The objective of this study is to inform the process of benefit design and operations design for the community health Insurance program in Bahraich district. The specific objectives of the study include assessing:

The experience of households with illness and health care utilization and the associated financial risks including informal risk sharing mechanisms,

The perceptions about financial risks and demand for protection from these risks, Knowledge of health insurance and risk pooling mechanisms, Social capital in the target populations, especially levels of institutional trust, and Health

service provider mapping (both government and private) and collecting details from all the facilities (both in-patient and out-patient)

1.3 Study Design and Methodology

One of the key objectives of the study is to examine the prevailing health scenario and assess awareness about health insurance at the community level and health care facilities provided by the organized sector. In order to access information a household survey has been conducted at the village level in Bahraich district of U.P. and facility mapping carried out for all health care providers in rural as well as urban areas in the district.

1.3.1 Sampling and Sample Size

House listing information laid the basis for the sampling frame. A two stage stratified sampling design has been followed for the present study. At first stage the villages were selected using the probability proportionate to size (PPS) methodology. At the second

stage, a required number of households were selected after a complete listing of households in the village.

The process of listing began at the northwest corner of a segment and all residential

addresses encountered were recorded while traveling in a clockwise direction around the segment. After complete listing of households in the village, 20 households were selected for the survey. Information about morbidity pattern was collected at the time of listing and households were stratified on the basis of that information. Based on house listing information, all households were grouped into two strata i.e. hospitalization stratum and non-hospitalization stratum based on hospitalization of any household member during one year preceding the survey.

For the household survey, at the first stage 280 villages were selected from the total list of villages in the district using the PPS methodology. At second stage 4 households from the hospitalization stratum and 6 households from the non-hospitalization stratum were taken from selected villages. Thus in all 2800 household were selected for the survey.

Stratum Sample

I Total Number of Villages selected 280

11 Total number of households selected 2800

1.3.2 Study techniques

Keeping in mind the qualitative nature of the study a semi-structured interview schedule was used for collecting the household data. The interview schedule consisted of both open and closed ended questions.

1n addition to this separate schedules were used for fisting of households and mapping of health facilities.

1.3.3 Development of the Brief Field Guide/Manual for Data Collection

Development of the field guide/manual for data collection was essential for ensuring smooth functioning of field operations. A brief note sheet and field guide/manual were made for the main survey and facility mapping before initiation of field briefing.

1.3.4 Pre-testing

In order to determine the suitability of the interview schedule, it was subjected to pre-testing before administering it for actual data collection. The semi-structured interview schedule developed for the household survey was thoroughly tested to ascertain the suitability of questions in actual field conditions.

1.4 Research team composition

The project was headed by Project Coordinator who was the chief functionary throughout the assignment. The Project coordinator was supported by an Advisor, Project Manager and one research executive.

There were two separate teams for Listing/ Facility Mapping and Survey. Each field team was

coordinated by one Field Manager along with requisite field supervisors. Fieid manager was

responsible for overall coordination, planning and quality of survey.

Household Survey: Team composition

Field Manger was the overall manager for the field operations and was responsible for

coordination, planning and execution of main survey. Field Manger consistently reported to

team leaders. The field supervisor was the senior member of the field team and was

responsible for the completion of the assigned workload and the maintenance of data

quality.

1.5 Training of field teams

The training of field teams is carried out in three phases.

1.5.1 Training for household listing

The training of investigators on the household listing exercise was conducted for 4 days,

which included two days of theoretical sessions and two days of field practise. During the

course of training due focus was laid on basics of household listing and.ways to collect

hospitalization and illness information during the last year.

1.5.2 Training for household survey

Training for the survey team consisting of investigators, supervisors and field executive on

the survey objective, survey tools, sampling design and on expected data quality was

scheduled for 4 days. First two days of the training comprised of theoretical sessions, which

focused on training investigators on household schedule containing details related to health

insurance and other information through lectures and mock and demonstration interviews.

The subsequent two days were utilized for field based training to the investigators to

familiarize them with the questions. Field practise included mock interviews in actual field

situations, which was carried out in the selected non-sampled sites at the district level, to

make the investigators comfortable and adapt to the field conditions. Further the training was

extended for one day, which was again spent in the field. This one-day extension helped

investigators to overcome their hesitations and become fluent in administering the

interviews.

Things ensured during training:

Investigators were recruited based on their educational qualification, maturity, their

ability to spend a long duration in the field, and their prior experience with similar kind

of surveys. To account for dropouts, 15-20 percent extra investigators attended the training.

During training investigators were screened out/ graded based on performance/skill shown during training.

1.6 Field Work: Quality Control Mechanism

Controlling the quality of the data collection is the most important function of the research professionals/field executive/supervisors. Throughout the fieldwork, they were responsible for observing interviews and carrying out field editing.

To ensure the quality of data collection the field supervisor observed interviewers throughout the course of fieldwork. Following quality control measures were taken care of during the fieldwork

Spot check and observation

Back check

Re-interviews

Re-visits to minimize non-response

1.7 Data Processing and Data Entry

The data entry and validation work of the survey was handled in-house using the most advanced data analysis package namely CS Pro. The project coordinators along with the research team members have provided inputs at various stages of data processing. After field editing, questionnaires were returned to the main survey office for data processing. The processing operation consisted of office editing, coding of others category - open-ended questions, data entry, and editing inconsistencies found by the computer programs.

As with the coding, the process of verification of office data entry involved double data entry i.e. two persons independently entered the data, and used a computer program which can check for any differences in the two data sets by generating error list. The errors were then resolved and corrected by a member of the research team.

The data was edited before using it as information. This action ensured that the information provided is accurate, complete and consistent. During data editing three types of checks are applied i.e.

Validity check

Range checks

Consistency checks

1.8 Analysis and Report Writing

After data processing, that includes data editing, recoding of new variables and data entry, data analysis was conducted. Analysis of the data was carried out using the most advanced data analysis package namely SPSS.

The analysis of the survey is guided by the specified research objectives. The core team members under the guidance of project coordinator and system analyst prepared the analysis/ tabulation plan. The required tables were then generated using latest version of analysis software SPSS/STATA.

Chapter II

Household Characteristics

2.1 Socio-economic Profile of the Household

A total of 2800 households across 280 villages were sampled for the Household Insurance Survey, out of which around 2662 interviews were completed. The household level questionnaire was administered mostly to the "head of the household". This section of the chapter will briefly discuss the profile of the respondents sampled for the survey.

The distribution of the sample shows that most of the households (69%) interviewed were Hindus and around one-third (30%) were Muslims. The caste desegregated profile of the sample reveals that around 53 percent were from OBC category and around 27 percent belonged to General category. Around 19 percent were from SC category.

Figure 2.1 Sample Size distribution by Caste

Table 2.1: Socio-demographic profile of households

Particular Percent

Religion

Hindu 69.4

Muslim 30.2

Christian 0.1

Sikh 0.3

Caste

Other Backward Caste (OBC) 53.4

General 26.6

Schedule Caste (SC) 19.1

Schedule Tribe (ST) 0.9

Number of households 2662

2.1.1 Type of Dwelling Study also tried to ascertain the type of dwelling in which the household lives and its ownership. It is found that 91 percent of the households were living in their own house. In terms of type of house, around 59 percent were found to be residing in Kuccha houses whereas almost 35 percent were living in Semi-Pucca houses.

Table 2.2: Type of dwelling owned

Particular Percent

Ownership of house

Yes 91.0

No 9.0

Type of house

Kuchha 58.6

Semi-Pucca 34.9

Pucca 6.5

Number of households 2662

Figure 2.2: Type of dwelling

Pucca, 6.5 Kuchha, 58.6

SemiPucca, 34.9

2.1.2 Access to Household Amenities Access to basic household amenities is one of the key determinants of the living conditions of the household. The study made an attempt to assess the access to basic amenities at household level. The major source of bathing water is hand pump in the residence or yard or compound, cited by around 66 percent of the households, followed by public hand pump cited by around 17 percent of the households.. The key source of drinking water was also found to be almost similar. The main source of lighting was kerosene as reported in around 96% of the cases. Respondents were also asked about the fuel they use for cooking, and as can be seen in the table below, nearly 88 percent of the respondents use firewood. Around eight percent of respondents also reported using crop residue. In 18 percent of the cases households have a separate room for use as a kitchen. Sanitation facilities at household level are found to be poor as almost 93 percent of the households don't have any toilet facility.

Table 2.3. Access to basic household amenities

Particuiars Percent Main source of bathing water

Hand pump in residence/yard/plot 66.7

Public Hand pump 16.7

Public tap 8.6

Public well 2.6

Piped water in residence/yard/plot 2.5

Well water in residence/yard/plot 2.1

Other sources 0.9

Main source of drinking water Hand pump in residence/yard/plot 66.2

Public Hand pump 17.1

Public tap 8.7

Public well 2.5

Piped water in residencelyard/plot 2.4

Well water in residence/yard/plot 2.2

Other sources 0.8

Kind of toilet facility

No facility/ Bush/ Field 92.8

Own flush toilet 1 3.7

Own pit toilet 2.4

Public/ Shared Pit toilet 0.7

Public/ Shared flush toilet 0.2

Other 0.2

Main source of lighting

Kerosene 95.6

Electricity 3.9

Gas 0.2

Other 0.2

Oil 0.1

Separate room for kitchen

No 81.1

Yes 18.9

Type of fuel used for cooking

Wood 88.1

Crop Residues 7.6

Dung Cakes 2.0

Liquid Petroleum Gas 1.9

Bio-Gas 0.3

Kerosene 0.0

Total 2662

Figure 2.3: Basic household amenities

Piped water Public tap Hard pump Public Hand Well water in Public well Other

in residence in residence pump residence sources

Bathing : Drinking

2.1.3 Household Asset Ownership

In order to assess the living standard of the community at household level, information was

sought about the ownership of household assets. The study shows that 98 percent of the

households own Cots/beds and around 63 percent own mattresses.

Table 2.4: Ownership of household assets

Assets Percent

Cot/Bed 97.7

Bicycle 73.4

Mattresses 62.9

Clock/VVatch 55.9

RadiolTransistor 27.0

Chair 18.5

Table 12.7

Mobile 10.9

Pressure Cooker 8.7

Electric Fan 7.6

Sewing Machine 5.5

Television (B&W) 4.8

Moped/Scooter/Motorcycle 4.5

Bullock Cart 3.3

Water Pump 3.0

Colour Television 2.5

Telephone 2.0

Tractor 1.5

Thresher 1.3

Refrigerator 0.7

Car/Jeep 0.7

Total 2662

Analysis of-findings reveals that nearly 13 percent have a table and around nine percent have their own pressure cooker. The study also tries to assess access to entertainment sources and it is found that around 27 percent of the household own a radio, while only 3-5 percent household own a television. Around 70 percent own a bicycle, and only five percent, have a scooter/motorcycle.

Figure 2.4: Ownership of household assests

2.1.4 Ownership of Agricultural Land and Livestock The Indian rural economy is agrarian, which shapes the majority of livelihood opportunities in rural India. Findings corroborate this as around 77 percent of the households reported ownership of land, out of which, almost 44 percent of the households own less than 1 acre of land, and another 29 percent own land in the range of 1-5 acre. Table 2.5: Ownership of agricultural land

Particular Percent

Ownership of agricultural land

Yes 77.2

No 22.8

Total 2662

Land Holding Pattern

< 1 Acre 43.6

1-5 Acre 29.0

5-10 Acre 4.3

10+ Acre 0.9

Total 2070

Figure 2.5: Amount of agricultural land

5-10 Acre, 4.3 - 10+ Acre, 0.9

1-5 Acre, 29.0

A significant proportion of the rural populace is dependent on livestock for a supplementary livelihood option. More than three-fourths of the surveyed households reported ownership of livestock.

2.2. Occupation/Main Source of Income

The study attempts to explore the occupational pattern of the respondents. In order to get data on the occupation of the respondent questions were asked to probe the main source of income. Around 44 percent of the respondents reported agriculture as their primary occupation followed by 36 percent of the respondents who work as wage labourers (nonfarm). Nearly six percent respondents earn their living by working as wage labourers on agriculture land and in addition doing small trade.

Analysis of secondary source of income reveals that for almost 29 percent of the respondents agriculture is the secondary source of income, followed by around 17 percent respondents who reported wage labour as the key alternate source of income.

Figure 2.6: Main source of income

Agriculture (own Agriculture (wage Wage labor Small trade Salary in public/ Other

land) labour) (Non-farm) private company

Main Source Secondary Source 2.3 Incomes and Expenditures 2.3.1 Income The average monthly household income among sampled households is found to be Rs 2,827. The monthly per capita income (MPCI) thus as whole was 579.4 considering a family size of 4.88 persons. In order to further desegregate the average income, the study makes an attempt to analyze the average income by land holding category for households whose primary source of income is Agriculture. As can be seen from the table the average monthly income for household owning less than 1 Acre is found to be Rs. 2129 per month which is substantially lower than the average income of households owning between 5-10 Acres or more than 10 Acres of land, highlighting the inequality.

Construction of Standard of Living Index (SLI): Since the household income reported in the household surveys is, often times, unreliable, the proxy variables will be used to assess economic status of the households. The computation of standard of living index was done using appropriate scores for housing and housing quality, civic amenities (possession of sanitary latrine facility and source of lighting), household assets possessed by the households, land holding, etc..The composite score anew thus obtained by adding the scores for different household assets/possessions was used to arrange the households in ascending order of the composite score. The lowest one-third of the households in terms of the composite score were classified as households with low level - of SltI, the households with middle one-third were grouped into medium SLI and remaining HHs as high SLI. List of variables and corresponding scores used in the construction of SLI

2.3.2 Expenditure Pattern

Among the sampled households, the average monthly household expenditure was Rs 2,229 and monthly per capita expenditure (MPCE) as whole was 456.76 considering a family of 4.88 people. Analysis of the expenditure pattern shows that food items constituted almost 57 per cent of the total expenditure among sample households. Out of non-food items, Medical expenses formed around 8 % of total expenditure whereas educational expenses constituted around 4% of total consumer expenditure. Travelling expense constituted around 6% of total consumer expenditure and recreation

(including alcohol and tobacco) formed around 4% of total expenditure. Table 2.9: Average monthly expenditure (in Rs.)

2.3.2.1 Ownership of Rotation card Around 70 percent of the respondents confirmed ownership of ration cards in the household. Study further probed about the type of colour of card owned and as can be seen from the

data around 42 percent of the households reported owning white ration card and 33 percent reported having Pink/Red ration card. Table 2.10: Ownership of ration card

Item Percent

Household with Ration Card

Yes 70.0

No 30.0

Number of households 2662

2.4 Savings and Debts

2.4.1 Saving Pattern

It is well known that a country's financial assets remain heavily skewed in favour of the urban middle and upper class. It's high time to recognize the financial dream of the rural class for financial inclusion. The present study tries to gauge the financial inclusion status of the respondents. As can be seen from the data, around one-third (30%) of the respondents have savings account out of which the majority i.e. 93 percent have the account in the bank.

In order to assess the self-help group movement in the district, the study tried to ascertain the contribution from community. As can be inferred from the data, contributory saving at the local self help group (SHG) is negligible.

2.4.2 Debts

Around 41 percent households reported having debts. Around one-third (34%) of the respondents reported having borrowed money for health expenditures,. Another 28 percent reported taking money for living expenses followed by 18 percent of the respondents who borrowed money for a wedding.

Table 2.12: Debt details

Household having debts

Yes 40.6

No 59.4

Number of households 2662

Reasons to borrow money

Health expenditures 33.7

Needed money for living expenses 27.1

Wedding in family 17.6

Other 12.1

Buying land / house 9.6

Number of households 1370

Figure 2.7: Reasons for debt

Buying land / Health Wedding in Needed money Other house expenditures family for living

expenses

Chapter III

Health Insurance 3.1 Knowledge about Insurance and its Availability The village populace, and especially vulnerable population, not only vary across place and time, they also vary by the type of risks they face such as death, illness, injury and accident. Though the risks are no different from those faced by others, they are more vulnerable to such risks because of their social and economic situation. Thus it is more so important that some social security mechanism is provided to the village populace especially to vulnerable population. Insurance is one such instrument which has been widely used as an effective social security mechanism, although the insurance sector for low-income families especially in the rural population remains at a very nascent stage in India. The study tried to understand the awareness of respondents on the very basic construct of insurance i.e. whether they have seen someone buying or selling a type of instrument such as Life insurance, vehicle insurance or Health Insurance. Around 38 percent of the respondents reported that they have ever heard of "BIMA and have seen someone buying or taking any kind of insurance instrument.

The study further tried to deconstruct the notion they had about insurance and around 29 percent of the respondents reported insurance as payout which is received by the family after the death of the insured. Another 24 percent were of the opinion that insurance returns the money after the duration for which the insurance is held, and a similar percentage reported money back in case of the sudden death of the insured person_

Table 3.1: Awareness and Perception regarding "BIMA" (insurance)

Item Percent

Ever hear of insurance (BIMA)

Yes 37.9

No 62.1

Total 2662

Understanding about insurance

Payout received by the family after death of the insured 28.9

Money back after complete duration of insurance 24.4

Money back at sudden death of insured person 24.3

Insurance provides more money when required 8.4

Have heard about insurance but don't know what i t i s 2.8

Money return w i t h interest when premium paid 2.0

No response 1.7

Insurance for health, refund of cost of drugs during illness 1.6

Provide compensation if something bad happens 1.6

Insurance makes life easier 1.1

Total 1010

3.2 Awareness about insurance It is widely believed that there exists a vast potential in the rural areas for insurance products and services. However, insurance as not been able to make inroads in the rural areas because of key reasons such as high cost of delivery and low awareness among the rural population about insurance products. Figure 3.1: Awareness and Perception regarding "BIMA"

In a bid to further understand the awareness and perception on insurance, the study probed respondents about insurance products and similarity to other prevalent products. As can be seen from the table, only around thirty two percent reported that insurance is the amount one pays to get some compensation if something bad happens. Around thirty one percent believed that insurance is similar to monthly thrift/savings. The perception of respondents clearly highlights that respondent's perception towards insurance and savings and their understanding of the benefits of these products are still nascent. _

Table 3.2: Perception about Insurance

Item Percent

Believe that insurance is similar to monthly thrift/savings

Yes 30.5

No 20.2

Don't know 49.2

Think Insurance is an amount you pay to get some compensation if something bad happens -

Yes 31.9

No 18.2

Don't know 49.9

Number of households 2662

3.3 Awareness about types of insurance products The study makes an attempt to analyze the awareness levels of the different types of insurance and as can be seen from the findings awareness for Life insurance (38.3%), is by

far the highest, fol lowed by vehicle insurance (15%) and property insurance (10%). The study also showed the awareness level to be the lowest in respect of health insurance.

3.4 Knowledge and familiarization about formal and informal social security mechanism The study also tried to ascertain the familiarization of respondents with the various kind of formal and informal social security mechanisms. The majority- of the respondents were aware about some kind of insurance wherein payout is received by family after the death of the insured. Around thirteen percent of respondents also confirmed that they are aware of the community collecting money from people and redistributing during need. Respondents also reported that they are aware that emergency funds can be borrowed from SHG. The study makes an attempt to explore the usage of formal and informal social security mechanisms Only three percent of the household confirmed that they borrowed some kind of emergency funds from a self-help group.

3.5 Health Insurance Health insurance is an instrument wherein `an individual or group purchase health care coverage in advance by paying a fee called premium.' In other words, it's an instrument which helps to defer, delay, reduce or altogether avoid payment for health care incurred by individuals and households. The insurance remains in force only for an agreed period in return for the purchaser paying an agreed premium. Policies can cover only the policy holder or the policy holder and immediate family members. The particular hospitals and medical services covered are clearly defined in the insurance policy. Respondents were probed about awareness about various probable social security/health insurance schemes currently being offered Around forty eight percent of the respondents were aware of Janani Suraksha Yojna. The awareness of other schemes such as Jana Raksha Scheme, Aarogya Raksha and Aarogya Bhagya scheme was found to be very low. An attempt was also made to see whether a household has ever availed of benefits of such schemes. Findings clearly indicate usage to be negligible, in line with awareness level which was found to be very low.

3.6 Willingness to pay Secondary data on micro-insurance has established the need of flexibility in terms' of premium amount, collection and mode of payment. In particular, the premium collection schedule should match with the cash flows. The cash flow varies for different categories of occupation groups in the village populace. For example, the cash flows in case of farmers would depend on the number of crop cycles in a year as well as on the timings of harvest, whereas for wage laborer it depends on the working and lean season.. The study made an attempt to explore the amount the community is willing to pay as premium for a policy which covers health expenditure up to Rs. 75,000 per year_ Findings reveal that fifty six percent of the respondent said that they are willing to pay a premium of Rs. 100-250 a year and another 23 percent reported a premium of Rs. 250-500 a year_

Table 3.6: Willingness to pay - Amount & Periodicity of Premium

Item Percent

Amount willing to pay for scheme

Rs 1500 or more a year 2.9

Rs 1000-1500 a year 3.4

Rs 500-1000 a year 8.2

Rs.250-500 a year 22.6

Rs.100-250 a year 56.0

Cannot pay anything 6.9

Choice of instalments to pay the premium

Monthly 5.8

Three monthly 11.0

Half yearly 41.9

Once a year 41.4

Numebr of households - - - - - --

2662

When probed about the choice of timing of instalment to pay the premium, around 42 percent reported half year cycle as preferred mode of premium and similar percentage reported a yearly cycle.

Figure 3.4: Willingness to pay - Periodicity of Premium

Aarogya Raksha 0.1 99.9

Aarogya Bhagya 0.1 99.9

Other health insurance scheme 0:8 99.2

,

Household or anyone in household a member of

Jana Raksha Scheme (Univ. Health Insurance) 0.1 99.9

Raksha , Aarogya

0.0 100

Aarogya Bhagya 0.0 100

Other health insurance scheme 0.7 99.3

Used services or benefits available as part of health insurance during the last year

0.5 99.5

Monthly, 5.8

Thus, flexibility in premium collection needs to be appropriate from the viewpoint of both the insurer and the insured and it can help in extending the micro-insurance net far and wide.

Figure 3.5: Willingness to pay - Amount of Premium (in Rs.)

Rs 1500 or Rs 1000-1500 Rs 500-1000 a Rs.250-500 a Rs.100-250 a Cannot pay more a year a year year. year year anything

Table 3.7: Insurance Products - Preferred Features

Insurance services Percent

Primary care (for normal cold cough fever etc)

Want included in insurance 26.0

Would be willing to pay 74.0

Hospital (large) expenses

Want included in insurance 85.7

Would be willing to pay 14.3

Maternal care & delivery

Want included in insurance ( 53.9

Would be willing to pay 46.1

Once a year, 41.4

3.8 Preferences for Payment of Premium

It's not only the amount and timing of premium payment but also the place of payment which

is key determinant in determining the success of any insurance policy. Bank (39%), Post office (27%) and insurance agent (23%) were termed as most convenient places to deposit the premium. Besides being convenient places to deposit premium, Bank (40%), Post office (28l) and insurance agent (22%) were also featured as the most trusted places for depositing premium payments.

Chapter IV

Morbidity

In a country where only about 3 per cent of the population has health insurance, most

Indians must pay the vast majority of their health care costs out of pocket. This burden is particularly high for those who are poor and prone to ill health. This chapter explores the morbidity pattern at the household level, and tries to map the access, availability and affordability of the health care facilities and the burden of morbidity at the household level.

4.1 Illness without Hospitalization

One of the key objectives of the study is to understand the morbidity pattern at the household level and to map the availability, accessibility and affordability of the health care facilities. In order to assess the household morbidity pattern responses were sought about the any illness in last two month at household level. Findings reveal that as many as 89 percent of the HH surveyed were affected by illnesses in the 2 months preceding the survey. Further in a HH the average number of members suffering from illness was observed to be 1.76 i.e. in a household on an average around two members were suffering from illness.

Household/Members with illness Weighted Unweighted

Total number of households showing illness 2379 2342

Total number of persons showing illness 4188 4139

4.1.1 Types of Illnesses

Morbidity Pattern

In order to ascertain the morbidity pattern, the study probed about the type of illness at the household level. As can be seen from the data, cold/fever accounted for the 57 percent of the morbidity at the household level, followed by cold/cough (10%) and stomach ache (6l0).

Table 4.1: Morbidity pattern in last 2 months

Disease Percent

Cold/fever 56.8

Cold/cough 9.7

Others 7.2

Stomach ache/ other related problem 5.7

Cholera 4.0

Wound/ boils 3.8

Malaria 2.6

Typhoid 1.7

Headache 1.7

Diarrhoea 1.4

Pneumonia 1.2

Body ache/ backache 1.0

Gastric problem/ acidity 0.9

Breathing problem 0.8

The study also made an attempt to ascertain the severity of disease. In around fifty five percent of the cases, the disease was perceived as not serious and only in around forty percent of the cases was it termed as serious.

4.1.2 Treatment Preferences In order to map the availability, accessibility and affordability of health care facilities, an attempt was made to map the type of health care facility the household has visited for treatment of illness. In about forty six percent of the cases, treatment was sought from an unqualified doctor. Drug store (18%) and Private Doctor-MBBS (14%) were other key facilities visited for treatment of illness.

Further analysis was carried out to identify the type of doctor/ facility visited with respect to the most frequently mentioned illnesses. It can be seen from the table below that for illnesses like cold fever, stomach related problems, wounds, cold/cough, malaria and cholera, unqualified doctors/ quacks are mostly preferred.

Amongst the rural populace a common practice is to self treat using traditional means or local herbs/booti. The survey showed that in 13 percent of the cases self treatment was used for the illness. In order to further probe the preference for a health facility, the respondents were asked whether they would have preferred to go to some other facility but couldn't go due to some reasons. Analysis clearly showed that they had gone for facilitythat they desired as in only five percent of the cases did they suggest that they would have preferred some other other facility.

One of the key objectives of the study is to examine the financial burden of treatment on the household and mode of payment. Findings reveal that in the majority of the cases the household paid from its own money and only in around ten percent of the cases did the household report borrowing from a friend to pay for the illness.

Support from friends and relatives 2.2

Sold Jewellery, belongings and goods 0.4

Did not have to pay 2.5

.

Number of sick persons 4188

The study further probed about the risk for not seeking care, it can be seen from the table that this happened in about forty five percent of the cases as the households did not have the money for treatment. Non-availability of doctor/health facility was also cited as one of the key reasons.

Table 4.7: Reason for not seeking care

Could not get away due to work 1.0

Did not have money 45.2

No doctor/health facility nearby 11.3

Was not serious 41.2

Others 8.8

123

4.2 Illness with Hospitalization

Illness with hospitalization results in a serious burden both in terms of cost and also in opportunity lost due to work. One of the key objectives of the study is to understand the morbidity pattern at the household level and to map the availability, accessibility and affordability of the health care facilities.

In order to assess the morbidity pattern due to illness with hospitalization at household level, responses were sought about any hospitalized case during last one year at the household ' level. Findings reveal that on an average around nine percent of the HH surveyed were affected by morbidity due to illness/injury with hospitalization.

Household/Members hospitalized during last one year Weighted Unweighted

Total number of households showing hospitalization 227 1010

Total number of persons hospitalized 240 1067

4.2.1 Types of Illnesses

In order to ascertain the morbidity pattern due to illness with hospitalization, the study probed about hospitalization at the household level. As can be seen from the data, in around sixteen percent of the cases households reported that a member was hospitalized for delivery. Japanese Encephalitis, Cholera (6 ! each), Ulcer and stone operation (5% each) account for the major illnesses treated with hospitalization at the household level:

Table 4.8: Morbidity pattern due to illness with hospitalisation

Defiv&ry 16.4

Others 16.3

Japanese Encephalitis 6.2

Cholera 5.9 .

Ulcer 5.2

Stone operation 4.9

Stomach ache 4.7

Tuberculosis 4.6

Fractured leg 3.9

Head wound 3.7

Eye operation 3.3 . Jaundice 2.9

Fractured hand 2.8

Dehydration 2.7

Pneumonia 2.7 -

Asthma 2.4

Minor wounds 2.3

Hydrocil operation 1.9

Urinary operation 1.7

Heart attack 1.6

High blood pressure 1.6

Malaria 1.1

Body ache 1.1

Number of hospitalized cases 240

The study also tried to ascertain the extent of the severity of the disease for which the household member has to be hospitalized. In around fifty six -percent of the cases the disease was perceived as quite serious and further in around thirty eight percent of the cases the disease was perceived as very serious. Table 4.9: Extent of Severity of Disease

Extent of severity of disease Percent

Not serious 6.5

Quite serious 56.2

Very serious 37.5

Number of hospitalized cases 240

4.2.2 Treatment Preferences In order to map the availability, accessibility and affordability of health care facilities, an attempt was made to map the type of health care facilities the household has been referred to for hospitalization. In around one-third of the cases, respondents were admitted to district government hospital/CHC followed by private nursing homes. Government medical college (18%) and Government PHC/Sub centre (14%) were other facilities referred for hospitalization.

Type of facility visited with respect to most frequently occuring illness is indicated in the table below. The findings indicate that majority of the delivery cases visited district government hospital/ CHC (33%), followed by private nursing home (29%) and government PHC or sub centre (25%). Similarly for other illnesses government health facilities are the most frequently visited.

.

Number of Weighted 39 Is 14 13 12 11 11

hospitalized cases

Un-weighted

The study also made an attempt to analyze whether patients have tried consulting another facility, for a second opinion or whether they have been referred to some other health facility. In more than three-fourths of the cases, the household didn't consult any other facility. Only in 5-6 percent of cases, Private practioners (MBBS) and Private practioners (Ayurvedic) were consulted for a second opinion.

The majority of the individuals suffereing from the most frequently mentioned illnesses have not opted for any alternate facility for treatment. Some have visited either a government health facility or a private practitioner-MBBS.

t

a

Unani 0.0 0.0 0.0 0.0 0.0 0.0 0.0

Drug store/ pharmacy 0.0 0.0 0.0 0.0 0.0 0.0 0.0

Other 0.0 6.7 0.0 0.0 0.0 0.0 0.0

Number of Weighted 39 15 14 13 12 11 11

hospitalized cases

Un-weighted

In order to further probe the preference about a health facility, the study asked whether they would have preferred to go to any other facility but could not do so due to some reason. Analysis clearly showed that they had gone for facility they desired as only in eight percent suggested that they would have preferred some other facility. Table 4.14: Preference for other health facility visited

Want to be admitted to other facility Percent

Yes 7.9

92.1

Total 240 (Weighted) 1067 (Unweighted)

Other preferred facility

Government PHC or sub centre 3.3

District government hospital/ CHC 19.9

Government medical college hospital or similar tertiary care facility

40.2

Private nursing home 20.9

Private hospital (large hospital such as medical college hospital)

10.2

Other (Ayurvedic/ homeopathic hospital) 5.6

Number of hospitalized cases 19 (Weighted)

74 (Unweighted)

One of the key objectives of the study is to examine the financial burden of treatment on household and the mode of payment. In contrast to outpatient treatment of illnesses, in the case of hospitalization in around forty two percent of the cases the household reported borrowing from a friend to pay for the treatment. Further in around twenty percent of the cases, the household has to borrow money from a moneylender to meet the hospitalization expense.

Table 4.15: Means of payment for treatment

Means of payment for treatment Percent

Own money 49.2

Borrowed money from employer 5.1

Borrowed money from money lender 19.6

Borrowed money from friends & relatives 41.8

Support from friends & relatives 2.6

Sold jewellery, belongings or goods 3.5

Sold property (land, house) 1.9

The following table shows that in a majority of the cases payment for the tratment of illness has been

made from own money, followed by money borrowed from friends & relatives.

4.3 Chronic Illness

In order to assess the morbidity pattern due to chronic illness in the household, responses were sought about any chronic illness being diagnosed during last one year at the household level. Findings reveal that as many as 29I of the HH surveyed were affected by chronic illnesses.

4.3.1 Types of Illnesses

In order to ascertain the morbidity pattern due to chronic illness, the study probed about the chronic illnesses at the household level. As can be seen from the data, in around 17I of the cases a household member suffered from arthritis and in 11 % of the cases members reported suffering from chronic asthma. In addition to this other kind of chronic illnesses like gastric problem (7%), breathing trouble (6%), piles (5%), liver problem (3:5%) are frequently mentioned in the `others' category.

The study also made an attempt to find out whether household members have sought any treatment for the chronic illness. As can be seen from the data, almost three-fourths of the household members are seeking treatment for chronic illness and rest who are not taking any treatment cited non-availability and affordability as the key reasons.

Figure 4.4: Reasons for not taking treatment

Too inconvenient,

The following table reveals that all individuals suffering from chronic arthritis, diabetes, and cataract are availing of treatment for these chronic diseases.

Table 4.19: Treatment vis-a-vis type of chronic illness

Name of the chronic 'illness

4.3.2 Treatment Preferences

In order to ascertain accessibility and availability of the treatment facility, the study probed about the nearest health facility available for treatment. Government PHC or Sub centre was reported as the nearest health facility in around 47 percent of the cases. District Hospital was reported as the nearest health facility in around 18 percent of the cases.

Table 4.20: Nearest Health Facility for treatment of chronic illness

Nearest Health Facility for treatment of chronic illness Percent

Government PHC or Sub Centre 47.1

District Government Hospital 18.2

Government Medical College 1.9

Private Nursing Home 7.5

Private Hospital 9.7

Ayurvedic Hospital 3.3

Others 12.4

Total 786 (Weighted)

816 (Unweighted)

The Government PHC or Sub centre was reported as the nearest health facility in around 47 percent of the cases and average distance was reported as 6km signifying that in a11 probability in almost half the cases, one has to travel a minimum of six km to avail of a health facility for treatment. The average distance for second most nearest health facility i.e. District government hospital was observed to be around 16 km

4.4 Opinion about Evening OPD Services In order to gauge the interest in having an evening OPD facility the study probed households about the need and willingness to pay for OPD services. Almost all the respondents reported the need for having an evening OPD service and around three fifths were also in agreement that an extra charge couldl be levied for such a service

Around 23 percent of the respondents reported that Rs. 2 should be levied as the evening OPD charge, another 22 percent reported amount of Rs. 5. A significant proportion also - mentioned Rs. 10 (25%) and Rs. 20 or more (18%) as evening OPD charge.

Chapter V

Social Capital

One of the key objectives of the study is to examine the associations of various dimensions of social capital with each other and with contextual and individual determinants.The study tried to ascertain the status of social capital by deconstructing the perception respondents have about trust.

5.1 Groups and Networks

The study probed about the association of individuals/ households with groups or organizations which could be formally organized or non-formally organized. It is found that only three percent of the total interviewed households/ individuals have any association with groups or networks. The analysis shows that there are certain kind of similariies within the groups pertaining to gender (71%), religion (61%), occupation (42l), caste (26%) and educational background (15%).

5.2 Trust and Solidarity On analyzing opinions on trust and solidarity around 66% of the respondents stated that one has to be careful while dealing with people, thereby highlighting the status of trust between community members_ When asked about the helpful attitude of neighbours, nearly three-fourths (75%) of the respondents were in complete agreement with the fact that most people in the neighbourhood are willing to help in need. Further when probed about the trust, around 69 percent of the respondents completely agreed that in the village one has to be alert otherwise someone else can take advantage of the situation.

Trust in Institutions Increasing evidence shows that social cohesion is critical for societies to prosper economically and for development to be sustainable. Social capital is not just the sum of the institutions, which underpin a society - it is the glue that holds them together. When we talk of forma! institutions, Panchayat Raj Institutions (PRI)' is one such institution, which can make an immense contribution in lending voice to poor and disadvantaged people. Further, PRl, which have been the basic conduit for funds for rural development and rural poverty alleviation, should have served as ideal platform for the participation of the poor. The present study tries to ascertain the trust community members have in institutions. Around 61% of the community members showed strong trust in Panchayati Raj officials while nearly 65% of the respondents confirmed strong trust in local ZP/State government officials. More than three fourths (76%) of the survey respondents have shown complete faith in central government officials thus highlighting the perception about and extent of social capital invested in the central government employees.

Decentralisation process was given a boost by the 73rd and 74th Amendments to the Constitution in 1992

Strongly Disagree 7.5

Local ZP/State Government Officials

Strongly Agree 65.0

Somewhat Agree 24.'I

Neither Agree nor Disagree 5.6

Somewhat Disagree 1.4

Strongly Disagree 3.9

Central Government Officials

Strongly Agree 76.0

Somewhat Agree 14.7

Neither Agree nor Disagree 5.5

Somewhat Disagree 0.7

Strongly Disagree 3.1

Total 2662

5.3 Collective Action and Cooperation Collective group action is one step that can help millions to work in cohesive manner to solve problems at the local level. In order to gauge the status of collective group action and community participation, respondents were probed about their participation in any community activity in the last 12 months. As can be seen from the data below, only 21 percent of the survey respondents confirmed their involvement in any community activity. However, in the majority of the cases the participation was limited to only one or two instances. In order to probe further about the level of likely cooperation, respondents were questioned about a situation such as water supply, or some other problem affecting the whole community. In response to the given situation 46% of the respondents mentioned that that it is `very likely' that community people will get together and cooperate to solve the problem. On the other hand nearly 31 percent respondents said it was `somewhat likely'.

Table 5.4: Community participation and coo eration Item Percent

Participated in an community activity in last 12 months

Yes 20.5 No 79.5

Total 2662

Number of times participated

1 35.6 2 43.5

3 10.6

4 4.3

5+ 6.0

Total 545

Figure 5.1: Community cooperation to solve the problem

When respondents were asked that if a community project does not benefit them directly would they be willing to contribute their time and money to that project, almost 70% of the survey respondents responded in the affirmative with regard to spending time, while nearly 40 percent showed their willingness to contribute in terms of money.

5.4 Information and Communication

Relatives, friends and neighbours are found to be the main source of information about health insurance (71%) followed by local markets and the radio around 54 percent each.

5.5 Social Cohesion and Inclusion The study also tries to determine the effect of differences in terms of societal parameters or economic wealth existing within the village or neighbourhood. As reported by nearly 27 percent of the respondents the effect of these differences in the village or neighbourhood were very small, and 23 percent said that the effect was small.. However, nearly 17 percent and 12 percent of the respondents felt that social and economic differences within the village or neighbourhood affects to a `very great extent' and to a `great extent', respectively. On the other hand almost 20 percent of the survey respondents mentioned absence of any such societal differences in or around the villages.

Table 5.7: Existence of social or economic differences

Existence of differences Percent :

To a very great extent 12.4

To a great extent 17.5

Neither great nor small extent 20.4

To a small extent 23.1

To a very small extent 26.6

Chapter VI

Further Analysis on Understanding / knowledge of health

insurance, willingness to pay and health seeking behaviour

In order to examine the relationship of the background characteristics (social caste groups, education of head of households, and standard of living) versus awareness and knowledge of health insurance; availability of health insurance cover; willingness to pay for health insurance; health seeking behaviour, amount of money spent for healthcare, etc., cross-tabulations of select variables were generated (See Annexure-2). Background characteristics Vs understanding/knowledge of health insurance

The understanding about insurance as `payout received by family after death of the insured' was almost negligible among households in low and medium SLI category, while this percentage was slightly higher (7.4%) among the households in high SLI. As the literacy of the head of the household increases, understanding about insurance also increased from 2% among illiterates as compared 11% among households whose heads had higher secondary education or above. When we tried to see how the understanding about insurance was among different social cast / groups, it was very minimal (3-8%) across social groups.

A minute proportion of households in !ow and medium SLI and one-tenth of high SLI category knew about availability of health insurance products. It was interesting to note that knowledge about availability of health insurance products was better (21.2%) among households whose heads had secondary education or above. A small percentage (4-5I) of households belonging to SC, ST and OBC category and nearly one-tenth of the general category had knowledge about health insurance products.

Higher percentage (54.1 %) of the respondents belonging to high- SLI category said that they heard about health insurance products like Arogya Raksha, Arogya Bhagya, etc. compared to their counterparts in low and medium SLI (44-46%). Percentage of respondents heard about health insurance products was lower among households whose heads had secondary education or more and this percentage increased as education of heads of households increased. When we tried to see whether any member(s) of households covered by health insurance product, a very negligible percentage of respondents across different SLI, caste groups education levels of households was enrolled in one or the other health insurance scheme.

Background characteristics Vs choice of health insurance product

Given a choice between insurance schemes with large coverage with a premium of Rs 200/-and complete coverage with a premium of Rs. 300/-, a vast majority of the respondents in different SLt, education levels of households and social caste/tribe preferred to have a complete cover with a premium of Rs 300/-. When asked to give th6ir preference to have either individual policy or family/ household floater policy, almost all respondents from households in different SLI categories,- literacy levels, social castes preferred to have family/household floater policy. A very high percentage of respondents across all SLI categories, literacy levels and castes preferred to have high cost health insurance with partial money back policy to low cost normal health insurance.

Background characteristics Vs willingness to pay In order to assess the willingness to pay for health insurance, information was collected to know how much premium they would like to pay. Only 7% respondents were not willing to pay any premium for health insurance. Among those who preferred not-to pay any premium, majority belonged to either lower/medium SLI or households with lower education levels or scheduled caste. Majority of respondents in lower socio-economic strata expressed their willingness to pay Rs. 100-249 towards premium, while a substantial percentage of respondents belonging higher SLI, secondary education or above were willing to pay a premium of Rs. 250 or more. Majority of respondents wanted to have a half-yearly or yearly installments for health insurance premium irrespective of the social caste/tribe, literacy of heads of households or SLI. Background characteristics Vs Health status I Illness episodes More than half of households (54.1%) reported that at least one member in the HH suffered

from an episode of illness in the last two months belonged to other backward castes (OBC), while more than one-fourth and nearly two-fifths HHs, whose members suffered from illness were general and SC/ST categories respectively. About 50% hospitalizations were among persons from OBC and a little less than a third from general category and one in every six persons hospitalized belonged to SC/ST. More or less the similar pattern was observed in case of persons suffering from chronic illnesses. The prevalence of illness episode leading to out-patient care (61.0%), hospitalizations (55.1%) and chronic illness (56_9%) was higher among HHs whose heads of household were illiterate. However, a small percentage of households whose members fell sick reported that their heads of HH had a minimum of higher secondary education or above. Background Characteristics Vs Health seeking behaviour In order to understand the health seeking behaviour of the respondents and to assess cost of availing out-patient care, information was collected on health facilities visited for seeking care, money spent on hospital/health center fee, consultation, lab investigations, medicines and travel. On the whole, two-thirds of the respondents visited public health facilities for in-patient care while the remaining visited private health facilities/providers. Majority of the respondents (60-70%) across different castes/tribes availed in-patient care from government health facilities followed by 29-38% from private health facilities. The same trend was observed across different education (of the heads of households) and SLI categories. Since there was lot of variation in the amount of money spent on different aspects, the median cost of care incurred for the last episode of illness (in-patient) was preferred to have a meaningful estimate_ The median cost of availing in-patient care was worked out to be Rs. 52811- for the last 6pisode of hospitalization. When analysed the cost incurred for in-patient care versus background characteristics, it was found that the median cost of care was found to be Rs_ 305E/- among respondents belonging to SC/ST, while this was higher for OBC (Rs.57241-) and general castes (Rs. 6247/-). It is interesting to note that respondents in the lower Sl.l category incurred more (Rs. 6429/-) compared to their counterparts in .medium (Rs.4754/-) and high SLI categories (Rs. 6103/-).

6

Irrespective of the social caste / tribe, more than two-thirds of the respondents said that they either borrowed money or received support from relatives to pay for inpatient care. Nearly one-tenth of the SC/ST respondents and 5l belonging to OBC and general category sold household assets as they had to pay for inpatient care. ,

Majority of the respondents from households whose heads of households were illiterate or had primary / secondary education, either borrowed money or availed relatives support in mobilizing money for paying the (in-patient) healthcare expenses incurred during the last episode of illness. However, less than half of the respondents hailing from households whose head had higher secondary education or above did borrow money to pay for inpatient care.

One-third of the respondents from low SL1 category had own money to meet in-patient healthcare costs and this percentage had increased in case of respondents from medium and high SLt categories. Higher percentage of respondents in !ow and medium SLI categories borrowed money to pay for in-patient care compared to their counterparts in high SLI category. This indicates the strong need for introducing financial protection scheme covering the healthcare costs.

Sizeable proportion (46.3%) of respondents availed out-patient care from unqualified doctors followed private qualified health providers (2'1 %). More or less an equal percentage (17%) of respondents sought treatment either from government health facilities or from pharmacy / drug store.

Across all social castes/tribes, about 80-87% respondents paid for availing out-patient care from their own savings/money, while the rest had either borrowed money or sold household assets for meeting healthcare expenses. Irrespective of the level of education of the head of the households, majority of the respondents had their own money to pay for out-patient care. However, nearly one-sixth of the illiterates and those with primary education had borrowed money for availing out-patient care and this percentage is -lower (10.9%) for respondents with higher secondary education and above. More than one-fifth of the respondents (22.3%) in low SLI category borrowed money to pay for health care cost and this percentage was decreased as we move to medium and high SLI categories.

A N N EXUCRE 1

FACT SHEET

Socio-Economic Profile Total number of completed households - 2662 69.4I of the surveyed respondents are Hindus and 30.2% are Muslims 53.4l0 of the respondents belong to OBC and 26.6% are from genera! category Only 19.1% of the respondents are scheduled caste while 0.9% are scheduled tribe 91 % of the interviewed respondents own house 58.6% of the respondents are residing in Kuccha house whereas 39.4l0 of the

respondents have Semi-Pucca house Hand pump inside the house is the main source of bathing (66.7l0) and drinking water

(66.2%) Only 3.7% and 2.4% of the respondents have their own flush toilet and pit toilet,

respectively white a majority i.e. 92.8l of respondents do not have access to toilet facility

Kerosene is used by 95.6% of respondents as main source of lighting Firewood is most commonly used fuel for cooking by 88.1 % of the respondents

Only 18.9% of respondents have a separate kitchen while 81.1% do not have separate kitchen in household

Majority of the households possesses household assets like cot/bed (97.7%), followed by bicycle (73.4%), mattresses (62.9%) and clock/watch (55.9)

77.2% of the households own agricultural land Majority i.e. 43_6% own less than i acre of land

76_7% of the households own livestock among which Milch Cattle (cow & buffalo) is most commonly owned (72.6%)

Agriculture is the primary source of income (for 43.8%) as well as secondary source of income (for 29.3%) of the households followed by non-farm wage labour

Income, Expenditure and Debt Pattern

Average monthly household income is Rs 2,827 and monthly per capita income (MPC!) is 579.4

Average monthly household expenditure is Rs 2,229 and monthly per capita expenditure (MPCE) is 456.76

Monthly expenditure on food is 57% of the total expenditure Among non-food items, medical expenses form 8.4 % of total expenditure, educational

expenses constituted 3.6% of total consumer expenditure, travelling expenses constituted 6.1%, white recreation (including alcohol and tobacco) formed around 3.9% of the total expenditure

70% of the households have ownership of ration card. Majority i_e. 41.9% of the households own white ration card while 33.3% have Pink/Red

ration card 29.5% of the respondents have savings account in the household *out of which

majority i_e. 93.1 % have their account in the bank 40.6% households are under debt, 33_7% of the households have borrowed money for health expenditures while 27.1 % have taken money to meet their living expenses

Need, Awareness and Preference of Health Insurance 37.9% of the respondents have ever heard of 4BiMA" and have seen someone buying or

taking any kind of insurance Around 28.9% of the respondents understand insurance as payput which is received by the

family after the death of the insured Majority of the respondents are aware about life insurance (38.3%) followed by vehicle

insurance (15.4%) and property insurance (10.4%) 56% of the respondents are willing to pay a premium of Rs.100-250 a year and another 23%

can pay a premium of Rs. 250-500 a year 41.9% respondents preferred half year cycle mode of premium while a similar"

percentage of respondents (41.4%) are found to be comfortable with annual payment cycle

91% of the respondents pr