In 2002, Vimo SEWA instituted a Monitoring and Research Unit with the aim of strengthening SEWA's insurance programme.

Shramjivi Salamati (2003-2006)

Shramjivi Salamati was a three year action-research project carried out at SEWA in collaboration with the London School of Hygiene and Tropical Medicine and funded by the Wellcome Trust. The project aimed at improving the utilization of the health insurance by the poorest. Two interventions were introduced under the project to increase the utilization of health insurance among poorer households. One intervention was aimed at increasing members’ awareness about the insurance scheme and strengthening their linkages with the aagewans. The second intervention involved tying up with two hospitals each in selected talukas in Gujarat. Insured members who got admitted to the selected hospitals were reimbursed before discharge from the hospital.

The interventions resulted in several positive outcomes. They led to an increase in the utilization of insurance among rural members and reduced the disparity in rates of claims submission between rural and urban members. However, within rural areas, better-off members claimed more than the poorest members. A likely reason for this is that the interventions addressed only some of the barriers faced by the poorer members in submitting health insurance claims, such as information about the scheme or available cash for paying the hospital. Other barriers, such as distance to the hospital, transportation costs and the opportunity costs of hospitalization, especially for women members with many household responsibilities, could not be addressed by the interventions. The poorest members live in more remote locations and women in these households have greater demands on their time. The interventions were limited in their ability to address these constraints.

Because of the observed benefits of the interventions, Vimo SEWA is continuing the interventions in the existing areas and introducing them in other talukas, Scheme administrators believe that over a longer duration, the interventions will increase scheme utilization disproportionately among its poorer rural members.

Understanding member dropout at Vimo Sewa (2005 -2006)

Building the commitment of the poor to a product like insurance is a challenge. For poor families with limited budgets and many basic issues of survival, it is difficult for others to have insurance on their list of priorities.

In 2005, Vimo SEWA carried out a study to understand why some members renew their membership while others dropout of the programme. The study examined both demand side and supply side factors that may affect a member’s re-enrolling or dropping out of the scheme. Few demand-side variables were significantly associated with dropping out, but some important trends were observed, and deserve further attention. Renewed members were more likely to come from better educated households and were more likely to have submitted an insurance claim during the year preceding the survey. Among renewed members (vs. dropouts) there was a trend towards higher SES and higher probability of hospitalisation per household.

There were important supply-side factors which prevented people from re-enrolling. Among those dropouts who could be contacted, 57% said that their primary reason for dropping out was that nobody had come to sell them the insurance. Women were significantly more likely to renew if they had stronger linkages with SEWA, including membership in SEWA Union or an account at SEWA Bank.

Evaluating the take-up of ‘Cashless Hospitalization’ in Ahmedabad city among Vimo SEWA members (2006 – 2007)

In January 2006, Vimo SEWA introduced a system of ‘cashless hospitalization’ in Ahmedabad city in selected hospitals on an optional basis. Under this system, Vimo SEWA members admitted to one of the selected hospitals were reimbursed for their hospitalization expenses before discharge from the hospital. The three primary objectives of this system were to facilitate access to hospitalization, reduce the burden relating to claims documents and to direct members to inpatient facilities with acceptable levels of quality.

In September 2006, Vimo SEWA carried out a survey of hospitalization claimants including those who had used the system and those who had not. The aim of the study was to examine why some members used the system and others did not. We compared three categories of claimants, viz. claimants that had used the CL system (CL users), those that had used CL hospitals but not used the CL system (system non-users), and those that had used non-CL hospitals (hospital non-users). We looked at both demand side and supply side factors with regard to the member’s decision to use the CL system.

Claimants in the three categories varied significantly in terms of levels of education and household income. System non-users had the lowest education and income levels, while hospital non-users had the highest levels among the three groups. The weakest economic position of system non-users is also evident from the fact that this category had the lowest proportion of Scheme 2 members.

Lack of knowledge was the primary reason for lack of demand of this system among both categories of non-users. Lack of understanding about how to use the system was the other barrier. Also, pre-occupation with tending to the hospitalized member prevented some members from being able to inform Vimo SEWA about the hospitalization. Members were less likely to use the system if the hospitalization was unexpected. Some system users learnt about the system only after they were admitted.

System users had a high degree of satisfaction with the system and the sthanikbens; hardly any problems in system utilization were reported. The study also found that the three main reasons that accounted for choice of hospital were previous utilization, convenient location, or referral by a doctor.

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