The authors have declared that no competing interests exist.
We aimed to find the population coverage, health service utilization and out-of-pocket spending among the elderly who are insured under Comprehensive Health Insurance Scheme (CHIS), Kerala through a longitudinal study of 600 non-rich households for nine months. The study found that only 57.7% the elderly were insured under CHIS which is lower than the population average of 80%. Single elderly from a socially backward caste, living alone in
The proportion of elderly in the population has been increasing in societies around the world, including in many low and middle income countries as a result of demographic transition. The size and the growth rate of the elderly population vary across regions, countries and within countries.
The state of Kerala in India is in the most advanced stage of demographic and epidemiological transition.
There are other important characteristics of the elderly which should be noted. About 75% of elderly live in villages and nearly half are of poor socioeconomic status (SES) in India.
According to NSSO Kerala state has the best access to health care and the highest proportion of private as well as public utilization of health facilities.
CHIS in Kerala has gone one step forward in terms of UHC and provided the insurance to Above Poverty Line (APL) households as well if they pay full premium, which is comparable to that of private health insurance schemes in Kerala. Currently CHIS covers more than 3 million households and is supposed to provide full financial risk protection to them.
This paper uses data from a larger longitudinal study conducted in two states, Kerala and Tamil Nadu with 1200 non-rich households which were followed up for a study period of nine months with the aim of studying UHC provided by government sponsored health insurance schemes like CHIS. In this paper we have included only data of elderly (age>=60 years) from Kollam district of Kerala.
Separate sample size calculations were done for three dependent variables for this study namely; population coverage, service coverage and financial risk protection (FRP) using epi-info statcalc version-3.5. The sample size was 600 non-rich households in Kerala after adding a non-response rate of 5%. Households were selected by three-stage (2 municipalities, 6
A total of 305 elderly were included in the study out of which 155 (50.8%) were males and 150 (49.2%) were females. The mean± SD age among the elderly was 68.5+ 9.0 (range 60-101). Elderly were mostly living with children or their extended families (84.5%), were currently married (63%), had primary education and above (74.6%), had no job or living on pension (72.1%) and were living with chronic disease (72.5%).
176 elderly (57.7%) were currently enrolled under CHIS and 129 (42.3%) were not covered under the scheme. Out of the 129 who were not covered, 40 (31%) were from households never-insured under the scheme, 40 (31%) did not renew the scheme for the year 2015-16 and 49 (38%) were uninsured elderly from the insured households.
Elderly who were married (65.1%), living in pucca (61.3%) or pucca/semi-pucca mixed houses (63.3%), who were living with spouses (81.6%), in Below Poverty Line (BPL) list (64.8%) and were working (74.1% ) had statistically a better chance of getting insured compared to their counterparts. Even though not statistically significant males (60.1%) and young-old (60.4%) elderly had more proportion of insured and on the other hand elderly from scheduled caste group had less number of insured (45.2%) as compared to other groups.
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60-69 (young-old) | 116 (60.4) | 76 (39.6) | .129 |
>=70 (old-old) | 60 (53.1) | 53 (46.9) | |
Male | 95 (61.3) | 60 (38.7) | .120 |
Female | 81(54.0) | 69 (46.0) | |
Un-married | 2 (25.0) | 6 (75.0) | .001 |
Married | 125 (65.1) | 67 (34.9) | |
Widow/separated | 49 (46.7) | 56 (53.3) | |
Pucca | 111 (61.3) | 70 (38.7) | .050 |
Mixed | 19 (63.3) | 11 (36.7) | |
Semi-pucca | 26 (59.1) | 18 (40.9) | |
Kutcha | 20 (40) | 30 (60) | |
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Living alone | 3 (33.3) | 6 (66.7) | .047 |
Living with spouse | 31 (81.6) | 7 (18.4) | |
Living with unmarried son/daughter | 20 (58.8) | 14 (41.2) | |
Living with married son/daughter | 41 (59.4) | 28 (40.6) | |
Living with extended families | 81 (52.3) | 74 (47.7) | |
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Living alone/with spouse | 34 (72.3) | 13 (27.7) | <.001 |
Unmarried/widowed elderly living with others | 40 (41.2) | 57 (58.8) | |
Elderly parents living with son/daughter | 102 (63.4) | 59 (36.6) | |
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Below Poverty Line (BPL) | 118 (64.8) | 64 (35.2) | .004 |
Recently added to BPL | 10 (66.7) | 5 (33.3) | |
Above Poverty Line (APL) | 43 (46.7) | 49 (53.3) | |
Recently added to APL | 5 (31.2) | 11 (68.8) | |
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1Extremely poor | 35 (50.0) | 35 (50.0) | .263 |
2 Poor | 26 (66.7) | 13 (33.3) | |
3Marginal | 53 (55.2) | 43 (44.8) | |
4Vulnerable | 62 (62.0) | 38 (38.0) | |
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Hindu | 131 (55.3) | 106 (44.7) | .258 |
Muslim | 42 (65.6) | 22 (34.4) | |
Christian | 3 (75.0) | 1 (25.0) | |
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SC |
28 (45.2) | 34(54.8) | .081 |
OBC | 111 (61.0) | 71 (39.0) | |
Others | 37(60.7) | 24(39.3) | |
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Illiterate | 45 (60.0) | 30 (40.0) | .598 |
<=4 years of schooling | 55 (52.9) | 49 (47.1) | |
5-9 years of schooling | 57 (62.0) | 35 (38.0) | |
>=10years of schooling | 19 (55.9) | 15 (44.1) | |
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Working | 63 (74.1) | 22 (25.9) | <.001 |
Un-employed /on pension | 113 (51.4) | 107 (48.6) | |
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Yes | 129 (58.4) | 92 (41.6) | .399 |
No | 47 (55.9) | 37 (44.1) | |
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Yes | 109 (58.6) | 77 (41.4) | .692 |
No | 67 (56.3) | 52 (43.7) | |
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Alcohol | 2 (50.0) | 2 (50.0) | .193 |
Tobacco | 30 (69.8) | 13 (30.2) | |
Both | 16 (45.7) | 19 (54.3) | |
None | 128 (57.4) | 95 (42.6) | |
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Poor knowledge | 69 (54.8) | 57 (45.2) | .477 |
Slightly aware | 56 (62.9) | 33 (37.1) | |
Fully aware | 51 (56.7) | 39 (43.3) |
For the purpose of analysis we have regrouped un-married and widow/separated into one single group and living alone and living with spouse into another group
The non-rich households were again categorized into four SES categories namely: Category1/extremely poor (<= 0.75 poverty line, PL) and SOL score <=12 : Category2/poor (0.75- 1PL) and SOL score 13-15: Category3/Marginal (1-1.25 PL) and SOL score 16-17 and Category4/vulnerable households (>2PL) and SOL score>=18.25
One ST family was also included in SC group
As CHIS only covered hospitalization, for service coverage we have only included data related hospitalization. Among elderly 54.4% (166) had been ever hospitalized in the last 1 year and 9 month period. Those who have chronic diseases (63.3%) had a statistically high chance of getting hospitalized. Being insured (65.4%) and being from a non-scheduled caste category had a statistically high association with hospitalization. Education had a protective effect on hospitalization, those who were educated for more than 10 years were much less likely to be hospitalized compared to other groups (32.4%).
Variables | Hospitalized n (%) | Not hospitalized | P value |
n (%) | |||
Age Group | |||
60-69 (young-old) | 102 (53.1) | 90 (46.9) | 0.317 |
>=70 (old-old) | 64 (56.6) | 49 (43.4) | |
Sex | |||
Male | 84 (54.2) | 71 (45.8) | 0.513 |
Female | 82 (54.7) | 68 (45.3) | |
Marital status | |||
Un-married/widowed/separated | 59 (51.3) | 56 (48.7) | 0.232 |
Married | 107 (56.3) | 84 (43.8) | |
Household (composition) | |||
Living alone | 5 (55.6) | 4 (44.4) | 0.782 |
Living with spouse | 23 (60.5) | 15(39.5) | |
Living with unmarried son/daughter | 21 (61.8) | 13 (38.2) | |
Living with married son/daughter | 36 (52.2) | 33 (47.8) | |
Living with extended families | 81(52.3) | 74 (47.7) | |
Category Below Poverty Line | |||
Below Poverty Line (BPL) | 96 (52.7) | 86 (47.3) | 0.18 |
Recently added to BPL | 5 (33.3) | 10 (66.7) | |
Above Poverty Line (APL) | 54 (58.7) | 38 (41.3) | |
Recently added to APL | 11 (68.8) | 5 (31.2) | |
Category SES* | |||
Extremely poor | 33 (47.1) | 37 (52.9) | 0.499 |
Poor | 21 (53.8) | 18 (46.2) | |
Marginal | 53 (55.2) | 43 (44.8) | |
Vulnerable | 59 (59.0) | 41 (41.0) | |
Caste | |||
SC | 29 (46.8) | 33 (53.2) | 0.036 |
OBC | 110 (60.4) | 72 (39.6) | |
Others | 27 (44.3) | 34 (55.7) | |
Education | |||
Illiterate | 48 (64.0) | 27 (36.0) | 0.001 |
<=4 years of schooling | 48 (46.2) | 56 (53.8) | |
5-9 years of schooling | 59 (64.1) | 33 (35.9) | |
>=10years of schooling | 11 (32.4) | 23 (67.6) | |
Occupation | |||
Working | 45 (52.9) | 40 (47.1) | 0.422 |
Un-employed /on pension | 121 (55.0) | 99 (45.0) | |
Chronic Disease | |||
Yes | 140 (63.3) | 81 (36.7) | <.001 |
No | 26 (31.0) | 58 (69.0) | |
Substance abuse | |||
Alcohol | 4 (100.0) | 0 | 0.158 |
Tobacco | 21 (48.8) | 22 (51.2) | |
Both | 16 (45.7) | 19 (54.3) | |
None | 125 (56.1) | 98 (43.9) | |
CHIS | |||
Yes | 112 (65.4) | 64 (34.6) | 0.001 |
No | 54 (41.9) | 75 (58.1) |
Variables | Insured | Un-insured | P value |
n (%) | n (%) | ||
Hospitalization | |||
Yes | 112 (65.4) | 54 (41.9) | 0.001 |
One episode | 72 (40.9) | 34 (26.4) | |
Two episodes | 27 (15.3) | 18 (14) | |
Three episodes | 13 (7.4) | 2 (1.6) | |
No | 64 (34.6) | 75 (58.1) | |
Total no. of episodes of hospitalizations | 165 (68.5) | 76 (31.5) | |
Covered by CHIS | 72 (43.6) | 0 | |
Not covered under CHIS | 93 (56.3) | 76(100) | |
Reason for hospitalization | |||
Fever | 42 (25.5) | 25 (32.8) | 0.022 |
Hernia, appendectomy, abscess | 16 (9.6) | 1 (1.3) | |
NCD related | 42 (25.5) | 22 (28.9) | |
Hysterectomy | 30 (18.1) | 13 (17.1) | |
Disk prolapse, fracture, accident | 15 (9.0) | 8 (10.5) | |
Infection, pneumonia | 11 (6.6) | 5 (6.5) | |
Cataract, eye surgery | 9 (5.4) | 2 (2.6) |
Out of the 166 elderly who had hospitalizations 112 were insured under CHIS with a total of 165 episodes of hospitalizations. The reasons for hospitalization among insured and un-insured elderly were significantly different. Even though insurance came out as a significant variable for the likelihood of hospitalization, only 59(52.7%) insured elderly had any episode covered under CHIS. Out of total 165 episodes of hospitalization among insured only 43.6% (72) episodes were covered under CHIS.None of the elderly with more than two episodes of hospitalization were fully covered under CHIS (could make use of CHIS smart card for all episodes of hospitalizations). Out of the 112 insured only 43 (38.4%) had been fully covered (all episodes) under CHIS and majority had none of the episodes covered by CHIS (47.3%).
Variables | Frequency | Episodes of | ||
hospitalization | ||||
No of elderly with hospitalization | 112 | 165 | ||
No. of elderly with single episode of | 72 | 72 | ||
hospitalization | ||||
Covered under CHIS | 33 (45.9) | 33 (45.9) | ||
Not covered under CHIS | 39 (54.1) | 39 (54.1) | ||
No. of elderly with two episodes of hospitalization | 27 | 54 | ||
Both episodes covered under CHIS | 10 (37.0) | 20(37.0) | ||
One episode covered under CHIS | 7 (26.0) | 7(13) | ||
None covered under CHIS | 10 (37.0) | 27(50.0) | ||
No of elderly with three episodes of | 13 | 39 | ||
hospitalization | ||||
All three episodes covered under CHIS | 0 | 0 | ||
Two episodes covered under CHIS | 3(23.1) | 6 (15.4) | ||
One episode covered under CHIS | 6(46.1) | 6 (15.4) | ||
None covered under CHIS | 4 (30.8) | 27 (69.2) | ||
Episode wise coverage | ||||
Any episode covered under CHIS | 59(52.7) | 72 (43.6) | ||
Fully covered (All episodes covered under CHIS) | 43 (38.4) | 53 (32.1) | ||
Partially covered (Some episodes covered under CHIS) | 16 (14.3) | 19 (11.5) | ||
None covered | 53 (47.3) | 93 (56.3) | ||
Mean days of hospitalization (95%CI) | ||||
Fully covered | 8.08 (6.72-9.45) | .068 ( p value) | ||
Partially covered | 5.21(3.64-6.78) | |||
None covered | 10.89 (7.90-13.00) | |||
Reasons for hospitalization | Fully covered | Partially covered | Not covered | |
Fever | 15(28.3) | 6(31.5) | 15 (16.1) | |
Hernia, appendectomy, abscess | 7 (13.2) | 2 (10.5) | 17 (18.3) | |
NCD related | 5 (9.4) | 1 (5.3) | 17 (18.3) | |
Hysterectomy | 9 (17) | 2 (10.5) | 21(22.3) | |
Disk prolapse, fracture, accident | 6 (11.3) | 0 | 12 (12.9) | |
Infection, pneumonia | 6(11.3) | 5 (26.3) | 11 (11.8) | |
Cataract, eye surgery | 5 (9.4) | 3 (15.8) | 0 |
While looking at further details about hospitalization we can see that the un-covered hospitalizations among the insured elderly were severe as the mean days of hospitalizations were significantly higher compared to the CHIS covered hospitalizations and major hospitalizations related to non-communicable diseases were not covered under CHIS. Hospitalizations covered under CHIS were of less severity like cases of fever, hernia, abscess related admissions or hysterectomies.
The mean indirect OOP expenses for hospitalization among insured were significantly higher compared to that of uninsured. Within the insured group it was significantly higher among the fully covered group. Even though not statistically significant the direct out of pocket expenses among un-insured and not covered among the insured were high compared to other groups. About 81% of the hospitalized households used one or more distress financing mechanisms such as un-secured loans, gold loans, sale of assets, assistance / gift, mortgage of assets and mortgage of land to meet the expenses associated with hospitalization
Insured | Un-insured | ||||
Fully covered | Partially covered | Not covered | P value | ||
Mean Direct OOP Expenses (95%CI) | 6235.85 | 5578.9 | 14600 | 10600 | 0.19 |
(3615.29-8856.41) | (1678.75-9479.13) | (7166.53-22091.31) | (6765.85-14401.26) | ||
Mean indirect OOP Expenses (95%CI) | 7679.25 | 7378.95 | 2205.7 | 4455.26 | 0.027 |
(5093-10264.56 | (3484.97-18242.87) | (1275-3136.39) | (1591.26-7625.23) | ||
Total Out-of-pocket expenses(95%CI) | 13915.27 | 12958.65 | 16835 | 15039 | 0.922 |
(9572.98-18257.20) | (1128.377-27044.16) | (8716.6-24952.62) | (9803.29-20274.33) |
Out of 305 elderly populations 186 were taking medications for chronic diseases daily. Out of this 166 (89.2%) were taking allopathic medicines, 9 (4.9%) were taking Ayurveda and 11 (5.9%) were taking homeopathy medicines. The mean monthly cost of drug among the insured 1105.09 (1193.711) and uninsured 650.03(914.416) were significantly different, p=.004.
A total of 419 (69.8%) currently insured and 181 uninsured households, with 1791 and 760 members respectively were there in the main study. Compared to younger adults, the elderly had less proportion insured, but they had the highest proportion of hospitalizations. We find that use of CHIS was more for elderly compared to other age groups in the insured households.
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Yes | 37 (14.9) | 229 (53.1) | 972 (62.1) | 176 (57.7) | <.001 |
No | 212 (85.1) | 202 (46.9) | 594 (37.9) | 129 (42.3) | |
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Yes | 64 (25.7) | 151 (35.0) | 544 (34.7) | 166 (54.4) | <.001 |
No | 185 (74.3) | 280 (65.0) | 1022 (65.3) | 139 (45.6) | |
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544 | 166 | |||
Insured | 16 | 93 | 412 | 112 | |
Any episode covered | 1 (1.6) | 34 (22.5) | 176 (42.7) | 59(52.6) | <.001 |
Fully covered | 1 (1.6) | 10 (6.6) | 89 (21.6) | 43 (38.4) | |
Partially covered | 0 | 24 (15.9) | 87 (21.1) | 16 (14.3) | |
Not covered | 14 (21.9) | 59 (39) | 236 (57.3) | 53 (41.4) | |
Un-insured | 49 (76.6) | 58 (38.4) | 132 (23.3) | 54 (32.5) |
This is one of the few studies from Kerala looking at the population coverage, service coverage and OOP expenses among elderly who are insured under the social protection scheme CHIS. We found that even in the state of Kerala with the highest literacy rate, the coverage of CHIS among elderly was only 57.7%, which is lower than the average for the target population i.e., 80%.
Next we tried to look at whether the population coverage translated into service coverage i.e., whether hospitalization among insured were covered by CHIS. Elderly being a vulnerable group with highest morbidity among all age groups also had the highest prevalence of hospitalization. Insured elderly had a higher proportion of hospitalizations compared to those who were un-insured. This result is consistent with the results of studies on GSHIS in Vietnam, Mexico, Colombia, Taiwan and India.
Lastly we tried to find out whether the elderly who were insured under CHIS incurred out-of-pocket spending, given that CHIS was introduced with the ultimate aim of reducing OOP. Since CHIS did not cover 56.3% episodes of hospitalizations among 61.6% of the insured elderly, the insured did incur both direct and indirect OOP expenses. We also found that instead of reducing the out-of-pocket spending during hospitalization, those who were insured had higher indirect OOP compared to un-insured. Interestingly within the insured group, those who were fully covered under CHIS for all episodes had higher OOP compared to those who were partially and not covered. This finding was contrary to many findings from Vietnam and a systematic review by Ernst Spann et al from Asia and Africa. These studies found that insurance reduced OOP expenses.
The financial burden borne by the households with elderly are immense. The mean OOP per episode of hospitalization is INR 14,569 and the mean drug expenditure per month is INR 1105.09 among insured, which is almost eight times the mean per capita expenditure (MPCE) of an urban household in Kollam (INR 1763.88) and 13 times the MPCE of the lowest quintile in Kerala (INR 1103).
There is an ongoing debate on UHC in terms of ethical, political and economic viability. In case of elderly it is again complicated due to the high morbidity and low economic productivity.
Authors also wish to thank all the study participants.