Management in Health, Vol 16, No 1 (2012)

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AWARENESS, ATTITUDE AND THEIR CORRELATES TOWARDS HEALTH INSURANCE IN AN URBAN SOUTH INDIAN POPULATION

AWARENESS, ATTITUDE AND THEIR CORRELATES TOWARDS HEALTH INSURANCE IN AN URBAN SOUTH INDIAN POPULATION

 

Bhageerathy.RESHMI, M.Sc. (Hospital and Health Information Management)

Assistant Professor, Department of Health Information Management

Manipal College of Allied Health Sciences

Manipal University, Manipal

 

N.Sreekumaran NAIR, Ph.D (Biostatistics)

Professor, Department of Statistics,

Manipal University, Manipal

 

SABU.K.M, Ph.D (Health Information Management)

Professor, Department of Health Information Management, Manipal College of Allied Health Sciences, Manipal University, Manipal

 

Dr B.UNNIKRISHNAN, M.D(Community Medicine)

Professor,

Dept of Community Medicine, Kasturba Medical College, Mangalore

Manipal University, Manipal

 

 

ABSTRACT:

BACKGROUND

In India, factors like lack of awareness about health insurance seems to have curtailed the growth of health insurance in the past and are likely to have an impact in the near future. A community based cross sectional study was carried out to find out the awareness about health insurance, attitude towards it and identify the correlates of these in an urban population in south India.

METHODS

The city of Mangalore in Karnataka state (India) with a total population of three hundred thousand was chosen for the study. The city had 60 wards (smallest administrative unit) of which 10 wards were randomly selected. Two hundred and forty two households from these ten wards were selected by probability proportional to size method for the study. The respondents from 242 households (male-38.4%; female-61.6%) were interviewed by using a pre tested questionnaire. The socio- demographic data and questions on awareness and attitude were collected using the questionnaire.

RESULTS

The awareness of health insurance was found to be 64.0%, it was significantly higher in those respondents whose educational status was above graduation level, who were holding white collar jobs and had a family income of US$200 and above per month. Religion, occupation, family income, educational status and socio-economic status had a statistically significant effect on awareness of the respondents about health insurance (p<0.05>). Thirty nine percent of the population was willing to take health insurance whereas 60% were not .Socio-economic status was found to be a significant correlate in determining the attitude towards health insurance (p<0.05). Approximately US$25 was the amount agreeable to be paid as premium.

CONCLUSION

The findings indicate that the health insurance companies should come out with a clear policy details, as many of the respondents have only vague ideas about their various benefits and risks involved in a policy.

Keywords: Awareness, Attitude, Health insurance, urban population

 

 

INTRODUCTION

The basic function of health insurance is to provide access to health care with financial risk protection [1]. The need for an insurance system that works on the basic principle of pooling of risks of unexpected costs, of persons falling ill and needing hospitalization, by charging premium from a wider population base of the same community is gaining popularity in India.

At present as many as 135 million Indians do not have access to health services [2]. In most developing countries regressive out-of-pocket payments represent a majority of total health spending and countries must find multiple ways to encourage the transition towards financing methods which provide adequate financial protection for their people [3] .In the present scenario the annual expenditure on health in India amounts to about $7 in rural areas and US$10 in urban areas per person, the majority of care being provided by the private sector[4].The high proportion of out-of pocket expenditures of 80% indicates that even the poor are willing to pay for better health services [5].

Against an estimated potential health insurance market of between $100-5000 million, with an average of US$200 million, is the present health insurance market in India [2]. The majority of this being provided by the government undertaking, the General Insurance Corporation (GIC) and its subsidiaries covering just 1.6 million people of the country [2].

There have been no specific studies which mention the rationale for such a situation. A reason estimated may be the lack of awareness of the ordinary citizen regarding the health insurance. Hence this study was carried out in the Mangalore city in the state of Karnataka in India with the following objectives, to find the awareness and attitude and their correlates, towards health insurance among an urban population.

 

METHOD

A community based cross sectional study was carried out in the Municipal corporation limits of Mangalore City, Karnataka, India. The striking feature of the study area is the socio economic development as reflected by high literacy rate of 91.14% (Male = 94.80%, Female =87.46%), a high Gender related Health Index (GHI includes life expectancy at birth, infant mortality rate, educational attainment ) with a score of 0.807 and a favorable sex ratio of 1001 females for 1000 males [6].

Sampling. The Mangalore Municipal Corporation consists of 60 wards (Smallest administrative unit) with a total population of 0.398 million. People in the age group 25 years and above, the age selected for respondents, comprises 0.179 million. Ten wards were selected out of 60 wards by simple random sampling method. The names of the sixty wards were written on pieces of paper and of that 10 were picked up using the lottery method. Eligible populations of selected wards were listed and population proportionate to the sample size was calculated from each of the 10 selected wards. Eligible populations of selected wards were listed and population proportionate to the sample size was calculated from each of the 10 selected wards.

Sample size estimation for estimating proportion of awareness in the population was calculated using the formula sample size (n) = Z2P (1-p) / d2 ;p= anticipated proportion of population aware about health insurance (15%);as per a study carried out in Rajasthan (India) [7] ;d = Absolute precision(5); (Confidence interval)l =95% ; Z=1.96; Total Sample size =196; Non response error =15% ;Final Sample size =230. Inclusion Criteria: Persons above or equal to 25 years of age; one person from one house

The information was collected using a semi structured and pre tested questionnaire. The questionnaire had four parts, the socio-demographic data; details about episodes of illness and the amount of money annually spend on health care for the family. Respondents were briefed about Health Insurance as purchasing a health care coverage in advance by paying a fee called premium and as a means of financial protection against the risk of unexpected and expensive health care. They were asked whether they were aware of this concept or not,, then they were asked about the benefits and the purpose of the same and the source from where they got to know about health insurance. Whether they were already enrolled under any health insurance plan, or availing benefits of hospitalization reimbursements from the organizations they are employed, or if they have purchased health care coverage by a particular hospital, frequently visited by them.

Questions on attitude asked about their willingness to purchase a health insurance scheme for the whole family, which will protect them against any uncertain financial risks arising out of an emergency health situation needing hospitalization and an out of pocket expenditure. A premium amount they were willing to pay for coverage of hospitalization expense for a family, was also asked to obtain a response on their willingness to pay an amount annually for their health security. The respondents were also asked about their preferences of government, private and hospital based insurance schemes.

Scoring for socio-economic status was done according to the Udai Pareekh scale [8] to classify the respondents as belonging to high, middle and low socioeconomic group.

The score of 70 and above were categorized under high socio-economic group, between 40-70 under middle group, less than 40 under the low socio-economic group.

During home visit the purpose and nature of the study was explained to the people and informed consent was taken from them. Before the house-to-house visit, a visit was made to the wards and with the help of a local volunteer, the entire ward was inspected and attempt was made to represent the entire ward. From each selected house the required information was collected by the investigator from the head of the family or any responsible member of the house. If the head of the family or responsible member of the selected house were absent or house was locked, adjacent household was selected. From each house only one member was interviewed.

Statistical analysis: Statistical package for social sciences version 11 was used for analyzing the data [9]. Chi-square test for association and linear trend was used and for quantitative variable ANOVA was done and p value less than 0.05 were considered as significant.

 

RESULTS

The baseline characteristics of the respondents were as follows. Majority of the people were in the age group of 35 44 years of age. Males constituted 38.4% and females 61.6% of the respondents. A majority of the respondents were living in a nuclear family. Almost half that is 54.13% of the respondents belonged to middle socio economic status. About 38.42% of the respondents had an monthly family income between $20 $100 and only 3.30% respondents had income of >= $500; 64% of respondents were aware of health insurance, as per the definitions stated in the methodology.

As shown in Table 1 the percentage of people who were aware of health insurance were significantly higher in Christians, nuclear families, those with white collar jobs, income above US$500 ,graduate or above and high socio economic group.

 

Tabel 1. Association between socio-demographic and awareness about health insurance

 

 

Correlates

AWARENESS

Total

Chi-square/ Fischer

P value

No

%

Religion

Hindu

Christian

Muslim

Jain

 

131

15

8

1

 

67.17

78.94

38.09

100

 

201

19

21

1

 

 

8.65

 

 

P<0.05

Type of Family

Nuclear

Joint

Extended

 

97

31

27

 

64.66

59.61

67.50

 

150

52

40

 

0.68

 

0.71

Occupation

White Collar jobs

Business

Skilled & unskilled worker

Retired

 

33

55

37

 

29

 

94.28

71.42

41.11

 

72.50

 

35

77

90

 

40

 

37.32

 

P<0.0001

Monthly Income

$20-100

$100-200

$200-300

$300-400

$400-500

$500 &above

 

38

46

28

15

7

6

 

40.86

70.76

87.50

93.75

100

75.00

 

93

65

32

16

7

8

 

 

40.72

 

 

P<0.0001

Literacy Status

Illiterate

Primary

Secondary

PUC

Graduate & above

 

2

6

42

26

73

 

25.00

14.28

59.15

72.22

85.88

 

8

42

71

36

85

 

67.34

 

P<0.0001

Socio Economic Status

High

Middle

Low

22

107

26

 

 

100

81.67

29.21

 

 

22

131

89

 

 

 

76.94

 

 

 

P<0.0001

 

When attitude of the respondents was studied about 40% of them were willing to get their health insured. The socio-economic status was an important correlate, which had a statistically significant effect (p<0.05) on the attitude towards health insurance of the respondents (Table2).The middle class were more willing to get their health insured.

In the correlation between awareness and willingness to take health insurance only 42.86% of those who were aware of health insurance are willing to take health insurance. But this relationship was not found to be statistically significant (p=0.306)

According to results inferred from Table 2 only the socio economic status had a significant effect on willingness to take health insurance, which was higher in the middle socio-economic group.

 

Tabel 2. Association between socio-demographic and attitude towards health insurance

 

Correlates

WILL TAKE HEALTH

INSURANCE

Total

Chi-square/ Fischer

P value

No

%

Religion

Hindu

Christian

Muslim

Jain

 

70

4

7

0

 

42.16

25.00

35.00

 

 

166

16

20

1

 

2.70

 

 

0.43

Family type

Nuclear

Joint

Extended

 

51

21

9

 

40.47

46.66

28.13

 

126

45

32

 

2.73

 

0.25

Occupation

White Collar jobs

Business

Skilled & unskilled worker

Retired

 

6

28

34

13

 

25.00

46.66

40.47

41.94

 

26

60

84

31

 

4.25

 

0.23

Monthly Income

$20-100

$100-200

$200-300

$300-400

$400-500

$500 &above

 

37

23

7

3

1

1

 

41.57

43.39

31.81

23.07

25.00

14.28

 

89

53

22

13

4

7

 

 

4.66

 

 

0.45

Literacy Status

Illiterate

Primary

Secondary

PUC

Graduate & above

 

3

14

29

14

21

 

42.85

34.14

48.33

45.16

33.87

 

7

41

62

31

62

 

 

3.11

 

 

0.53

Socio Economic Status

High

Middle

Low

 

2

47

32

 

10.52

47.47

37.64

 

19

99

85

 

9.38

 

P<0.05

 

In table 3 the mean premium agreeable to pay was found to be high in the high socio-economic group, which includes the higher monthly income group of US$400 and above, the occupational group holding white collar jobs and the respondents who were graduates and above and this was found to be statistically significant. Thirty dollars approximately was the mean amount agreeable to be paid as premium by the respondents

 

DISCUSSION

Overall the awareness of health insurance was relatively high (64%) in the present study. Results of some studies carried out elsewhere were also in corroboration with the present study. Mathiazhagan concluded in his studies that the studied population had reasonable knowledge about health insurance [10] . But a study carried out by Sodani in Rajasthan (India) concluded that only 15% of the studied population was aware of health insurance [7].

Only 10% of the high socio-economic class was willing to take health insurance. This attributes to the fact that the higher socio economic group was better off financially than the middle socio-economic group. A similar study found out that socio-economic factors appeared to be significant determinants of the participants in joining health insurance schemes [10]

The awareness of health insurance did not seem to affect their attitude towards having a health insurance scheme, as it was not found to be statistically significant. Although in a study on the health insurance status among the unorganized sector in Gujarat(India) showed that most of the people were ready to enroll for a community based health insurance scheme[11].

None of the respondents quoted a premium of less than US$2 annually which could mean that the people are ready to part with a reasonable amount of money for health security which is a positive trend for insuring the health of the public. In an option proposed recently suggests that a rural hospitalization insurance scheme for people below the poverty line could be initiated as a part of an antipoverty program at a cost of US$200 million, presuming a low premium of US$0.67 per head for the estimated 300 million poor in the country[12]

Gumber and Kulkarni [11] also reported from their study that both rural and urban respondents were willing to pay an amount ranging from US$2-$3 by the type of coverage of services.

The middle and low socio-economic group are a potential market to be tapped as they are ready to spend a reasonable amount as premium payable per annum rather than huge medical expenses in case of any adverse situation. If the private insurers venture into the market, they should try to instill trust in the people.

Instability in the price of insurance premiums is a particular problem where government intervention on provider prices and utilization of services is minimal. Capital premium setting mechanisms can improve the predictability of premiums because, like life insurance policies, they include a reserve for future costs of health care [13].

 

CONCLUSION

Socio-economic status had a significant impact on the awareness and attitude of respondents towards health insurance. The association between socio-economic status and amount of premium payable were significant. The higher socio-economic status higher was the amount agreeable to be paid as premium. The health insurance companies should come out with a clear policy details, as many of the respondents had only vague ideas about their various benefits and risks involved in a policy. This may be the reason for low health insurance penetration among the general public, in spite of a reasonably high awareness about health insurance as showed the results of this study To develop a viable health insurance scheme, it is important to understand peoples perceptions and develop packages that are accessible, affordable and acceptable to all sections of the society.

 

ACKNOWLEDGEMENT

The authors are grateful to the Manipal Health Systems for providing financial support in carrying out the study. The authors also acknowledge the contribution of the Manipal College of Allied Health Sciences, Manipal University ,Manipal. The study was funded by the Manipal Health Systems, Bangalore, Karnataka,India. The study was approved by the Institutional Ethics Committee of the Manipal College of Allied Health Sciences, Manipal University, Manipal, Karnataka,India

 

 

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