Gollan, Christina (2019). Access to outpatient health care services in rural India – The contribution of health microinsurance. PhD thesis, Universität zu Köln.


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It is estimated that around 8 % of the Indian population is driven into poverty by high health care costs every year. Despite this, financial protection in the form of health insurance coverage remains low at around 25 % among the Indian population. Health Microinsurance (HMI) schemes have emerged throughout the country to protect the low-income population from catastrophic health care expenditures and to improve their access to care. HMI are based on the same insurance principles as conventional insurance but due to targeted and limited portfolios, they can offer their products at lower prices. Because of an underdeveloped public health care sector, private Non-Degree Allopathic Practitioners (NDAPs) are the most important source of care for acute illness episodes in rural areas in India. These providers lack a formal qualification in Western medicine, but practice it anyway. Their inclusion into insurance arrangements could be a chance to improve financial access to care. Therefore, in 2010, three newly established HMI schemes in rural northern India integrated NDAPs into their portfolio. According to our knowledge, they were the first HMI scheme in India to have done so, which makes it particularly valuable to study the effect on access to outpatient care. The present thesis consists of various independent publications which together address the question whether the inclusion of NDAPs in HMI schemes can improve access to quality outpatient health care in rural India. The focus lies on the subjective experiences of the insured themselves and how they perceive the effect of being insured on their access to outpatient care from NDAPs. I make use of an analytical framework which differentiates between three dimensions of access: physical access (availability), financial access (affordability) and cultural access (acceptability). A cross-cutting issue is quality of care, defined within this framework as the perceived technical ability of health services to affect people’s health. The thesis follows a qualitative, exploratory research approach as the research questions address how the insured themselves perceive the effect of insurance to access and what facilitators or barriers they experience. This information is important for understanding dynamics in place when insured make or not make use of insurance-related health care services and for improving accessibility of these. Ultimately, the insureds’ subjective perception of the impact of being insured is also fundamental for understanding their decision to (re-)enroll into a scheme or not. Each independent study follows its own qualitative, exploratory research approach, adapted to the specific sub-question under study. These approaches comprise a systematic review (analyzed by applying a thematic synthesis), a cross-sectional study based on focus-group discussions (analyzed using a directed qualitative content analysis) as well as longitudinal case study with insured and non-insured households based on in-depth interviews (and analyzed by applying case description and analysis and explanation of themes and patterns, both within and across cases). The systematic review of existing qualitative studies on access to care through HMI shows that a lack of physical access to care provided under HMI and dissatisfaction with its quality are among the most frequently identified problems with access to care through HMI. This confirms the relevance of my research question for different countries and schemes, as the integration of local providers such as NDAPs in combination with an involvement of insurance clients into the selection of these providers tackles just these shortcomings. Second, the review also reveals the limitations of this approach. Given that health system-related barriers to accessing care can compromise the schemes’ efforts, it makes clear that complementing measures addressing system-related shortcomings are indispensable. With regard to the initial health care seeking behavior for acute illness episodes among the HMI’s target population and the popularity of NDAPs, the thesis presents evidence that because of their proximity, flexible payment options and familiarity with patients’ belief systems, among other things, local NDAPs are physically, financially and culturally accessible. They have a “high degree of fit” with their patients. Usually, they are the first contact points for patients before turning to qualified practitioners, and treat minor illnesses, provide first relief, refer patients to other providers and administer formally prescribed treatments. These findings again confirm specifically for the Indian case the relevance of our HMI schemes’ decision to include NDAPs into their portfolio for the provision of outpatient care. Finally, the thesis shows what effect on access to outpatient care is perceived by the HMI-clients under study, how they utilize the services offered and what factors facilitate or hamper their access to services. It shows that households appreciate to have immediate access to outpatient care from NDAPs without co-payment. Perceived low quality of care and limited physical access are important barriers experienced by the insured. Both factors are partly caused by how HMI-associated NDAPs are integrated into the insurance schemes. While some households do not consult them due to the barriers perceived, others integrate them and their services into their health care seeking behavior or even use them exclusively. Based on the evidence presented, it is concluded that HMI has the potential to improve access to quality outpatient care services in India from the point of view of the insured by including popular providers such as NDAPs into their portfolio and making use of their physical and social embeddedness. However, their inclusion needs to be designed carefully to not let external regulation of NDAP-patient-relationships restrict already existing access as it had happened in some cases in the insurance scheme under study. At the same time, it is necessary to also implement measures within the health care system itself, mainly addressing the quality of health care provision by NDAPs through qualification and formalization efforts by the Indian government. A close monitoring of the effect of these measures on accessibility of NDAPs would be necessary. This should also include the perspective of the NDAPs themselves on HMIs and its effect on their relations with their patients. Although the findings are not easily generalizable to other regions or countries, they can serve as valuable input for HMI schemes which aim to improve access to outpatient care while confronted with a similar significance of NDAPs.

Item Type: Thesis (PhD thesis)
CreatorsEmailORCIDORCID Put Code
URN: urn:nbn:de:hbz:38-93265
Date: 2019
Language: English
Faculty: Faculty of Management, Economy and Social Sciences
Divisions: Faculty of Management, Economics and Social Sciences > Social Sciences > Multidisciplinary Social Sciences > Social Policy and Cooperative System > Department of Cooperative System
Subjects: Social sciences
Medical sciences Medicine
Uncontrolled Keywords:
Access to careEnglish
Health microinsuranceEnglish
Health financingEnglish
Developing countriesEnglish
Qualitative studiesEnglish
Informal health care providersEnglish
Date of oral exam: 15 January 2019
NameAcademic Title
Rösner, Hans JürgenProf. Dr.
Schulz-Nieswandt, FrankProf. Dr.
Refereed: Yes
URI: http://kups.ub.uni-koeln.de/id/eprint/9326


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