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Socially inclusive health care financing in West Africa and India<br/>Short title: Financing health care for inclusion

Final Report Summary - HEALTH INC. (Socially inclusive health care financing in West Africa and India<br/>Short title: Financing health care for inclusion)

Executive Summary:
The Health Inc project put forward the hypothesis that social exclusion is an important cause of the limited success of recent health financing reforms in low and middle-income countries. To explore this hypothesis, research was conducted on the RSBY (RashtriyaSwasthyaBimaYojana) insurance scheme in two states of India (Maharashtra and Karnataka), the National Health Insurance Scheme (NHIS) in Ghana and the Plan Sesame exemption scheme for older people in Senegal.

The project found that awareness levels of RSBY and Plan Sesame were poor and current enrolment rates in all three schemes studied were low, never exceeding 55% of the sample. While the SHP schemes studied did improve access to health care, not all those who claimed health services received the benefits of free or partially exempted health care as stipulated by the programme. Significantly, despite their intention to cover poor and vulnerable groups, all three social health protection (SHP) schemes disproportionately benefited those who were socially, politically, economically and/or culturally privileged. Patterns of inequity differ between the schemes studied, but overall wealthier, more educated individuals with greater political participation and social networks were more likely to capture the benefits of the schemes studied.

These inequities in access to and use of SHP were driven by numerous exclusionary mechanisms. For example, at the local level, “street level bureaucrats” confronted with unavailability of resources and ambiguous, contradictory and sometimes even unattainable role expectations decide who is in or who is out of the SHP programme, based on their relationship to the receiver of the benefit (social networks). The socially excluded themselves also identified SHP schemes as “something that is not meant for people like us”, as a way of coping with a situation of often prolonged deprivation over which they have very limited or no control or power.

These results suggest that limitations in the design of SHP schemes inadvertently serve to reinforce rather than overcome deeply embedded processes of social exclusion. It is important that SHP schemes undertake specific reforms to become more socially inclusive. These reforms may include designing more socially inclusive information, education and communication campaigns, improving targeting by focusing on social inclusion, strengthening local scheme administration in a way that focuses on socially excluded groups and areas, improve purchasing mechanisms and ensuring that SHP schemes are adequately resourced.

Project Context and Objectives:
There has been a recent proliferation of health financing reforms in low and middle income countries (LMIC) which aim to introduce prepayment at affordable prices for vulnerable populations. However, while such reforms have led to increased utilization of health care, it is often the case that the poor and informal sector workers continue to be excluded from coverage. The Health Inc. research project put forward the hypothesis that social exclusion is an important cause of the limited success of recent health financing reforms. Firstly, social exclusion can explain barriers to accessing health care due to disrespectful or discriminatory practices of medical professionals and their organisations, within the context of poor accessibility and quality of care. As a consequence, removing financial barriers does not necessarily guarantee equitable access to health care. Secondly, social exclusion can explain barriers to accessing the health financing mechanism itself. Differential access to information, bureaucratic processes, complex eligibility rules and crude and stigmatizing criteria for means testing prevent socially excluded groups from enrolling in financing schemes, even if they are fully subsidised. Social inclusion, by contrast, may explain why more powerful, wealthy and vocal groups disproportionately ‘capture’ the benefits of publicly funded health care.

To explore whether social exclusion is in fact limiting the success of health-financing reforms, the Health Inc project undertook primary research in a number of geographical settings on a variety of social health protection schemes. In two states of India, Maharashtra and Karnataka, research was conducted on the RSBY (RashtriyaSwasthyaBimaYojana) insurance scheme for below poverty line families. In West Africa, the National Health Insurance Scheme (NHIS) in Ghana and the Plan Sesame exemption scheme for older people in Senegal were investigated. These locations provided ideal settings for the research as they are all experimenting on a large scale with a variety of financing mechanisms that offer tax funded subsidies to indigents and vulnerable groups and/or contributions set at a low, supposedly “affordable” price. Mixed methods research techniques were utilised in these settings to analyse whether different types of financing arrangements overcome social exclusion and increase social inclusion by empowering marginalised groups.

The main research questions addressed by Health Inc are:

i. a. What does social exclusion mean and how is it understood by stakeholders in LMIC?
b. What are the indicators of social exclusion in LMIC?

ii. How have the health care financing arrangements studied influenced social exclusion?

iii. Can anything be learnt about the influence of social exclusion on health care financing from a cross-country comparison of health care financing arrangements studied?

iv. What is the potential of policy makers in health and other sectors for reducing social exclusion in health care financing arrangements?

v. What are the reasons for the limited success of the health financing arrangement in providing free or “affordable” access to care in LMIC?

The project additionally sought to:
a. Contribute to the international debate and knowledge base on health financing in LMIC
b. Increase the capacity in health systems research of LMIC partners
c. Develop and disseminate widely applicable research methods for studying social exclusion in health systems in LMIC
d. Develop and disseminate widely applicable policy tools for increasing social inclusion and avoiding social exclusion in health systems in LMIC

Project Results:
The Health Inc project studied social exclusion from social health protection (SHP) mechanisms in three different countries (Ghana, India and Senegal). It also covered several different contexts, including two states in India (Karnataka and Maharashtra) as well as both urban and rural study sites across the various countries and states. These diverse contexts were all studied using the Health Inc methodology, whose backbone is the ‘SPEC-by-step tool’. This tool proposes a step-wise approach to evaluate how inclusive/exclusive health financing arrangements are, and identifies the mechanisms that shape and maintain social exclusion. Our stepwise deconstruction enabled us to study who was excluded at each implementation step – from being aware of a scheme through to enrolment, receiving membership cards, utilising health care and receiving financial protection – and how and why this exclusion occurred in the social, political, economic and cultural domains of social exclusion. It follows the flow of people through the scheme and is essentially people-centred, not resource-centred. This common methodology was designed to facilitate comparison across the various contexts studied.

Step-wise comparative summary of Health Inc results

i. The “awareness” step

Ideally, all targeted (or eligible) people become aware of a SHP programme. However, the Health Inc project found that in practice this is rarely the case. In several cases, much of the target population was completely unaware of the SHP programme. Furthermore, even among those who were aware or were enrolled, the depth of awareness was variable. Indeed, the project found that “awareness” has several different components or levels and that very few target beneficiaries were informed about the full range of benefits available to them. In general, the SPEC-by-step tool assumes awareness of the scheme to be a prerequisite for using the scheme and benefiting from it. However, it should be noted that although we use it as “step one”, awareness of an SHP programme can also happen at a later step, for example at the time of utilisation when those who go to a hospital are informed of an exemption or insurance scheme by a health worker.

In Karnataka, 49% of eligible households were completely unaware of RSBY (had never heard about the scheme and never seen the RSBY card). Among those who had heard of the scheme, awareness about the details of the scheme was patchy, illustrating that the concept of “awareness” needs to be unpacked. Three broad levels were identified: those who were minimally aware (41%), those with broader or more comprehensive awareness (9%) and those with in-depth awareness of the scheme (less than 1%). Households belonging to Scheduled Tribe (ST) communities that did not speak the state’s official language, resided far from government health centres, and reported poor local political participation were among those less likely to be aware of the scheme.

Awareness was even lower in Maharashtra, where 70% of the sample (again consisting only of eligible households) reported that they did not know about RSBY. Only 4% were found to be “fully aware” of all the components of the scheme. Urban households had a considerably lower level of knowledge than their rural counterparts, while female-headed households and households with an uneducated head were also less likely to receive information about RSBY. Of enrolled households, 20.5% did not know anything about the provisions of expenditure allowed under the scheme, only 29.0% knew about hospitalisation benefit, 33.7% knew about hospitalisation benefit up to INR 30000 per year and only 16.8% were aware of the additional benefit of claiming travel expenses.

Seeking to understand this low level of awareness of RSBY, the Health Inc project found that although in principle the insurance companies and third party administrators (TPAs) are primarily responsible for awareness generation in the community, in practice they greatly relied on Gram Panchayat (local authority) members for making eligible beneficiaries aware of RSBY. In both Karnataka and Maharashtra, this over-reliance on Gram Panchayat members for IEC (information, education, communication) left enormous scope for exclusion of households from knowing about RSBY. Local officials at the Gram Panchayat office did not consider RSBY to be their department’s work and therefore little priority was given to RSBY-related activities. Second, access to information about the RSBY enrolment camps largely depended on the political contacts and networks of households and hence the chances of getting information were low for those not associated with the Panchayati Raj Institutions (PRI). In part, this was because Gram Panchayats were given very little notice to inform beneficiaries (1-3 days instead of the 1 month that the guidelines stipulate). As a reaction to this they informed the people they knew, who lived close by and frequented the office.

A similar pattern emerged in Senegal, with 49% of the elderly sampled not informed of the existence of Plan Sesame. Among those who were informed, 67% did not know basic details about Plan Sesame, such as the services offered by the Plan. However, those working in the formal sector were relatively advantaged in terms of awareness.

The NHIS in Ghana is ostensibly the exception in terms of awareness; the Health Inc survey revealed that awareness of the existence of the NHIS was 100%. However, when questioned about details of the scheme, similar issues emerged as in the other case studies, since many people did not understand the principles of the NHIS. For example, around a third of respondents to the household survey in Ghana agreed with the statement that “health insurance is something for the poor”. Additionally, stakeholders interviewed about the NHIS said that men often believed that health insurance is meant for women and children. Yet the scheme is in principle mandatory and targeted at the entire Ghanaian population. However, this lack of awareness may not be related to social exclusion per se, and rather be caused by other limitations of the IEC campaign.

These findings point to serious difficulties in designing and implementing effective IEC campaigns across all three SHP programmes studied. Health Inc research into who was excluded from the awareness step and why points to distinct patterns of inequity in both Senegal and India.

ii. The “registration” or “enrolment” step

Health Inc results suggest that of those eligible for and aware of the programme, not all register (or enrol, according to the particular terminology).

In Karnataka, 77% of aware households were enrolled in RSBY. This implies that only 39% of the total 6040 households surveyed were enrolled in the scheme. A number of operational issues prevented people from enrolling, such as the short notice given to both local organisers and beneficiaries about the enrolment camp, misinformation spread about the enrolment procedure caused by a lack of training of organisers and, as in the awareness step, over-reliance on Gram Panchayats in the enrolment process. Since the enrolment camp was organised on a particular day and time, people who were likely to be unavailable such as casual-wage workers or migrants had little opportunity to enter the scheme. Indeed, the one-time enrolment camp implicitly assumes that the beneficiaries don't have work, family or educational commitments. Perhaps therefore it is unsurprising that households headed by women, the elderly, households that are large in size (more than 5 members), in the lowest economic quintile, and households from Scheduled Caste and Scheduled Tribe communities were less likely to be enrolled.

Similarly in Maharashtra, it was found that only 22% of households in the entire sample of eligible below poverty line (BPL) households were ever enrolled in RSBY. The results suggest that male-headed, non-labourer households, households belonging to majority religion and those residing in urban areas and from Vidharbha region were less likely to be included in RSBY. The results on rural / urban differences in Maharashtra are striking - the enrolment rate was considerably higher in rural areas (27%) than in urban areas (13%). This is contrary to the results from the other Health Inc research sites. One explanation might be that insurance companies have an incentive to focus on the rural areas (according to the Insurance Regulatory and Development Authority (IRDA) regulations they are supposed to meet the rural sector obligations by earning at least seven percent of their premium revenues from rural areas). The likelihood of reporting enrolment was much lower among single-member households than joint and extended families. Households that did not know any influential person were less likely to be enrolled in RSBY than those who did know such people. Those who expressed lack of trust in institutions were significantly less likely to be enrolled in RSBY. The qualitative evidence points to the following reasons for low enrolment rate: flawed BPL lists, corruption and nepotism, death of the head of the household, movement of large population to other places, seasonal migration for work, lack of administrative support on the ground, cost of enrolment, no compulsive mandate on the insurance company to achieve a higher enrolment rate, limited and inflexible time span of enrolment process and ineffective oversight by the Department of Labour.

Ghana again ostensibly seems to be the exception, with nearly 73% of household members in the sample having at some time registered with the NHIS. This can probably be attributed to the high level of awareness of the scheme, as compared to the other research settings. However, dropout was a major problem in the Ghanaian NHIS, with around 20% of those who had ever enrolled failing to renew their membership. Our survey found around 54% of household members were active NHIS members (currently insured) during the survey; official statistics report that active (current) membership is much lower, at only at 36% of the population. We found that around 44% of those who had dropped out complained that the premium and the registration fees were expensive. The next most common reason cited was not falling sick and therefore not needing the insurance. Economic status was similarly a major determinant of why some people had never become insured. The never-insured also lived further away from educational, health and transport infrastructure and services than those who had ever been insured. Furthermore, a higher proportion of the never-insured felt their concerns, questions and feelings were not taken seriously by medical staff and a lower proportion of the never-insured strongly agreed that they were treated with respect at the health facility. Some individuals had withdrawn their membership from or decided not to enrol with the NHIS because of a lack of trust in the scheme and bad experiences with health professionals in the past.

In Senegal elders are not required to “enrol” in Plan Sesame. However, they are required to present a national biometric identity at health facilities to get the exemption. We therefore considered elders to be enrolled if they had a valid card and also were aware of Plan Sesame. Health Inc found that the requirement to possess an ID card was not a major barrier to enrolling in Plan Sesame. Almost all those who had heard of the scheme also had a card (48% of the sample was “enrolled”). Being male, being a household head, having some formal education and living in urban areas all increased the odds of enrolling in Plan Sesame by almost twofold. Belonging to the majority ethnicity also increased the odds of enrolling. Strong evidence of adverse selection was found, with those hospitalised in the last 12 months being 1.8 times more likely to enrol. With regard to sociocultural variables, elders who were not members of sociocultural associations were less likely to enrol. The results show that elders belonging to richer households were significantly more likely to enrol in Plan Sesame. Also, elders who were vulnerable in all dimensions of social exclusion (using a social exclusion index) had lower odds of enrolling in Plan Sesame. These patterns point to social exclusion in Plan Sesame enrolment and are explained in more depth in Section 2 below.

In sum, current enrolment rates in all three schemes studied were low, never exceeding 55% of the sample. Difficulties with administrating the schemes were the main causes of these low enrolment rates; however, these difficulties seemed to affect some social groups more than others.

iii. The “membership card” step

Many SHP programmes, including RSBY and the NHIS, are supposed to provide those who enrol or register with a membership card. These programmes also require periodic renewal of the card. However, Health Inc found that not all people who register in a programme receive their card on time and that some people don’t receive it at all. As such, renewal confronts potential beneficiaries with the same difficulties as enrolment, again and again. However, compared to the previous steps (awareness and registration or enrolment), this step seemed to be a less serious barrier to roll-out of the SHP programmes studied.

In Ghana only around 6% of those who had registered had not received their card.

In Karnataka, 16% of registered households did not receive the smartcards needed for utilising the scheme. Some local administrators or health workers reported poor incentives with high workload and at times, non-payment of incentives as reasons for being disinterested in actively distributing the cards. Known social contacts and those who proactively asked were given the cards, but those who did not seek out the cards often were not sought out. In some villages, beneficiaries reported that the local administrators used the cards as leverage to extract unpaid dues and, in some cases, bribes. Casual wage workers and those in Scheduled Caste and Scheduled Tribe communities also reported that at various instances local authorities verbally abused them (for being poorly dressed or illiterate) when they asked for their cards.

In Maharashtra, of the currently enrolled households, 5% did not possess smart cards. The analysis of survey data reveals that technical problems were reported by 37% of the respondents as a reason for not getting the smart card. A third of respondents said that they did not know why they had not received the card. Delay in distribution of smart card was consistently reported in almost all focus group discussions.

Furthermore, in RSBY our research revealed that in addition to problems obtaining cards, some households experienced problems enrolling all eligible members of the household onto the card. Overall, only 57.5% (6,140 out of 10,704) of household members belonging to card-holding households reported to be registered on the card. This is a limiting factor of the design of RSBY, as benefits can be availed only by those household members who have their name and relevant information (photographs and thumbprints) registered on the card (up to a maximum of five members per household). Only 51% of small sized households (up to 5 members) and 38% of large households (more than 5 members) were fully covered (all 5 members enrolled).

Our data suggest that gender, age and relationship to the head of household determine one’s chances of being enrolled. Granddaughters and the daughter-in-law of the oldest male member were most often excluded from RSBY. In most instances, the highest earning member of the household (usually the oldest son) would take decisions on the family's expenses and inclusion in welfare schemes. These gender differentials are discussed further in Section 2 below.

These results suggest that specific procedures used for distributing membership cards created barriers to fully enrolling intended beneficiaries in SHP, particularly in the case of RSBY where, for example, the enrolment limit of five members per household was exclusionary in its very design. As in the previous steps, social drivers (such as gender and tribal status) and political drivers (such as lack of political networks) seem to play a role in preventing full implementation of the scheme.

iv. The “accessing care” step

Being enrolled or registered in an SHP programme with a valid membership card should in principle ensure access to health care for the beneficiary. The “accessing care” step was difficult to study due to small sample sizes. However, Health Inc found that while the SHP schemes studied did improve access, in some cases cardholders did not visit a service provider and request services, despite having a health problem that merited them doing so.

In Karnataka, among registered members in card-holding households, the annual hospitalisation rate was calculated to be 42 per 1000 while that among the non-registered was 34 per 1000. This difference is statistically significant, and reflects higher access to hospitalisation among registered members.

Similarly, in Ghana around two-thirds of the insured who reported ill in the last two weeks sought care from formal health care providers, compared with only around half of the never-insured. One of the main aims of the NHIS scheme is to improve access to healthcare and this could be an early indication of the success of this policy intervention. Yet one-third of the insured did not seek formal care. The main reason given for this was that the illness was not considered serious, but a small percentage (around 5%) cited “high cost of seeking healthcare”, suggesting that the insurance did not successfully remove all financial barriers.

In Senegal, some elders did not use Plan Sesame despite being informed of its existence. One reason given for this was a high level of distrust in Plan Sesame and in those who initiated it.

In short, despite the numerous barriers encountered at each preceding step, overall the SHP programmes did seem to enhance access to health care for those who were registered or enrolled. However, even for members of the schemes who were in possession of the necessary ID card, the SHP programmes did not overcome all barriers to utilisation.

v. The “benefiting from the scheme” step

When utilising health services, members of an SHP programme should receive care for free or at a greatly reduced cost. However, Health Inc found that not all those who claimed health services received the benefits as stipulated by the programme.

In Karnataka, a total of 264 hospitalisations were reported in six months among the registered members. Only 33 (13%) of those hospitalised benefitted from the scheme. None among them reported a cashless experience implying that all the beneficiaries incurred some out-of-pocket health expenditure with a median of Rs. 5500 (approx. 100 USD, Rs. 30 – 34,500). The reported expenditure was mainly on medicines and diagnostic tests conducted outside the hospital. Nearly two-thirds of the hospitalised did not visit an RSBY-empanelled hospital, making this the main reason for not benefitting from the scheme. This can be explained in part by the finding that only 11% of households got the leaflet with the list of empanelled hospitals at the enrolment camp. Ten percent tried to use the card but the hospital refused it. Another 12% forgot to take the card with them in an emergency, while a few others went to an empanelled hospital that did not treat their particular illness. As per the results on awareness summarised above, most beneficiaries were unaware of where to go or how to use the scheme. For some beneficiaries, having social contacts in or related to the hospital facilitated accessing services and hence the scheme.

Similarly, in Maharashtra, among the households with valid RSBY card with at least one hospitalisation case in the one year prior to the survey date, only 12% had used the cash-less services from the listed hospitals of RSBY. The qualitative interviews suggest that lack of information regarding the listed hospitals, inability to recognise the use of the smart card, non-availability of listed hospitals in their neighbourhood and invalid smart card were the leading causes of this poor performance.

In Senegal, only around 10% of the sample was ever treated under Plan Sesame. In part, this low level of utilisation of the scheme was caused by inconsistent funding at the health facility level, which restricted the benefit package to consultations only. As a result, some facilities decided to put Plan Sesame on hold. Most of those who did manage to benefit from the scheme were male, living in urban areas, with higher education levels and having retired from the formal sector.

Similarly in Ghana, there have been delays in reimbursement to service providers under the NHIS scheme, which in turn meant that hospitals experienced stock-outs and patients were not treated under the NHIS scheme as expected. However, only around 5% of those who reported a need for health services did not use care under the scheme.

These results suggest that all three SHP programmes (especially RSBY and Plan Sesame) experienced serious difficulties in achieving their goal of providing health services that are free at the point of use, even for scheme members. This was attributable to inadequate funding and limitations of provider payment mechanisms, and overly complex programme rules and regulations.

Processes of exclusion and socially excluded groups

The previous section focused on the SPEC-by step cascade, in order to summarise findings on the social, political, economic and cultural inequities that characterise the schemes in terms of steps such as raising awareness, enrolment of the target population and utilising health services. This section seeks to summarise the mechanisms of social exclusion that help to explain these patterns.

In RSBY, the reliance on local socio-political networks to inform, organise and distribute cards often led to those without political connections to be excluded from the scheme. In both Maharashtra and Karnataka, tribal communities were a group that was particularly disadvantaged. In-depth analysis in Karnataka helps to explain this pattern. Health Inc identified that the process of exclusion includes the following, possibly overlapping, mechanisms: lack of political networks, political neglect, lack of a political voice, low literacy and education, and social-spatial isolation. The implementation of the scheme was embedded in existing social, economic, political and cultural structures that typically exclude tribal communities. For instance, delegating responsibility to Gram Panchayat members and health workers for creating awareness and organising enrolment camps for RSBY in a village allowed existing perceptions and exclusionary processes to continue unchallenged. In terms of their scattered settlements and small numbers there is a need for increased effort in terms of resources (financial, manpower and time) to reach out to ST households To insurance companies (that get paid a premium for every household enrolled), ST households were largely ‘unattractive’ in terms of the business model of implementation of RSBY. Furthermore, the 5-person enrolment limit per household served to exclude women from RSBY. The women of the household had little to no say in whether they were enrolled. Women of the households accepted the legitimacy of the highest earning male member in making these types of decisions. Women were hardly ever allowed to work outside the home so they were stuck in a vicious cycle of not earning and therefore not feeling worthy enough to make decisions and demand their inclusion in welfare schemes.

In Senegal, being retired from the formal sector constituted a clear advantage to accessing Plan Sesame resources. This advantage is explained by the fact that the lobbying efforts for Plan Sesame were first led by associations of formal pensioners. Moreover, their representatives were involved at the design stage of the programme; this facilitated the spreading of information among the formal sector pensioners. This category was also privileged in the utilisation step. Retirees from the formal sector, both from the public and private sectors, had already experienced formal health coverage during their years of employment. As a result, they had more experience with the standard administrative procedures and personal contacts with health personnel. The exclusion of the informal sector was also structural and rooted in some central features of the programme, i.e. the hospital-centrism which further widened the rural / urban gap. This exclusion was also social: Plan Sesame operated in a system in which social connections are determinant to access health services. Finally, Health Inc also unravelled a worrying phenomenon: the acceptance of discrimination by the "socially excluded". This discrimination has become normative, a phenomenon that often prevented them from utilising health services.

In Ghana, the NHIS premium payment exemption policy also has important limitations. Indigents are supposed to be exempted from making direct financial payments to enrol in the NHIS but, despite this, economic status continues to be a determinant of enrolment. This is in part because few indigents have been registered, due to the lack of a robust methodology for identifying the poor or defining “indigents” in the NHIS. Elders are also exempted from premium payment. However, there is strong evidence of inequity in enrolment of the elderly in the NHIS caused by a combination of economic, political and socio-cultural factors, with elders in the richest quartiles being more likely to enrol than those in the poorest quartile. Women who lived in rural areas and were elderly, widowed, uneducated and from poor households were particularly unlikely to be insured. Though exempted from paying the premium, they still have to pay a registration fee which many may not be able to afford; women dominate the informal economy of Ghana with small businesses and low incomes and due to patriarchal gender relations are in a position subordinate to men in decision-making. They also may not be aware of the exemption package, due to lower levels of education. These results suggest that, as with RSBY and Plan Sesame, the very design of a scheme (in this case a complex and incomplete exemption policy) may undermine the principles of SHP and cause exclusion of those who are most in need by failing to take into account underlying socially and culturally embedded barriers.

In sum, overall across all three schemes, we found that despite their intention to cover poor and vulnerable groups, the SHP schemes disproportionately benefited those who were socially, politically, economically and/or culturally privileged. Numerous mechanisms caused the processes of social exclusion that resulted in the exclusion of vulnerable groups. At the national or state level, these include the power of “gatekeepers” who are influenced by the political currents and policy priorities that are dominant at the moment of conception and can result in the political interest for or neglect of a certain population group. Meanwhile at the local level, “street level bureaucrats” confronted with unavailability of resources and ambiguous, contradictory and sometimes even unattainable role expectations decide who is in or who is out of the SHP programme, based on their relationship to the receiver of the benefit (social networks), passive exclusion on an unintentional basis due to poor information, or at worst, greed and corruption.
Another mechanism observed was “network diffusion” where the social networks of the targeted population groups raised the thresholds for collective behaviour, due for example to a lack of trust in the institutions providing the SHP programme. A further mechanism identified was “cognitive dissonance” or “adaptive preference formation”, where the people who were targeted by the SHP scheme talked about it as “something that is not meant for people like us”, as a way of coping with a situation of often prolonged deprivation over which they have very limited or no control or power. A further mechanism was “discounting”; in the target population, the future benefits of the SHP programme are strongly discounted in favour of the more pressing, daily needs. Therefore, even if the scheme has no direct cost such as a premium payment, due to badly designed enrolment processes the opportunity cost of enrolling was so great that it created an insurmountable barrier to those who relied on daily wage labour for example.

These results suggest that limitations in the design of SHP schemes inadvertently serve to reinforce rather than overcome deeply embedded processes of social exclusion. While SHP schemes cannot be expected to undertake profound social, political, economic and cultural transformations without broader inter-sectoral government and social action, there are specific reforms that SHP schemes could undertake to become more socially inclusive. To this end, Health Inc has developed a set of policy recommendations that apply to the three schemes studied, but may also apply to SHP more widely.

Potential Impact:
Potential implications: Lessons learnt, and Policy recommendations

Health Inc results suggest that limitations in the design of SHP schemes inadvertently serve to reinforce rather than overcome deeply embedded processes of social exclusion. While SHP schemes cannot be expected to undertake profound social, political, economic and cultural transformations without broader inter-sectoral government and social action, there are specific reforms that SHP schemes could undertake to become more socially inclusive. To this end, Health Inc developed a set of policy recommendations that apply to the three schemes studied, but may also apply to SHP more widely.

International policy recommendations

i. Design more socially inclusive information, education and communication campaigns for SHP
• Health Inc has highlighted the need for extensive educational and public awareness programmes to improve the perception of SHP programmes and the principles underlying them, to encourage more people to register or enrol, and remain registered or enrolled. These need to be tailored to specific sub-populations. They need to take into account illiteracy and other barriers experienced by socially excluded groups. Some ideas include:
o Developing creative and meaningful IEC campaigns that make the scheme relevant to people’s lives with messages that resonate with the sociocultural context and take illiteracy into account. This approach recognises that the problem is not that the targeted group doesn’t look for the right information, but rather that the information is out of their reach. This takes into account the underlying social context of a low level of education, rather than pointing to a lack of interest or understanding in the target population.
o Identifying and mapping known excluded groups will help target IEC initiatives. This will ensure that IEC campaigns are tailored to the specific community and, in special cases, even design new material and strategies to help include these groups or areas.
o Increasing the frequency of IEC campaigns, especially in areas of known excluded groups, making it part of the everyday conversation. Campaigns should become more detailed over time, to help ensure an appropriate depth of awareness about the objectives and functioning of the scheme (e.g. eligibility, benefits etc.).
o Designing multiple strategies and media channels for delivering the IEC campaigns to ensure that beneficiaries can access information about the scheme despite their social, political or educational profile. To this end, various relevant government ministries and departments should be involved in disseminating information about SHP to socially excluded groups with which they may interact (e.g. Department of Welfare).

ii. Strengthen local scheme administration, focusing on socially excluded groups and areas

• In each locality (e.g. district), designate an existing local centre such as the sub-centre or specific NGOs as a permanent resource centre for the SHP scheme where all relevant information is available throughout the year for beneficiaries.
• District level stakeholders should come together and review the plan or guidelines set by the state and adapt it to their own district, taking social exclusion into account.
• Geographical exclusion is a serious issue for the programmes studied. Therefore:
o registration centres should be more accessible and transportation facilities should be provided in areas excluded because of their physical distance.
o at the same time, in contexts where urban households are found to be disadvantaged, socially excluded groups in these areas also need to be targeted.

iii. Increase the capacity of and incentives for scheme staff to enhance social inclusion

• Provide training to stakeholders on the purpose of the programme and on existing structures and processes that cause social exclusion of the target group, in order to enhance the motivation of stakeholders to counteract social exclusion via SHP.
• Employ relevant stakeholders such as civil society organisations, NGOs and researchers to help design programmes and implementation processes of an inclusive nature. This would involve providing the training and mandate to identify beneficiaries, assist in enrolment, liaise with the local authority on behalf of beneficiaries and so on.
• Provide incentives and possibly penalties to local stakeholders to identify vulnerable households or communities and ensure their participation. These could be financial or non-financial.

iv. Improve purchasing mechanisms and ensure SHP schemes are adequately resourced

• Improved financial reimbursement systems and sufficient resources are needed to ensure that providers are able to deliver services, in order to ensure correct functioning of the scheme and prevent dropout. Without this, implicit rationing will take place, disadvantaging the socially excluded.

v. Improve targeting by focusing on social inclusion

• If exemptions and targeting are to be used in SHP, there is a need for more robust definition and identification of who is eligible, using the conceptual framework of social exclusion.
• Having established the target group, people who qualify for the SHP programme must be conscientiously identified and assisted to enrol and access care. Processes are needed to counteract existing structures that promote social exclusion. These might include:
o focused monitoring systems and financial incentives to include socially excluded groups.
o investment in more politically neutral processes which prevent local politicians and leaders from becoming the only gateway that determines who is enrolled and who is not. Instead, multiple channels are needed to allow the target groups access regardless of their local socio-political standing.
o enrolment centres should be conveniently located and open throughout the year, not just on certain days or annual events.

vi. Devise socially inclusive complaints procedures

• The state needs to provide transparent avenues for socially excluded groups to register complaints and get information about their entitlements. One possibility would be to enlist trusted civil society or non-governmental organisations as independent regulators to ensure that information and welfare schemes reach excluded groups.

vii. Consider removing enrolment as a step in SHP programmes

• Enrolment and awareness created the greatest barriers to health care utilisation in the SHP programmes studied. In light of this, policymakers should consider removing enrolment as a step in SHP programmes. Making inclusion an explicit objective and keeping the social mandate at its core would take SHP closer to fulfilling its overarching aim and negate the need for the enrolment step. Omitting this step would also allow resources and efforts to be channelled into creating much needed awareness about the schemes and improving monitoring processes. In SHP programmes where enrolment aims to raise revenue for the scheme, alternative revenue sources such as taxation should be considered. This has occurred in Ghana. In SHP programmes where enrolment is supposed to be used to identify eligible or exempted groups, other existing means of identification could be used, such as national ID cards (as in Senegal), existing membership of other types of social protection schemes, diagnosis of a particular disease or condition (e.g. exemption for pregnant women in Ghana), geographic area, profession / source of income, or attendance at another institution (such as schools).

viii. Supply-side measures to improve the delivery of health services

• Improvement in availability of high quality health services is needed, especially in rural communities. Without this, SHP programmes cannot achieve their goals.

Taken together, the proposed reforms represent a formidable challenge for SHP programmes. Yet without these improvements, SHP programmes such as the NHIS, RSBY and Plan Sesame will not succeed. Purchasing health services effectively to ensure that funds are available at the provider level is another key reform needed in all the schemes. Again, the details of these reforms are beyond the scope of Health Inc. Meanwhile, Health Inc has shown that socially inclusive, administratively simple forms of targeting as well as tailored IEC to inform targeted beneficiaries of free or subsidised services are crucial reforms needed to expand coverage which require considerable investment and capacity building. These should be key areas of intervention for policymakers, with the goal of contributing to profound social, political, economic and cultural transformations needed to overcome deeply embedded processes of social exclusion. If countries do decide to persevere with the steps of enrolment and providing SHP cards to beneficiaries, these processes similarly need to be underpinned by considerable investment and capacity building in order to overcome deeply embedded processes of social exclusion.

Influencing policy

The Health Inc project took active steps to engage policy makers in order to translate research into policy. In the last year of the project, policy options that had been developed based on quantitative and qualitative data analysis were presented to policy makers and other key stakeholders in all study sites with the objective of agreeing on feasible and realistic policy options.

In Banagalore, Karnataka, IPH held a one day dissemination workshop on 23rd August 2014. The workshop contained 46 participants representing scheme beneficiaries, researchers, Civil Society and Government. The discussions and points raised directly influenced the final list of feasible policy recommendations that were proposed at the end of the study to help make health protection programmes more inclusive.

In Maharashtra a stakeholder workshop was held on 17th October 2013. There were 19 participants for the workshop consisting of academicians, officials of a new insurance scheme called RGJAY (Rajiv Gandhi Jeevandayee Aarogya Yojana) that is currently being implemented in the state and public health activists involved in betterment of health system in Maharashtra. Participants were actively involved in the discussion and discussed feasible recommendations for other SHP schemes that may be introduced in the state.

In Senegal, CREPOS undertook focus group discussions, interviews and a workshop with stakeholders to discuss practical and appropriate recommendations for the improving the capacity and inclusiveness of Plan Sesame. These activities took place between 24 June 2013 to 16 July 2013.

In Ghana a stakeholder workshop was in August 2014. Stakeholders included representatives from the National Health Insurance Authority, Ghana Health Service, academics from the University of Ghana, representatives of Coalition of NGOs in Health, Pharmaceutical Society of Ghana, Parliamentary Select Committee on Health, Christian Health Association of Ghana, Ghana Medical Association, Ministry of Employment and Labour Relations and other private consultants.

The stakeholder consultations in all study sites were highly successful in actively engaging policy makers. They resulted in the development of a number of policy briefs that contained feasible policy recommendations for improving the inclusiveness of social health protection in low and middle income countries.

Dissemination Activities

Results from the Health Inc project have been disseminated both nationally and internationally through a variety of methods:

• Two Health Inc films have been produced to publicise the findings of the project from Ghana and Senegal. The films can be accessed from youtube at:


• Two peer-reviewed open access articles have already been published, with a further 10 articles at various stages of development (please see Second Period Report for details). The articles already published cover both West Africa and India. References for the articles are as follows:
1. Parmar D., Williams G., Dkhimi F., Ndiaye A., Ankomah FA., Arhinful DK., Mladovsky P. 2014. Enrolment of older people in social health protection programs in West Africa – Does social exclusion play a part? Social Science & Medicine. Volume 119: 36-44, Available at:
2. Ghosh, S. Publicly-Financed Health Insurance for the Poor. Understanding RSBY in Maharashtra. Economic and Political Weekly. Vol - XLIX No. 43-44. Available at:
• Two books have been published and are freely available to the public via the Health Inc website. The first book was published in English, covers results from the entire project and contains national and international policy recommendations for Social Health Protection Schemes. The second book is published in French as part of the ‘Francopush’ strategy of the project and covers results and policy recommendations applicable to Social Health Protection for older people in West Africa. References for both books are as follows:
1. Health Inc Consortium. 2014. Towards equitable coverage and more inclusive social health protection. Antwerp: ITG Press. Available at:
2. Ndiaye, A.I. et Ba, M., (sous la dir. de). 2014. Les personnes les plus âgées en Afrique. Santé et inclusion sociale. Dakar: Editions Crepos. Available at:
• A number of policy briefs have been developed and submitted to the EC via ECAS, Four first round policy briefs were presented to scheme stakeholders in the four countries/states as part of the stakeholder dialogues
• Two Health Inc organised sessions were held at international conferences including the AfHEA conference in Nairobi in March 2014 at the Third Global Symposium in Health Systems research in Cape Town in October 2014
• Multiple presentations were given at a number of conferences including:
o The Second Global Symposium on Health Systems Research, Beijing, China.
o The Health Systems in Asia conference in Singapore in December 2013
o The consortium presented five posters and were awarded the Social Science and Medicine prize for best posters
o Health districts in Africa: Progress and Prospects: 25 years after the Harare Declaration, Dakar, Senegal in October 2013
o 10th World Congress of the International Health Economics Association iHEA in Dublin July 2014
• A final Health Inc conference was held on 28-29th October 2014 in Antwerp, Belgium, where final results from the project were discussed. This conference was attending by approximately 90 experts in social exclusion and/or health financing in low and middle income countries from both research and policy making
• At the country level, partners have been active in meeting and discussing results with stakeholder groups and policy makers involved in the design and implementation of the social health protection schemes under study.

The Health Inc project has been publicised in a number of blog entries:

• CREPOS presented the results of Health. Inc research and distributed the French Health Inc book at the national level and in the West African sub-region as part of the Francopush strategy for the project. Stakeholder participation in these activities was good and the local press reported information from the meetings in the national media. Workshops were held in Niamey (Niger), Lome (Togo) and Bamako (Mali). The Francopush strategy proved to be very successful and provided the foundation for the formation of a multi-country network that will focus on researching aging issues in West Africa; this network will consist of civil society, public facilities and research centers.
• TISS presented at a number of locations in the USA, including the Universities of Louisville, Minnesota and Texas A & M and the headquarters of Management Sciences for Health. These presentations disseminated Health Inc findings to a large audience of public health and health policy researchers and helped raise awareness of European Funded research in the USA

Further details of the publications and dissemination activities listed below can be accessed via the project website,

List of Websites:

Coordinator (partner 1): LSE Health, London School of Economics and Political Science, UK. PI: Alistair McGuire,
Partner 2: Institute of Tropical Medicine, Antwerp, Belgium. PI: Bart Criel,
Partner 3: Tata Institute of Social Science, Mumbai, India, PI: Harshad Thakur,
Partner 4: Institute of Public Health, Bangalore. PI: Deva Nevadasan,
Partner 5: CREPOS, Senegal. PI: Alfred Ndiaye, alfred@refer.senegal
Partner 6: ISSER, University of Ghana. PI: Felix Asante,