Health insurance for world's poorest

Bihar is one of India's poorest states. Situated in the country's northeast, Bihar is neatly bisected by the Ganges river which flows west to east through the state. Its biggest city, Patna, is on the river's south bank.

If you set out from Patna and cross the river by way of the five-kilometer-long (3.1-mile-long) Mahatma Gandhi Setu bridge, drive north along Highway 22 for about an hour, and then take a right onto Mahua Road, in another half hour or so you will arrive in the village of Gorigama, in the district of Vaishali.

It's a place David Dror knows well. "I spent 10 years in India, starting in 2005," he told DW. "My team was in Vaishali several days each month for five years. We started the field work for the community-based mutual health insurance fund in Gorigama in 2009, working with an NGO called Nidan. We launched the fund in 2011."

At meetings with rural people in Gorigama and many villages like it, Dror and his colleagues patiently engaged in what he calls "insurance education," answering questions from villagers about how local mutual health microinsurance works, discussing its benefits and costs.

Protection against financial disaster

In one Bihar village some years ago, a woman named Bimla Devi told her story to a writer accompanying Dror on a field outing. Devi's son and daughter were both very ill, and she knew they needed health care. "Earlier, if anyone of us got sick, my heart would shake with fear," she said. "What if the doctor wanted some test or medicine that I just could not afford? What would I do then? Do you know how much these things cost? I would have been finished!"

If villagers are uninsured, in an emergency they often either get no medical care, or they borrow money from local money lenders who charge high interest rates. This can generate a downward spiral of permanent indebtedness and hardship, sometimes even forcing them to sell their animals or their land — a disaster for a rural family.

"Attempts to provide health care have been least effective in rural and informal settings where most of the world's poorest people live and work," Dror said. By setting up local savings pools — microinsurance funds — members can avoid becoming destitute if they need medical treatment that they could not otherwise afford without borrowing money. The amounts involved are surprisingly small: "Three to five euros a year per person is a typical pay-in," Dror said. "Yet if a few thousand people join, this small amount can save member families from destitution if there's a medical emergency."

Community-based health insurance (CBHI): How it works

It takes a long time — at least six weeks, and sometimes nearly a year, Dror said — to organize a CBHI. A group of villagers, prompted and advised by a CBHI facilitator, decide whether to set up a local microinsurance scheme, what medical services to cover, and what the cost of joining should be. It's a grassroots, democratic process.

Typically, CBHI schemes cover elements of outpatient care that can have big variations in price, like medical tests and imaging. Health micro-insurance aims to reduce the risk of destitution or dependence on loan sharks.

Not covered by CBHI, in general, are hospital stays (because people believe the government covers these, even if in reality they are often not available), medicines (because they're too expensive), and routine consultations whose price is known and stable.

Local care delivery

Villagers typically do not like to travel long distances to health care centers in town, Dror said, because travel is expensive, stressful, time-consuming and disruptive. The downside is that care-givers in rural areas are often not professionally qualified; they are "unqualified" practitioners. Some are better than others, but on the whole, Dror said, "they're better than nothing," and they have the advantage that they deliver "all included" doorstep services:

Their fee includes services such as diagnosis, setting a broken limb, some medicine or an injection; and if they are uncertain, sometimes they refer a case to a better qualified doctor.

"Even in industrialized countries, there's a shortage of doctors in rural areas," Dror pointed out. "In India or Africa, it's worse. Doctors like living in towns, where their kids can get a good education. So in rural areas, the choice is often between an untrained practitioner or nothing at all."

Dror acknowledged that it would be very good if these informal allopathic practitioners would be given ongoing training in practical nursing by government programs, to improve the quality of the care they deliver. However, doctors' associations tended to oppose this, ostensibly to avoid legitimizing quacks, but in reality, Dror suggested, the real motivation may be to prevent competition. 

Dror's big challenge now is to scale up the microinsurance approach to encompass millions of people, rather than a few tens of thousands as at present. He says that between 1 and 3 billion people in rural India, Africa, and elsewhere could potentially benefit if it were rolled out on a big scale. After 10 years of field work, he knows what works and what is missing.His next target is to establish a program in Africa.

Ethiopia could be next

"About a year ago, in June 2018, I met with Dr. Tedros, director general of the World Health Organization, the first Ethiopian in that post. I offered the WHO help with its activities in support of community-based health insurance," Dror said.

"I have discussed with them preparatory steps, notably the need to educate a cadre of persons that could then work in the field. I proposed that Mekele University should launch an MSc in financing and administration of microinsurance."

In early June of this year, Dror was informed that professor Kindeya, president of Mekele University, and Dr. Hagos, head of the Health Bureau, have agreed to develop an MSc program on health financing to help effective implementation of CBHI in Tigray region, which is home to nearly 7 million of Ethiopia's estimated 112 million people.

In Ethiopia, Dror explained, the CBHI strategy draws on a traditional Ethiopian practice known as Idir, a long-standing system of pooling savings amongst neighbors to have funds available to pay for funerals when member families have deaths. CBHI proponents proposed redirecting some Idir money to life-saving expenses, including costs of basic health care services delivered at local health care centers.

A decade in the field

During the first three years of his field work on CBHI, Dror said, he commuted between Delhi and Europe — he had University duties as a professor in Rotterdam. Then he shifted to living full-time in Delhi for seven years, where he founded the Micro-Insurance Academy. 

Dror is a tall, fit man with a powerful physique; to look at him, you'd say he is about 65 years old. But in fact he is 76. For the past few years, he has lived in Geneva in semiretirement.

Yet he keeps working on promoting the adoption of community-based health insurance, because he has seen with his own eyes that it can make a night-and-day difference to thousands of rural families. His goal is to firmly establish this model of health insurance by seeing at least 1 million people enrolled in CBHI.

"I have to get this done during my lifetime," he told DW in a tone of firm determination, so given his age, his quest is urgent now.