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Central University of Tamil Nadu 
Neena Elezbeth Philip 
Corresponding Authors:
Neena Elezbeth Philip 
DOI #: 
Service Coverage and Financial Risk Protection Among Urban Poor Under Tamil Nadu’s Voluntary Government-sponsored Health Insurance Scheme 
eSocialSciences and Humanities (eSSH) 
CMCHIS, Coverage, Health Insurance, Health Utilization, Financial Risk Protection, Out-of pocket Expenses, Service Coverage 
Providing financial risk protection (FRP) to the poor and vulnerable population by preventing the incurrence of Catastrophic Health Expenditure (CHE) is critical to achieving Universal Health Coverage in any country. The World Health Organization has endorsed the ability of pre-payment financing mechanisms such as Social Health Insurance (SHI) to provide FRP and to improve access to healthcare for the poor. The state of Tamil Nadu in India introduced one of the early state- sponsored health insurance programmes in 2009, known since 2012 as the Chief Minister’s Comprehensive Health Insurance scheme (CMCHIS). The scheme covers lowincome households for hospitalizations. In this paper we examine the extent to which CMCHIS has enabled urban poor households to meet all their healthcare needs without the risk of incurring CHE. We conducted a ten-month longitudinal study of 600 urban- poor households, selected using multi-stage random sampling, in the Kanyakumari district of Tamil Nadu. We categorized the poor households into four, based on their socioeconomic status: very poor, poor, marginal and vulnerable. Four waves of data were collected at zero, one, six and ten months, from six wards of two municipalities. Healthcare needs of the household were defined as any household member having chronic disease, seeking out-patient care (acute morbidity) or in-patient care (hospitalization). Out of the 600 households 300 (50 per cent) households had one or more healthcare needs during the tenmonth study period. Only 13 households out of the 138 (9.4 per cent) had all the hospitalizations in their households fully covered by CMCHIS, and a vast majority (113 or 81.9 per cent) had no member or episode of hospitalization covered. Households that were identified as Above Poverty Line (APL) by the government; and the marginal and vulnerable households with a relatively better economic status among the poor, were more likely to have service-coverage as compared to Below-Poverty-Line (BPL) households and very poor and poor households. Single episodes of hospitalizations with fewer days of admission in hospital were more likely to be covered by CMCHIS. Almost 64 per cent of the households with hospitalizations incurred catastrophic health expenditure, with a mean OOP of Rs 34,700, and the range was Rs 1560- Rs 7, 35,600). More than one-fourth of the households with CHE were APL card holders (28.8 per cent). Twenty-two households used CMCHIS and had hospitalizations and of these, 15 (68.2 per cent) had CHE. Only seven households enjoyed Financial Risk Protection by using CMCHIS. More than one third (33.7 per cent) of the households spent more than 100 per cent of their capacity to pay to take care of the health-related expenses. More than four-fifths (83 per cent) of the households with hospitalizations used distress financing mechanisms like sale of assets, un-secured loans, gold loans, mortgage of assets, mortgage of land or assistance / gift to meet the healthcare expenses. This study indicates that even in a context of high availability of public and private sector health facilities and high literacy, the CMCHIS, which has a relatively higher utilization rate and one of the best benefit packages in the country, offered little service coverage with very poor financial risk protection to low income populations. This study suggests the need for careful reconsideration of the shift to a predominantly health insurance- based healthcare system in the current Indian setting 
Entered by:
Neena Elezebeth Philip on 2020-09-03 
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