INTRODUCTION
 

Group Insurance is not a new thing to the Adivasis ! Even now in many adivasi villages, whenever somebody becomes seriously ill and needs to be taken to a hospital, there used to be a “collection” among all the houses in that village. With this money, they hire a vehicle and come to the hospital in a group. This kind of ‘sharing the risk’, which is fundamental to any group insurance scheme, had been practised by the tribals for ages ! However, the modern economic systems and lifestyles needed some fine-tuning to their traditional practices. This realisation was the root of the Composite Tribal Insurance Scheme of ASHWINI.
 

BREAKING THE FINANCIAL BARRIER
 

The main objective of the insurance scheme is to break the financial barrier of the adivasi families at the time of illness. We have noticed that lack of liquid cash at the time of illness is one of the most serious barriers to the adivasis, preventing them from getting safe medical care and accessing hospitals. Our challenge was to encourage them to plan ahead and save something for the possible event of sickness in the future. For a community, eking out a day-to-day existence, this was a radical change. Saving for the future itself was a new thing - leave alone for their health needs. But, we were convinced that this had to be done and hence, pursued our idea with the people relentlessly.
 

When Gudalur Adivasi Hospital was started in 1990, we discussed with the village sangams about the financial aspects. On the one hand, none of us wanted the hospital treatment to be totally free as this would not be sustainable in the long run. However, on the other hand, it would be difficult for the adivasi patients to pay the entire costs of hospitalisation. Combining this need for resources with the adivasi tradition of sharing, we arrived at the concept of group insurance. Though providing health care through insurance coverage is a very modern idea, we hit upon the same solution, but through a very different route and rationale.
We approached various agencies including some insurance companies. However, the insurance policies existing at that time were targeting primarily middle and high income people living in the cities. The premiums were high as the claims ran into Lakhs to cover "costly" diseases like heart attacks and bypass surgeries. These policies would be totally inappropriate for the adivasi community where anaemia, malnutrition, safe delivery and care of young children were the major problems.

So, we needed a simple package covering these illnesses. Fortunately, following a long search, we met some enterprising officers of the New India Assurance Company who were willing to design a special package for the adivasis of Gudalur. After more than two years of discussions and negotiations, we were able to design a scheme which would address the specific health needs of our people. We finally launched the composite tribal group insurance scheme in 1992.
According to this policy, for a premium of Rs. 15 per person per year, hospitalisation expenses up to Rs.1500 would be reimbursed by the insurance company. The Adivasi Munnetra Sangam decided to insure all its members. We started by insuring 5000 adivasis in 1992 and the number has risen to 13000 by 2002, as new villages and members join the AMS.
 

POLICY DETAILS
 

To avail of the Group Discount and Long Term Discount offered by the insurance company, ASHWINI insured all the members of the AMS for five years by paying the premium en bloc. In turn, the activists of AMS, including the Health Animators of ASHWINI collect the premium from the members every year. So, in essence, ASHWINI has taken a Policy with the Insurance company for five years, whereas the AMS takes a policy for its members with ASHWINI every year.

 

This arrangement made sense, considering the many restrictions imposed by the insurance company on the diseases covered under the policy, the Rs.1500 ceiling and the delay in the reimbursements. To encourage the tribal patients to seek health care at the earliest and to make the health system more effective, our health care system has to be comprehensive and should provide for all the health needs of the community.   For example, pregnancy related admissions were not covered under the policy during the first seven years. But, one of our major aims was to reduce the maternal mortality and to encourage the tribal women to choose safe confinement.

Policy Highlights (1992-2002)   *  Started : in 1992   *  Membership : About 12000   *  Agency : New India Assurance Co.    *  Annual Premium : Rs.15   *  Claim Limit : Rs.1500   *  Only Inpatient Care

So, even while the insurance company was not reimbursing the expenses of pregnancy related admissions, we continued to provide free treatment to the insured tribal women who get admitted for pregnancy related causes. However, due to our persistent efforts and representations to various authorities including the Finance Minister of Government of India, the policy was subsequently modified in 1997 to include pregnancy related admissions for the 1st and 2nd deliveries ! The table below gives the differences between the policy offered by the company and the scheme offered by ASHWINI for the comprehensive health care of the AMS members.

PREMIUM COLLECTION
 

Insurance collection is a major annual event ! The collection season commences with a meeting of the tribal staff of ASHWINI and the field activists of AMS to decide the premium to be collected from the members that year. Apart from the financial status of ASHWINI, issues like the income levels of Adivasi families and the general economic situation of the Society are considered while deciding the premium.

We started with Rs.2 per person per year in 1992, gradually increasing it every year. We are collecting Rs. 20 per person for the year 2002. The collection period commences on December 5th, a special day celebrated as Adivasi Day by the AMS and goes on till April 14th, another special festival, “Vishu” [New Year]. Depending on the situation each year, the collection period may get extended. In the earlier years, the sangam activists used to go from house to house, from village to village explaining the insurance scheme and collecting the premium. Now, as people are aware of the scheme, they come to the sub-centres to pay the premium.

The exercise of insurance collection is an important aspect of ASHWINI’s health programme, as it keeps the focus continuously on the community. Instead of interacting only with the patients in the hospital, the insurance scheme gives an opportunity for the field workers and sangam activists to interact with all the sangam members, to explain the health programme and to get a true feedback from them.

The percentage of AMS members who pay the premium to ASHWINI has been hovering around 50%. A survey done among the AMS members revealed that the main reason for non-payment of premium was the lack of ready cash during the collection period.

ROYAL SUNDARAM ALLIANCE INSURANCE COMPANY
 

When the policy expired in March 2002, the New India Assurance Company informed us that they were considering a steep increase in the premium from Rs.15 to about Rs.40 per person per year. ASHWINI was not prepared for this precipitous hike, as it was using all its resources to meet the operational costs of the health programme. Subsequently Sir Ratan Tata Trust, Mumbai was approached for financial assistance to pay the insurance premium and we were extremely happy to get a positive response from them in July 2002. After a comprehensive review of our 10 year experience with the insurance scheme and some negotiations, we had designed a new policy with Royal Sundaram Alliance Insurance Company in May 2003.

The Shakthi Shield policy of the Royal Sundaram was redesigned to suit our needs and a new scheme called Tribal Health Shield was launched. This policy is subsequently being renewed every year and the policy features are being modified as per the growing needs of the community. The major highlights of the current policy are :
 

  #  Coverage of Rs.2500 per person per year
  #  No exclusions, except psychiatric illnesses
  #  All deliveries and pregnancy related admissions are allowed.
  #  For delivery related admissions, a ceiling of Rs.1000 is fixed
  #  Premium is Rs.45 per person per year.
  #  Referral claims upto a maximum of Rs.30,000 per year with a ceiling of Rs.2000 per person.
 

During the next few years, our efforts will not only be to consolidate our insurance programme in the sangam villages, but also to share our experience with other charitable organisations working with underprivileged people, so that a larger insurance scheme involving them could be created. Thus our successful experiment with group insurance could spread to other people who wish to address their own health needs effectively . 
 

ADIVASI HEALTH INSURANCE FUND
 

Although we continue to encourage the tribals to pay the premium every year, we need to insure them irrespective of whether they pay the premium or not. This is because ASHWINI has taken the moral responsibility of taking care of all the tribals in this area; thus, when a tribal who has not paid the premium falls sick and comes to the hospital, he is looked after and his expenses are subsidised by ASHWINI. 

In view of this, we have constituted a special fund called the Adivasi Health Insurance Fund. Apart from the premium collected from the AMS members, we are trying to raise money from other sources like individuals, charitable organisations and Government agencies, so that we can pay the insurance premium for all the AMS members. We request your contributions to this Fund. For more details, please go to the Donations page.

Other Resources 

1) ASHWINI's health insurance programme - An article published by us in Economic Politial Weekly
2) Community Health Insurance programmes in India - An article by Dr.Devadasan
3) Community Health Insurance Network - A website with lot of resources and links to community health insurance.

4) Institute of Public Health, Bangalore - A website with more materials and publications related to community health insurance.