Abstract
Background:
Health is a fundamental right of every individual. As lifestyle diseases are becoming more common these days, need for health care services increases. Globally, medical inflation has been on the rise. Even in a country with a robust healthcare system, the unexpected costs of medical emergencies can pose a significant financial burden. Hence, there is a need for health insurance schemes as it provides financial security to the family. Unfortunately, many people remain unaware of the benefits of health insurance, leaving them vulnerable to financial distress during times of medical crisis.
Materials and Methods:
This cross-sectional study was conducted at the Urban Health Training Centre. Adult patients (age ≥25 years) attending the OPD were included. A semistructured questionnaire assessed sociodemographic factors, health insurance awareness, type, coverage, and reasons for nonenrollment. Descriptive statistics and Chi-square tests analyzed associations between sociodemographic factors and health insurance awareness/enrollment. Binary logistic regression identified predictors of awareness and enrollment.
Results:
Above 70% were aware of health insurance. Colleagues were a primary source of information. Lack of awareness was the main barrier to enrollment. Higher education, male gender, and joint family living were associated with greater awareness. Enrollment rates were significantly higher in government employees (P = 0.004), individuals with higher education (P = 0.001), and living in joint families (P = 0.04).
Conclusion:
The study revealed a significant gap between health insurance awareness and coverage. Government-sponsored schemes without premiums and employer mandates were the main reasons for enrollment (36.5%). Lack of awareness, perceived good health, and affordability concerns were the primary barriers to enrollment.
Keywords: Awareness, coverage, health insurance, India, sociodemographic, urban
INTRODUCTION
Health is a fundamental right of every individual. In India, health policies are based on the principle of equity with prioritizing the needs of the underprivileged section of the population.[1] India has a framework of both public and private healthcare systems. Health systems play an important role in determining how health services are delivered and used by the community.[2,3]
In the Indian context, the concept finds its place in the Rig Veda in the form of “Yogakshema” or well-being of the society. The inception of the indigenous insurance sector can be traced back to the year 1818 with a focus on life insurance. Traditionally, individuals in India exhibit a tendency toward risk aversion rather than risk-seeking behavior.[4] The population is aging and India is in the middle of an epidemiological transition with an increase in the occurrence of noncommunicable diseases along with the continuation of communicable diseases. The increased burden of noncommunicable diseases is attributed to changing lifestyles and increased life expectancy.[5] This has necessitated the people to have a re-look on their actual monthly expenditures, spending patterns and simultaneously allocate a proportion of their income toward personal healthcare.
Health insurance serves as a protective mechanism that provides financial security in the event of unexpected medical crises. Health Insurance is one such mechanism that when opted for, acts as a cushion against any health emergencies.[6] Also, it acts like a financial safety net for the family. Many people are not aware of this concept of health insurance thus making them financially vulnerable. Expanding health insurance coverage is crucial for India to improve healthcare access and reduce poverty.[7,8] Although mandatory schemes such as CGHS and ESIS exist for certain workers, and public sector organizations offer employer-based plans, a significant portion of the population remains uninsured. To address this, the government has introduced initiatives such as Ayushman Bharat and Rashtriya Swasthya Bima Yojana to expand healthcare access and reduce disparities.[9]
Although government-initiated schemes exist, they do not reach all citizens, leading many to opt for private insurance plans. These plans, either an individual or family floater, vary in cost and coverage. The escalating prevalence of chronic diseases coupled with soaring healthcare costs has resulted in substantial out-of-pocket expenses for people from all socioeconomic strata.
As per World Bank report, out of pocket expenditure in India was 49.82% in 2021.[10] This financial burden can have catastrophic consequences, often forcing individuals into debt or the sale of assets, and pushing many into the poverty trap. Despite the availability of both government and private health insurance schemes, awareness and enrolment rates remain low. According to NFHS-5, health insurance penetration in India is 41%, whereas in Punjab, it is only 25.2%.[11] Hence, there is a need to do a gap analysis in the awareness and coverage of health insurance in India.
With the paucity of data on health insurance awareness and coverage gaps in Punjab, this study was undertaken to determine the level of awareness and coverage among patients attending the OPD at the Urban Health training Centre located in slum area.
MATERIAL AND METHODS
This is a cross-sectional study, carried out at Urban Health and Training Centre (UHTC), from February to April 2023. The study subjects were the patients more than 25 years of age attending OPD at UHTC.
Using systematic random sampling method, every fifth patient attending OPD at UHTC between February-April 2023 was recruited in the study. Those patients who were interviewed earlier and had visited Urban Health Center again for consultation were excluded from the study.
A total of 564 subjects were included in the study. A predesigned semi-structured questionnaire was used to assess the subject’s socio-demographic profile, which included age, gender, marital status, education status, type of family, occupation, type of house and monthly family income. Information on awareness, type, and coverage of health insurance was taken from the subjects. Reasons for not enrolling in health insurance were also ascertained. Socio-economic status was assessed using Modified Kuppuswamy scale.[12] Due approval was received from the Institutional Ethics Committee vide IEC No 2023-159. Subjects were briefed about the objectives of the study, and written informed consent was taken before administering the questionnaire.
Data were entered into Excel and analyzed using IBM SPSS Statistics for Windows, version 20.0 (IBM Corp., Armonk, NY, USA).[13] Descriptive statistics (mean ± SD for continuous variables, frequencies and percentages for categorical variables) were computed. The association between sociodemographic factors and both health insurance awareness and enrollment was assessed through the Chi-square test. Binary logistic regression was used to identify predictors of awareness and enrollment. Variables with a P value less than 0.2 in univariate analysis were included in the multivariate model. Multicollinearity was evaluated using the variance inflation factor (VIF), and variables with a VIF less than 10 and a P value less than 0.05 were considered statistically significant.
RESULTS
A total of 564 patients who visited Urban Health Training Centre were enrolled in the study. Out of these, 17 patients refused to give consent. Eventually, 547 patients were included in the study. More than half of the study subjects were men and in the age group of 25 to 55 years old. The mean age of the subjects was 42.1 ± 13.2 years. Most study subjects were married, living in a nuclear family and most had 6-10 years of schooling. Self-employment and private-sector jobs were the most common occupations. Most of the study subjects resided in well-built pucca houses that they owned themselves and the most common income bracket was within the range of 10,000 to 20,000 rupees per month [Table 1].
Table 1.
Sociodemographic profile of the study participants (n=547)
| Variables | Frequency | Percentage |
|---|---|---|
| Age | ||
| 25-40 | 281 | 51.4 |
| 41-55 | 177 | 32.4 |
| 56-70 | 76 | 13.9 |
| >70 years | 13 | 2.4 |
| Gender | ||
| Male | 363 | 66.4 |
| Female | 184 | 33.6 |
| Marital status | ||
| With Spouse | 468 | 85.6 |
| Without Spouse | 79 | 14.4 |
| Religion | ||
| Hindu | 239 | 43.7 |
| Muslim | 6 | 1.1 |
| Sikh | 301 | 55.0 |
| Christian | 1 | 0.2 |
| Years of Education | ||
| Illiterate | 45 | 8.2 |
| 1-5 | 52 | 9.5 |
| 6-10 | 273 | 49.9 |
| >10 | 177 | 32.4 |
| Occupation | ||
| Self employed | 173 | 31.6 |
| Homemaker | 129 | 23.6 |
| Private employee | 169 | 30.9 |
| Govt employee | 76 | 13.9 |
| Ethnicity | ||
| Punjabi | 467 | 85.4 |
| Migrant | 80 | 14.6 |
| Type of house | ||
| Pucca | 541 | 98.9 |
| Semi pucca | 6 | 1.1 |
| Ownership of house | ||
| own | 462 | 84.5 |
| Rented | 85 | 15.5 |
| Migration duration | ||
| Migrated within the last 10 years (recent migrant) | 21 | 27.3 |
| Migrated and staying here for more than 10 years (settled migrant) | 56 | 72.7 |
| Income/month | ||
| <10,000 | 71 | 13.0 |
| 10,000-20,000 | 316 | 57.9 |
| 20,000-30,000 | 112 | 20.5 |
| >31,000 | 47 | 8.6 |
| Type of Family | ||
| Nuclear | 304 | 55.6 |
| Joint | 243 | 44.4 |
Above 70% (n = 387) of the subjects were aware of health insurance schemes. With over a third of subjects (35.9%) reported getting information about health insurance from colleagues. Health workers (23.3%), family members (17.3%) and friends (13.2%) follow as the next most common sources. Very few subjects (0.3%) reported television and newspaper as sources for health insurance information. Notably, insurance agents had a negligible influence on community awareness.
Out of those, who had awareness regarding health insurance 53.7% of subjects were enrolled in it. Over one third of the subjects had enrolled in Government schemes without premiums. Employer compulsion and need for medical coverage were seen as the driving force for their enrollment in 31.3% of subjects each [Figure 1].
Figure 1.
Reasons for enrolling in different types of health insurance
The primary barrier to enrollment in health insurance schemes was lack of awareness (44%) about their existence or how to avail it. While 33% perceived themselves to be in good health and nearly one-fifth of subjects believed insurance processes to be cumbersome. Additionally, 28% of subjects reported low income as the reason for not enrolling as they couldn’t afford [Figure 2].
Figure 2.
Reasons for not enrolling in health insurance scheme
Table 2 depicts the association of socio demographic factors of study subjects with awareness regarding and the enrollment in the health insurance schemes. It was seen that with increasing years of education, there was an increasing trend towards awareness of health insurance schemes and this difference was statistically significant (P = 0.001). Men were more likely to be aware of health insurance schemes compared with women (P = 0.009). Among occupational groups, private employees exhibited more awareness of health insurance schemes, followed by government employees and self-employed. Homemakers had the lowest awareness regarding health insurance schemes and this difference was statistically significant (P = 0.002). Also, subjects who owned house had more awareness than those residing in rented houses (P = 0.001). Subjects living in joint families exhibit greater awareness as compared with those living in nuclear families (P = 0.001).
Table 2.
Association of sociodemographic variables with awareness regarding the health insurance schemes and its enrollment in any of the schemes
| Variable | Awareness regarding health insurance schemes | χ2 (P) | Enrolled in any health insurance scheme | χ2 (P) |
|---|---|---|---|---|
| Age (years) | ||||
| 25-40 (n=281) | 204 (72.6) | 1 (0.606) | 105 (37.4) | 2.3 (0.316) |
| 41-55 (n=177) | 121 (68.4) | 63 (35.6) | ||
| >55 (n=89) | 62 (69.7) | 40 (44.9) | ||
| Marital status | ||||
| With Spouse (n=468) | 329 (70.2) | 1.90 (0.388) | 175 (37.4) | 0.550 (0.458) |
| Without Spouse (n=79) | 58 (73.4) | 33 (41.8) | ||
| Gender | ||||
| Male (n=363) | 270 (74.4) | 6.87 (0.009) | 140 (38.6) | 0.134 (0.714) |
| Female (n=184) | 117 (63.6) | 68 (37.0) | ||
| Years of Education | ||||
| Illiterate (n=45) | 13 (28.9) | 75.8 (0.001) | 7 (15.6) | 34.0 <0.001 |
| 1-5 (n=52) | 29 (55.8) | 16 (30.8) | ||
| 6-10 (n=273) | 186 (68.1) | 89 (32.6) | ||
| >10 (n=177) | 159 (89.8) | 96 (54.2) | ||
| Occupation | ||||
| Self-employed (n=173) | 123 (71.1) | 14.7 (0.002) | 51 (29.5) | 13.1 (0.004) |
| Homemaker (n=129) | 76 (58.9) | 44 (34.1) | ||
| Private employee (n=169) | 134 (79.3) | 77 (45.6) | ||
| Govt employee (n=76) | 54 (71.1) | 36 (47.4) | ||
| Ethnicity | ||||
| Punjabi (n=467) | 348 (74.5) | 21.9 (0.001) | 185 (39.6) | 3.42 (0.064) |
| Migrant (n=80) | 39 (48.8) | 23 (28.7) | ||
| Ownership of house | ||||
| Own (n=462) | 348 (75.3) | 30.1 (0.001) | 182 (39.4) | 2.36 (0.124) |
| Rented (n=85) | 39 (45.9) | 26 (30.6) | ||
| Migration duration | ||||
| Migrated within the last 10 years (n=21) | 8 (38.1) | 1.46 (0.226) | 6 (28.6) | (1.000) |
| Migrated and staying here for more than 10 years (n=56) | 30 (53.6) | 16 (28.6) | ||
| Type of Family | ||||
| Nuclear (n=304) | 197 (64.8) | 11.7 (0.001) | 104 (34.2) | 4.23 (0.04) |
| Joint (n=243) | 190 (78.2) | 104 (42.8) |
The study also examined factors influencing enrollment in one or the other health insurance schemes. Individuals with higher education (P = 0.001), government employees (P = 0.004), and those living in joint families (P = 0.04) exhibited significantly higher enrollment rates.
Binary logistic regression was also conducted to look into factors influencing awareness and enrollment in health insurance schemes. The regression analyses confirmed the positive associations between education level (adjusted odds ratio (AOR) [CI] =0.061[0.026-0.142]), homeownership (AOR [CI] =2.359 [1.331-4.184]) and being a nonmigrant (AOR [CI] =1.996 [1.105-3.606]) with awareness of health insurance [Table 3]. In addition, education (AOR [CI] =1.99 [1.105-3.606]) was the only significant factor influencing enrollment in health insurance schemes.
Table 3.
Logistic regression analysis with dependent variable awareness regarding health insurance schemes
| Variables | B | Sig | Crude OR with 95% CI | Adjusted OR with 95% CI |
|---|---|---|---|---|
| Constant | 0.456 | 0.252 | 1.572 | |
| Gender | ||||
| Male® | ||||
| Female | .1164 | 0.763 | 1.663 (1.135-2.435) | 1.124 (0.526-2.396) |
| Years of Education | ||||
| Illiterate® | ||||
| 1-5 years | -1.118 | 0.011 | 0.322 (0.138-0.751) | 0.326 (0.134-0.796) |
| 6-10 years | -1.424 | 0.001 | 0.190 (0.095-0.380) | 0.241 (0.116-0.500) |
| >10 years | -2.795 | 0.001 | 0.046 (0.020-0.103) | 0.061 (0.026-0.142) |
| Occupation | ||||
| Self employed® | ||||
| Homemaker | 0.615 | 0.165 | 1.716 (1.061-2.774) | 1.850 (0.776-4.413) |
| Private employee | -0.333 | 0.236 | 0.643 (0.391-1.056) | 0.717 (0.413-1.244) |
| Govt employee | 0.063 | 0.855 | 1.002 (0.553-1.817) | 1.065 (0.541-2.098) |
| Ethnicity | ||||
| Punjabi ® | ||||
| Migrant | 0.692 | 0.022 | 3.074 (1.892-4.995) | 1.996 (1.105-3.606) |
| Ownership of House | ||||
| own® | ||||
| Rented | 0.858 | 0.003 | 3.601 (2.236-5.797) | 2.359 (1.331-4.184) |
| Type of Family | ||||
| Nuclear® | ||||
| Joint | -0.334 | 0.138 | 0.514 (0.350-0.755) | 0.716 (0.460-1.114) |
DISCUSSION
India, a major economic force and one of the world’s fastest-growing economies, faces significant challenges in its healthcare system. This study explores public awareness of health insurance schemes in India, a crucial component in addressing these complexities and the existing gaps in insurance coverage.
In the present study, majority (70%) of the subjects demonstrated awareness regarding health insurance. This finding was generally consistent with a study conducted in South India by Reshmi et al.[14] which reported awareness rates of 64% among urban patients. However, other studies report varying levels of awareness ranging from 19% to 91.3% in India.[15,16,17,18] These disparities highlight the influence of demographic and socioeconomic factors on health insurance awareness.
In this study, colleagues (35.9%) were the main source of health insurance information, followed by healthcare workers (23.3%), family (17.3%), and friends (13.2%). These findings contrast with Unnikrishnan B et al.[19] who identified friends and neighbors as the sources of information. Reshmi et al.[14] in South India, Bawa SK and Verma R in Punjab and Yellaiah J in Hyderabad emphasized the role of media in disseminating information about health insurance.[18,20] These studies also suggested that insurance agents had minimal contribution to awareness of health insurance schemes.
Among those aware of health insurance in this study, only 53.7% had enrolled in it. This finding aligns with research by Unnikrishnan,[19] who reported that not all aware patients at a Delhi tertiary care hospital were insured (29% of aware patients lacked coverage). However, other studies have shown varying enrollment rates. Indumathi K et al.[21] found enrollment rate of 66.9% among aware rural residents in Bangalore,] while Sharma D et al.[18] reported enrollment rate of 40% among aware adults in Pokhara.[16] In contrast, Bawa SK and Verma R observed low enrollment rate (28.1%) among aware patients in their study. These discrepancies highlight a significant gap between health insurance awareness and its coverage.
A primary barrier to health insurance enrollment identified in this study was a lack of awareness regarding the availability of such schemes (44%), followed by a perception of good health (33%). These findings were consistent with other research studies, which had identified lack of awareness as a significant impediment to enrollment.[19,22,23] While other studies found affordability and financial concerns as the primary deterrent to health insurance adoption.[24,25] These findings suggest that the factors inhibiting health insurance enrollment are multifaceted and context-specific.
In this study, 36% of subjects were enrolled in government-sponsored insurance schemes such as Ayushman Bharat without incurring any premiums. Employer mandates were another significant factor driving enrollment in health insurance plans, accounting for 31.3% of subjects. These findings contrast with studies by Unnikrishnan et al.[19] and Indumathi et al.,[21] which identified covering medical expenses as the primary motivation for purchasing health insurance among patients in Mangalore and Bangalore, respectively. However, other studies highlighted employment mandates as the primary driver of enrollment.[14,26]
Effective information, education, and communication activities are essential in improving the understanding of the people about insurance. This study revealed a positive correlation between educational attainment and health insurance awareness. These findings align with those of Chopra et al.[24] who reported higher health insurance awareness among individuals with at least high school education, compared with those with lower levels of education, in both rural and urban areas of Meerut.
In this study, it was seen men were more likely to be aware of the health insurance schemes. Similar trends were observed by Bansal et al.[27] in their community-based study among rural north Indian Population. Enrollment in health insurance schemes was also seen more among men in this study. This was in consonance with the findings of Ahira N and Rishipathak P in their population based study in Maharashtra.[28] Hence, the reason could be that men mostly worked outside in the present study.
In this study, homemakers had the lowest awareness regarding health insurance schemes and this difference was statistically significant. Similar findings were seen by Shende and Wagh in their review study, they observed homemakers had limited awareness as compared with working individuals.[29] This necessitates the role of television and newspaper in increasing the awareness among homemakers.
The present study revealed a significant positive association between higher education and health insurance enrolment, consistent with the findings of the study done by Netra G et al.[30] in Karnataka. In addition, a significant association was observed between joint family structure and government employees with enrolment in health insurance schemes, corroborating with the findings of Chopra et al.[24]
CONCLUSION
This study highlights a significant gap between health insurance awareness and actual coverage among participants. Education was identified as the major determinant of insurance coverage, indicating that merely increasing awareness is insufficient to boost protection rates. In this study, Government-sponsored schemes without premiums, followed by employer mandates, were the primary reasons (36.5%) for enrolling in health insurance plans.
To bridge this gap, the government should implement clear-cut policies to promote health insurance. In addition, private insurers must conduct thorough market research to develop accessible, affordable, and appealing plans for all segments of society. To further bolster coverage, effective Information, Education, and Communication (IEC) campaigns are essential to raise public awareness about the increasing need for health insurance to mitigate the financial burden of unpredictable medical expenses.
Conflicts of interest
There are no conflicts of interest.
Funding Statement
Nil.
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