management initiatives in a community-based health insurance scheme

international journal of health planning and management

Int J Health Plann Mgmt 2007; 22: 289–300.

Published online 21 August 2007 in Wiley InterScience

(www.interscience.wiley.com) DOI: 10.1002/hpm.898

Management initiatives in acommunity-based health insurance scheme

Tara Sinha1*,y, M. Kent Ranson2z, Mirai Chatterjee2x

and Anne Mills2�

1Self-Employed Women’s Association, Chanda Niwas, Opposite Karnavati Hospital,Ellisbridge, Ahmedabad, India2Health Economics and Financing Programme, Health Policy Unit, London School ofHygiene and Tropical Medicine, London, UK

SUMMARY

Community-based health insurance (CBHI) schemes have developed in response to inade-quacies of alternate systems for protecting the poor against health care expenditures. Some ofthese schemes have arisen within community-based organizations (CBOs), which have stronglinks with poor communities, and are therefore well situated to offer CBHI. However, themanagerial capacities of many such CBOs are limited. This paper describes managementinitiatives undertaken in a CBHI scheme in India, in the course of an action-research project.The existing structures and systems at the CBHI had several strengths, but fell short on somecounts, which became apparent in the course of planning for two interventions under theresearch project. Management initiatives were introduced that addressed four features of theCBHI, viz. human resources, organizational structure, implementation systems, and datamanagement. Trained personnel were hired and given clear roles and responsibilities. Lines ofreporting and accountability were spelt out, and supportive supervision was provided to teammembers. The data resources of the organization were strengthened for greater utilization ofthis information. While the changes that were introduced took some time to be accepted byteam members, the commitment of the CBHI’s leadership to these initiatives was critical totheir success. Copyright # 2007 John Wiley & Sons, Ltd.

key words: Community-based health insurance; India; management; SEWA

INTRODUCTION

In many low-income countries, community-based health insurance (CBHI) schemes

have developed in response to the inadequacies of public health care systems and the

limitations of informal and market-based risk protection systems available to poor

* Correspondence to: T. Sinha, Self-Employed Women’s Association, Chanda Niwas, Opposite KarnavatiHospital, Ellisbridge, Ahmedabad 380 006, India. E-mail: [email protected] Coordinator at Vimo SEWA.zLecturer in LSHTM.xCoordinator at SEWA Social Security.�Professor in LSHTM.

Copyright # 2007 John Wiley & Sons, Ltd.

290 T. SINHA ET AL.

households. CBHI schemes are recommended by the World Health Organization as a

useful method for protecting the poor against health risks (World Health

Organization, 2002). CBHI is part of an overall health financing strategy in a

number of countries, given the high out-of-pocket financing of care, the uncertainty

surrounding anticipated financial flows from donors, the large rural and informal

sector populations, and the weak capacity of governments to raise taxes (Gottret and

Schieber, 2006). While CBHI schemes vary widely on a number of aspects, they

share the characteristics of being voluntary, not-for-profit health insurance schemes

aimed at the people working in the informal sector (Cripps et al., 2000; Ekman, 2004;

Gottret and Schieber, 2006) who do not get the social security benefits normally

available to workers in an industry or firm.

Some of these schemes have arisen within community-based organizations

(CBOs) in response to the needs of their members. Others have evolved out of

traditional risk pooling mechanisms such as burial societies and gifts or loans

provided by family, friends, or employers in times of crisis (Morduch, 1999; Roth,

2002; Bennett et al., 2004). CBOs are well suited to instituting CBHI programs for

their members. They usually enjoy the trust of the local community, and are in touch

with the needs of members. They are well placed to harness information, monitor

behavior, and enforce contracts which are either too difficult or costly for the

government or any private insurance agency (Tabor, 2005).

However, insurance as a service is technical in nature. The insurance product is

governed by a firm set of rules. Receiving a benefit from this service, i.e., getting

reimbursed for a loss, needs to be bound by many terms and conditions. The

characteristics of the insurance product and the conditions under which a member

can benefit under it are not always easy to explain or to understand (Cripps et al.,

2000; Derriennic et al., 2005; Tabor, 2005). Moreover, there is the possibility of

mis-use or over-use of the insurance coverage, which also necessitates strong

management of the schemes (Jakab and Krishnan, 2001; Ahmed et al., 2005). Thus,

once a CBHI launches an insurance service, it becomes necessary to institute the

requisite systems for providing a satisfactory service to its members.

Several reviews of CBHIs have pointed to the limited managerial skills available

in these organizations. Setting up and managing a unit able to cope with the task of

providing health insurance service to poor households is a big challenge for many

organizations (Bennett et al., 1998; Cripps et al., 2000; Derriennic et al., 2005;

Schramm and Sodani, 2005; Tabor, 2005; Gottret and Schieber, 2006). Bennett and

Mills have suggested that capacity to design and manage effective CBHI schemes is

one of the greatest barriers to realizing their potential (Mills and Bennett, 2002).

A few manuals have been produced on how a CBHI can be started or how best to

manage a CBHI (Cripps et al., 2000; International Labour Office—(STEP Unit),

2005; Devadasan, 2006). These documents describe methodologies for setting up

and managing a CBHI program. Others have documented their experience of

introducing management systems for better fund management (Musau, 2004).

This paper contributes to this small body of literature on management of CBHIs by

describing a set of initiatives introduced in a CBHI program. These initiatives were

introduced in the course of an action-research project carried out at a CBHI in

Gujarat, India between 2003 and 2006. The management initiatives that were

Copyright # 2007 John Wiley & Sons, Ltd. Int J Health Plann Mgmt 2007; 22: 289–300.

DOI: 10.1002/hpm

MANAGEMENT INITIATIVES IN A CBHI SCHEME 291

introduced are not novel from a management perspective. The contribution of this

paper lies in identifying areas of organizational functioning that strengthened the

delivery of CBHI by a member-based organization. Given that a large number of

CBHI schemes are run out of such organizations, the experience is relevant both to

organizations providing CBHI and more broadly to member-based organizations.

The next section describes the CBHI scheme. A brief description of the research

findings that guided the management initiatives undertaken is then given. This is

followed by a discussion of the key organizational features before, and after, the

initiatives were introduced. The conclusion highlights some challenges that were

faced in implementing the management initiatives and the impact of these

initiatives.

SEWA’S INTEGRATED INSURANCE SCHEME

The Self-Employed Women’s Association (SEWA) is a trade union of informal

women workers, started by Ela Bhatt in Ahmedabad in 1972. Headquartered in

Ahmedabad (Gujarat, India), and including members from 11 of the state’s 25

districts, ‘It is an organization of poor, self-employed women workers. . .who earn a

living through their own labor or small businesses. . . (and who) do not obtain regular

salaried employment with welfare benefits like workers in the organized sector’

(Self-Employed Women’s Association, 1999). The organization has two main goals:

to organize women workers to achieve full employment, i.e., work security, income

security, food security, and social security; and to make women individually and

collectively self-reliant, economically independent, and capable of making their own

decisions.

In 1992 SEWA started an integrated insurance program, SEWA Insurance, for its

members. SEWA Insurance provides life, accident, hospitalization, and asset

insurance as an integrated package. Membership is voluntary. Women are the

principal members, and can also buy insurance for husbands and children. Most

members pay an annual premium, and this amount is passed on to insurance

companies, which shoulder most of the financial risk. Members also have an option

of making a one-time fixed deposit in SEWA Bank—the interest from this deposit is

used to pay the annual premium.

SEWA Insurance is run by a team of full time staff and local women leaders called

‘aagewans.’ The aagewan is a grassroots level worker who is the primary contact

person for the Vimo SEWA member and the critical link between the member and the

scheme administrators.

When SEWA Insurance started in 1992, the primary thrust was on enrolling

members in Ahmedabad city. This was because the Insurance team and SEWA Bank

(a co-operative bank for SEWA members) were located in the city. As the insurance

program stabilized, it expanded to the rural members in the eleven districts.

Membership grew steadily from 7000 in 1992 to over 30 000 in 2000. In 2001,

membership jumped to over 90 000—an increase attributed largely to a greater

appreciation for insurance following a devastating earthquake in January 2001. By

calendar year 2003, SEWA Insurance had over 110 000 members—over 85 000 adult


DOI: 10.1002/hpm

292 T. SINHA ET AL.

women and almost 25 000 adult men. Two-thirds of scheme members were in rural

areas and one-third in urban areas (i.e., Ahmedabad City). The vast majority, 97% of

members, were enrolled under the 1st and least expensive policy.1

Under the health insurance component of the insurance program, a member can

select a hospital of her (or his) choice. She pays out-of-pocket for her hospitalization

expenses. On discharge from the hospital, the member submits her hospitaliza-

tion-related documents to the program for reimbursement.

RESEARCH PROJECT, FINDINGS AND SUBSEQUENT INTERVENTIONS

In 2003, Vimo SEWA, in collaboration with the London School of Hygiene and

Tropical Medicine (LSHTM), initiated an action-research project aimed at

improving the equity of the health insurance component of the scheme. The

motivation for carrying out the project was the shared interest of the SEWA Insurance

leadership and the LSHTM researchers in assessing and improving the reach of the

insurance program among the poorest SEWA members. One of the LSHTM

researchers (MKR) had carried out his PhD research at SEWA Insurance and

developed a sound understanding of the program. SEWA Insurance and LSTHM

therefore jointly developed and implemented the action-research project aimed at

improving the program’s equity.

Baseline findings of the research project showed that while poor members were

enrolled in the scheme in both rural and urban areas, utilization of the scheme was

equitable only among the urban membership. In rural areas, better-off members were

benefiting significantly more than the poorer members (Ranson et al., 2006a).

Qualitative research revealed the problems of the scheme (Sinha et al., 2006).

Barriers faced by the members in scheme utilization

Poorer rural members faced several barriers that prevented them from utilizing the

scheme. Members’ understanding about the scheme and its benefits was limited. It

was found that many members were unclear about their membership in the scheme.

They also had incomplete information about the benefits available under the scheme

and how these could be accessed. Insurance products are difficult to understand even

for literate populations; the majority of SEWA Insurance members were semi-literate

or non-literate, which made it more difficult for them to understand the scheme

details. The members’ limited understanding of the product also had an adverse

affect on members’ continued membership in the program.

The scheme had a database which recorded details about each enrolled member.

However, servicing of the insurance members, especially with regard to submission

1In 2003, SEWA Insurance offered three schemes to its members. All three schemes were bundled andcovered death, accidental death, hospitalisation, and asset loss. They differed in terms of premium chargedand amount of insurance coverage. The first scheme was the least expensive and had the lowest amount ofinsurance coverage while the third scheme was the most expensive and provided the highest insurancecoverage.


DOI: 10.1002/hpm


of claims, had several gaps. The aagewans were the primary link between the

members and the health insurance program, and were expected to facilitate

utilization of the scheme by the members. However, the aagewans were able to fulfill

their role only partially, in part due to inadequate contact between them and the

members. The members were geographically dispersed, the telecommunication

infrastructure was poor, and written communication was not useful due to the limited

literacy skills among members and some aagewans. Personal contact was the only

effective means of communication. While the aagewans did appear to make regular

visits to villages where the members lived, there was no system for formal recording

and monitoring of the contact made between aagewans and members. The servicing

of the scheme was further affected by the moderate capacities of the aagewans. The

support and supervision provided to them was limited, and needed to be enhanced to

significantly strengthen their capabilities.

Some features of the scheme’s design and management made it difficult for

members to benefit under the scheme. Hospitalized members were required to make

out-of-pocket payments for their hospitalization. They then had to submit all

hospitalization documents to the scheme administrators for reimbursement.

Members often faced problems in getting these documents, either because they

forgot to take them at the time of discharge from the hospital or because the doctor

refused to give the required papers. Aagewans tried to assist claimants in gathering

the required documents by making visits to the hospitals after the patient’s discharge,

but this had an adverse impact on the scheme’s administrative expenses.

Interventions introduced under research project to address the barriers

The research project therefore implemented two interventions aimed at improving

the equity of the scheme. These were intended to reduce the informational,

communication, and financial barriers identified through the qualitative research.

Under the first intervention, each member was visited in her home and given

complete information regarding the scheme and claim procedures. She was also

given an attractive wall piece as a reminder of her membership and information to

communicate with the Vimo SEWA office. Under the second intervention, a system

of prospective reimbursement for hospitalized members was introduced. The

objective was to pay the member for hospitalization expenses at the beginning of her

hospitalization and thus eliminate the burden of paying out of pocket. Under this

system, soon after a member was hospitalized, a family member phoned up the

SEWA insurance representative. The representative visited the member in hospital

and paid her 80% of her expected hospitalization expenses (as estimated by the

doctor) at the beginning of her hospital stay. More details about this system are

discussed in another paper focusing on the system of prospective reimbursement

(Ranson et al., 2006b).

The interventions were designed to use existing organizational resources and

structures. In the course of planning for and implementing the interventions, a variety

of issues related to management of a CBHI scheme became apparent. These were

jointly addressed by the scheme administrators and the research team through a


DOI: 10.1002/hpm

294 T. SINHA ET AL.

series of management initiatives. This paper draws on this evidence and experience

to reflect on the challenges of managing a CBHI.

The management initiatives that were introduced in the course of implementing

the interventions had an impact on four organizational dimensions, viz.

organizational structure, human resources, implementation systems, and data

management. Figure 1 shows some key features of these four dimensions before and

after the initiatives. In the following section, we discuss each of the four dimensions

as they existed in the program before the management initiatives; the strengths and

limitations of these and the initiatives that were introduced. The initiatives were led

by the research team, which functioned both as researchers and managers.

ORGANIZATIONAL FEATURES AND INITIATIVES INTRODUCED

In Vimo SEWA, the organization’s structure and implementation systems were

closely related to the organization’s human resources. In the following paragraphs,

therefore, we first describe the previous functioning for the first three features listed

in Figure 1 above, viz. human resources, structure and implementation systems, and

the corresponding strengths and limitations of these. The management initiatives that

were introduced to address these three features are described together for all three

features. Data management is then considered subsequently.

Organizational structure

•Flat structure

•Multiple roles played by one person

Human resources

•Drawn from members

•Limited managerial skills

•Limited formal orientation and training provided

Implementation systems

•Primarily oral communication

•Limited monitoring

•Limited supervisory systems

•Limited quality check

•Limited utilization in field

•Supervisory structure

•Clear role assignment

•Professionally trained staff

•Suitably oriented and trained

•Quality check before use

•Field level utilization

Human resources

Organizational structure

Implementation systems

•Written reports

•Recording and monitoring systems

• Strong supervisory systems

FEATURES PREVIOUSLY PRESENT INITIATIVES INTRODUCED

tnemeganaM ataDtnemeganaM ataD

Figure 1. Organizational features at SEWA Insurance and initiatives introduced


DOI: 10.1002/hpm


Human resources

Previous functioning. Like a majority of CBHIs, SEWA Insurance was housed in a

not-for-profit organization—a trade union of workers in the informal sector. The

organization’s focus was on organizing its membership and building a

member-managed organization. As a member-based organization, SEWA Insur-

ance’s philosophy was to build the capacities of members to be owners, users and

managers of the organization. The long-standing strategy, therefore, had been one of

identifying members who exhibited leadership potential and building the capacities

of members to take on supervisory and managerial roles. A majority of the team

members were, therefore, from the member community. There was a small team of

managers with professional training that was responsible for recruiting and

supervising the larger team.

Strengths and limitations of the human resource strategy. The advantage of having

a team made up predominantly of personnel drawn from backgrounds similar to

Vimo SEWA’s members was that it was relatively easy for the members to relate to

the organization. The members felt a sense of belonging and ownership in an

organization whose representatives were like them. Another advantage of such a

workforce was the relatively low cost, since they had modest salary expectations.

Team members drawn from this population also had lower turnover. They came with

less formal training and thus had fewer options in the job market, making retention

easier. Consequently, SEWA was able to maintain the sizable workforce it needed to

facilitate face-to-face communication with its members.

However, a workforce drawn from the member-community had its limitations,

primarily with respect to managerial capacities. A majority of the team members had

little formal education; only some had completed college and a few were even

illiterate. For a large proportion of the team members, this was their first ‘job’ outside

the home. This may have led to limited appreciation of their work’s implications for

the functioning of a large formal organization providing insurance services. As the

organization and its membership grow in size, suitable management systems with

appropriately skilled supervisors and managers are required to ensure that the

activities are being carried out effectively towards meeting the organization’s

objective.

Organizational structure and implementation systems

Previous functioning. In keeping with the nature of the team, which comprised a

large number of workers from the grassroots and a very small number of trained

professionals, SEWA Insurance had a relatively flat organizational structure. While

some key responsibilities were assigned to specific personnel, role definitions were

not rigid and a high value was placed on collective decision-making. Ultimate

responsibility for the program’s performance lay with the program head, and

structures at the middle level were poorly developed.

Given the relatively flat organizational structure and the limited formal training of

a majority of team members, systems leaned toward the informal and supervisory

structures were limited. Oral communication was the predominant mode of


DOI: 10.1002/hpm

296 T. SINHA ET AL.

conveying information within the organization, and there was limited recording of

decisions taken or changes made in the existing mode of functioning.

Strengths and limitations of the organizational structure and functioning. The

relatively flat structure contributed significantly to the spirit of solidarity that was the

underpinning philosophy of the organization. Team members had a high sense of

ownership about their work and the organization. Since role definitions were blurred,

team members were willing to take on a variety of tasks as the need arose. On the

reverse, however, this sometimes hindered effective program operations. It was

difficult to hold individuals accountable for specific tasks.

The system of oral communication was undoubtedly strong and effective, and

team members that had good working relationships with each other did not wait for

formal communications to undertake specific tasks. However, the lack of written

communication and written reporting meant that information and tasks sometimes

fell through the cracks.

The systems for monitoring and supervising tasks were weakly developed. It was

not uncommon for junior team members to be left to their own devices for dealing

with situations to the best of their ability. To illustrate this point: we mentioned above

that one of the factors preventing utilization of the scheme, especially among the

poorer members, was limited understanding about the scheme. Vimo SEWA realized

the importance of maintaining regular contact with members and providing refresher

sessions about the scheme to educate members. For this, part of the aagewans’

responsibility was to visit all the members they were responsible for, and not just

members who needed to submit claims. But while there was follow-up done by

supervisors for claims-related visits, member-contact visits were left relatively

unmonitored. Organizational theory underscores the need for management initiated

support and supervision systems. These include holding regular meetings to review

progress, discuss issues, provide feedback, and agree on possible solutions (Cripps

et al., 2000).

Management initiatives to address human resources, organizational structure, and

implementation systems. One of the management initiatives was to hire

professionally trained team members. Each of them was assigned roles and

responsibilities in keeping with her abilities. This enabled them to perform focused

tasks and demonstrate their capacities. New recruits were provided with an

orientation to the organization and its philosophy of putting the SEWA member first.

This helped them to view their position and role in the context of the larger

organization. The organizational culture required professionals to work on equal

terms with team members who had fewer skills than them and also with the poor

members of the insurance program. The example set by the organizational leadership

guided the new recruits into the organizational culture. Further, the new recruits were

hired as members of the research team, and not as a part of the mainstream

operational team. This greatly reduced any resentment that other team members may

have felt towards the new appointees.

Three distinct levels were laid out in the team hierarchy—the research team

leader, the research associates, and the grassroots researchers. Lines of reporting


DOI: 10.1002/hpm


were clearly defined, with the grassroots researchers reporting to the associates and

the latter reporting to the team leader; each person knew who she was expected to

report to. Team members were free to seek assistance and work closely with any of

the others within their team or within the larger team, but accountability was made

clear.

To ensure successful completion of the required tasks, systems were laid out; time

lines were planned and supportive supervision provided by the senior team members

to the juniors. For instance, to implement house-to-house visits to members, a new

implementation system was put into place. First, village-wise member lists were

generated. Supervisors sat with the aagewans to make micro-plans for conducting

the visits, by clubbing geographically proximate areas and working out estimated

time to make the visits. The objective of the micro-planning was to ensure the

maximum member coverage with minimal cost. This resulted in setting up an entire

management subsystem to carry out the series of tasks for making and recording

member education visits. Each week, supervisors sat with aagewans to jointly plan

the visits for the upcoming week and take stock of visits made during the previous

week. This system of micro-planning and close supervision had several positive

outcomes. First, the aagewans appreciated the support that they received in carrying

out their tasks. The detailed reporting that they did each week led them to value their

work. This in turn enhanced their motivation and commitment levels.

Data management

Previous functioning. Management information systems, either manual or

computerized, are critical to the effective operation of a CBHI (Tabor, 2005).

Being an insurance organization, SEWA Insurance maintained one database on

members who enroll in the program and another on the claims submitted to SEWA

Insurance. The member database was used primarily to send a list of insured

members to the insurance company and to verify the membership status of persons

submitting claims. Occasionally lists of members had been generated from this

database to aid aagewans in their work, but the utilization of these lists had not been

monitored.

Strengths and limitations. The fact that a computerized database of SEWA

Insurance members was available was in itself a strong position to begin from.

However, a close examination of the data showed errors and gaps. To make house

visits to each member, accurate lists giving the members’ names and addresses were

required. For example, addresses entered in the database were incomplete in some

places and incorrect in others. The data in its existing state could not be used to

generate complete member lists. It had to be ‘cleaned’, i.e, addresses checked and

corrected, before final member lists could be generated.

Management initiative. Cleaning of the members’ database was done in a detailed

and systematic fashion. Each member’s record was examined to identify errors and

gaps. These were then corrected to the extent possible. The data cleaning required a

few sittings with the district teams who are best acquainted with the details of their


DOI: 10.1002/hpm

298 T. SINHA ET AL.

respective districts. While this process was tedious, it enabled the interventions to

reach far more members than would have been possible in the absence of this

cleaning.

Cleaning of the data allowed it to be put to much more practical use, and its utility

was enhanced by using barcodes. A system was needed for both research and

management purposes of recording visits to members. As we mentioned above, the

aagewans had limited literacy skills, so a recording system was needed that required

minimal literacy skills. A set of four barcode stickers was generated for each primary

member corresponding to her unique identification number using the cleaned

member data. When an aagewan visited a member, she gave the member her set of

barcode stickers. The aagewan then took one sticker back at each visit and pasted it

in a register. The register with the pasted barcode stickers was returned to the office

where it was scanned using a bar code reader and a report generated showing which

members had been successfully visited. This information was available to the team

leaders without requiring any written recording by the aagewans of the members she

had visited.

The experience showed the many practical uses of this data and underscored the

importance of having ‘clean’ data for it to be useful. At all levels of the organization,

the importance of data accuracy has been reinforced, right from the aagewans who

write down member data in the enrollment campaign to the data entry operators. This

has resulted in a greatly improved database and in greater utilization of the data for

management, planning, and reporting. The system of using barcodes to record visits

to members was mainstreamed in the insurance program.

CONCLUSIONS

The discussion above highlights four areas where improvements in the scheme’s

management were introduced—human resources, organizational structure, imple-

mentation systems, and data management. These changes were introduced in

the course of implementing two interventions under the action-research project.

The interventions were later incorporated into the CBHI’s operational systems, as

were several aspects of the management systems that were used to implement the

interventions.

Not surprisingly, there were some challenges in instituting the new systems, as the

‘old’ and the ‘new’ working styles had to be gradually brought together so that they

worked in tandem. Areas of tension included the higher compensation expectations

of professionally trained staff compared to the majority of the team members and the

changing work culture such as time-bound functioning, formal reporting, and

accountability for assigned tasks. It took some time for team members to make the

transition from the previous, more informal style of functioning to the new systems.

However, being a learning organization, SEWA Insurance’s senior management

provided the support needed to institute these new systems. The successful

completion of the research activities using the management initiatives further

bolstered SEWA Insurance’s commitment to these.


DOI: 10.1002/hpm


The initiative using barcode stickers also indicated that modern technology is

readily accepted in hitherto ‘traditionally-functioning’ member-based organizations

when it is seen to clearly enhance efficiency. Both the managers of SEWA Insurance

and the barely-literate aagewans enthusiastically adopted the technique of barcode

stickers for recording visits; in fact this method was very soon incorporated into other

SEWA Insurance activities, including a campaign to increase member retention in an

urban center.

While the operational success of the management initiatives was evident by the

end of the research project, the financial implications of the new systems are not yet

clear. For instance, has the hiring of professionally trained staff led to greater

efficiency in systems of functioning, so that the higher staff costs have been offset by

more cost-effective functioning? A CBHI scheme planning to revise its management

systems would find it worthwhile to evaluate operational costs at baseline and again

after introduction of the new management initiatives to assess the financial

implications of these changes.

The experience of introducing management initiatives at SEWA Insurance has two

important lessons. The first is that CBHIs can successfully combine a grassroots

orientation with professional systems of functioning. Undoubtedly, member

orientation and strong community networks act as the foundation. However, to

become successful service providers, CBHIs need to adopt good management

practices. Appropriate modifications are required to the team’s composition,

organizational hierarchies, and systems of planning and implementation. Key

resources like data require attentive management to be fully utilized by the program.

The commitment of the senior management of the CBHI to these changes is critical

to their success.

Second, to change systems of functioning in an ongoing organization, it is useful to

introduce the changes in a phased manner, and somewhat removed from the

mainstream operations. This may be carried out in the context of a research project,

as was done in this case, or be adopted in one part of the organization to begin with.

This slow introduction allows for wrinkles in the new system to be ironed out and

also increases its acceptability among the larger organization.

ACKNOWLEDGEMENTS

Financial support for this study was provided by the Wellcome Trust (Grant

No.GR067926MA).

REFERENCES

Ahmed MU, Islam SK, Quashem MA, Ahmed N. 2005. Health Microinsurance: A Com-parative Study of Three Examples in Bangladesh (Case study no. 13). CGap Working Groupon Microinsurance. World Bank: Washington, DC.


DOI: 10.1002/hpm

300 T. SINHA ET AL.

Bennett S, Creese A, Monasch R. 1998. Health insurance schemes for people outside formalsector employment. Division of Analysis, Research and Assessment. World Health Organ-ization: Geneva.

Bennett S, Kelley AG, Silvers B. 2004. 21 Questions on CBHF. Partners for Health ReformPlus Project. Abt Associates: Bethesda.

Cripps G, Edmond J, Killian R, Musau S, Satow P, Sock M. 2000. Guide to designing andmanaging community-based health financing schemes in east and southern Africa. PHRPlus, USAID: Bethesda, Maryland.

Derriennic Y, Wolf K, Mukiibi PK-M. 2005. An assessment of community-based healthfinancing activities in uganda. Abt Associates: Bethesda, Maryland.

Devadasan N (ed.). 2006. Planning and Implementing Health Insurance Programmes in India.An Operational Guide. Institute of Public Health: Bangalore.

Ekman B. 2004. Community-based health insurance in low-income countries: a systematicreview of the evidence. Health Policy Plan 19(5): 249–270.

Gottret P, Schieber G. 2006. Health Financing Revisited: A Practitioner’s Guide. The WorldBank: Washington, DC.

International Labour Office—(STEP Unit). 2005. Health Micro-Insurance Schemes: Feasi-bility Study Guide, Vol. I and II. ILO: Geneva.

Jakab M, Krishnan C. 2001. Community Involvement in Health Care Financing: A Survey ofthe Literature on the Impacts, Strengths and Weaknesses. HNP Network, World Bank:Washington, DC.

Mills A, Bennett S. 2002. Lessons on sustainability from middle and lower income countries.In Funding Health Care: Options in Europe, Figueras J, Saltman R, Mossialos E (eds).Open University Press: Buckingham; 206–255.

Morduch J. 1999. Between the state and the market: can informal insurance patch the safetynet? World Bank Res Observer 14(2): 187–207.

Musau S. 2004. The community health fund: assessing implementation of new managementprocedures in Hanang district, Tanzania. Abt Associates, Partners for Health Reform Plus:Bethesada, MD.

Ranson MK, Sinha T, Chatterjee M, et al. 2006a. Making health insurance work for the poor:learning from SEWA’s community-based health insurance scheme. Soc Sci Med 62(3):707–720.

Ranson MK, Sinha T, Gandhi F, Jayswal R, Mills AJ. 2006b. Helping members of acommunity-based health insurance scheme access quality inpatient care through develop-ment of a preferred provider system in rural Gujarat. Natl Med J India 19(5): 274–282.

Roth J. 2002. Informal microinsurance schemes: the case of funeral insurance in South Africa.Small Enterprise Dev 12(1): 39–50.

Schramm B, Sodani PR. 2005. Capacity building for the development of health insurancesystems in India. J Insur Risk Manag III(6): 99–103.

Self-Employed Women’s Association. 1999. Self-Employed Women’s Association: AnnualReport 1999. SEWA: Ahmedabad.

Sinha T, Ranson MK, Chatterjee M, Acharya A, Mills AJ. 2006. Barriers faced by members ofa community-based insurance scheme in accessing benefits: lessons learnt from SEWAInsurance, Gujarat. Health Policy Plan 21(2): 132–142.

Tabor SR. 2005. Community-based health insurance and social protection policy. World Bank:Washington, DC.

World Health Organization. 2002. Macroeconomics and Health: Investing in Health forEconomic Development. WHO: Geneva.


DOI: 10.1002/hpm

management initiatives in a community-based health insurance scheme

Documents