Authors:
Introduction
Universal health coverage (UHC) is a health policy goal for many developing countries, including India. UHC means that “all people have access to the full range of quality health services they need, when and where they need them, without financial hardship” (World Bank, n.d.). To achieve this goal, governments worldwide, including India, are designing health insurance programs that provide varying levels of dual access, i.e., healthcare and financial protection (Forgia & Nagpal, 2012). Further, several smaller and targeted community-based health insurance (CBHI) programs have taken shape to provide such access to poorer populations (Bhat et al., 2017). However, for many of these programs, the road to realizing these objectives and translating them into improved health outcomes is riddled with multiple challenges.
These challenges may originate from both the demand and supply sides, ultimately impacting the consumer. To illustrate, challenges on the demand side may include behavioural biases impeding insurance uptake (Ashraf et al., 2021). On the supply side, the design of health insurance programs may also give rise to certain challenges. For instance, the type of incentives offered to healthcare providers may affect the provision of healthcare services, such as under or over-provisioning, denial of services, or the quality of healthcare services provided (Ashraf et al., 2021).
When viewed from a consumer’s perspective, these challenges manifest at different stages of their journey with a health insurance program, beginning from the decision to enrol in a program and ending at the renewal stage. While tweaks to the design of the health insurance program or moving to a more integrated model of healthcare provision may help (Ashraf et al., 2021), in this blog post, we explore the role that social capital can play in circumventing some of these challenges.
Social Capital and Health Insurance
The concept of social capital is closely linked to the concept of a community. Social capital, where it exists, can be traced to the existence of a community and social relationships among members of such a community. Unlike an arbitrary group of people, a community represents a group with shared interests, goals, experiences, values, language, religion, etc. For example, migrant workers may become part of a community at their workplace because of shared ethnicity, such as coming from the same Indian state and speaking the same language. Such commonalities can bring people together, and interactions among them can lead to individual and group bonds developing. We can imagine such individual and group interactions occurring as part of everyday lives or as part of deliberate attempts to create a community. In the previous example, migrant workers may interact with each other frequently on account of being at the same job site, or an event may be organized to bring workers with a shared ethnicity together. Both forms of interactions, repeated over a period, can strengthen bonds, create a sense of belonging and gradually lead to a close-knit community forming.
Within communities, member interactions, both planned and unplanned, may evolve into rituals that become markers of belongingness but also act to strengthen existing bonds. Here, rituals refer to behaviours and actions that community members regularly display or follow. In the previous example of migrant workers, an example of a ritualmay be workers coming together once every day to prepare and share meals. Over a period, such rituals and the spaces for interactions they create allow members to share their everyday lives and experiences, generating a sense of trust, reciprocity, and solidarity among the members. These aspects are what we refer to as social capital[1].
In health insurance, the concept of social capital has been recognized as a key determinant of the success of CBHI programs which are often voluntary and require prepayment to access services. In particular, feelings of trust and solidarity have been found to significantly influence the willingness of community members to enrol (Donfouet & Mahieu, 2012; Dror et al., 2016; Negera & Abdisa, 2022). However, beyond enrolment into such programs, the potential of social capital in mitigating many of the other challenges consumers may face with health insurance programs remains largely unexplored. While the discourse around social capital also cautions against its downsides (Moore & Kawachi, 2017; Donfouet & Mahieu, 2012), we restrict our focus in this blog post to social capital as an enabler.
A Consumer’s Journey with Health Insurance
A consumer’s journey with a health insurance program may be broadly divided into five stages, as mentioned below. We argue that there is scope at each of these stages for leveraging social capital and the rituals integral to generating and sustaining it[2]. We identify community members, community health workers, and community leaders as relevant stakeholders in this context. Regular interactions among them, whether formal or informal, can provide potential avenues through which social capital can be put to work to address many of the challenges consumers may face in effectively benefitting from health insurance programs.
- Enrolment in a health insurance program
A consumer’s decision to enrol in a health insurance program may be affected by several factors, chief among which are awareness of one’s healthcare needs, awareness and appreciation of health insurance, and behavioural biases associated with seeking healthcare and health insurance (Ashraf & Nambiar, 2021). Even if these challenges were resolved, consumers might still have program-specific concerns, such as apprehensions regarding the potential misuse of premium money. We see a role for social capital in addressing such concerns. For instance, when community members interact with those in the community that have experienced health insurance benefits, they may come to see the value of health insurance and be persuaded to enrol in a program.
- Utilization of healthcare services
Accessing healthcare through the insurance program can either involve only inpatient care (as in many indemnity programs) or the entire spectrum of services encompassing preventive care, primary care, and hospitalization (as in managed care programs) (Ashraf, 2021). It should be obvious that better health outcomes are more likely as a system moves closer to offering the entire spectrum of services, or at the very least, a combination of preventive care and medical advice regarding, firstly, the judicious use of medicines and, secondly, appropriate levels of secondary or tertiary care. In India, however, an integrated and holistic approach to healthcare is mostly absent due to the preponderance of indemnity insurance. Therefore, Indian consumers do not generally seek preventive care, and when they require hospitalization, they often face challenges in choosing and accessing appropriate care. Here too, then, we see a critical role for social capital. For instance, interactions with trusted community health workers and leaders may persuade members to avail appropriate preventive healthcare. Further, trust and feelings of solidarity may prompt members to assist each other in accessing time-sensitive information about healthcare providers covered under an insurance program during health shock.
- Claims settlement process
In insurance programs that offer cashless treatment, consumers ideally do not incur out-of-pocket expenses for treatment. However, where insurance programs pay retrospectively for treatment expenses, consumers need to seek reimbursement through a claims settlement process that may involve multiple interactions with an insurance program’s administration. Without awareness of and access to necessary information, consumers will find the claims settlement process to be cumbersome and challenging. Here, social capital may allow community members to assist each other, making the process more accessible, simpler, and less resource intensive for the aggrieved member.
- Grievance redress mechanism
From their experience of accessing and utilizing healthcare services, consumers may suffer grievances that need redressal. These may include denial of healthcare, delay in receiving healthcare, poor quality of services received, overbilling, or even problems with the claims settlement process. Again, as with the claims settlement process, a lack of awareness of grievance redress mechanisms and access to necessary information may make the redress process challenging. Community bonds may be leveraged to disseminate information on filing a grievance, to provide periodic updates on the progression of grievance processing, and to make community members aware of available avenues for escalation.
- Renewal decision
At the end of a consumer’s journey with a health insurance program (in one membership cycle), they may choose to renew their enrolment or opt out. Broadly, two factors may influence this decision. One, the absence of a health shock during the previous subscription period may cause consumers to question the merits of renewing. Two, for consumers who experienced a health shock during the previous subscription period, their experience of utilizing healthcare through the program can become dispositive.
Social capital can help address some of these concerns. For instance, interactions with other members who have experienced a health shock and availed of healthcare under an insurance program may persuade members who did not have to use the services to nevertheless renew. Further, community leaders could be actively involved in capturing and relaying consumer feedback to program heads inspiring consumer confidence in the scheme despite isolated incidences of poor services.
Conclusion
The role of social capital in health insurance has been explored previously but to a limited extent from a consumer’s perspective. In this blog post, we have attempted to map consumers’ journey with health insurance programs, identify potential challenges they may face in effectively benefitting from the programs, and provided examples of how social capital can be put to work to overcome those challenges. To effectively leverage social capital in this way, some rituals that bring community members together may need to be formalized. Once fully developed, this framework can potentially form a useful lens to evaluate health insurance programs from a consumer perspective and aid in developing community-driven solutions to consumer challenges.
References
Ashraf, H. (2021). Managed Care: Linking Health Care with Health Insurance. Dvara Research Blog. https://www.dvara.com/blog/2021/02/16/managed-care-linking-health-care-with-health-insurance/
Ashraf, H., Ghosh, I., Kumar, N., Nambiar, A., & Prasad, S. (2021, June 28). Pathways to Reimagining Commercial Health Insurance. Dvara Research Blog. https://www.dvara.com/research/blog/2021/06/28/pathways-to-reimagining-commercial-health-insurance/
Ashraf, H., & Nambiar, A. (2021, November). Demand for Health Insurance. Dvara Research Blog. https://www.dvara.com/research/blog/2021/11/16/demand-for-health-insurance/
Bhat, R., Menezes, L., & Avila, C. (2017). Review of Community/Mutual-Based Health Insurance Schemes and Their Role in Strengthening the Financial Protection System in India. USAID. https://www.hfgproject.org/review-community-mutual-based-health-insurance-schemes-role-strengthening-financial-protection-system-india/
Claridge, T. (2017). Introduction to Social Capital. https://www.socialcapitalresearch.com/wp-content/uploads/edd/2018/08/Introduction-to-Social-Capital-Theory.pdf
Donfouet, H. P. P., & Mahieu, P.-A. (2012). Community-based health insurance and social capital: A review. Health Economics Review, 2(1), 5. https://doi.org/10.1186/2191-1991-2-5
Dror, D. M., Hossain, S. A. S., Majumdar, A., Pérez Koehlmoos, T. L., John, D., & Panda, P. K. (2016). What Factors Affect Voluntary Uptake of Community-Based Health Insurance Schemes in Low- and Middle-Income Countries? A Systematic Review and Meta-Analysis. PloS One, 11(8), e0160479. https://doi.org/10.1371/journal.pone.0160479
Forgia, G. L., & Nagpal, S. (2012). Government-Sponsored Health Insurance in India: Are You Covered? World Bank Publications – Books. https://ideas.repec.org//b/wbk/wbpubs/11957.html
Fukuyama, F. (2002). Social Capital and Development: The Coming Agenda. SAIS Review (1989-2003), 22(1), 23–37.
Kawachi, I., Subramanian, S. V., & Kim, D. (2008). Social Capital and Health. In I. Kawachi, S. V. Subramanian, & D. Kim (Eds.), Social Capital and Health (pp. 1–26). Springer. https://doi.org/10.1007/978-0-387-71311-3_1
Lin, N. (2001). Building a Network Theory of Social Capital. In Social Capital. Routledge.
Mladovsky, P., & Mossialos, E. (2008). A Conceptual Framework for Community-Based Health Insurance in Low-Income Countries: Social Capital and Economic Development. World Development, 36(4), 590–607. https://doi.org/10.1016/j.worlddev.2007.04.018
Moore, S., & Kawachi, I. (2017). Twenty years of social capital and health research: A glossary. J Epidemiol Community Health, 71(5), 513–517. https://doi.org/10.1136/jech-2016-208313
Nambiar, A. (2021, March 18). Community-based Health Insurance: The VimoSEWA Case. Dvara Research Blog. https://www.dvara.com/research/blog/2021/03/18/community-based-health-insurance-the-vimosewa-case/
Negera, M., & Abdisa, D. (2022). Willingness to pay for community based health insurance scheme and factors associated with it among households in rural community of South West Shoa Zone, Ethiopia. BMC Health Services Research, 22(1), 734. https://doi.org/10.1186/s12913-022-08086-z
Pauly, M., Zweifel, P., Scheffler, R., Preker, A., & Bassett, M. (2006). Private Health Insurance In Developing Countries. Health Affairs (Project Hope), 25, 369–379. https://doi.org/10.1377/hlthaff.25.2.369
Woolcock, M., & Narayan, D. (2000). Social Capital: Implications for Development Theory, Research, and Policy. The World Bank Research Observer, 15(2), 225–249.
World Bank. (n.d.). Universal Health Coverage. World Bank. Retrieved 17 May 2023, from https://www.worldbank.org/en/topic/universalhealthcoverage
[1] Scholars across disciplines view social capital differently; no single agreed-upon definition exists. However, the current discourse widely credits two sociologists, Pierre Bourdieu and James Coleman, for theorizing the concept. While both consider social capital as a resource that emanates from and resides in societal relationships, there are certain differences in their respective conceptualizations. Bourdieu felt that social capital allows individual access to resources hitherto unavailable, the absence of which deprives one of the same. On the other hand, Coleman regarded social capital as a quality of the collective that garners the whole group greater access to resources or goodwill (Claridge, 2017). Eventually it was a political scientist, Robert Putnam, who popularised the term and aggregated it to the trust that facilitates interpersonal cooperation.
[2] The consumer journey stages, processes involved at each stage, and their sequence in the journey may vary based on the insurance policy and the country context.
Cite this blog:
APA
Prasad, S. G., & Nambiar, A. (2023). Can Leveraging Social Capital Enhance Consumers’ Experience with Health Insurance? Retrieved from Dvara Research.
MLA
Prasad, Sowmini G and Anjali Nambiar. “Can Leveraging Social Capital Enhance Consumers’ Experience with Health Insurance?” 2023. Dvara Research.
Chicago
Prasad, Sowmini G, and Anjali Nambiar. 2023. “Can Leveraging Social Capital Enhance Consumers’ Experience with Health Insurance?” Dvara Research.
