DOES COMMUNITY BASED HEALTH INSURANCE INCREASE ACCESS TO HEALTH CARE

Objective: The present study was undertaken to understand whether insurance played a role in health seeking behaviour among women undergoing hysterectomy. Method: A pre-tested questionnaire was developed and evaluated on 776 females who underwent hysterectomy. Results: Majority [32%] of insured patients had symptoms of less than 6 months duration, while in a majority [30%] of uninsured patients it was more than 2 yrs. Also the most severe disease that is carcinoma [uterine or ovarian or tubal] is seen more among uninsured patients [17%] compared to insured women [11%]. Conclusion: This indicates that insured patients are seeking health services earlier than uninsured ones and before the benign form of disease progresses to malignant one.


INTRODUCTION
The launch of National Rural Health Mission has strongly recommended that rural populations be covered by risk pooling mechanisms especially by community health insurance. The main objectives of Community Based Health Insurance are to improve access to health care and to protect the household from high medical expenditure 1 Among various surgeries performed in our hospital, hysterectomy is quite common. Factors significantly associated with hysterectomy included having health insurance, lower levels of education, being married and having more than two children, and other gynecological and non-gynecological surgical procedures 2 .
As in past, many times association between health insurance and availing of health services by the people has been established 3,4 . Considering these we have studied the association between insurance and hysterectomies performed in our hospital with the following objectives. To study the insured and uninsured who underwent hysterectomy in terms of, symptoms, and the duration of symptom in terms of difference in timing of seeking health services

2.2.
Exclusion Criteria: Records with incomplete information were excluded.
Information was collected on their demographic information, presenting complaints, duration of complaints, no of visits to health care provider, community based health insurance status and type of hysterectomy performed. Data was collected on a predefined and structured questionnaire.

RESULTS
A total of 776 women underwent hysterectomy over a period of 3 years. Of which 176 were insured. The median age of the insured was 50 years (SD 11 years) and 40 years (SD 10 Years) for Uninsured respectively. Table 1 shows the age distribution of insured and the uninsured. The duration of symptoms was less than six months in (32/%) of insured as compared to 22% among uninsured, it was also observed that 57% of insured seek health care in less that 12 months of onset of symptoms as compared to 48% among uninsured . (Table -2

DISCUSSION
It is observed that majority fifty seven present of insured seek health care in less that 12 months of onset of symptoms as compared to forty eight percent among uninsured . This indicates that insured patients are seeking health services earlier than uninsured. As the uninsured patients have to pay from their pocket, they come to hospital only when their symptoms worsen or it starts disturbing their routine activities. If we consider the least severe indication fibroid, is seen more in insured [23%]. This again indicates that insured patients are seeking health services earlier than uninsured. On the other hand, the most severe disease 'carcinoma' is more among uninsured patients [17%] again indicating that insured patients are seeking health services earlier than uninsured. Access to health care has many determinants 2,3 distance, financial barriers, acceptance of the provider, social and economic class of the patients, and effectiveness of the care provided. Supply side moral hazard could be yet another explanation of the high admission rate as the treating physician gets incentives 5 . However, the proportion of insured with symptoms of disease visiting the hospital was much early. This is striking and indicates that the insured have much more access to hospital care in comparison with the uninsured. As perception of ill health depends on individual 6 the uninsured may have lower perception because they are financially poor and there is not much they can do form their side as this would mean expenditure, this could also be the reason why the insured reported early compared to the uninsured among those who had prolapse and lastly this might be the reason why the end stage diseases carcinoma remain high among the uninsured.

CONCLUSION
In this study we found that insurance status substantially determines utilization of hospital services. There is evidence that the insured are able to access the hospital services earlier in comparison to uninsured. This has policy implication, as it informs the government that their move to initiate Community health insurance under the NRHM can improve access to care for the poorer sections of society.