1. Health care utilization and Health Insurance among Urban Poor: A study of three cities in India Ankita Siddhanta International Institute for Population Sciences, Mumbai, India

2. Background and Rationale Being home to the largest slum in Asia and having one-third of its population living below the poverty line (BPL), India is constantly struggling against the inexorably increasing poverty, increasing pace and volume of urbanization and for the health and development of its people and society. Witnessed a sizeable proportion of the population living in slums. Indication of worsening living conditions and increasing poverty The financial burden of health care is a universal phenomenon, cutting across different socio-economic and cultural settings but the implications are more pronounced among urban poor Self-sponsored treatment can be potentially burdensome and even catastrophic particularly amongst urban poor, a large majority of them do not find the public health care facilities efficient enough and attractive.

3. Objective of the study In view of continuously increasing medical poverty among urban poor, this paper aims at developing a background, using patterns of health care service utilization among urban poor, for the need and enhanced coverage of health insurance for urban poor. Against this backdrop this paper aims to analyze barriers in coverage of health insurance among urban poor with various hybrid solutions. The specific objectives of the study are- To analyze the under utilization of public health facilities by Urban Poor To examine the coverage of health insurance among urban poor, identifying the major barriers in insurance coverage and possible strategies to address the issue of medical poverty among urban poor.

4. Data and Methods The basic data used in this paper have been collected from three cities of India namely, Bhubaneswar, Jaipur and Pune as a part of USAID funded intervention to improve the health related quality of life of urban poor, commonly known as “Health of Urban Poor” in 2011-12. A representative probability sample was drawn from slum and non-slum localities in each of the metropolis. The findings of thee paper are based on information collected from a total of 1839 households and 1322 ever married women from Bhubaneswar; 1996 households and 1614 ever married women from Jaipur, and 1884 households and 1418 ever married women from Pune.

5. Utilization for general health needs Overall, results show that private medical sector is the primary source of health care for urban people housing in both slum and non-slum areas in the three cities with a large majority reporting using private facility in incidence of sickness (63% in Bhubaneswar, 60 % in Jaipur, and 84% in Pune). Even among the household from low SLI, a large proportion opted to go for private health facility (40% in Bhubaneswar, 62% in Jaipur and 77% in Pune). Utilization of healthcare facilities by urban poor Utilization of Public Health Facilities

6. The slum dwellers in Bhubaneswar are 1.65*** times more likely to visit public health facilities than those living in non-slums Compared to the Hindus, the Muslims in Bhubaneswar are 53% less likely (p<0.05)and those in Pune and Jaipur are 1.3 times(p<0.10) and 1.6 times more likely (p<0.05) to avail public health facilities In Pune those who have more than 5 years of education are 80% less likely (p<0.01) to use public health facilities

7. Utilization for MNCHN Overall the proportion of women taking ANC services from private sector varied from 53 to 76 percent. 32-40 % women living in slums reported resorting to private facilities for ANC In terms of child health facilities private sector more popular even for the basic need, vaccinations (specially in Pune) 43 to 63 percent women opted for private facilities for institutional deliveries. Slum 21 - 39% Non-slum 46 - 68 %

8. Reasons for underutilization of state run health facilities Proximity/ Non- availability of the facility around the locality of residence Poor quality of care Longer waiting time at the facility Low utilization of public health services Bhubaneswar 38% Jaipur 53% Pune 41% One third Bhubaneswar Jaipur Pune 49%

9. Health Insurance for Urban Poor Rationale of health insurance coverage to minimize out of pocket expenses for Urban Poor Health spending, especially in private sector -- heavy debt Self-sponsored treatment bring with itself catastrophic burden of health care expenditures Poor are unable or unwilling to take health insurance due to lack of knowledge Enhancing insurance coverage is the best way to protect poor household to the risk of health spending leading to poverty.

10. However, most of the state governments in India are facing two potentially competing challenges-strengthening urban health delivery system despite severe shortage of funds and skilled manpower and rolling out of state run health insurance schemes focusing at urban poor. Moreover, despite the availability of state run facilities, poor especially in urban areas are often resorting to expensive private health facilities. This may be either due to lack of faith in Public health system or accessibility to facility ultimately leading to massive out of the pocket expenditure.

11. Health insurance coverage Results portray a very weak coverage of health insurance among the urban poor Only one-fifth of the households in all the three cities (except Pune- 33%) have at least one member in the family covered under any health insurance scheme Further lower among slum dwellers as only one in every tenth household reported having at least one member covered in any health insurance scheme

12. The HHS where the Head’s education is ten years and above are more covered by Health Insurance in both slum and non-slum areas than the HHS with less education of HH Head. With reference to HHS having Low SLI, the middle SLI HHS are 1.5-2.5 time and the High SLI HHs are 4.5-5.5 times more likely to have Health Insurance in all the three cities. In Jaipur, Compared to the SC/ST caste, the OBC caste are 33 % less (p), likely to have any Health Insurance. Compared to the Hindu HHs, the Muslims are 60% less likely to have health insurance in Jaipur and Pune. slum households are significantly less likely to have health insurance despite a considerable proportion of them are visiting private health facilities. Urban poor are highly deprived in coverage of health insurances

13. The public sector urban health delivery system, especially for poor, has so far been sporadic, far from adequate and limited in its reach and further constrained due to social exclusion of slums, weak social fabrics and lack of coordination among stakeholders. Slums typically form a disadvantageous sub-group among the larger category of Urban poor both in terms of availability of public health facility as well as coverage under health insurance Major barriers in insurance coverage like Rashtriya Swasthya Bima Yajana (RSBY) are lack of awareness of protocols and low perceived quality of such schemes that needs to be dealt in generating demand for health insurance among urban poor. Need to widen the coverage of RSBY Conclusion Conclusions and Recommendations

14.  Health facilities should be organized and expanded irrespective of notified or non-notified slums with a humanitarian approach so that those living at outskirts of cities may have access to basic health facilities.  All urban health posts should have a provision of mobile clinics to enhance the reach and coverage of MNCH services among urban poor and ensuring equitable access to affordable health facilities.  Promoting public private partnership to widen insurance coverage with a provision of administrative quality control with vertical accountability.

15. Thank You