INTRODUCTION
Health of the community needs higher attention while considering the development of a region or a country. Providing health insurance or health security for poor people continues to be one of the most important unresolved policy issues for the world.[ 1 ]
Out-of-pocket medical expenses account for more than four-fifths of total health-care spending in India.
It has been found that one of the major reasons for low health insurance coverage in India is the lack of awareness of health schemes among the people.[ 2 ]
When people have to pay fee for health care, and the out-of-pocket payments are so high in relation to their income, it results in “financial catastrophe” for the individual or the household. To ensure good health to all the people of the country is the responsibility of government irrespective of their income level.[ 3 ]
Various schemes are initiated by the Government of India periodically. Many people living in India are either not aware or not motivated to utilize these available schemes.[ 4 ] Health schemes have not been able to make inroads in the rural areas because of key reasons such as high cost of delivery and low awareness among the rural population. The utilization of government schemes among postnatal women was 9% to 20%. The awareness of health insurance was found to be 64.0%.[ 5 ]
It is seen that due to financial constraints, 30% of the rural population did not avail any medical treatment, and in most of hospital admission in rural or urban areas, people are paid either by taking loans or sale by their assets.[ 6 ]
These schemes have the potential to play an important role in India’s move toward universal health coverage (UHC). To do this, however, scheme awareness should be increased.[ 7 ]
Health insurance schemes may be defined as a protection tool which reduces the risks against unpredictable spending and provides social protection and security to the public through the government-owned insurance companies or private insurance companies or any other.[ 8 ] Over 63 million people in India face poverty every year due to health-care costs alone.[ 9 ]
According to the National Sample Survey 2015, 41.9% of the rural population relies on public health care as compared to private health care due to financial constraints. A report done by the Public Health Foundation of India found that only 25% of the Indian population is covered by health insurance, of this only 0.3% of the rural population is covered by private insurance. According to National Health Family Survey (NHFS) 4 (2015–16), rural Tamil Nadu boasts with 69.1% of the households covered by any form of health scheme or insurance.[ 10 ]
The Government of India aims to develop India as a global health-care hub. It has created the National Health Mission for providing effective health care to both the urban and rural population. During the last 53 years, India has developed a large government health infrastructure with more than 3601 Ayush hospitals, 196,312 hospitals, 156,926 subcenters and 808 medical colleges in India.[ 11 ]
A variety of socioeconomic variables such as age, sex, social-economic status, severity of illness, access to services (proximity), and quality of services provided influence the health-care-seeking behavior.[ 12 ]
Studies regarding government health schemes in the rural population are scarce. In view of these missing data and with an intent to assess the awareness and knowledge among patients attending Rural Health Training Centre (RHTC), largely rural population, this study was conducted.
Aims
The aim of this study was to assess the knowledge about national health schemes and to determine association between knowledge with various sociodemographic variables among patients attending RHTC of medical college in Visnagar.
SUBJECTS AND METHODS
It was a cross-sectional study conducted from October to December 2020 among patients attending the Outpatient Department (OPD) at RHTC of Community Medicine Department in a medical college in Visnagar, Mehsana, Gujarat.
Assuming approximately 50% of patients may have knowledge about various government health schemes, with 95% confidence interval (CI) and 10% allowable error, the sample size of 107 was calculated using the following formula: n= Z2Pq/d2, where Z is value from standard normal distribution corresponding to desired confidence level (Z = 1.96 for 95% CI); P is expected true proportion = 0.5; q = 1-P; d is desired precision = 10% of P.
Patients attending OPD at RHTC were interviewed on continuous basis until the required sample size was achieved. Patients above the age of 18 years and patients willing to participate were included in the study while patients unable to give satisfactory interview, patients having mental illness or disorder, and patients not willing to participate were excluded from the study.
Data were collected by the investigator using convenience sampling technique. Maximum of two visits were made in a week to RHTC until desired sample was achieved. Data were collected by interviewing the participants in a local language after taking written consent. Privacy was ensured and individual results were kept confidential. A pretested, semi-structured questionnaire was used consisting of two sections.
First section consisted of sociodemographic information such as age, sex, education, occupation, marital status, religion, family size, family type, and income.
Second section comprised questions to assess the knowledge and awareness of participants about various national health schemes . It assessed information such as awareness, source of awareness, eligibility criteria, benefits derived, beneficiaries, and illnesses covered of various government health schemes such as Ayushman Bharat (Pradhan Mantri Jan Arogya Yojana [PM-JAY]), Mukhyamantri Amrutum (MA) Yojana, Janani Suraksha Yojana (JSY), Janani Shishu Suraksha Karyakram, Kasturba Poshan Sahay Yojana, Bal Sakha Yojana, Chiranjeevi Yojana (CY), Pradhan Mantri Matritva Vandana Yojana, Atal Sneh Yojana, Rashtriya Kishor Swasthya Karyakram, Pradhan Mantri Suraksha Bima Yojana (PBY), Pradhan Mantri Jeevan Jyoti Bima Yojana, Pradhan Mantri Bhartiya Janaushadhi Kendra, and Integrated Child Development Services (ICDSs) scheme.
Knowledge about national health schemes was assessed with the help of questionnaire. The knowledge questions consisted of Yes/No response categories. Knowledge scores were used to categorize into good knowledge and poor knowledge .
The responses of the participants were entered and statistically analyzed by using SPSS v. 20 (IBM SPSS Statistics). Descriptive analysis for categorical and continuous variable was performed. Categorical variable results were expressed in frequency (percentages). Chi-square test was applied to know the association between demographic variables and knowledge . P < 0.05 is considered statistically significant and <0.01 is considered to be highly significant.
To ensure quality control, a pilot study was done for 10% of the sample size. Checking and reviewing of questionnaire was done after data collection by the investigator. Ethical clearance was obtained from Institutional Ethical Committee before the start of study.
RESULTS
Table 1 reveals that 61.68% of participants had heard about Pradhan Mantri Jan Arogya Yojana which is highest among all health schemes. Maximum participants knew about ICDS scheme with respect to its benefits (36.44%), beneficiary (36.44%), how to avail benefits (25.23%), portability (24.29%), and goal (24.29%).
Table 1: Distribution of participants according to knowledge of various health schemes (n =107)
It is evident from Table 2 that awareness regarding various schemes (PMJAY, MA, and ICDS schemes are included as awareness is higher for these schemes) was proportionately higher (52.63%) in age ≤30 and in male sex (60.52%) and card availability (82.89%). No significant association was found between knowledge and education, occupation, number of family members, type of family, and income.
Table 2: Association of knowledge of schemes with various variables on applying Chi-square test
Table 3 reveals that only 32.71% of participants have ever applied for any government health scheme while only 29.90% of participants ever received benefit from any government scheme. Only 34.57% of participants had any mediclaim.
Table 3: Distribution of participants according to health scheme benefit availed (n =107)
Figure 1 shows that out of all participants, 46.72% were having below-poverty line (BPL) card while 53.27% were having MA card and 58.87% were having Ayushman Bharat Figure 2 shows that for majority (32.71%) of study participants, doctor/health workers were the source of information followed by newspaper (22.42%) and family/friends (18.69%).
Figure 1: Distribution of participants according to card availability (n = 107)
Figure 2: Distribution of participants according to source of information (n = 107)
DISCUSSION
Pavithra and Manjunath found that 25.83% of the respondents benefitted by getting surgeries done for different ailments related to stomach, gallbladder, bone, and kidney; nearly 6% of respondents have availed the benefits of most advanced and expensive open heart surgery under the health scheme. The possible reasons might be that poor and disadvantaged sections are daily wage workers, agricultural laborers, construction workers and domestic workers, farmers, tribal population, etc. Thirty-one per cent of the respondents were found in the low overall awareness category which is line with our findings.[ 1 ]
Amin et al . revealed in the study that about 66.7% of participants had average knowledge , 27% had good knowledge , and 6.3% had poor knowledge . Only 27% of the participants were utilizing these services. Out of 300 participants, majority, 95%, of them were living in rural areas. Major source of information was television, i.e., 71.7%.
Among 81 participants, 30.86% of participants had utilized Pradhan Mantri Suraksha Bima Yojana, 26.16% of participants utilized Atal Pension Yojana, 29.63% used Pradhan Mantri Jeevan Jyoti Bima Yojana, while in our study, 32 (29.90%) have utilized any health scheme. This clearly shows a very low utilization rate due to lack of awareness. There was a significant association between the awareness on newly initiated government schemes and selected demographic variables such as monthly family income (χ2 = 22.881, P = 0.011), educational qualification (χ2 = 20.753, P = 0.023), and occupation (χ2 = 26.69, P = 0.021) in contrast to our study.[ 4 ]
Chauhan et al . (2015) showed in a study conducted in Himachal Pradesh that majority of the JSY beneficiaries (50; 64%) were in the age group of 20–25 years and 43 (55.1%) of them heard about the JSY scheme in contrast to 24 (22.42%) in our study which reveals lack of awareness in the study population. Anganwadi workers, 78 (100%), and female health workers, 62 (79.5%), were the main sources of information. In the present study also, health-care workers were major source of information. This shows the importance of their role in creating awareness about schemes.[ 13 ]
A study by Selvam et al . conducted in Tamil Nadu showed that 36% of the respondents agree that they were aware of integrated child development scheme while 35% of the respondents agree that they were aware of reproductive, maternal, newborn, child, and adolescent health scheme and initiates by the government. In our study, 48 (44.85%) had heard about the ICDS scheme showing better awareness about this scheme.[ 14 ]
Chauhan showed that around 45.4% were aware about mediclaim scheme and 16.36% about Janani Suraksha Yojana.[ 8 ]
Reshmi and Sreekumaran Nair conducted a study in South India and showed that of the total 242 respondents, 64% were aware of health insurance and 34.8% said that family/friends were main source of information. In the present study, major source of information was doctors or health workers, 35 (32.71%). The determinants of awareness were religion, type of family, occupation, family income per month, educational status, and socioeconomic status, while in our study, age, sex, and card availability. Thus, different factors affect different regions. Thus, various such studies should be conducted to assess the determinants of awareness.[ 5 ]
Yadlapalli (2018) conducted a study in Delhi and found that only 19% knew about health insurance; 18% had health insurance (Employees’ State Insurance Scheme [ESIS] – 8%, central government health scheme [CGHS] – 1.4%, and Rashtriya Swasthya Bima Yojana [RSBY] – 9.4% of the eligible households). In case of health needs, 95% of CGHS, 71% of ESIS beneficiaries, and 9.5% of RSBY beneficiaries utilized the schemes for episodic and chronic illnesses. For hospitalization needs, 54% of RSBY, 86% of ESIS, and 100% of CGHS utilized respective services. This clearly shows that most people are not aware, but those having such scheme enrollment utilized them.[ 9 ]
A study by Raja T K et al . found that 51% were aware about health insurance, and source of awareness was mostly from television (38.3%). There was a statistically significant association between education (P = 0.000), socioeconomic (P = 0.001) status, and insurance.[ 10 ]
Netraji (2019) conducted a study in Devangere in which the awareness, coverage, and willingness to avail health insurance were 65.7%, 45.5%, and 77.1% among the total families (600) studied, respectively. Similarly for awareness about the health insurance also, education (χ2 = 34.11, P = 0.00) and socioeconomic status (χ2 = 11.96, P = 0.01) are significantly associated.[ 15 ]
Public spending on health care in India is among the lowest in the world at just over 1% of gross domestic product. There is a need for wide reforms across public and private providers of care if India is to meet its stated aims of providing UHC for its population. The success will rely on a reformed and adequately resourced public sector to lead implementation, delivery, and monitoring of the schemes.[ 16 ]
Joseph et al . found in a study conducted in Manipal that majority (85.5%) of subjects had poor knowledge and (14.5%) average knowledge regarding the Below Poverty Line (BPL) schemes. In our study also, knowledge regarding various schemes was found to be poor. Knowledge had a significant association between education (χ2 = 11.866, P < 0.05) and type of family (χ2 = 4.118, P < 0.05).[ 17 ]
In a study conducted by D. J. Bhanderi (2008) in Gujarat found that utilization of government schemes among postnatal women was 9% to 20%. Out of 97 women who delivered in private hospital, 64 women were eligible for the benefits of CY, being BPL. Out of these 64 women, only 6 (9.4%) women got the benefit of this yojana. Similarly, out of 123 women who were eligible for the benefits of JSY, only 25 (20.3%) women got the benefit of this yojana. In the present study, utilization of various schemes was found to be poor 32 (29.90%) due to poor knowledge about how to avail the benefits.[ 18 ]
CONCLUSIONS
It is evident from the present study that knowledge regarding various health schemes in the study population is inadequate. It is recommended to take steps to increase knowledge and thus utilization of schemes using various sources and considering significant sociodemographic determinants. Therefore, it is the need of the hour to increase the awareness of schemes among people with respect to their benefits, eligibility criteria, how to avail benefit, etc., The findings from the present study will be an eye-opener to know where the patients stand with regard to their knowledge about health schemes. This will be helpful for future studies. It can also help the policymakers to become aware of the present status among participants and take the necessary steps in this regard. Furthermore, similar studies conducted in other parts of the country will help to add to the knowledge further.
Financial support and sponsorship
ICMR funded project Short Term Studentship (STS 2020).
Conflicts of interest
There are no conflicts of interest.
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