Making Insurance work for the poor!!

Insurance is generally perceived to be for the rich and by nature exclusionary, out of poor people’s reach. It was only after the tsunami devastation that we thought of leveraging the ‘power’ of insurance for ‘the poor’ by adapting it to the needs of the low income population. (Right: women waiting in queue during the enrolment drive.)

Post tsunami, the question that hounded us was how long aid and subsidies could continue to be the only answer to the emergency response. An urge to weave insurance into household and livelihoods fabric was felt across board but the challenge was how to attract insurance providers to look at the marginalised and excluded communities. So we put together most risks faced by the community, aggregated the demand for insurance services and customized the insurance products making the insurance product cheaper and affordable. The premium was a low as INR 250 for covering life and non life risks.

Benefits Demonstrated:
The incidence of the cyclone Nisha which hit Tamil Nadu in November 2008 and left vast stretches of crops, huts and assets damaged. By this time we had already reached a substantial number of people. The insurance provider, Bajaj Allianz, settled 12,700 claims amounting to INR 35 million, approximately USD 800,000. Since then, there has been spurt in enrollments reinforcing community’s belief that insurance will work at times of disasters!

Low cost health insurance coverHealth risks are ranked as top priority by the communities in general, which was reinforced by our demand cum risk assessment study. But in our quest to develop a suitable health insurance product, we found that health insurance is generally costly and excludes most illnesses. In partnership with Allianz-a lead player in insurance globally- we came up with an innovative risk pooling mechanism between community and company. Now health insurance for the whole family costs as low INR.392/- or USD 8 is a reality.

Insuring People Living with HIV/AIDS(PLWHA)
Traditionally communities affected by HIV/AIDS do not enjoy any insurance support from insurance companies as they are perceived as ‘very high risk population’. Companies are scared to underwrite insurance for the life of HIV population perceiving them to be people on the “brink of death”. But taking into account the reality of the lives of the PLWHAs and the desire on their part to leave something behind for their dependents on their death, we designed a life insurance cover for the Persons Living with HIV/AIDS (PLWHAs) in partnership with the community.
The product was designed taking into account the average life span of a PLHA which is observed to be 13-14 years since they are identified as positive. This product also has provision to cover their funeral expenses in the event of death.

Other innovative products covering excluded illnesses and excluded communities
Critical illnesses such as cancer, diabetes, bronchitis are not covered by the existing insurance products. We initiated a pilot project to explore the feasibility of developing micro health insurance products that offer exclusive cover for such excluded diseases.

The salt pan workers produce salt under hazardous conditions but are not covered under insurance. Now a system of rain index based insurance reassures production losses on account of rains during May in coastal belts of Andhra Pradesh. (Left: A salt pan worker).

Educating about micro-insurance
One of the important factors that cause low acceptance of insurance amongst the poor communities is the lack of awareness on insurance. We have invested more resources in community education on insurance principles and risk profile. Thus, we have worked to sensitise our partner NGOs to use a variety of communication tools and strategies to attract rural communities so as to enable them to understand and appreciate the need for insurance services.

R. Devaprakash is Project Director, Insured Lives and Livelihoods and Director Tsunami Response Programme.

Coming together to address health care needs
Meera Sundararajan

For someone struggling to make ends meet by earning wages falling sick is a scary thought. S/he can ill afford to fall sick as it means foregoing one’s wages and spending one’s meagre savings on doctor and medicines. Women, the pillars of poor households have to often deal with these crises taking loans to pay for medicines and hospitalisation. Any sickness speeds up the further descent of the family into poverty.This is also a reality of the lives of women in the Colachel region of Kanyakumari district in Tamil Nadu.

Kanyakumari is considered to be one of the more “developed” districts of Tamil Nadu. There is a high proliferation of private health care institutions which affect the health seeking behaviour of the people making them more inclined through these private institutions as opposed to government run health care institutions. One disadvantage of the using the private system is that it is very expensive and many a times the quality of health care is also dubious. These concerns were shared by the members of the women’s collectives that CARE works with in Kanyakumari. The women shared that although they get loans through the collective at subsidised rated but they did not have any safety net for health related risks.

After a series of discussions with the collectives, the women themselves came up with an option of pooling their risks. They decided that each family comprising of at least four members would contribute a sum of INR 390, approximately USD 8, to which would generate the pool fund to pay for health expenditure. The CARE team facilitated linkage with a private insurance company, Bajaj ,Allianz. Slabs for payouts were fixed with a maximum of INR 10,000 for surgery, INR 5000 for general hospitalisation and Rs 1000 for day care at hospital. The company agreed to share 50% of the payout within the fixed slabs.

To work out the economics, it was imperative that there be at least 1500 members. The federation leaders of the various women’s collectives decided to tackle myths and barriers by speaking to women one-on-one. Concerns like what happens if they do not fall ill or that we are a healthy family were raised. Practical analogies helped the women to understand the need for this safety net. They were also helped to understand the leveraging of larger resourced by investing a small amount as the actual costs far exceed the paltry sum of INR 390. Gradually the women were convinced and they began to join in. The numbers have now increased to over 1600.

The next stage was identification of a network hospital and a referral doctor. After a series of consultation that was also arrived at and the program began to be operational. While protecting from health risks and saving on expenditure is one side to this story- the women were thrilled about their ability to negotiate with the health care providers. No longer were doctors put on a pedestal. They are beginning to be perceived as professionals providing services for a fee which could be negotiated. Negotiations with pharmacies and doctors paid dividends. Pharmacies agreed to provide a discount of about 5% to federation members.

Dealing with claims has made members look critically at the quality of health care. The scene is now ready for some consumer education- women are beginning to see themselves as consumers who have the right to good services!
The women have learnt that it is critical to stay together if they need to negotiate- the have learnt power in numbers.

Meera Sundarajan is Manager, Monitoring, Evaluation and Documentation in the Tsunami Response Programme which works in 7 districts across the states of Tamil Nadu and Andhra Pradesh and the Union Territory of Pondicherry. She has over 15 years of rich experience in the field of social development. Meera has been associated with many pro-poor research and projects in areas like micro-financing, banking, fisheries development to trainings in local self governance.

Mainstreaming gender and sexuality in CARE’s work

Improving lives of women through social change: Mainstreaming gender and sexuality in CARE’s work

Suman Bisht

In country after country, CARE’s experience has shown that investing in women reduces overall poverty. It makes perfect sense when women who represent more than fifty per cent of the world’s population are equipped to make decisions about themselves and their families. Most than often it means engaging with gender based unequal power relations, social norms and ideologies, especially around their sexuality which seeks to undermine their worth and relegates them to a low social position.

The silence around these issues often perpetuates conditions of poverty and social injustice. In order to bring about meaningful change in the lives of individuals, especially women, it is important that strategies to address these factors are systematically integrated into any program. This was the genesis of the Inner Spaces Outer Faces Initiative (ISOFI).

The Journey Begins…
ISOFI, is a novel project, which focuses on gender and sexuality as important factors that influence reproductive health outcomes. CARE’s Sexual and Reproductive Health (SRH) team evolved strategies for integrating gender and sexuality into reproductive health interventions in technical collaboration with International Centre for Research on Women (ICRW) and with financial support from FORD Foundation in India.

ISOFI, Phase I, was developed on one simple principle: “To effectively address gender and sexuality factors in programmes, it is necessary that personal beliefs (inner spaces) of the staff need to be in line with their professional duties (outer faces)”.

In its first phase ISOFI focused on organizational transition through personal change by looking at CARE staff as agents of social change. It proposed organizational change strategy by promoting deep personal learning among CARE staff to bring about a significant shift in how they implement the reproductive health programme. The approach focused on facilitating safe and non-judgmental space for the RACHNA staff to explore culturally sensitive issues relating to gender and sexuality, normally considered taboo for discussion even in professional settings, and then unpack their personal biases. Through regular staff reflective practice; participatory learning approach (PLA); and personal learning narratives the CARE staff was encouraged to become agents of social change and not just implementers of programmes.

ISOFI I resulted is a set of processes and tools that identify, explore, and challenge the social construction of gender and sexuality in the lives of project staff, project participants, in programme interventions and within CARE as an institution. Building on the lessons learned in the first phase, ISOFI moved into its second phase of ISOFI. The initiative has now moved beyond the focus on health services and behaviour change to influence reproductive health outcomes, by meaningfully addressing inequities around gender and sexual behaviour to ensure reproductive rights to women.

ISOFI II: 2007 – 2009 From personal change to programmatic innovation
ISOFI II is an operations research designed to gather evidence of the health impact associated with interventions aimed at improving knowledge, attitudes and behaviour related to gender equity and sexuality. The hypothesis is that by addressing gender & sexuality as an integral part of routine maternal and neonatal health interventions will lead to better maternal and neonatal health.
The platform for operations research is the implementation site of Sure Start, a project implemented by CARE India, in Rae Bareilley and Barabanki districts of Uttar Pradesh. The project is funded by Melinda and Gates Foundation and managed by PATH and aims to reduce new born and maternal morbidity and mortality in the states of UP and Maharashtra. The planned Sure Start interventions are based on technical best practices and evidences that have shown to improve maternal and newborn health at the community level and feasibility of their intervention at scale.

As part of Operations research, the brief of ISOFI II is to conduct baseline survey in the two sites, layer gender and sexuality interventions in experimental site onto ongoing Sure Start programme, and finally conduct an endline survey to assess the success of ISOFI interventions in the experimental site, Barabanki as compared to Rae Bareilley.

The ISOFI experiment in Barabanki In Barabanki, where Sure Start is being implemented, ISOFI II addresses some of the social and discriminatory factors around gender and sexuality that have direct impact on the lives of pregnant and lactating women and indirectly on the lives of newborn. Primary among them being lack of decision making power that affects the health of pregnant women as they are not able to take decisions related to seeking timely health care in time of emergency, deciding on place of birth and determine practices around delivery, and family planning.

Restricted access and control of women over resources like money, information, or food negatively impacts their ability to save money, procure medicines, or nutritious food. For example, it is often believed that it is normal for women to have Reproductive Tract Infections (RTIs) and other related diseases, pains and discomforts during pregnancy.

Restricted mobility of women impacts their utilisation of health services
including immunisation, participation in Anganwadi Centre[1] activities, seeking medical help during emergency. Unequal division of labour that women are burdened with has bearing on lack of adequate rest during and after pregnancy besides affecting the growth and all round development of the girl child.

Violence in all forms, from physical from beating and enforced sex during pregnancy to emotional and psychological violence related to son preference or pressure to give birth to a male child often leads to miscarriages or other complications during pregnancy. Availability of appropriate services is of no use if women are not able to utilise them.

Gender enforced roles of men restrict their involvement in care for women and
children: it is believed that in many instances husbands and fathers are willing
to get involved in care for women and children.

However, the socio-cultural set-up that defines the roles, responsibilities and authority for men and women, restricts the involvement of men in ‘domestic’ and ‘family’ issues; it negatively affects the family and community based care for mothers and children.

Increasing Communication between couples Couples meet were organised to involve men in maternal and neo natal health. Through interactive sessions and games, couples were encouraged to learn about each other and acknowledge the importance of communicating with each other. Men learnt about the changes that a woman’s body and mind go through during the process of child birth and the basic requirements for safe delivery and neo natal health.Therefore, ISOFI interventions included innovative strategies at the community level to build women’s agency, organise women for community level action, and to promote inter-spousal communication around reproductive health issues. The ISOFI team organised many innovative outreach activities to bring about normative changes around son preference, early age at marriage, promoting women’s mobility, participation in local governance as well as community decision making to create a more enabling environment for women to seek their own choices and rights.

These outreach activities included increased communication between couples. Men’s group meeting especially with new fathers and husbands of pregnant women were organised in those villages where routine maternal health services were unavailable. Besides sensitising men on maternal health issues, their role in ensuring adequate nutrition and rest for their wives, importance of consensual sex, as well as their involvement in child care was also stressed.

Through an intensive campaign, the community was sensitised to focus on maternal and the health of the new born. Through magic shows, puppet shows, film screenings and street plays messages on gender discrimination and equity as well as maternal and child health, were given to the community. Issues of domestic violence, preference for male child, and forced sex within marriage as well as sexual exploitation of women were also raised through these shows. This campaign was organized in twenty specific villages over a period of four months.

The frontline health service providers were put through intensive gender and sexuality training to help them identify the social causes of poor maternal health and address these in their regular work. They were also encouraged to reach out to counsel husbands and other family members on maternal health.

The endline survey of ISOFI II begins in April 2009 and will provide concrete evidence that greater self-esteem of women, increase in women’s personal autonomy and decision making, supportive environment at household level positively affect maternal and neo natal health besides reducing gender disparities.

[1] Government run day care centre with health services for pregnant women

Suman Bisht is Manager Gender Equity and Diversity in CARE India. She has done her doctorate at the Department of Sociology, Delhi School of Economics. She has been involved in research and training on gender and health issues. She has co-authored ‘From Thought to Action: Building strategies on violence against women’. She has also compiled a resource document on reproductive and sexual health and rights of women titled Networking for Rights.