Health Inc, a new research project co-ordinated at LSE with partners* in India and West Africa, investigates the impact of social exclusion on vulnerable groups’ access to health care services.

Achieving universal coverage in health care to ensure all people have access to affordable, preventative, curative and rehabilitative health services is a key goal for any health system. In an effort to reach this goal, low- and middle-income countries have introduced a variety of health financing reforms, which aim to introduce prepayment for health care at affordable prices for low socio-economic groups as well as targeted subsidies for other vulnerable groups. Examples of these social health protection (SHP) schemes include community-based health insurance in India and Burkina Faso, vouchers and conditional cash transfers for maternal health in India and Pakistan, and national and social health insurance in Ghana and Vietnam.

Despite the implementation of these health financing mechanisms, more than one billion people worldwide still lack access to affordable health care and 150 million annually face financial catastrophe as a consequence of paying health care costs (Xu et al., 2005).  It is clear that some of the poorest and most vulnerable people are not benefiting from health financing reforms. What is not clear is why, even with free or subsidised enrolment, vulnerable groups are not enrolling in SHP schemes and accessing healthcare.

The Health Inc research project puts forward the hypothesis that social exclusion is an important cause of the limited success of recent health financing reforms. Firstly, social exclusion can explain barriers to accessing health care. Social exclusion from health care provision may be due to disrespectful, discriminatory, or culturally inappropriate practices of medical professionals and their organisations, within the context of poor accessibility and quality of care. Social exclusion from health care services means that removing financial barriers does not necessarily guarantee equitable access to health care.

Secondly, social exclusion can explain barriers to accessing the health financing mechanism itself. There are underlying social, political, and cultural reasons for lack of financial coverage. Differential access to information, bureaucratic processes, complex eligibility rules, and/or crude and stigmatising criteria for means testing prevent socially excluded groups from enrolling in financing schemes that provide access to health care at an affordable price (e.g. community health insurance) or even free of charge (e.g. exemptions). Leakage, on the other hand, may explain why more powerful and vocal groups are able to capture the benefits of targeted schemes that aim to cover the poor.

Health Inc will explore whether and how social exclusion in India and West Africa restricts access to health care services despite recent health financing reforms and how social health protection can be increased for the most vulnerable groups.

In India, Health Inc is studying the Rashtriya Swasthya Bima Yojana, a national health insurance scheme launched in August 2007 for families living below the poverty line. In West Africa, research is being conducted on the Ghanaian National Health Insurance Scheme and the Senegalese Plan Sesame, an exemption scheme for people aged 60 and over.

To ensure the viewpoints of the most vulnerable are heard and understood, mixed research methods, including household surveys, focus groups discussions, and in-depth interviews are being conducted.

To further bridge the gap between research and policy, Health Inc will identify and test policy recommendations using an innovative approach involving two stages of fieldwork: the first gathers data and develops policy options to promote social inclusion for accessible health care. In the second phase of fieldwork, the case studies epilogue will consult local policymakers and population groups on their views of the feasibility of the proposed recommendations to generate an improved set of realistic arrangements.

Data collection is currently being conducted by Health Inc partners in India and West Africa and provisional results from the first phase of research will be available in December 2012 and the project will conclude in April 2014.

*Health Inc (Financing health care for inclusion) is a three-year collaborative research project between LSE Health (project coordinator), the Institute of Tropical Medicine in Antwerp, Tata Institute of Social Science in Mumbai, Institute of Public Health in Bangalore, the Centre for Research on Social Policies in Senegal and the Institute of Statistical, Social and Economic Research in Ghana. Health Inc is funded by the European Commission’s 7^th Framework Programme. More information about the project can be found on the Health Inc website.

References: K. Xu, D. Evans, G. Carrin and A. M. Aguilar-Rivera, of the Department of Health Systems Financing (HSF), WHO. 2005. Designing Health Financing Systems to Reduce Catastrophic Health Expenditure. Technical Briefs for Policy Makers, Number 2. Geneva.