From the book - A compiliation of community health

insurance schemes in India. Ed: N. Devadasan, FWWB 2004

The Student’s Health Home – Kolkata

Dr. N. Devadasan, SHH team.

Introduction
The Student’s Health Home (SHH) is the oldest community based health insurance programme
in our country. Initiated in 1952 by students, the main objectives were

To organise the students …… for health awareness and to ensure both preventative
and curative health care for the student community.
It is seen more as a self-help movement of the students focussed mainly on the broad definition
of health i.e. physical, social and mental well being. Today the SHH is owned by a body of
volunteers and managed on a day to day basis by a management committee headed by the
General Secretary of the SHH.

Design
The SHH is a provider model of CBHI, with the SHH taking on the responsibility of both
providing health care as well as managing the insurance fund.
Figure 1: The design of the Student’s Health Home CBHI.

STUDENT’S HEALTH
Premium
HOME

SCHOOLS / COLLEGES Primary

&
Secondary Care
Annual
Premium

STUDENTS IN WEST BENGAL

Community
The target community are all the students from Class V to University level. The unit of
enrolment is the school / college. Once an institution joins the SHH, then all the students in that
institution are mandatorily enrolled as members of the SHH. This is one of the only mandatory
CBHIs in the country.
Other than institutional membership, individual students can join independently as a member (in
case their institution has not enrolled). Especially if the student is from the weaker sections of
society. They have to submit an application that includes their family income. A committee
screens these applications and decides on whether to accept or reject the application. However,
these instances are rare and not encouraged.
As all schools and colleges are targeted, this is an excellent example of risk pooling – wherein
the wealthy and the poor share the risks.

Premium
The premium is Rs 4 per student collected annually at the beginning of the academic year (July).
The premium is collected through the schools and submitted to the SHH. It is mandatory for all
the students in an enrolled institution to pay the premium.
There is no waiting period, but there is a definite collection period.
Marketing activities are limited as most of the institutions are aware of the SHH and its benefits.
Each student from an enrolled institution can avail of the services of the SHH through his/her
student id card.
Individuals who join have to pay a premium of Rs 60 per person and is given a photo id card.
Universities also pay a lumpsum of Rs 7500 per year to the SHH.
Institutions that default for two consecutive years are removed from the SHH membership.

Provider
The SHH has its own network of health care institutions. The main centre is at Kolkata and is a
70 bed hospital with various speciality services. However the specialists come on specific days,
and not all the days. Thus a particular specialist (and hence the speciality service) will be
available only once a week. The Kolkata centre also has adequate equipment including ECG,
Echocardiogram etc.
Other than this, the SHH has 32 regional centres at the district headquarters. These regional
centres vary in capacity. Some have a few beds, but most of the others mainly have only OP
services. For IP services, the regional centres refer the patients to the government hospitals.
The doctors work mainly on a voluntary basis. This helps to keep the costs down.

Benefit package
The benefit package consists of OP and IP services. The OP services include general and
specialist OP. IP services include surgerical and medical specialities. All the OP services at both
the Kolkata and the regional centres are free. The insured patients have to pay a nominal co-
payment for IP services. This ranges from Rs 2 per day for all medicines to Rs 25 a day for
admissions and Rs 75 for surgeries
While most conditions, including chronic diseases and HIV are included in the benefit package,
pregnancy and emergencies are excluded from the purview of the insurance programme.
If the patient requires any service that is not provided by the SHH, then s/he is referred to the
government hospital. Any expenses incurred by the patient there is reimbursed by the SHH.
Insurer
The SHH takes the responsibility of managing the insurance funds. They receive a token grant
from the Government of West Bengal. This plus the voluntary services of the doctors help them
to meet their expenses with the premium collected. There is no linkage with any insurance
company.

Administration
Collection of premium
This is minimal as it is done by the educational institutions.

Claims and reimbursements

Again this is limited to managing the accounts at the Kolkata centre as well as the
regional centres.

Risk Management
Measures to control adverse selection
This has been well developed through the mechanism of mandatory subscription, the
institution as the unit of enrolment and a definite collection period.

Measures to control moral hazard

As most of the doctors are employed on a voluntary basis, there is no incentive for supply
side moral hazard. On the other hand, because of a strict referral mechanism from the
regional centre to the main centre, the demand side moral hazard is also kept to a
minimum. However, there seems to be anecdotal evidence to suggest that because of the
voluntary nature of the service providers, the efficiency of the Kolkata centre leaves
much to be desired. The average length of stay is very long as doctors come only once a
week. And because there is hardly any charges, the patients also prefer to remain
admitted in the hospital.

Measures to control cost escalation

Co-payments are the only measure used. While the management tries to purchase generic
medicines, many of the doctors prescribe branded drugs.

Achievements
Coverage
As per reports in 2003, there were about 5 lakh students enrolled in the scheme.

Utilisation
Figures not available for recent years. Data from 1993 indicate that the admission rates is
about 1 to 2 per 1000 insured.

Cost recovery
Data not available. Apparently they manage with the premium collected and the co-
payments and a Rs 3.5 lakh donation from the government of West Bengal
Conclusions
The SHH is one of the oldest CBHI schemes and has insured the student community against
medical costs. By collecting a low premium and using the voluntary services of the doctors, they
have been able to establish a low cost and equitable CBHI scheme that covers about 5 lakh
students. However, there is considerable room for improvement – especially in the depth of the
benefit package, the efficiency of the services and the awareness among the student body. Of
course this requires more resources.