Health Insurance Perception and Challenges: A Qualitative Study Among Fishermen

INTRODUCTION

Universal Health Coverage (UHC) aims to ensure access to quality healthcare for everyone, especially the most vulnerable, without causing financial hardship. This is particularly critical in India, where households face significant economic burdens due to high out-of-pocket healthcare expenses.^[1] The governments of numerous first-world countries have preserved their citizens’ health by providing high-quality medical treatment for free or at a low cost.^[2] The National Health Policy (NHP) 2017 aims to reduce out-of-pocket healthcare costs and decrease the proportion of households facing catastrophic health expenditures, thereby preventing impoverishment.^[3] In India, households bear a significant financial burden due to excessive private healthcare spending and out-of-pocket expenses.^[4] Hence, health insurance is a sustainable economic solution for accessing quality healthcare.^[5] Lack of education or awareness of the need for health insurance hinders its uptake. Individuals with inadequate health insurance literacy (HIL) are at a higher risk of experiencing negative financial consequences.^[6] According to the World Bank Open Data, 49.8% of India’s current health expenditure (CHE) was out-of-pocket expenditure.^[7] Perceptions of health insurance are influenced by factors such as awareness, experience, and the complexity of insurance products. The perceptions, subjective expectations, key problems, and practical needs of the end-user must be evaluated to understand the current situation.^[8,9]

Simplifying the enrolment process, lower premiums, and increasing ease of access can increase the uptake of health insurance among people from the informal sector and low-income groups.^[10] Community outreach programs, camps, and the use of media, along with existing local organisations such as societies and self-help groups, can help spread awareness about the need for health insurance. This would not only influence building trust but also the decision to enrol in health insurance schemes.^[10,11] The perceptions and challenges regarding health financing and the challenges around it among the stakeholders provide a better insight into reforming the existing schemes and taking a step forward by introducing newer schemes.^[12] Post-COVID pandemic measures were taken to strengthen the healthcare/insurance infrastructure by expanding the coverage to vulnerable populations in India.^[13] The varying climate and availability of fish have a direct impact on the socio-economic status of fishermen, and the uncertainties of income push them further into hardships, making them more vulnerable.^[14] Many studies have been carried out in low- and middle-income countries (LMICs) to understand health insurance utilisation, but no study has been conducted in the fishermen’s community on perception and challenges with health insurance.

The overall goal of the study was to identify the gaps that need to be addressed to enhance awareness, enrolment, and acceptance of various health insurance programs, thereby reducing out-of-pocket and other catastrophic expenses. This study aims to understand the challenges and perceptions of health insurance in the informal sector. Through qualitative interviews, an attempt has been made to understand the current perceptions and challenges among the fishing community. The current study combined two conceptual models to address the factors that influence health insurance knowledge and its use: The health belief model (HBM) describes health behaviours as a person’s belief about their risk (susceptibility), the severity of disease, the benefits of taking action, and the barriers to taking action, and Andersen’s behavioural model of health service utilization describes factors influencing health service use and includes the importance of pre-disposing factors (e.g., age, beliefs), enabling factors (e.g., income, access) needs (e.g., perceived need to receive treatment). The models are useful for examining the themes derived from the data and are indicative of not only individual opinions but are representative of structural and contextual challenges that the fishing community faces.

MATERIAL AND METHODS

The study is grounded in the constructive paradigm, which emphasises understanding human behaviour in social, economic, and cultural contexts.^[15] This approach allows for an in-depth exploration of subjective attributes to health insurance uptake among fishermen, including their perceptions, challenges, and decision-making. The study is guided by the HBM and Andersen’s Behavioural Model.^[16,17] With the integration of two models, the study effectively examines attitudes and barriers that influence enrolment in health insurance.

Conceptual framework

This concept demonstrates that raising awareness is the first step towards increasing health insurance enrolment. Positive impressions and fewer barriers are required to convert awareness into enrolment and continued use. Addressing all three components (awareness, perceptions, and barriers) is critical to increasing health insurance enrolment among fishermen [Figure 1].

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Figure 1:

Conceptual framework.

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There are no prior studies among fishermen in coastal Karnataka to understand the gaps in health insurance uptake. This study focuses on previously unexplored dimensions, including distrust, procedural barriers, and the impact of seasonal income on insurance uptake. Prior studies conducted among the fishermen’s community have focused on socio-demographic correlates using surveys.^[18] It is challenging to capture the essence of understanding the problems and perceptions of health insurance using quantitative methods; hence, the present study incorporated a qualitative research approach. A total of six focus group discussions (FGDs) with 58 pertinent stakeholders from the unorganised fishing sector were conducted. Each FGD had an average of nine participants. A trained researcher with experience in qualitative research oversaw moderation, and a note-keeper was assigned to capture group dynamics and non-verbal cues. All the FGDs were conducted in a community hall to encourage open discussion.

The institutional ethical committee approved the study. The FGD guide was developed through a comprehensive literature review and subsequently validated. The FGD guide included questions on health insurance awareness, sources of awareness, utilisation, challenges and perceptions of health insurance, and measures to improve awareness of health insurance in the community. Participants were selected using purposive sampling to ensure a diverse representation of experiences and perspectives from the fishing community. The socio-demographic characteristics of the participants were captured using a structured, validated questionnaire after a formal introduction to the topic of discussion. FGDs were conducted after obtaining informed consent from the participants. The proceedings of FGDs were captured via audiotape and transcribed from the local language to English without changing the original meaning of the quotes within 24 hours of completion of each FGD. FGDs were conducted until data saturation was achieved and then analysed.

Data analysis: The researcher used the field notes and audiotapes to verify the findings. Reflexivity was maintained by regularly reviewing and seeking clarification from participants where necessary to avoid misrepresentation. A reflexive thematic analysis approach was employed, guided by Braun and Clarke’s six-step process ^[19]

RESULTS

A total of six FGDs were conducted among 58 participants from the fishermen’s community.

Perceptions of Health Insurance

Positive perception

• Beneficial to meet healthcare needs

“If there are any problems related to health, we can use health insurance and take the benefits.” FGD6_P1

“If there are health problems/issues, we have benefits, so we take health insurance.” FGD1_P2

Negative perception

• Lack of awareness of health insurance

“ If we get admitted to the hospital and if the bill amount is big (above 50,000/- or 1 lakh), only then insurance is applicable (can be claimed), otherwise no. FGD2_P7

• Lack of specific schemes for fishermen

“We know about different kinds of insurance like life insurance, oriental insurance, and all, but are not aware of specific health insurance that is designed for fishermen.” FGD4_P8

• Past negative experiences while utilising health insurance

“Even after paying, only a few diseases are covered under the scheme, so why do we have to pay?” FGD3_P12

• Distrust of health insurance

“There are a lot of hidden clauses in the insurance, which are not explained to us while enrolling in these schemes.” FGD6_P6

These quotes exemplify the participants’ perceptions of health insurance. The participants had more negative perceptions than positive ones. Participants shared negative experiences they faced while utilising health insurance.

Table 2 describes the sub-themes and codes that emerged under the theme of challenges with health insurance, based on the transcriptions of FGDs. A few of the statements made by the participants are as follows:

Table 2: Displays codes deducted from FGDs among the study participants under the theme of challenges with health insurance

Theme	Challenges	Sub-theme	Code	Sub code
		Access	Pre-approval for referral/pre-authorisation related problems	Delay in authorisation, referral issues
			Complex procedure to avail of health insurance	Multiple steps, lack of guidance, multiple/confusing steps
			Documentation-related issues	Mismatch in IDs, lack of clarity on required documents, and document lost during the process.
		Coverage issue	Out-of-pocket expenditure	All services not covered, partial coverage, co-payment
			Reimbursement-related issues	Delay, partial payment, unclear timeline
			Limited Coverage, limited health facilities listed under the scheme	Specific disease only covered, a few listed hospitals
		Affordability	Inability to pay, varying income, seasonal income	High premiums, debt, and fluctuating income
		Policy	Limited knowledge about terms and conditions	Hidden clause, exclusions unclear, unclear terms
			Insufficient information, procedural gaps, and limited knowledge of coverage and procedure	No clear information, limited knowledge

FGDs: Focused group discussions, IDs: Identification document.

Challenges with insurance

• Pre- authorisation-related problems

“We had to wait for a long time to get the signatures and approvals.” FGD6_P10

• Complex procedure to avail of health insurance

“They say it is not applicable here.” FGD6_P5

“If we go to private hospitals with this insurance, they say it is not covered in the scheme.” FGD6_P6

• Documentation related issues

“If the names in the Aadhar card and the ration card are different… they won’t see while doing the insurance, later when we go to the hospital and try to avail insurance, they reject it by saying the names are different in the Aadhar card and the ration card.” FGD1_P4

• Out-of-pocket expenditure

“If we are not well, we have no other way but to spend money out of our pocket and get medicines for it.” FGD4_P4

• Reimbursement related issues

“It was a lengthy procedure, and it took a lot of time. We had to approach the insurance agent to submit all the documents.”FGD4_P5

“My husband has suffered a lot for claiming the insurance (crying)… he had to travel a lot.” FGD5_P8

“While claiming the insurance, it is extremely difficult.”FGD5_P7

• Inability to pay, varying income, seasonal income

“Paying so much is difficult for us, hence we hesitate to buy insurance. If it is free, it would be really beneficial and good for us.”FGD4_P5

“We are not so financially sound as we don’t earn, so it is difficult to opt for insurance schemes for us now.” FGD5_P2

• Limited health facilities listed under the scheme

“The benefits of the insurance should be accessible at all the hospitals, not limited to any one hospital.” FGD6_P7

• Limited knowledge of terms and conditions

“The insurance companies have clauses saying that after this particular age, there are no benefits in the insurance and or it is not applicable as there is an age limit. There are many such clauses, which we are not aware of” FGD1_P1.

• Insufficient information, limited knowledge of coverage

“There are such instances where they won’t even say, while taking the insurance, that only these diseases are covered.”FGD3_P12

The quotes expressed by the participants indicate the challenges they have with health insurance. The participants also emphasised a lack of awareness about health insurance due to complexity, understanding of the terms and conditions, knowledge about the need for health insurance, and experience with documentation.

Figure 2 depicts the commonly mentioned words by the participants during the FGDs. Words like policy limitations, complexity and time-consuming, fishermen-specific plans, and free schemes were frequently used by the participants, highlighting their perception and challenges among the participants.

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Figure 2:

Represents the word cloud of commonly mentioned terms by the participants in FGDs. FGDs: Focused group discussions, NGO: Non-governmental organization.

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DISCUSSION

Health insurance can be considered an umbrella that helps reduce the unforeseen, expensive healthcare costs of an individual or a household. The present study provides insight into both challenges and perceptions of health insurance among the rural fishing community. The study reveals that the fishing community predominantly holds negative perceptions of health insurance, citing issues such as lack of awareness, complexity of insurance products, and past negative experiences. These findings align with previous studies conducted in similar low-income settings, emphasising the need for targeted interventions.^[20-22] The challenge within the community regarding health insurance can be linked to a lack of awareness, limited knowledge, and unaffordability of enrolling in insurance schemes.

The findings of the study reveal that there are significant gaps in health insurance awareness and understanding among the fishing community. Participants expressed both positive and negative perceptions. In the present study, approximately half of the participants reported that health insurance was beneficial, which is lower than the rate found in a study conducted by Shrestha et al. among locals in municipal settings.^[23] However, the results were found to be consistent with a study conducted by Wang et al among low-income populations who are insured.^[24] The participants also cited negative past experiences, such as being unaware of the exclusion of certain procedures, delayed reimbursement, and lengthy documentation procedures, among others. These negative perceptions among the participants were found to be higher in the present study compared to a study conducted by Ponnusamy et al. among middle-income households in urban Puducherry.^[25] Families with formal higher education and awareness of health insurance were more likely to be enrolled compared to those with lower levels of education. Lack of awareness, negative experience, and negligence were the main factors for not enrolling in health insurance schemes among the participants.

Despite the availability of multiple health insurance schemes, many factors contribute to their uptake. The major factors related to access to health insurance can be divided into issues with referral/authorisation of health insurance by the designated authority, complex procedures in availing the benefits, and documentation issues. In the present study, over half of the participants quoted that they found the procedures of health insurance to be complex. The findings of the present study are supported by a study conducted by Diaz et al.^[26] Improving the infrastructure by simplifying the process and enhancing consumer engagement through communication would enhance effective use and better engagement among consumers.

Issues such as limited coverage, out-of-pocket expenditure, and reimbursement-related issues are other challenging factors faced by the participants. A report by the Ministry of Finance, Government of India, indicates a decline in out-of-pocket expenditure as a percentage of total health expenditure, from 64.2% in FY14 to 48.2% in FY19, thereby reducing the financial burden and hardships faced by citizens.^[27] In the present study, approximately two-thirds of the participants reported that limited coverage has a significant financial impact on individuals. Factors such as the exclusion of certain conditions, OOPE, and upfront payment of medical expenses, and then a claim for reimbursement, were barriers to obtaining insurance schemes. Navigating through the claim process was exhaustive as it involved submitting various documents and still dealing with denials or partial payments from insurance companies. A study on Out-Of-Pocket payments on hospitalisation by Mohanty S highlights OOPE as a significant source of financing healthcare in India.^[28] Similar trends were observed in studies conducted by Nanda et al. and Rajasulochana et al. in various settings across India.^[29,30] The findings of the present study align with the findings of these studies, emphasising the need for better schemes to reduce the burden of catastrophic healthcare expenses.

Low socio-economic status is a key factor that constrains access to quality healthcare services. Individuals from low and middle-income families face greater challenges in affording health services. In the present study, three-fourths of the participants reported that low income, higher premiums, and irregularity or uncertainty in income were major factors preventing them from enrolling in insurance schemes. A study conducted by Weinick et al.^[31] highlights that insurance alone is insufficient to afford necessary care. Low income limits their ability to obtain needed care.^[31] Enhancing access to quality, safe, and affordable health care, thereby reducing the financial burden, helps in achieving the United Nations’ Sustainable Development Goal of UHC. Tailored schemes for fishermen, such as Ayushman Bharat, would bridge the gap by providing access to quality healthcare. This can be implemented in the fishing community residing along India’s vast coastal belt.

Lack of awareness and limited understanding of terms and conditions were found to be significantly associated with not enrolling in health insurance schemes. In the current study, nearly two-thirds of the participants had difficulty understanding the terms and conditions of health insurance schemes. The findings of the present study are backed by studies conducted in Ethiopia by Fite et al., Minyihun et al., Bayked et al, and Yadav et al. in India, in which it was noted that those with a higher level of awareness were more likely to enrol than those with less awareness.^[32-35] Enhancing community awareness through health education/camps/involvement of NGOs, etc., could be a way to improve enrolment in various health insurance schemes.

The study identifies specific barriers for fishermen, such as seasonal income and financial constraints, high premiums, distrust in existing schemes, and occupational risks. The policy inflexibility exacerbates vulnerabilities, urging the need for tailored insurance schemes that address the needs and support fishermen during off-seasons. The study’s findings expand the HBM by highlighting previously unaddressed barriers. The findings show fishermen confront deterrents such as varying income, distrust in policies, and policy complexity. These findings suggest that socio-economic variables should also be considered as an important factor in the HBM model. Furthermore, the study also supports Andersen’s behavioural model by depicting how economic uncertainty, seasonal income, and trust deficit influence healthcare access decisions. Measures to increase awareness, simplify the procedure, and streamline administrative processes, like minimal documentation and paperwork, would enhance investments in insurance among the fishing community.

CONCLUSION

To improve health insurance awareness and accessibility among fishermen, multi-faceted interventions are required. These should address financial, procedural, and trust barriers through targeted educational campaigns, simplified procedures, and leveraging local leaders. Tailored insurance policies that meet the specific needs of the fishing community can significantly enhance enrolment and health outcomes. The study found that a lack of awareness, unstable income, a negative perception of health insurance, and challenges related to limited coverage, affordability, and knowledge were impeding factors in the uptake of insurance. There are limited policies specific to the fishing population. Tailored policies and enhanced government initiatives like incentives, support in enrolment, streamlining the procedure with the use of technology, integrated education, workshops, and local community organisations/leaders would not only build trust but also significantly improve insurance uptake, leading to better health outcomes and financial security for this vulnerable group.