International Journal of Healthcare Management

ISSN: 2047-9700 (Print) 2047-9719 (Online) Journal homepage: https://www.tandfonline.com/loi/yjhm20

Health insurance schemes: A cross-sectional study

on levels of awareness by patients attending a
tertiary care hospital of coastal south India

Bhaskaran Unnikrishnan, Abhinav Pandey, Jillela Sairama Gayatri Saran, C.

Praveen Kumar, Basavaraj Ulligaddi, Ashfiya Afrath Mariyam & Priya
Rathi

To cite this article: Bhaskaran Unnikrishnan, Abhinav Pandey, Jillela Sairama Gayatri Saran,
C. Praveen Kumar, Basavaraj Ulligaddi, Ashfiya Afrath Mariyam & Priya Rathi (2019): Health
insurance schemes: A cross-sectional study on levels of awareness by patients attending a
tertiary care hospital of coastal south India, International Journal of Healthcare Management,
DOI: 10.1080/20479700.2019.1654660

To link to this article: https://doi.org/10.1080/20479700.2019.1654660

Published online: 21 Aug 2019.

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 INTERNATIONAL JOURNAL OF HEALTHCARE MANAGEMENT
https://doi.org/10.1080/20479700.2019.1654660

Health insurance schemes: A cross-sectional study on levels of awareness

by patients attending a tertiary care hospital of coastal south India
Bhaskaran Unnikrishnan a, Abhinav Pandeyb, Jillela Sairama Gayatri Saranb, C. Praveen Kumarb,
Basavaraj Ulligaddib, Ashfiya Afrath Mariyamb and Priya Rathi a

a
Community Medicine, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, India; bKasturba
Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, India

ARTICLE HISTORY
Received 13 December
ver, only 15% of the Indian population purchased some kind of HI. Thus, we aimed to study the awareness, enrollment,
2017 and reasons for non-enrollmen
ic and private hospitals attached to a medical college in Mangalore. Patients were interviewed using a pre-tested,Accepted
semi-structured questionnaire after o
13 July 2019
ds and Newspaper.71% had purchased a HI. The foremost reason to purchase a HI was to cover medical expenditure (84.6%), chiefly the surgical exp
KEYWORDS
Gross domestic product
spent on health; out-of-
pocket expenditure on
health; tax benefit of health
insurance

Background Authority (IRDA) act, established in 1999 and

In India, expenditure on health is around seven dollars
in rural areas and nearly ten dollars in urban areas per
person per year. Health care is majorly provided by
the private sector [1]. Three-fourth of the expenditure
is spent through Out-of-Pocket Expenditure (OOPE).
India ranks third in OOPE in South-east Asia region
[2]. Increase in literacy rate and rise in average
income have led to the increase in demand for better
health ser- vices [1]. Studies conducted in the past
show that the catastrophic cost of illness paid from the
household income pushes the general population into
poverty [3–5]. Health insurance (HI) is one of the
ways by which OOPE can be reduced. The term
‘health insur- ance’ denotes an insurance purchased to
cover the expenses of medical care and which are
meant to provide protection against unexpected
medical emergencies.
The Government of India (GOI) spends about
4.2% of Gross Domestic Product (GDP) on health,
which is considerably lower than that of other devel-
oping countries [6–8]. The GOI introduced HI in
1954 to manage the problems of health care for cen-
tral government employees which was known as Cen-
tral Government Health Scheme (CGHS) [9].
However, it was not available for other civilians in
the country. Insurance Regulatory Development
amended in 2002, made provisions for HI in private
sectors which could reduce OOPE and make health
care more affordable for the general population [1].
Rashtriya Swasthiya Bima Yojana (RSBY),
Yeshasvini, Vajpayee Aarogyashree Scheme,
Rashtriya Bal Swasthya Karyakram (RBSK) and
Mukhyamantri Santhvana Harish Scheme (MSHS) are
some of the government-initiated health schemes
exclusively for public sector, whereas Non-
Governmental Organiz- ations (NGOs) like
Sampoorna Suraksha, Karuna Trust, ACCORD
provide HIs to both public and pri- vate sectors.
Details of various insurance schemes are given in Box
1.
According to World Bank data, only 15% of the
Indian population purchased some kind of HI [2].
This might be due to lack of knowledge regarding
HIs among the population. Hence, the present study
is to find out the level of awareness about various
HIs among patients attending government and private
tertiary care hospitals. We also assessed the
knowledge regarding benefits, the purpose for
purchasing insur- ance among the insured patients and
reasons of not purchasing HIs among the uninsured
patients. This would shed some light over the current
popularity of HI as well as pave a way to increase the
usage of HIs in India.

CONTACT Priya Rathi priya.rathi@manipal.edu Community Medicine, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education,
Manipal 575001, India
© 2019 Informa UK Limited, trading as Taylor & Francis Group
2 B. UNNIKRISHNAN ET
AL.

Box 1. HI/schemes our study population had enrolled.

Governmental organization/non- governmental organization

Non-governmental organization (based out of Dharmasthala)
Governmental organization Premium to be paid
Name of the HIs Eligibility criterion Benefits availed 380/- person
Sampoorna Suraksha All categories Covers all ailments up to INR 10,000 per person

Rashtriya
Covers Swasthiya
all ailmentsBima
up toYojana
INR 30,000
(RSBY)
for up to 5 members
All the BPL
in theration
family
card holders 30/- family (only the head of the fa
210/- person
Covers for about 823 different surgical procedures to the farmer co-operators and family and up to INR 1, 00,000 for a single surgical procedu
Yeshasvini Cooperative FarmersGovernmental
Health Care Scheme
organization
Farmers, who are members of cooperative societies
Instant and immediate medical treatment for road traffic accidents during the golden hour (48hrs) up to a maximum amount of INR 25,000 per
Covers for all the catastrophic illnesses and neonatal cases
Covers the 4Ds: Defects at birth, Deficiencies, Diseases and Developmental delays including disability

All road(MSHS)
trafficorganization
Mukhyamantri Santwana HarishGovernmental
Yojana accident victims, irrespective of APL/BPL status, state or nationality Free
All the BPL ration card holders
All children between the age groups 0–18 years

Vajpayee Aarogyashree
Governmental
Scheme
organization Governmental organization Free
Rashtriya Bal Swasthya Karyakram (RSBK)
Free

Methods comprised of the following sections: socio-demo-

Mangalore, which is one of the rapidly developing
cities in Karnataka, India, has a literacy rate of
93.72% (Male 96.09% and female 91. 41%) [10]. The
population of Dakshina Kannada district was
20,89,649 and 55,497 people were reportedly
admitted and treated in hospitals in 2015–2016
[10,11]. There are about 52 hospitals in which there
are 5 government hospitals (public sector) and 47
private hospitals (pri- vate sector) [12].
A hospital-based cross-sectional study was con-
ducted among patients attending both public and pri-
vate hospitals attached to a medical college in
Mangalore. We used a non-probability sampling
method. The sample size was calculated based on the
findings of a study done in South India [1]. Using the
formula n = (Zα/2)2 pq/d2where, ‘p’ is the proportion
of population aware about HI (64%), ‘q’ is the pro-
portion of people unaware about HIs (100−p), Z
α/2 is
a constant whose value is 1.96 and ‘d’ is the absolute
precision (5%). With 95% Confidence Interval (CI),
power of 80% and α-error of 5%, we obtained ‘n’
value as 369. Assuming 10% non-response rate, 403
people were approached. The data collection was
started in February 2017 and the required patients
were recruited over a period of two months.
After obtaining Institutional Ethics Committee
(IEC) clearance and permission from the hospitals,
patients aged 18 years and above attending these hos-
pitals were approached. The purpose of the study was
explained to the patients in their local language and a
written informed consent was obtained. Information
was collected using a semi-structured tool which had
been developed based on the literature review and
had been content validated. The questionnaire
graphic characteristics, awareness and source of infor-
mation about HIs, premium paid, benefits availed and
satisfaction among insured patients, and reasons for
non-enrollment among non-insured patients. Socio-
economic status was determined using modified Kup-
puswamy scale [13].
We analyzed the data using Statistical Package for
Social Science (SPSS) version 25. Categorical data
were summarized using percentages. Continuous data
were summarized using median and Inter Quartile
Range (IQR). Chi-square test was done and P < 0.05
was considered statistically significant.
Operational definitions
. Insurance – is a contract, represented by a policy, in
which an individual or entity receives financial pro-
tection or reimbursement against losses from an
insurance company [14].
. Health Insurance – Insurance taken out to cover
the cost of medical care [14].
. Out-of -pocket expenditure – Any direct outlay by
households, including gratuities and in-kind pay-
ments, to health practitioners and suppliers of phar-
maceuticals, therapeutic appliances, and other
goods and services whose primary intent is to
contribute to the restoration or enhancement of the
health status [15].
Results
A total of 403 patients were interviewed, 154 (38.2%)
were from public sector and 249 (61.8%) were from

private sector hospitals. The proportion of patients Of the total patients interviewed, 82.6% were males.
who were aware of HIs were 300(74.4%). Most of the patients belonged to the age group of 18–
 INTERNATIONAL JOURNAL OF HEALTHCARE MANAGEMENT 3
30 years. Three-fourth of the patients were married.
Half of the patients belonged to the general category of the study patients spent more than INR 5000
based on caste (51.6%). A quarter of the patients were annually on medical care.
edu- cated up to high school level (26.8%) and Out of the 403 patients interviewed, 328(81.4%)
graduate level (25.3%) and only 5.7% were illiterate. patients had heard about the term ‘health insurance’,
Below pov- erty line (BPL) card holders were 51.9%. while 300(74.4%) patients were aware about HIs
Based on Kup- puswamy classification, 35.3% of including their types and the benefits they could
patients belonged to Lower Middle class. The Median avail. Awareness among males was higher. The major
(IQR) monthly income was INR 12,500 (9000, sources of information were friends or neighbors fol-
24000). Almost 60% lowed by newspapers and television. Factors like edu-
cation, type of occupation, poverty were significantly
Table 1. Association of sociodemographic characteristics and associated with the awareness, whereas factors like
awareness regarding HI among patients attending hospitals N age, religion and socio-economic status did not show
= 403. any association with awareness (Tables 1 and 2)
Aware participants Unaware participants Overall, 213(52.9%) patients had HIs. Patients cov-
Characteristics number (%) n = number (%) n = P-value
300 103
ered by private HIs (56.2%) were more as compared
Gender to those covered by public HIs (41.2%). However,
-Male 257(77.2) 76(22.8) 0.01 2.6% had both public and private HIs. Most common
-Female 43(61.4) 27(38.69)
Age group (years) private HIs purchased were employer-provided, while
-18–30 96(76.8) 29(23.2) 0.28 most common public HIs enrolled were Rashtriya
-31–40 81(68.1) 38(31.9)
-41–50 97(78.2) 27(21.8) Swasthiya Bima Yojana (RSBY) and Yeshasvini. The
- >51 26(74.3) 9(25.7) average number of family members covered under a
Marital status scheme was three.
-Married 220(71.9) 86(28.1) 0.01
-Unmarried 80(83.3) 16(16.7) Data in Tables 3 and 4 show that the primary pur-
-Divorcee 0(0) 1(100.0) pose to buy a HI was to cover medical expenses,
Religion
-Hindu 243(73.4) 88(26.6) 0.19 most commonly for chronic illnesses. The surgical
-Muslim 34(82.9) 7(17.1) expenses were the most covered expenses followed by
-Christian 23(76.7) 7(23.3)
-Jain 0(0.0) 1(100.0)
hospital stay charges and the pharmaceutical
Social group expenses. More than 50% of the patients completely
-General 163(78.7) 44(21.3) 0.07 understood or were fully aware of each aspect of the
-Scheduled tribe 18(75.0) 6(25.0)
-Scheduled caste 13(59.1) 9(40.9) HI they had purchased or availed. Most of the patients
-Other Backward 106(71.1) 43(28.9) were com- pletely satisfied with the HI they had
Classes
-Others 0(0.0) 1(100.0) purchased with respect to the information provided by
Ration card the insuring company, the premium amount they had
-APL 125(82.2) 27(17.8) 0.02
-BPL 146(69.9) 63(30.1)
to pay and the benefits they could avail. The Median
-Not Issued 29(69.1) 13(30.9) (IQR) pre- mium paid by an enrolled patient was INR
Education 800 (220, 3675). However, in public sector, Median
-Professional or 11(84.6) 2(15.4) 0.00
Honors (IQR) pre- mium paid was INR 480 (165, 1850) and
-Graduate or PG 90(88.2) 12(11.8) in private sec- tor it was INR 1000 (250, 4000). Table
-Intermediate 60(75.0) 20(25.0)
-High School 77(71.3) 31(28.7)
5 shows the reasons of not purchasing or enrolling in
a HI and will- ingness to buy a HI in Future. The
median premium

-Middle School 27(58.7) 19(41.3) Table 2. Awareness about HI among patients attending
-Primary School 20(64.5) 11(35.5) hospitals n = 403.
-Illiterate 15(65.2) 8(34.8)
Occupation Total number
Characteristics
(%)
-Professional 40(90.9) 4(9.1) 0.00
-Semi-Professional 46(90.2) 5(9.8) Familiar with HI
-Skilled 120(75.9) 38(24.1) -Yes 328(81.4)
-Semi-Skilled 49(61.3) 31(38.7) -No 75(18.6)
-Unskilled 9(60.0) 6(40.0) Aware about public and private health Sector/
-Unemployed 36(65.5) 19(34.5) insurances
Socioeconomic Class(Modified Kuppuswamy Scale) -Yes 300(74.4)
-Upper 24(88.9) 3(11.1) -No 103(25.6)
-Upper Middle 95(83.3) 19(16.7) 0.00 Source of information (n = 300)
-Lower Middle 106(73.1) 39(26.9) -Friends/neighbors 148(49.3)
-Upper Lower 71(64.0) 40(36.0) -Newspaper 86(28.6)
-Lower 4(66.7) 2(33.3) -Television 67(22.3)
Household annual expenditure (INR) on medical care -Internet 34(11.3)
-Less than 5000 107(67.7) 51(32.3) 0.07 -Company 29(9.6)
-5001–10000 87(76.3) 27(23.7) -Society 22(7.3)
-10001–25000 60(80.0) 15(20.0) -Hospital 17(5.6)
-25000< 46(82.1) 10(17.9) -Agent 12(4.0)

purchased among enrolled patients n = 213.

Table 3. Type, purpose and awareness about the HI Characteristics Total number
4 B. UNNIKRISHNAN ET
AL.
(%)
Type of HI Table 5. Reasons for non-enrolment and willingness to buy
-Public HI 92(41.2) HI amongst unenrolled participants N = 190
-Private HI 115(56.2) Characteristics Total number (%)
-Both 6(2.6)
Purpose Reasons
-Covers medical expenses 181(84.9) Lack of awareness 103(54.2)
-Compulsion from employers 39(18.3) -Not a priority for me 60(31.6)
Tax Benefits 24(11.2) Financial issues 33(17.4)
Medical reasons (n = 181) 45(24.8) -Trust issues 21(11.1)
-Acute illness 91(50.3) -Superstition 8(4.2)
-Chronic illness 2(1.1) Willing to buy HI 91(47.9%)
-Terminal illness 50(27.6) Sector
-Prophylactic measure -Public 67(73.6)
Terms and conditions -Private 16(17.5)
-Fully aware/understood 114(53.6) -Both 8(8.9)
-Partially aware/understood 74(34.7)
-Not aware/understood 25(11.7)
Amount of coverage Non Govenmental Organisations [17]. Since a large
-Fully aware/understood 130(61.0)
-Partially aware/understood 54(25.4) amount of expenses are being paid by the consumers
-Not aware/understood 29(13.6) themselves in the form of OOPE, good quality
Empaneled hospitals medical care costs are unaffordable by a majority of
-Fully aware/understood 120(56.3)
-Partially aware/understood 72(33.8) Indian population [18,19].
-Not aware/understood 21(9.9) HI sector in India needs a major haul as life span
HI scheme
-Fully aware/understood 110(51.6) and lifestyle related morbidities are on a rise [20].
-Partially aware/understood 81(38.0) The occupational stress and hectic lifestyle is compel-
-Not aware/understood 22(10.4)
ling people of younger age to seek medical care
facilities [20]. They are in greater need of HIs to
which the partcipants were willing to pay was 300(30, curtail OOPE. In Indian population, awareness and
1000). knowledge about HIs play a great role in their
utilization [20]. This association was also seen in
other developing countries such as Bangladesh [21].
Discussion In this study, we attempted to assess the awareness
The GOI has been providing free of cost medical ser- regarding HIs among patients attending tertiary care
vices since independence, but the utilization of the hospitals.
same is extremely low due to various reasons, most In our study, 74.4% of the patients were aware
importantly the quality of services. India allocates about various HIs which is similar to the observations
only 4.2% of its GDP on health care and 1.2% of made in studies conducted by Reshmi et al. [1] where
GDP on public health care [4,16]. Of the total annual 64% of patients were aware and Kaur et al. [22] where
health expenditure, about 71% is self-financed, 20% awareness was at 91.3%. In line with other studies,
by government, 7% is employer provided and 2% by we found that education, occupation, income and
socioeconomic status were the major determinants of
Table 4. Benefits and satisfaction regarding HI awareness among our patients [1,4,22–27]. In
purchased among enrolled participants (n = 213).
addition to the above determinants, there was an
Characteristics Total number
(%) association between marital status and awareness.
Coverage Moreover, in previous studies, the awareness
-Surgery 210(98.6)
-Hospital stay 184(86.3)
regarding HIs was higher among males as compared
-Pharmaceutical 172(80.7) to females. This could be due to lack of confidence in
-Postsurgical 146(68.5) females and being risk averse as compared to men
-Consultation 136(63.8)
Insurance scheme [28–31].
-Fully Satisfied 158(74.1) The most common source of information regarding
-Partially Satisfied 43(20.2)
-Not Satisfied 12(5.7) HI in our study was through friends and neighbors
Information provided by insurance agency fol- lowed by newspaper and television although in
-Fully Satisfied 136(63.8)
-Partially Satisfied 68(31.9)
other studies newspaper and television were the major
-Not Satisfied 9(4.3) awareness influencers [1,22]. Surprisingly, the role of
Premium amount agents and the companies providing insurance in giv-
-Fully Satisfied 165(77.5)
-Partially Satisfied 41(19.2) ing such information first hand was quite low similar
-Not Satisfied 7(3.3) to the studies done by Vellakal et al. [32] and Kaur
Benefits of scheme
-Fully Satisfied 166(77.9) et al. [22]. This indicates that no increase in initiatives
-Partially Satisfied 35(16.4) to educate people about HIs has been attempted by
-Not Satisfied 12(5.7) insurance companies and its representatives.
In the present study, 56.2% of our aware patients
had subscribed to private HIs. This might be due to
the fact that the private insurance companies hold
much greater accountability than the public sector HI

providers [33]. The benefit availing process is much
simpler in the private sector HIs than the public sector
HIs. In a study in the rural population of Bangalore,
people preferred to be treated in the private hospitals
because of better care and facilities available [23].
The government insurances are not accepted by the
private hospitals. Furthermore, a consumer always
has certain priorities in mind while purchasing a HI
such as the affordability of the premium amount, its
benefits and coverage, the number and quality of the
empaneled hospitals and the paperwork required
[34,35]. Thus, accessibility, ease of processing, higher
empaneled hospital coverage, and better coverage ser-
vices provided by private HI, might have led the
patients to buy private HIs. In developed countries,
there is implementation of (HDHPs) High Deductible
Health Plans (HDHPs), usually for young earning
population. Such schemes can also increase the
enroll- ment in developing counties like India [36].
In our study, the main purpose to buy a HI was to
cover medical expenses followed by tax benefits and
compulsion from employers which is in line with the
studies done by Reshmi et al. [1] and Thomas et al.
[37]. Majority of those who availed the benefits of
their HIs were fully satisfied with the coverage and
ser- vices as compared to the patients in previous
studies [23,38]. The coverage of the insurances
purchased by our patients included consultation and
pharmaceutical expenses rather than just covering in-
patient charges which is the prevalent condition in
Indian HI sector. This indicates a positive growth for
the consumers in the health sector market because
according to a study by Danis et al. [39] the majority
of patients expect full reimbursements for costs of
preventive care, mater- nity care and all indirect costs
and at least half reimbur- sements for pharmaceutical
costs, hospital stay charges and consultation charges.
However, not all aware patients had subscribed to
insurances. 29% of the aware patients had not
enrolled for any HI which is in contrast to the results
found in study done by Kaur et al. where 71.9% of
aware patients had no insurance [22]. The most
common reason given by them was that it was not a
priority for them followed by financial issues, trust
issues and social issues. These observations confirm
to those done in previous studies [22,23,25].
The most common cause found in our study for
non-enrollment to HIs was lack of awareness. It is a
dominant factor as seen in a study conducted by Ran-
son et al. [24]
In this study, we also made an attempt to determine
the willingness of the non-enrolled patients to buy a
HI. We found that 47.9% of the non-enrolled patients
were willing to buy a HI. These observations confirm
to those made by Kaur et al. [22] where 11.9% of
patients were willing to buy an insurance and 19.8%
were will- ing to buy an insurance if their conditions
were
INTERNATIONAL JOURNAL OF HEALTHCARE MANAGEMENT 5
fulfilled. The upper and upper middle classe families
preferred private HIs in contrast to the lower middle
and upper lower classes who preferred public HIs.
Similar observations were made by Reshmi et al. [1]
as well as Kaur et al. [22]. The median annual
premium amount that the patients were willing to pay
was INR 300(30, 1000), which was 0.25% of the
median annual income. Dror et al. showed in his
study, that patients were willing to pay 1.3% of their
annual income as pre- mium [40]. Thomas et al. also
observed in his study that 59.7% of patients were
comfortable paying pre- mium up to INR 6000 [37].
These variations necessi- tate the need for assessment
of perception as well as assessment of paying capacity
of the general population before implementing any HI
policy. There have been studies done outside India
where before implementing National Health Policy,
perception was studied which facilitated its
implementation at community level with community
participation [41].
Conclusions and recommendation
The study found that the awareness regarding HIs was
high in patients attending tertiary care hospitals in
Mangalore. However, not all who were aware had an
insurance due to various reasons. The government
should step up policies in the HI sector as they are
the sole providers of proper health care to poor popu-
lation who cannot afford the relatively costly private
sector premiums. A National health policy covering
all citizen of India can be brought out. It can be
implemented at the community level after understand-
ing people’s perception and requirements and their
premium-paying capacity.
Among those who did not purchase any insurance,
lack of awareness was the most common reason. The
hospital authorities as well as the insurers and their
agents should lay greater emphasis on giving more
information about the HIs to the patients attending
hospitals. Frontline workers (ASHA, ANM, AWT
and MPW) at village level should be deployed for
increasing awareness about various HIs when they go
for house visits.
It can build public–private partnerships with private
hospitals to take level of healthcare up a notch. These
improvements can bring about a significant change in
the condition of HIs in India and establish a better
healthcare network. In order to improve the services in
empaneled hospitals certain indicators like Medicare
hospital value-based purchasing program which
involved feedback from HI buyers can also be utilized
[42].
Implications of the study
(a) This study will help the policy makers understand
the basic level of awareness regarding HI among
6 B. UNNIKRISHNAN ET
AL.
general population and the main source of infor-
mation for the same.
(b) Results also highlight the fact that although lack
of awareness remains the most common cause of
not purchasing a HI, not all who are aware
purchased HI. This highlights the need for
behavior change communication, which can be
sorted out with community participation.
Feedback mechanism can be the first step in
increasing the insurance lit- eracy among users.
(c) Our study shows the median premium that our
population was ready to pay. This figure can be
taken into account while designing a HI for gen-
eral population. HI plans like HDHPs, with low
premium should be considered in developing
countries as well.
(d) Our study population is interested in purchasing
public HIs. Mixed model community-based HIs
can be designed in Public Private Partnership.
This will reduce the burden of premium and
increase the number of empaneled hospitals for
insurers.
(e) This study sends across the knowledge and will-
ingness to purchase a HI to policy makers. If
policy makers modify and bring about new HIs
based on the findings of the study, the public will
be able to purchase customized HIs with low
premiums.
Disclosure statement
No potential conflict of interest was reported by the authors.
Contributors Dr. B. Unnikrishnan contributed to litera- ture
search, figures, study design, data analysis, data
interpretation, and writing. Mr. Abhinav Pandey contributed
to literature search, figures, study design, data collection,
data analysis, data interpretation, and writing. Mr. Jillela
Sairama Gayatri Saran contributed to literature search,
figures, study design, data collection, data analysis, data
interpretation, and writing. Mr. C. Praveen Kumar contrib-
uted to literature search, figures, study design, data collec-
tion, data analysis, and data interpretation. Mr. Basavaraj
Ulligaddi contributed to literature search, figures, study
design, data collection, data analysis, and data interpretation.
Ms. Ashfiya Afrath Mariyam contributed to literature search,
figures, study design, data collection, data analysis, and data
interpretation. Dr. Priya Rathi contributed to literature
search, figures, study design, data analysis, data interpret-
ation, and writing.
Ethics approval Institutional Ethics Committee, Kas-
turba Medical College, Mangalore.
Notes on contributor
Dr. Bhaskaran Unnikrishnan, (MBBS, MD) is presently
working as Associate Dean & Professor of Community
Medicine at Kasturba Medical College, Mangalore,
Manipal Academy of Higher Education, Manipal. His area
of interest is in the field of Health systems research, Health
Insurance and Maternal and Child health care. Dr Priya
Rathi,
[16] Government of India Ministry of Finance. Union
(MBBS, MD) is presently working as Assistant Professor in
the department of Community Medicine, Kasturba Medical
College, Mangalore. Her area of interest is the field of
health insurance, Health economics and Health policy. All
other co- authors are MBBS students of Kasturba Medical
College, Mangalore actively involved in healthcare
research.
ORCID
Bhaskaran Unnikrishnan http://orcid.org/0000-0003-
0892-8551
Priya Rathi http://orcid.org/0000-0002-1550-459X
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