Introduction Healthcare utilisation requires knowing one’s
entitlements and how to access them (navigation) and having
access to grievance redressal when entitlements are denied.
To ensure citizen access to and use of health insurance
entitlements, the Health Insurance Fund established an initiative
called the Protector of Patients’ Health Insurance Entitlements
(PPHIE). PPHIEs are supposed to provide patient navigation
and grievance redressal services. This paper explores to what
extent this initiative meets its objectives and is used by the
elderly in rural areas.
Methods This study employed a mixed methods
approach. We conducted in-depth interviews with elderly
patients in rural areas, PPHIEs, health providers and health
insurance managers (N=39), as well as focus groups
(N=5) and a household survey (N=715) with elderly rural
patients. Qualitative data were analysed using content
analysis, and the household survey results were analysed
using descriptive statistics.
Results The majority of elderly patients were not aware of
the PPHIE initiative and instead received patient navigation
support from their healthcare providers. The PPHIE
programme was poorly publicised among the population.
Although PPHIEs had a mandate to pursue grievance
redressal they rarely did so, and their role in the system
was more symbolic than functional.
Conclusion While healthcare providers have (by default)
filled the navigation role left by inactive PPHIEs, the
grievance redressal role remains unfilled. Information
about health insurance entitlements and access to
grievance redressal must be provided through visible,
accessible and efficient mechanisms that should be
continuously monitored and improved.
