1. INDIA: LINKAGES BETWEEN NATIONAL AND COMMUNITY-BASED SCHEMES STRATEGIES FOR THE EXTENSION OF SOCIAL PROTECTION A 900625 Turin, Italy, 13 – 24 November, 2006 STRATEGIES FOR THE EXTENSION OF SOCIAL PROTECTION A 900625 Turin, Italy, 13 – 24 November, 2006 ILO SUBREGIONAL OFFICE, NEW DELHI STEP (Strategies and Tools against social Exclusion and Poverty) Asia Coordination

2. STRUCTURE OF THE PRESENTATION EXTENDING HEALTH PROTECTION TO ALL IN INDIA: AN UNPRECEDENTED CHALLENGE… WHAT ARE THE POSSIBLE EXTENSION MECHANISMS? ADDRESSING THE FINANCING/EQUITY CHALLENGE… LOOKING AT SOME LINKAGE EXPERIENCES ILO’S CONTRIBUTION TO KNOWLEDGE DEVELOPMENT I. II. III. IV. V.

3. MEASURING THE MAGNITUDE OF THE CHALLENGE… POPULATION: 1.1 BILLION 370 MILLION WORKERS OPERATING IN THE INFORMAL ECONOMY 92% OF THE LABOUR FORCE LEFT WITHOUT ANY SOCIALPROTECTION BENEFIT HEALTH PROTECTION: STILL A DREAM FOR SOME 950 MILLION PEOPLE… … THE BIGGEST EXTENSION CHALLENGE IN THE WORLD…

4. HEALTH PROTECTION EXTENSION: HOW TO ANSWER THE CHALLENGE? A UNIQUE CHALLENGE: NO ROADMAP AVAILABLE… HENCE THE NEED FOR A DIVERSITY OF INNOVATIVE MECHANISMS… GIVEN THE MAGNITUDE OF THE EXCLUSION PHENOMENON, MANY MORE ACTORS HAVE A ROLE TO PLAY… HENCE, THE NEED FOR MORE ADVOCACY AND FOR A MULTI-PARTNERSHIP APPROACH… THERE IS NO ADVOCACY WITHOUT EVIDENCE… HENCE, THE NEED TO DEVELOP MORE KNOWLEDGE AMONGST ALL ACTORS… ACCESSING, WITHOUT FINANCIAL BARRIERS, QUALITY HEALTH CARE SERVICES IS THE PRESSING NEED OF THE DAY… HENCE, THE NEED TO FOCUS ON HEALTH PROTECTION INCLUDING MATERNITY PROTECTION… THE BEST WAY FORWARD: LET A THOUSAND FLOWERS BLOOM… AND LEARN FROM BEST PRACTICES BEFORE SCALING UP…

5. HEALTH PROTECTION: ESTIMATED PRESENT COVERAGE FORMAL AND INFORMAL SYSTEMSNo. BENEF EMPLOYEES’ STATE INSURANCE SYSTEM (ESIS)32,500,000 CENTRAL GOVERNMENT HEALTH SCHEME (CGHS)4,300,000 DEFENCE/POLICE EMPLOYEES6,600,000 RAILWAYS EMPLOYEES HEALTH SCHEME5,500,000 CESS-BASED CENTRAL WELFARE FUNDS4,000,000 STATE-LEVEL WELFARE FUNDS3,000,000 EMPLOYER-SPONSORED INSURANCE SCHEMES20,000,000 INDIVIDUAL COMMERCIAL INSURANCE6,000,000 MEDICLAIM18,000,000 UNIVERSAL HEALTH INSURANCE SCHEME1,100,000 HEALTH MICRO-INSURANCE SCHEMES7,000,000 TOTAL106,100,000 % OF POPULATION9.7%

6. MAIN HEALTH PROTECTION EXTENSION MECHANISMS ESIS COVERAGE: GRADUAL EXTENSION TO INFORMAL ECONOMY WORKERS WELFARE FUNDS: FUNDS CREATED THROUGH CESS / CONTRIBUTION CATERING FOR A SPECIAL CATEGORY OF WORKERS – TRIPARTITE MANAGEMENT – BROAD RANGE OF BENEFITS: EDUCATION GRANTS, OLD-AGE PENSION, MEDICAL CARE, LIFE… (EXAMPLE: KERALA - 24 WELFARE FUNDS) MICRO-INSURANCE PRODUCTS: PROVIDED BY INSURANCE COMPANIES (BOTH PUBLIC AND PRIVATE) AND TARGETING THE DISADVANTAGED GROUPS (RURAL & SOCIAL SECTORS) IN-HOUSE MICRO-INSURANCE SCHEMES: DEVELOPED BY A WIDE DIVERSITY OF ACTORS SPECIAL FUNDS: ALLOCATED BY STATE GOVERNMENTS TO PAY FOR SURGICAL PROCEDURES NEEDED BY BPL POPULATION (EXAMPLE: JHARKHAND – US$ 2.2 MILLION/YEAR)

7. HEALTH PROTECTION EXTENSION MILESTONES 1999: IRDA - OPENING THE INSURANCE MARKET TO PRIVATE COMPANIES 2002: SOCIAL OBLIGATIONS FOR PRIVATE INSURANCE COMPANIES 2003: UNIVERSAL HEALTH INSURANCE SCHEME 2004: SOCIAL SECURITY SCHEME FOR IE WORKERS 2005: NATIONAL RURAL HEALTH MISSION (18 STATES) 2005: MICRO-INSURANCE REGULATIONS 2006: MATERNITY VOUCHER SHEME FOR BPL WOMEN (10 STATES) 2006: NATIONAL COMMISSION FOR ENTERPRISES IN THE UNORGANIZED SECTOR – SOCIAL SECURITY PROPOSAL (TARGETING 300 MILLION WORKERS & THEIR FAMILIES) 2006: EXTENSION OF UNIVERSAL HEALTH INSURANCE SCHEME (INSURANCE MODELS)

8. CENTRAL GOVERNMENT: HEALTH PROTECTION EXTENSION STRATEGIES WELFARE FUNDS (6) PUBLIC INS. Co. (4)PRIVATE INS. Co. (15) WITH / WITHOUT SUBSIDYTHROUGH REGULATIONS MICRO-INSURANCE HEALTH PROVID. NON-GOV. ORG. MICRO- FINANCE CO-OP. MOVEM. TRADE UNIONS LOCAL GOVERNM. YESHASVINI IN-HOUSE (30%) PARTNER-AGENT (70%) NAANDI INDORE TRADE UNIONS CO-OP. MOVEM. MICRO- FINANCE NON-GOV. ORG. HEALTH PROVID. UHIS (SUBSIDY) MECHANISM 1 MECHANISM 2 INSURANCE PRODUCTS

9. STATE GOVERNMENTS: HEALTH PROTECTION EXTENSION STRATEGIES WELFARE FUNDS (55) PUBLIC INS. Co. (4)PRIVATE INS. Co. (11) WITH SUBSIDY BELOW POVERTY LINE POPULATION JHARKHAND STATE GOVERNM MECHANISM 1 MECHANISM 2 MECHANISM 3 INSURANCE PRODUCTS STATE-ASSISTED MEDICAL FUNDS

10. HEALTH MICRO-INSURANCE: TOWARDS SELF-RELIANCE? SCHEMESN0 OF BENEFIC. TYPE OF SCHEME TYPE OF COVERAGE TYPE OF BENEFIT TYPE OF SUBSIDY YESHASVINI1,830,000IN-HOUSETER.CASHL.DIRECT DHARAMST.400,000P.AGENTSEC.CASHL.- SEWA174,000P.AGENTSEC.REIMB.INDIRECT VHS124,000P.AGENTPR/SECCASHL.INDIRECT KARUNA118,000P.AGENTPR/SEC.REIMBIND/DIRECT PREM108,000IN-HOUSESEC.CASHL/REIMINDIRECT NAANDI60,000IN-HOUSEPR+SEC+TERCASHLESSIND/DIRECT AROGYA60,000P.AGENTSEC.CASHL.INDIRECT INDORE49,000P.AGENTSEC.CASHL.DIRECT H.FIELDS30,000P.AGENTSEC.CASHL/REIMINDIRECT UPLIFT16,000IN HOUSESEC.REIMB.INDIRECT ASHWINI12,000P.AGENTPR/SECCASHL.IND/DIRECT

11. HEALTH MICRO-INSURANCE: THE FINANCING CHALLENGE…  PLANNING COMMISSION DEFINITION: VALUE OF A SPECIFIED NUTRITION REQUIREMENT o 26% o 278 MILLION  UNDP DEFINITION: LESS THAN 1 US/DAY/PERSON o 35% o 374 MILLION  UNDP ANALYSIS: LESS THAN 2 US/DAY/PERSON o 80% o 855 MILLION …AT THE END OF THE DAY… NOT MUCH LEFT TO PAY FOR INSURANCE…

12. HEALTH MICRO-INSURANCE: THE FINANCING CHALLENGE (Rs.)

13. HEALTH MICRO-INSURANCE: ENTERING INTO A VICIOUS CYCLE… LIMITED CONTRIBUTION LIMITED BENETITS ADVERSE SELECTION DISSATISFACTION & DROP-OUT COST INCREASE PREMIUM INCREASE

14. HEALTH MICRO-INSURANCE : THERE IS NO SAFETY IN NUMBERS, UNLESS…   FROM PRODUCT DESIGN TO BENEFIT DELIVERY: A LONG AND BUMPY ROAD… ADVERSE SELECTION & MORAL HAZARD WEAK CONTRIBUTORY CAPACITY, HENCE, LIMITED BENEFITS, DISSATISFACTION & DROPOUT OVER-PRESCRIPTION & OVER-TARIFFICATION

15. HEALTH MICRO-INSURANCE: THE EQUITY CHALLENGE: NEED TO SHARE THE BURDEN… FORMAL ECONOMY WORKERINFORMAL ECONOMY WORKER INCOME: Rs. 2,000/MONTH ESIS CONTRIBUTIONS:RS 1.700 INCOME: Rs. 2,000/MONTH MI CONTRIBUTIONS: Rs. 365? VERY LIMITED SCOPE AND LOW LEVEL OF BENEFITS BROAD SCOPE AND HIGH LEVEL OF BENEFITS LESS ADMINISTATIVE EXPENSES: AGENT COMMISSION, TPA, INS.Co,TAX) LESS COSTS OF ADVERSE SELECTION & OVER PRESCRIPTION FULL ALLOCATION TO BENEFITS

16. HEALTH PROTECTION: LOOKING AT SOME LINKAGE EXPERIENCES… UNIVERSAL HEATH INSURANCE SCHEME (THROUGH PUBLIC INSURANCE COMPANIES) – CENTRAL GOVERNMENT SUBSIDY COMPONENT YESHASVINI (NO INSURANCE COMPANY) – STATE GOVERNMENT SUBSIDY COMPONENT INDORE MUNICIPAL CORPORATION (THROUGH PUBLIC INSURANCE COMPANY) – LOCAL GOVERNMENT SUBSIDY COMPONENT NAANDI FOUNDATION (NO INSURANCE COMPANY) – CORPORATE SECTOR/CIVIL SOCIETY SUBSIDY COMPONENT JHARKHAND (NO INSURANCE COMPANY) – CORPORATE SECTOR/STATE GOVERNMENT SUBSIDY

17. UNIVERSAL HEALTH INSURANCE SCHEME (UHIS) MARKETED THROUGH PUBLIC INSURANCE COMPANIES COVERS ONLY HOSPITALIZAZION EXPENSES (UP TO Rs. 15,000) TARGETS PEOPLE IN THE AGE GROUP (3 MONTHS-65 YEARS) EXCLUSIONS: PRE-EXISTING DISEASES, DELIVERY, PREGNANCY-RELATED ILLNESS… PREMIUM:  INDIVIDUAL: Rs. 165/SUBSIDY Rs. 200  FAM. UP TO 5 MEMBERS: Rs. 240/SUBSIDY Rs. 300  FAM. UP TO 7 MEMBERS: Rs. 330/SUBSIDY Rs. 400 THROUGH TPAs (26 TPAs TO THIS DAY) CASHLESS SERVICES COVERAGE (2005): 1,100,000

18. YESHASVINI CO-OPERATIVE FARMERS HEALTH SCHEME (KARNATAKA) PRIVATE TRUST (HEALTH PROVIDERS / GOVERNMENT) MARKETED THROUGH THE COOPERATIVE MOVEMENT COVERS ONLY SURGICAL PROCEDURES (1.600 PROCEDURES) UP TO Rs. 100,000 PER YEAR PREMIUM: Rs. 120 /PERS /YEAR (Rs. 60 FOR CHILDREN UNDER 18) IN-HOUSE MODEL (NO INS. CO) TPA (FAMILY HEALTH PLAN) HOSPITAL NETWORK (169) CASHLESS SERVICES GOVERNMENT DIRECT SUBSIDY COVERAGE (2006): 1,830,000 SECOND LARGEST IN THE WORLD

19. YESHASVINI: EVOLUTION OF PERFORMANCE INDICATORS PREMIUM VERSUS SUBSIDY PER INSUREDADMINISTRATIVE COST PER INSURED EVOLUTION OF NUMBER OF INSURED

20. INDORE MUNICIPAL CORPORATION HEALTH INSURANCE SCHEME (MADHYA PRADESH) PUBLIC DEPARTMENT (IMC) TARGETS SENIOR CITIZENS (60 TO 80 YEARS OLD) COVERS HOSPITALIZATION COSTS UP TO Rs. 20,000 PREMIUM: Rs. 475 /PER PERSON /PER YEAR (FULLY PAID BY MUNICIPAL CORORATION) PUBLIC INSURANCE COMPANY TPA (MD INDIA) HOSPITAL NETWORK (14 PRIVATE HOSPITALS) CASHLESS SERVICES COVERAGE (2006): 49,419 ALREADY REPLICATED IN GWALIOR

21. INDORE: EVOLUTION OF PERFORMANCE INDICATORS ADMINISTRATIVE COST PER INSUREDPREMIUM VERSUS CLAIMS COST EVOLUTION OF NUMBER OF INSURED

22. NAANDI FOUNDATION SCHOOL HEALTH PROGRAMME (ANDHRA PRADESH) NGO / PRIVATE TRUST TARGETS YOUNG CHILDREN (6 to 14 YEARS-OLD) ENLISTED IN PUBLIC SCHOOLS (HYDERABAD CITY) COMPREHENSIVE COVERAGE (WHOLE CARE) – WITH NO LIMITATION PREMIUM: Rs. 120 PER CHILD PER YEAR (FULLY PAID BY CORPORATE SECTOR/ EMPLOYEES) SERVICES PROVIDED BY NODAL HEALTH CLINICS + BASE HOSPITAL + REFERRALS CASHLESS SERVICES ALL-INCLUSIVE COVERAGE (2006): 60,000 ALREADY REPLICATED IN UDAIPUR

23. HEALTH PROTECTION IN JHARKHAND: THE SITUATION… CARVED OUT OF BILAR IN 2000 POPULATION: 26.9 MILLIOn BPL POPULATION : 54% HEALTH INDICATORS: AMONG THE WORST IN THE COUNTRY INFANT MORTALITY RATE 71/1000 75% DELIVERIES WITHOUT MEDICAL ASSISTANCE

24. HEALTH PROTECTION IN JHARKHAND: TAKING UP THE CHALLENGE… FIRST PHASE TARGET: TO COVER THE BPL POPULATION (15 MILLION) FIRST SCHEME TO BECOME UNIVERSAL (27 MILLION) FIRST SCHEME TO RELY ON PRIVATE-PUBLIC PARTNERSHIP FIRST SCHEME TO BE ALL-INCLUSIVE (COVERS ALSO PEOPLE LIVING WITH HIV AND GROUPS AT RISK) FIRST SCHEME TO HAVE A CONTRIBUTION FROM EMPLOYERS (LONG-TERM FINANCIAL COMMITMENT) FIRST SCHEME TO BE MANDATORY COMPREHENSIVE HEALTH CARE CASHLESS SERVICES NO INSURANCE COMPANY

25. HEALTH PROTECTION IN JHARKHAND: ADDRESSING THE ACCESSIBILITY ISSUE…   INSURANCE: REMOVING THE FINANCIAL BARRIER… AT BOTH ENDS : POOR CANNOT PAY BUT IF INSURED…

26. ADVOCACY CAPACITY BUILDING KNOWLEDGE DEVELOPMENT NEED TO INCREASE THE ACTIVE SUPPORT OF POLICY MAKERS UNDER THE NATIONAL SOLIDARITY PRINCIPLE NEED TO ENHANCE THE TECHNICAL CAPACITIES OF THE VARIOUS ACTORS INVOLVED IN THE MANAGEMENT OF HEALTH MICRO-INSURANCE SCHEMES NEED TO DEVELOP STRONGER EVIDENCE ON SOCIAL PROTECTION BEST PRACTICES AT THE GRASSROOTS LEVEL… ILO STRATEGY: FROM KNOWLEDGE DEVELOPMENT TO ADVOCACY… …THROUGH A MULTI-PARTNERSHIP APPROACH ILO STRATEGY: FROM KNOWLEDGE DEVELOPMENT TO ADVOCACY… …THROUGH A MULTI-PARTNERSHIP APPROACH

27. Survivors Benefit Medical Care Case Studies Case Studies Thematic issues or wide geographical coverage Analysis of a specific in-country experience Broad overview or narrowing down on a specific aspect Contribution To overall capacity building effort Sickness Benefit Unemployment Benefit Invalidity Benefit Maternity Benefit Family Benefit Employment Injury Benefit Old-age Benefit Technical Papers Technical Papers Studies Tools KNOWLEDGE DEVELOPMENT PROCESS KNOWLEDGE CREATION PROTECTION PRIORITIES

28. KNOWLEDGE DEVELOPMENT PROCESS Documents shared in-country with all interested organizations Documents shared in-country with a group of specialists and evolving over time Documents published at country level - Worldwide dissemination (STEP website) Documents published at headquarters level – Worldwide dissemination (ILO Website) Publications Working Papers Working Papers Discussion Papers Discussion Papers Information Papers Information Papers KNOWLEDGE DISSEMINATION

29. Informal Economy Formal Economy Main Actors Insurance Companies Third Party Administrators Healthcare Providers Micro-Finance Institutions Local Organizations OVERVIEW OF ILO’S CONTRIBUTION TO KNOWLEDGE DEVELOPMENT Formal Social Security Syst. State Governments Central Government LOOKING AT THE DIVERSITY OF INITIATIVES AT ALL LEVELS STUDIES & CASE STUDIES STUDIES & CASE STUDIES

30. THE ASIAN MICRO-INSURANCE NETWORK (AMIN) 350CHEMES… SO FAR… SET UP AN EFFICIENT MECHANISM ALLOWING FOR THE REGULAR SHARING OF INFORMATION AND EXPERIENCE AMONG MICRO- INSURANCE PRACTITIONERS DEVELOP THE DOCUMENTATION PROCESS ON MICRO-INSURANCE INITIATIVES, INNOVATIONS AND ACHIEVEMENTS BUILD UP TECHNICAL CAPACITIES OF MICRO-INSURANCE ACTORS STRENGTHEN COLLABORATION AND PATNERSHIP AMONG MICRO- INSURANCE SCHEMES HIGHLIGHT AND CLARIFY ISSUES, CHALLENGES AND OPPORTUNITIES RELATED TO THE CONTRIBUTION OF MICRO-INSURANCE TO SOCIAL PROTECTION EXTENSION OBJECTIVES: