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SAURABH SHARMA Uplift Health Mutuals. Community based health fund (CBHIs, MHOs) Uplift Mutuals: Group of Social Sector Organisations Based in Maharashtra.

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Presentation on theme: "SAURABH SHARMA Uplift Health Mutuals. Community based health fund (CBHIs, MHOs) Uplift Mutuals: Group of Social Sector Organisations Based in Maharashtra."— Presentation transcript:

1 SAURABH SHARMA Uplift Health Mutuals

2 Community based health fund (CBHIs, MHOs) Uplift Mutuals: Group of Social Sector Organisations Based in Maharashtra & Rajasthan

3 Uplift Health Mutuals: A Case Study Purpose of Study Document the Uplift Model & Processes Review Key Performance Indicators, Sustainability, and Client value Method of Study Qualitative and Quantitative  Literature review  Interviews with process managers, clients and senior management  Secondary Data Analysis  Observation of key procedures

4 Flow of Presentation Community Based Health Insurance Uplift: Timeline, Model & Product Growth & Impact  KPIs  Client Value Program Sustainability  Cost model  Program Costs Way Forward

5 Outreach of Community Based Insurance in India

6 Challenges for community based risk solutions Source: ILO, MIF Low community participation Lack of professional management Small size of risk pool Incomprehensive product Isolation from formal insurance mechnisms

7 Uplift: Timeline, Model & Product

8 A Decade for Uplift 2003 Uplift Mutuals established 2004 Registration of Uplift India Association PSW Pune Joined Product Modification Arogyanidhi 2 Launched Enrollments crossed 100,000 3 More partners Joined ,000 Members Expansion to Rajasthan

9 Partner Members S NONameLocationYear of Joining Primary Activities 1Swabhimaan Pune, Maharashtra 2003 Microfinance & Health 2 Inter Aide (Technical partner and Grant Provider) France2003 Supporting Development Activities 3Navnirman Samaj Vikas Kendra Mumbai, Maharashtra 2011 Microfinance & Health 4Parvarti Swayamrojgar Pune, Maharashtra 2004 Microfinance,Enterprise Development & Family Program 5 Annapurna Parivar Vikas Samvardhan Pune & Mumbai, Maharashtra 2003 Microfinance, Enterprise Development & Health 6Disha Kendra Pune, Maharashtra 2004 Microfinance 7 Annapurna Mahila Mandal Credit Cooperative Society Mumbai, Maharashtra 2003 Credit Cooperatives 8Chaitanya Pune, Maharashtra 2010 Microfinance, SHG & federation promotion 9PEDO supported FederationsRajasthan2012 SHG & federation promotion

10 Arogyanidhi: the product FeatureUplift Mutuals Compulsory/VoluntaryCompulsory for MFI credit customers Payment TypeReimbursement Eligibility Criteria:No age limit Premium Contribution For a family of four: Rs. 400 (approx. USD 8) per year For individuals: Rs. 150 (approx. USD 3) per year Period of Cover 12 months from the date of issue of policy Sum Insured Rs. 15,000 per person per year subject to policy exclusions Benefits Offered  In patient hospitalization expenses for treatment in general ward  10 days of pre and post hospitalization cover including expenses for one time diagnosis of the ailment and the cost of medicines prescribed during this period  Pre-existing diseases covered from 3 rd year onwards Stipulation Pertaining to Health Care Providers  100% : Public Hospital  80% : Networked Private Hospitals  No reimbursement : Non Networked Private Hospitals, except emergencies

11 Value Added Services: Reducing Health Risk ServiceDetails Outpatient careBeat doctor Discounts on drugs and Diagnostics Networked pharmacy and diagnostic centres Free generic medicines Health camps & TalksHealth awareness sessions Client education Sessions about insurance and the HMF program 24/7 helplineHelpline for guidance or referrals Access to Uplift’s network of HCPs Uplift has established a network of more than 300 healthcare providers for better quality of care, and to control cost. Uplift signs MoU with these HCPs with negotiated medical costs. Referrals/guidanceAssistance by a service executive

12 Awareness Material Awareness Sessions Health Education: Reducing Risk

13 How it Works Uplift Mutuals Managers/ Astt Managers Arogyasakhis Arogyasakhi Arogyasakhis Uplift As TPA InterAide Uplift as TPA Negotiated Rates Monitoring HCPs Health seeking Guided by Arogyasakhis Networked Health Care Providers Claim Processing Final Claim Settlement & Disbursement at community level

14 Growth & impcat

15 Reviewing Growth: Number of Ongoing Members

16 Uplift: Efficiency & Client Value 24% Reduction in Out of Pocket expenditure  Remarkable impact Service Ratio at 56%  Proportion of clients using IP/OP insurance Services Claim rejection Ratio at 2%  Initial high rate at 10.5%  Key for Community Based Models Voluntary enrolment at 8-10%

17 Client Value: PACE Analysis Source: ILO, MIF

18 Reducing Out Of Pocket Expenditure

19 Improving Client Value Challenges in improving client value  Reimbursement based product  High OP Care expenses leading to high OOP Challenges in providing Cash less system  Increase in negotiated prices  Role of community diminished  Increased chances of Fraud

20 Program sustainability

21 Costing Model 100% Gross Premium Collected  60%: Claim Fund  Claims Disbursed  Solidarity Fund  20%: Uplift  TPA Services  Value Added Services  Opex  20%: Partner Organization  Value Added Services  Opex Subsidy Provided by Inter Aide  Opex  Value added services

22 Total Program Costs ClaimsValue Added Services OpexTOTAL APVS Pune 56.5 (41%) 24.3 (18%) 57.6 (41%) APVS Mumbai 60.4 (42%) 26.6 (19%) 55.9 (39%) PSW 45 (24%) 31 (17%) 107.9(5 9%) Total Program Costs on Per Member basis for Partner Organizations Source: 2009

23 Dependency on Claim Funds Claim Ratios for Partner Organizations

24 Operating Expenses Operating Expenses on Per Member basis for Partner Organizations

25 Dependency on Subsidy

26 Way Forward High Operating expenses for partner organizations  Tripling the current outreach  Automation of routine functions Enhancing Client Value  Instant Cash Loan Product (Health Expenses)  Reinsurance facility to increase cover Structural challenges  Attrition of Service executives  Adverse Selection  Fund management at branch level

27 QUESTIONS?


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