Seite 1 A Step Towards Universal Coverage in India – Example of RSBY Dr. Nishant Jain

Seite 2 Page 2 Role of the Government  Government is both Financial and Service Provider in Health Sector in India  Government spends only 1% of GDP on Health  Government is suppose to provide free health care to the population across India with their own infrastructure at different levels  However, the ground level situation is very different  People spend on an Average Rs even when they are hospitalised in a Government hospital  Though the facilities per se are free but a lot of these expenditure is related to the medicines, diagnostic tests, food, transportation etc.  To take care of these expenditures people often have to borrow money or sell assets  7.6% of households fall BPL due to healthcare payments.

Seite 3 Page 3 Role of the Government in Health Insurance  Very Low penetration of Health Insurance (Less than 100 million people covered with health insurance till 2007)  Objectives of Government Funded Health Insurance  Gradual Shift From Supply Side Financing to Demand Side Financing  Strengthening Public Health Care by bringing competition and incentives  Providing Power of Choice to the Beneficiaries in terms of treatment  Reduce OOPE on health care  A health insurance scheme (RSBY) was designed keeping in mind the characteristics of the beneficiaries  RSBY was designed as a “Business Model” for a social sector initiative

Seite 4 Page 4 OUT OF POCKET (OOP) EXPENSES AND INDEBTEDNESS IN INDIA (Amount in $US) ALL INDIAPOOREST 1.Average OOP Payments made per hospitalization in Govt. facilities Average OOP Payments made per hospitalization in private facilities %age of people indebted due to OP Care %age of people indebted due to IP Care 5264 SOURCE: NSSO, GOI

Seite 5 Page 5 What is RSBY  Benefits  Cover for Hospitalisation Expenses of Rs. 30,000/- (US$ 650 ) per family per annum on a family floater basis (Upto five family members)  All hospitalisation is covered and for 1020 surgical packages including Maternity & Newborn Care rates are pre-defined  Cover for Day Care Surgeries  All Pre-existing Diseases to be covered  1 day pre and 5 day post hospitalisation Expenses  Transportation costs (Rs.100 per visit) with overall limit of Rs.1000 (US$ 22)  Sources of funding for program  Rs. 30 (US$ 0.65) per family per year from Beneficiaries  75% of Premium from Central Government  25% of Premium from State Government  Both Public and Private providers can be empanelled  Beneficiary can get cashless treatment in empanelled hospital

Seite 6 Page 6 Main Processes Involved  State Government set up an independent nodal agency which prepares the BPL data in specified format  Insurance Company is selected through an open tendering process  A list of potential beneficiaries is prepared based on defined criteria  Insurance Companies need to go the field and enroll beneficiaries in the village after taking fingerprint and photo  A smart card is printed and given on the spot and a Government representative authenticates it by his/ her smart card and fingerprint  A beneficiary can go to any public and private empanelled hospital and get cashless treatment through smart card  Data flows every day from each hospital to the insurer  Paperless claim settlement process for the hospitals

Seite 7 Page 7 Enrollment Station

Seite 8 Page 8 Key transfer Verification by FKO by fingerprint and smart card Data of Beneficiary family FKO Card RSBY Card

Seite 9 Page 9 Innovative Use of Technology  RSBY uses different technologies to effective reach its objectives  Biometric Technology for identification of beneficiaries and reduce fraud  Smart Card technology to ensure that benefits can be provided electronically even in cases where there is no regular internet facility available and provide portability of benefits  Web based services to ensure that data is transferred securely and all the activities are transparent  Mapping and GIS services to track developments in the field on a regular basis  Key Management System to ensure that Smart card is issued to the right beneficiary and used at the right place  Trigger based automated data analysis to prevent, detect and analyse fraudulent practices

Seite 10 Page 10 Progress Over Time Estimate d

Seite 11 Page 11 Current Status of RSBY Implementation in India  Cards issued – App million  People enrolled – App. 119 million  Number of People benefitted till now – App. 4.8 million  Number of Hospitals Empanelled – App. 12,000  States and UTwhere Service delivery has started – Twenty Eight  Number of Insurance Companies Involved – Fifteen

Seite 12 Page 12 Financial Implications  Per family premium to Insurance Company – US$ 8  Current enrolled families 33.9 millions  Total Expenditure for these families – US$ million  Targeted families – 70 million  Cost of Smart card, issuance and implementation is part of the premium and borne by the Insurance Company  Administrative costs generated through registration fee – US$ million  This money can be used by the Government for different administrative purposes  Total Expenditure for targeted families once they all will be enrolled – US$ 560 million

Seite 13 Page 13 Trends From Data

Seite 14 Page 14 Hospitalisation Ratio  Access to hospitals has increased for RSBY beneficiaries  Districts which have finished more years have higher hospitalisation  There is huge variations across different States

Seite 15 Page 15 Hospitalisation Numbers Over Time

Seite 16 Page 16 Male - Female Distribution

Seite 17 Burnout Ratio for All Districts Burn-Out Ratio for 322 Districts where 1 year is complete Burn-Out Ratio for 211 Districts where 1 year is complete Burn-Out Ratio for 211- Districts where 2 years are complete

Seite 18 Page 18 Success So Far

Seite 19 Page 19 Beneficiary Physical Mental Social Improved access to Health care Reduction in OOPE Improved Quality Care Mental Security Reduction in indebtedness Migrant worker’s Family is covered Scheme is working well even in Naxalite districts Improved gender utilisation Providing Social Identity Health is a state of complete physical, mental and social well-being (WHO definition) Benefits for Beneficiary in RSBY

Seite 20 Page 20 Success So Far – Improving Access  Improvement in access to Healthcare for targeted segment in comparison to NSSO Data  In the worst naxalite affected areas also RSBY has been able to provide benefits to people  There is a marked improvement in utilisation by women in the scheme  Out of pocket expenditure for health is coming down  State Governments are improving their BPL list because RSBY is bringing out the discrepancy  Able to provide social identity to people

Seite 21 Page 21 Success So Far  Competition between Public and Private Hospitals  Incentives for staff of public hospitals from Insurance money  Hospital retains the insurance money in the hospital and can be used for the hospital by the hospital.  Increase in capacity of private hospitals  Setting up of Hospitals by Private sector in remote areas  Use of IT ensure that Insurance Company and Government gets data daily from the Hospitals  This data is analysed for patterns/ spikes and strong action taken against errant hospitals  Cashless & paperless transaction for people  paperless claim process for hospitals

Seite 22 Page 22 Evaluation Studies – Satisfaction Level of Beneficiaries from RSBY

Seite 23 Page 23 Key Results from Latest Evaluation  90% of the enrolled and hospitalized respondents, spent no money at the hospital for the last policy period  In comparison to this non enrollees on an average Rs. 17,000 (USD 320) per year from their own pocket  90% of beneficiaries were satisfied with the scheme  More than 94% of beneficiaries said that they will enroll even next year even if they had not used hospitalisation services

Seite 24 Page 24 Challenges

Seite 25 Page 25 Challenges  Beneficiary Data Preparation  Improving the quality of data  Building on the previous year enrolled data for next year  Updating the BPL data  Preparing data for new categories  Improving Enrollment  Informing and motivating families to come and enroll  Improving average family size  Which intermediaries to engage for this purpose  Information dissemination  Designing and Implementing effective communication strategies  Ensuring that beneficiaries are enrolled and know how to use the benefits of RSBY  Collecting feedback from beneficiaries

Seite 26 Page 26 Challenges  Capacity building.  Designing different capacity building materials for different stakeholders  Organising separate training workshops for different stakeholders  Early Detection/ Prevention of fraud.  Closely monitoring the hospital’s performance and trends  Identify early hospitals engaged in malpractices  Strict action against errant hospitals  Incentivising better performing hospitals

Seite 27 Page 27 The Road Ahead

Seite 28 Page 28 Future Plan  RSBY is being extended to many other categories which will be partially or fully sibsidised  NREGS Beneficiaries  Building and Construction Workers  Railway Porters  Postmen  Domestic Workers  Street Vendors  Beedi Workers  Many other categories of informal sector workers are in the process of being added

Seite 29 Page 29 Providing Outpatient Benefits  RSBY started with providing only inpatient care through a network of empanelled public and private health care providers  In 2011 two experiments on providing Outpatient benefits to RSBY beneficiaries were started  In both the experiments, the provision of Outpatient benefits is done through the intermediation of the Insurance Companies  Initial Results of these experiments are quite positive  Now more experiments on providing Outpatient benefits have started/ are starting in more States

Seite 30 Page 30 Extension and Expansion of RSBY Below Poverty Line (30%) Government Employees Private Insurance B& C Wor kers Dom estic Wor kers NRE GS Work ers RSBY Fully Subsidised Other Occupational Groups e.g Taxi drivers RSBY Partially Subsidised/ Non-Subsidised Primary Care/ Outpatient Secondary Care Tertiary Care Curative Continuum Str eet Ve ndo rs

Seite 31 Page 31 Expansion of RSBY – Smart Card Platform  Decision taken to test the utilisation of RSBY Smart Card Platform for providing benefits of other Social Security Schemes  Life and Disability Insurance scheme called Aam Aadmi Bima Yojana (AABY)  Indira Gandhi National Old Age Pension Scheme  Some of the State Governments have taken decision to use RSBY Smart card platform to deliver benefits under Public Distribution System for food subsidy

Seite 32 Page 32 Future Focus Areas for RSBY  For expenditures beyond Rs. 30,000 different State Governments are linking with other funds/ schemes  RSBY provides them a platform to transparently deliver this  Improving the quality of service at the hospitals  Government of India has designed an Quality management system  Evolving a robust back-end data base management  Capacity Building at each levels for all the stakeholders  Provide Outpatient benefits integrated with RSBY  Store Health related data on the smart card with proper security  Use the Smart Card for other targeted interventions  Cooperating with other Countries which are interested in RSBY

Seite 33 Page 33 What have we learned in India?  If you believe you have a reasonably good UHC plan it is better to start than keep waiting to design “perfect” product (often the biggest enemy of “good” is “best”)  We must leverage the private sector and their strengths as they can compliment in the efforts of the Government  Buy-in of stakeholders is very important for success  From fixing “Targets” to a model of developing “Business models” for Social sector schemes is the way forward  Generate regular evidence to feed into policy design and keep improving  Technology today has power to change  Focus should be on ease of access for Beneficiary than easy of implementation for Government

Seite 34 Thank You