2. Background (1) In India, 71 000 multidrug-resistant (MDR)-TB cases are estimated to emerge annually among notified pulmonary TB cases (WHO Global Tuberculosis Report 2015. Available from: http://www.who.int/tb/publications/global_report/en/)http://www.who.int/tb/publications/global_report/en/ In many high-burden countries such as India, TB patients incur catastrophic expenditure, directly and indirectly, for diagnosis and treatment of their disease (Available from: http://www.who.int/tb/lonnroth_tb.pdf )http://www.who.int/tb/lonnroth_tb.pdf Drug-Resistant TB cases are more likely to be fatal and are as much as 100 times more costly to treat, as compared to drug- sensitive TB cases (Available from: http://www.stoptb.org/assets/documents/events/meetings/amsterdam_conference/ahlburg.pdf)http://www.stoptb.org/assets/documents/events/meetings/amsterdam_conference/ahlburg.pdf Post-2015 WHO Global TB Strategy Framework (End TB Strategy), one of the key targets set for 2035 is no affected families face catastrophic costs due to tuberculosis. (Available from: http://www.stoptb.org/assets/documents/events/meetings/amsterdam_conference/ahlburg.pdf)http://www.stoptb.org/assets/documents/events/meetings/amsterdam_conference/ahlburg.pdf

3. Background (2) “Rashtriya Swasthya Bima Yojana (RSBY)” Or National Health Insurance Scheme “Mukhyamantri Swasthya Bima Yojana (MSBY)” Or Chief Minister’s Health Insurance Scheme Govt. of India Initiative. “Rashtriya Swasthya Bima Yojna (RSBY)”, is a social health insurance mechanism in India (Cashless, Paperless and Portable Scheme through Smart Cards) Caters BPL, MGNREGA, BoC, Street Vendor, Coolies, Domestic Maids Covers around 3.2 million families (CG) Govt. of Chhattisgarh, India Initiative (The state of Chhattisgarh (CG) in central India with population of 25 million, has 80% of the population living in rural areas and 30% considered ‘tribal) Caters State BPL & State APL Covers around 2.4 million families 1.Beneficiaries need to pay only 0.50 US $ as registration fee 2.Central and State Government pays the premium @ 63 US $ to the insurer selected by the State Government on the basis of a competitive bidding. 3.Total insurance coverage amount is up to 30 000 (US $ 500) per annum: for five enrolled members in a family; covering transportation UHIS* *Universal Health Insurance Scheme (UHIS) The economic burden imposed by TB disease on individuals and families can be reduced through a well designed and implemented social health insurance scheme

4. Multi Drug Resistant TB (MDR-TB) package for RBSY beneficiaries. C Approved 3 RSBY MDR-TB Package includes Creation of Special RSBY & MSBY MDR-TB Packages 2 1 3 Pre-Treatment Evaluations (67 USD) Follow-up Evaluations (55 USD) Hospital Stay (93 USD, @16 USD/ Day) Chhattisgarh,India RSBY & MSBY MDR-TB Packages are applicable for MDR-TB patients who are diagnosed as a ‘MDR-TB’ case from a RNTCP certified/ any recognised laboratory. RSBY & MSBY MDR-TB Package is a step in developing synergy between the TB Programme and existing social protection schemes. Intervention RSBY & MSBY MDR-TB PACKAGE DETAILS Medical/ surgical MDR-TB package name Package details Package cost Number of times/days claims can be processed Medical conditions Pre-treatment evaluations Chest X-ray, relevant haematological and biochemical tests: complete blood count (CBC), liver function tests (LFT), thyroid function tests (TFT), blood urea nitrogen (BUN), creatinine, urine (routine & microscopic), urinary pregnancy tests (UPT) 4000 (US$ 67 a ) Once Medical conditions Follow-up evaluations Chest X-ray, relevant haematological and biochemical tests: CBC, LFT, BUN, creatinine, urine (routine & microscopic) 3300 (US$ 55) Maximum five times for creatinine and all other tests for maximum of twice Medical conditions Hospital stayBed charges, doctors’ consultation fees and any other additional/ancillary drugs 5600 (US$ 93 @ US$ 13/day) Maximum 7 days’ stay on pro-rota basis

5. Methods Study Design: Descriptive study Data on the uptake of insurance claim packages (from January 2013 to April 2014) was collected from the RSBY electronic server in Raipur and then directly exported to Microsoft Excel for further analysis. A simple survey was conducted in public health facilities (Two Medical Colleges where functional DR-TB centres are located) and private health facilities, to estimate the direct expenditure a patient with MDR-TB incurs in the public and private sector, from diagnosis to treatment completion. The two districts of Raipur and Bilaspur in Chhattisgarh were selected purposively for the survey A standardised questionnaire was used to ascertain the cost for laboratory investigations (including the cost for X-rays) and a hospital stay in both public and private health facilities.

6. Results PrivatePublic (medical colleges with DR-TB centres) Items PTE, average cost, FE, average cost, HS, 800/bed × 7 days PTE, average cost, FE average cost HS, 10/bed × 7 days X-ray263525 55110 Electrocardiogram2100 350 Laboratory analysis Complete blood count 270540 3365 Liver function tests 5251050 130260 Creatinine100500 45225 Blood urea nitrogen 100200 2550 Urine (routine & microscopic) 85170 815 Thyroid function tests 5780 1750 Urinary pregnancy tests 1900 250 HIV3150 4000 Biopsy4880 1050 OPD card100 50 Total3134 (~ 52 USD)2985 (~ 50 USD)5600 (~ 93 USD)1041 (~ 17 USD)725 (~ 12 USD)70 (~1.2 USD) Table 1. Estimated costs of laboratory investigation and hospital stay based on a simple market survey conducted in Raipur and Bilaspur districts of Chhattisgarh DR-TB: drug-resistant tuberculosis; FE: follow-up evaluations; HS: hospital stay (including doctors’ fee, nutritional support and ancillary drugs); OPD: outpatient department; PTE: pre-treatment evaluations. Private-sector expenditure, Public-sector expenditure, Average laboratory investigations cost (pre- treatment evaluations ) 31341041 Hospital stay including nutritional support, ancillary drugs and doctors’ fee (for 7 days’ stay @ 800/day in private and @ 10/bed/day in government medical college hospital) 560070 Average cost of laboratory investigations cost (follow-up evaluations ) 2985725 Travel cost1800 Drugs 103 920 Free Diagnosis2800 Free Total120 238 (~US$ 2000) 3636 (~US$ 61) Table 2. Estimated expenditure a MDR-TB patient incurs in the private and public sector from diagnosis to treatment completion MDR-TB: multidrug-resistant tuberculosis. a Costs were estimated considering the cost of drugs and diagnosis is absorbed by the Government in the public sector and is based on simple market survey conducted in the districts of Bilaspur and Raipur, Chhattisgarh. Table 3. Status of uptake of insurance claims by TB patients in RSBY (1 January 2013 to 30 April 2014) TB/MDR-TBHospital type (public or private)RSBY and MSBY package nameInsurance claims MDR-TBPrivate (private/NGO hospital) Pre-treatment evaluation-MDR-TB: X- ray, laboratory analysis, CBC, LFT, creatinine, BUN, urine (R&M), TFT, UPT (only MDR-TB-diagnosed patient from recognized laboratory) 7 MDR-TB-hospital stay (only MDR-TB- diagnosed patient from recognized laboratory) 13 MDR-TB follow-up examination (only MDR-TB diagnosed patient from recognized Laboratory) 0 Public (district hospital/community health centre/primary health centre/medical college) Pre-treatment evaluation-MDR-TB: X- ray, laboratory analysis, CBC, LFT, creatinine, BUN, urine (R&M), TFT, UPT (only MDR-TB-diagnosed patient from recognized laboratory) 106 MDR-TB-hospital stay (only MDR-TB- diagnosed patient from recognized Laboratory) 68 MDR-TB-follow-up examination (only MDR-TB-diagnosed patient from recognized laboratory) 13 Total claims in MDR-TB package 207 Public (district hospital/community health centre/primary health centre/medical college) Respiratory TB, bacteriologically and histologically confirmed 137 Private (private/ NGO hospital) Respiratory TB, bacteriologically and histologically confirmed 196 Total claims in TB package333

7. Number of claims processed/beneficiary costing RSBY-MSBY package name/item Private sector (number of claims processed or number of beneficiaries) RSBY-MSBY MDR-TB package rate, Unit cost (applicable cost per patient in private sector, see Table 4 Public sector (number of claims processed or number of beneficiaries) Unit cost (with free diagnosis and drugs in public sector), Total expenses to be incurred by MDR-TB patients without any insurance cover, abcde f = (a × c) + (d × e) Claims processed in MDR-TB pre- treatment evaluation package (laboratory investigations) 7 4000 3134 106 1041 132284 Claims processed in MDR-TB hospital stay package (up to 7 days’ stay) 135600 687077 560 Claims processed in MDR-TB follow- up evaluation package (laboratory investigations) 033002985137259425 MDR-TB drugs7 Linked with RNTCP 103 920106Free727 440 MDR-TB diagnosis7 Linked with RNTCP 2800106Free19 600 Total travel cost for MDR-TB patient and one attendant in 2 years of treatment 71000/year18001061800203 400 Total catastrophic expenditure saved due to uptake of RSBY-MSBY MDR-TB health insurance packages 1 169709 (~US$ 20 000) a Table 4. Total catastrophic expenditure estimated to be saved due to uptake of insurance claims of RSBY and MSBY MDR-TB packages Total catastrophic expenditure ~US$ 20 000 was estimated to be saved through the uptake of 207 claims in RSBY and MSBY insurance mechanism

8. Conclusions and Key Recommendations First study which delves into the initial work on linking National Health Insurance Scheme (RSBY) in saving catastrophic expenditure from MDR-TB diagnosis to treatment. Innovative engagement of private providers in extending care and treatment support to the MDR-TB patients through the national health insurance mechanism (uptake of 20 claims from 11 private hospitals). The RSBY and MSBY MDR-TB Packages could empower the MDR-TB patients to avail cashless, paperless and portable transactions as per their choice in any RSBY and MSBY empaneled hospital across Chhattisgarh, thereby encouraging them to adhere to treatment and achieve treatment success with better survival probabilities. In order to address the social protection component of post 2015 End TB Strategy, mechanisms emphasizing collaboration with existing social health insurance schemes needs attention in the national policy framework for TB control. (Full paper is accessible at - http://www.searo.who.int/publications/journals/seajph/issues/innovative.pdf?ua=1) http://www.searo.who.int/publications/journals/seajph/issues/innovative.pdf?ua=1

9. Acknowledgements Rashtriya Swasthya Bima Yojna (RSBY) and Mukhyamantri Swasthya Bima Yojana (MSBY) State Nodal Agency, Directorate of Health Services, Government of Chhattisgarh. India The State TB Officer of Chhattisgarh. India Central TB Division, Ministry of Health and Family Welfare, Government of India. WHO Country Office for India. Strategic Alliance Management Services (SAMS), New Delhi.