1. Shib Sekhar Datta Social Health Insurance

2. Framework What is Insurance Why Health Insurance Types of Health Insurance Social Health Insurance History Characteristics of Health Insurance Models in Different Countries Indian Scenario of SHI CGHS and ESIS Problems and Challenges Conclusion Recommendation Way Forward References

3. WHY Health Insurance ? Has the potential To increase access To provide financial protection To improve quality of Care To control costs To regulate the private sector Downside Has been introduced for wrong reasons Is conceptually difficult to explain Is administratively more complex Needs extra resources

4. Insurance 1.Voluntary health insurance schemes or private-for-profit schemes 2.Employer-based schemes 3.Insurance offered by NGOs / community based health insurance, 4.Mandatory health insurance schemes or government run schemes (namely ESIS, CGHS). Social health insurance in India and Europe, Germany, Japan and so on…… Social health insurance in these countries, in fact, evolved from a conglomeration of small community health insurance schemes.

5. Health Insurance Framework INSURER ORGANIZER COMMUNITYPROVIDERS MANAGEMENT PAYMENT CARE PREMIUM NGOs

6. Mandatory health insurance where everyone has to enroll and pay a specified premium. Everyone enrolled is entitled to specified benefits. Benefits and premiums determined by regulations – difficult to adjust Funds are earmarked for health service Direct relation between demand and insurance premium 2 types a. BISMARCK system – Employs multiple organizations which call for sickness funds b. Only one parastatal agency outside the day-to-day control of the political process Social Health Insurance

7. Buyers voluntarily purchase insurance coverage from private, independent, competitive, for-profit or not-for-profit insurance companies. Premium that reflect buyers risk rather than their ability to pay. Groups/ Individuals are usually based in employment Problems with Private Health Insurance a. Adverse Selection b. Risk Selection (Cream Skimming) c. Informational Asymmetry and Moral Hazard Private Health Insurance

8. Can complement taxation and social & private insurance in order to reach those left out by formal taxation and insurance schemes such as employed in the informal sector, the unemployed, living in rural areas. Mostly evolve in the context of severe economic constrains, political instability, and lack of good governance [ eg: such arrangements improve peoples access to drugs, primary care, and even to more advanced hospital care. This community involvement allows rural and low-income populations to raise more resources with which to pay for health care than would otherwise have been possible.] Study done by Preker et al (2002) Community Financing

9. Out-of-Pocket Payments Payments by patients directly to health services providers that are not reimbursable by an insurance scheme. User Fees Subcomponent of OOP s and refer to payments when these are made for services provided by the public sector In both the system money is raised and spent locally less leakage through insurance system patients see direct result for their payment so, more willing pay monitor services better – enhanced quality service in not free !

10. Social insurance is an earmarked fund set up by government Explicit benefits in return for payment It is usually compulsory for certain groups in the population Premiums are determined by income (and hence ability to pay) rather than related to health risk. The benefit packages are standardized Contributions are earmarked for spending on health services The government-run schemes include Central Government Health Scheme (CGHS) Employees State Insurance Scheme (ESIS) Social Health Insurance

11. To generate sufficient and sustainable resources for health To use these resources optimally (by modifying incentives and through appropriate use of these resources) To ensure that everyone has financial accessibility to health services. Targets of Social Health Insurance

12. Social Health Insurance - financing targets and final health system goals Performance of social health insurance scheme in key design issues Responsiveness Fair financial contribution Health Resource generation (sufficient & sustainable) Fin. accessibility of health services for all Optimal resource use

13. CGHS (Central Government Health Scheme) Since 1954, all employees of the Central Govt. (present and retired); some autonomous and semi-government organizations, MPs, judges, freedom fighters and journalists are covered under the CGHS Designed to replace the cumbersome and expensive system of reimbursements (GOI, 1994). Aims at providing comprehensive medical care to the Central Govt. employees and benefits offered include all OPD facilities, and preventive and promotive care in dispensaries. Inpatient facilities in government hospitals and approved private hospitals are also covered.

14. CGHS (Central Government Health Scheme) Mainly funded through Central Govt. funds Premiums ranging from Rs 15 to Rs 150 per month based on salary scales. Coverage has grown substantially with provision for the non-allopathic systems of medicine as well as for allopathy. Beneficiaries at this moment are around 432 000, spread across 22 cities. Criticized from the point of view of quality and accessibility. Often high out-of-pocket expenses due to slow reimbursement and incomplete coverage for private health care (as only 80% of cost is reimbursed if referral is made to private facility when such facilities are not available with the CGHS).

15. ESIS (Employees State Insurance Scheme) Enactment of ESI Act in 1948 led to formulation of ESI Scheme. Provides protection to employees against loss of wages due to inability to work due to sickness, maternity, disability and death due to employment injury. Offers medical and cash benefits, preventive and promotive care and health education. Medical care is also provided to employees and their family members without fee for service. Service establishments like shops, hotels, restaurants, cinema houses, road transport and news papers printing are now covered. Monthly wage limit for enrolment in the ESIS is Rs. 6 500

16. ESIS (Employees State Insurance Scheme) Prepayment contribution in the form of a payroll tax of 1.75% by employees, 4.75% of employees' wages paid by the employers, 12.5% of the total expenses are borne by the state governments. Beneficiaries are over 33 million spread over 620 ESI centres across states. Under the ESIS, there were 125 hospitals, 42 annexes and 1450 dispensaries with over 23 000 beds facilities. Scheme is managed and financed by the ESI Corporation (a public undertaking) through the state govt., with total expenditure of Rs. 3300 million or Rs 400/- per capita insured person.

17. Existing infrastructure under ESIS in India No. of Centers632 No. of Insured Persons/Family Units84,45,000 ESI Hospitals125 Number of ESI Hospital Beds23,334 ESI Dispensaries1,443 Insurance Medical Officers6,220 Insurance Medical Practitioners2,900

18. Problems faced in the ESIS Some of the problems are: Large number of employers try to avoid being covered under the scheme, A large number of posts of medical staff remains vacant because of high turnover and lengthy recruitment procedures, There is duality of control, Rising costs and technological advancement in super specialty treatment, Management information system is not satisfactory. There is low utilization of the hospitals The workers are not satisfied with the services they get. In rural area the access to services is also a problem.

19. ESIS (Employees State Insurance Scheme) CGHS (Central Government Health Scheme) ContributionEmployees: 4.75% of wages. Employers: 1.75% of wages. All contributions are deposited by the employer. State governments contribute a minimum of 12.5 % on ESIS expenditures in their respective States Pay/pension Contribution (Rs/month) (Rs/month) <3,000 15 3001–6000 40 60001–10000 70 10001–15000 100 >15000 150 The bulk of resources (85%) come from general revenues of the Central Govt. ReimbursementDoes not allow reimbursement of medical treatment outside of allotted Facilities. 1. Reimbursement of consultation fee, for up to four consultations in a total spell of ten days (on referral) 2. Cost of medicines 3. Charges for a maximum of ten inj. Reimbursement for specified diseases Social Health Insurance Schemes

20. ESIS (Employees State Insurance Scheme) CGHS (Central Government Health Scheme) Entitlement1.OPD care at dispensaries or panel clinics, 2. Consultation with specialist and supply of special medicines and tests in addition to outpatient care; 3. Hospitalization, specialists, drugs and special diet. 4. Cash benefits: Periodical payments to any insured person in case of sickness, pregnancy, disablement or death resulting from an employment injury. 1. First-level consultation and preventive health care service through dispensaries and hospitals under the scheme 2. Consultation at a CGHS dispensary / polyclinic or CGHS wing at a recognized hospital. 3. Treatment from a specialist through referral, emergency treatment in private hospitals and outside India. EligibilityEmployees (and dependants) working in establishments employing ten or more persons (with power) or twenty or more persons (without power) and earning less than Rs. 6 500 per month. Employees of the Central Government (excepting railways, Armed Forces pensioners and Delhi Administration), pensioners, widows of Central Government employees, Delhi Police employees, Defence employees and dependants residing in 24 specified locations

21. Membership is usually voluntary Spread of risk coverage from healthy to sick and rich to poor 3 common features 1. Affiliation is based on community membership and the community is strongly involved in managing the system 2. Beneficiaries are excluded from other kinds of health coverage 3. Members share a set of social values (In order to deal with limited ability of community financing Reinsurance tried: Transfer of liability from primary insurer to another insurer) Community Health Insurance Non-profit social insurance schemes

22. Type I Provider + Insurer Type I: ACCORD, MGIMS, RAHA, SHH, VHS Community

23. Name and Location of the CHI as Well As Year of Initiation Target PopulationRemarks ACCORD Nilgiris, TN 1992 Scheduled tribes who are members of the Adivasi Munnetra Sangam (AMS) – the tribal union. (N = 13,070 individuals) Linked with the New India Assurance Company MGIMS Wardha, Maharashtra 1981 The small farmers and landless labourers living in the 40 villages around Kasturba Hospital. (N = 30,000 individuals) No linkages. The organisation operates the scheme RAHA Raigarh, Korba districts of Chhattisgarh 1980 Poor people living in the catchment area of the 92 rural health centres and hostel students. (N = 92,000 individuals). Have their own providers Students Health Home Kolkata, West Bengal 1952 Full-time student in West Bengal state, from Class 5 to university level. (N=5.6 million students) Have their own health facilities Voluntary Health Services Centre, Chennai 1972 Centres in the suburbs of Chennai. (N= 104,247 individuals in two blocks) Have their own hospital and health CHI Schemes in India – Type I

24. Type II Insurer (NGO) Type II: DHAN, Yeshasvini Community Provider Premium Care Fees

25. Name and Location of the CHI as Well As Year of Initiation Target PopulationRemarks DHAN Foundation Theni district, Tamil Nadu 2000 Poor women members of the community banking scheme and living in the villages of Mayiladumparia block. Total of 4,514 members and their families. (N = 19,049 individuals). No linkages. The women operate the scheme by themselves Yeshasvini Trust Bangalore, Karnataka 2003 Members of the cooperative societies in Karnataka (N = 25 lakhs) Operate their own programme CHI Schemes in India – Type II

26. Type III Insurer Company Type III: BAIF, Buldhana, Karuna Trust, Navsarjan, SEWA Community NGOProvider Premium Care Reimbursement

27. Name and Location of the CHI as Well As Year of Initiation Target PopulationRemarks BAIF Uruli Kanchan, Pune 2001 Poor women members of the community banking scheme and living in the 22 villages around Uruli Kanchan town. (N= 1,500 women) Linked with United India Insurance Company BULDHANA Urban Cooperative and Credit society. Buldhana, Maharashtra Farmers living in Buldhana District (N = 175,000) Linked with United India Insurance Company Karuna Trust Mysore, Karnataka 2002 Total population of T Narsipur block and Bailhongal block, with a focus on scheduled tribes and scheduled caste population (N=634,581 individuals) No linkages. The organisation operates The scheme Navsarjan Trust Pathan District, Gujarat 1999 (Discontinued in 2000) Select scheduled caste individuals in two blocks of Patan district, North Gujarat (N= ?) Linkage with New India Assurance Company SEWA 11 districts of Gujarat 1992 534,674 SEWA Union women members (urban and rural), plus their husbands living in 11 districts (N = 1,067,348 individuals) Linkage with National Insurance Company CHI Schemes in India – Type III

28. Launched on April 2007 Take care of Rs. 30,000 annual hospitalization expenditure Five members of a BPL family in any part of the country Even if they migrate The BPL beneficiary has to pay Rs. 30 per year to get the smart card with his thumb impression on the chip to identify Each year, 1.2 crores BPL family members will be targeted Total 60 million cards will be issued under the RSBY scheme over the next five years. Rashtriya Swasthya Bima Yojana

29. RSBY Framework STATE NODAL AGENCY INSURANCE COMPANY COMMUNITYPROVIDERS MANAGEMENT PAYMENT CARE REGISTRATION NGOs SMART CARD STATE GOVERNMENT CENTRAL GOVERNMENT PREMIUM – 25 % PREMIUM – 75 %

30. Insurance schemes in other countries Universal compulsory social health insurance is not possible in India at this stage Experiences from other countries such as Malaysia and Philippines needs to be studies (Malaysia 1999, Philippines 1999) Key FeaturesAmerican SystemGerman System Owners of health insurance Private companiesSickness funds composed of Members who are workers of one type - as in a cooperative Coverage, and access to health care 70 % of population covered, access to health care unequal 99.5% of population covered and access to every one is equal Selection and refusals Do occurNot allowed by law Choice of providersYes - but being restricted in HMO system Yes wide choice Nature of regulation Minimal by government, mostly by market forces Self-regulation by autonomous bodies under overall framework of social legislation

31. Conclusion A nodal agency is important Social Health Insurance has the potential To increase access to health care To provide financial protection To improve quality But a lot of systemic changes need to be made Long term perspective Freeze a design but with some flexibility Use competition to get a reasonable premium Need for building capacity of the government !!

32. References 1.World Health Organization. Reaching universal coverage via social health insurance. WHO, Geneva, 2004. 2.Richard BS, Reinhard Busse, Josep Figueras. Social health insurance systems in western Europe. England: Open University Press; 2004. 3. Doetinchem O, Schramm B, Schmidt, Jean O. The Benefits and Challenges of Social Health Insurance for Developing and Transitional Countries: Series International Public Health, Germany, 2006. 4.Devadasan N, Ranson K, Van DW, Criel B. Community Health Insurance in India: An Overview. Economic and Political Weekly; 2004. 5.Mavalankar D, Bhatt R. Health Insurance in India Opportunities, Challenges and Concerns. Indian Institute of Management, Ahmedabad; 2000. 6.Ranson K and Acharya A. Community based health insurance: The Answer to Indias Risk Sharing Problems?. Health Action, 2003.