Section F, Group 5

Priyesh Tiwari | Pusyakant Tiwari | Rachna Ravi | Richa Singh | Rohan Gautham

Challenges in the sustainability of a targeted health care initiative in India

Introduction
Economic liberalization has created extensive growth concerns remain regarding inclusive growth Policy of programmes like MGNREGS, Mid-day meals etc. is to provide transparency and sustainability of the models Rashtriya Swasthya Bima Yojana (RSBY) unique health insurance initiative to address inequity in healthcare in Indian societal setup Launched by Ministry of Labour and Employment, Govt. of India to provide health insurance for families BPL in April 2008 Insecurity related to absence of quality health care and assured health insurance among poorer classes there is persistence of extreme inequality and disparity both in terms of access to care as well as health outcomes Estimated that of all Indians fall into poverty as a result of medical expenses in event of hospitalization Private expenditure accounts for 80.4% of total health spending

Contd.
Increasing cost of health care + loss of working days and wages economic burden on poor vicious cycle of poverty

Scheme provides Rs. 30000/- per annum of hospitalization coverage in empanelled hospitals Family coverage restricted to 5 members per family Pros: Covers pre-existing conditions from day one, no age bar imposed, supposed to reimburse travel costs of patients as well Cons: No outpatient care cover and many common but non-critical treatments excluded

Implementation
Health insurer chosen by state govt. through open bidding, from contenders insurance companies licensed by IRDA Hospitals empanelled by state selected insurance agencies based on pre decided criteria Repeated annually Hospitals can be deempanelled for untoward and illegal practices

Potentially excellent system hospitals reimbursed directly, premium (estimated to be Rs. 750) jointly incurred by Central and State Governments (75:25), use of biometric smart cards which allow ease of access and portability nominal registration fee for smart card of Rs.30 to induce feeling of ownership

Can the goal to provide minimal health coverage to all be sustained?

One of the most innovative social security schemes in the world ET 2011
Higher enrolment and higher awareness result in higher burn-out ratio , whereas low societal participation and paper-based scheme means lower burn out ratio some districts may benefit at expense of others in comparatively backward areas Sustainability
1. Institutional problems Empanelled hospitals force patients to spend out of pockets for medicines and transport 72% of all private spending for this population is on medicine Prices not adjusted to cover costs Lack of compliance of rules of enrolment, out-dated BPL lists used etc. Under-utilization Initiative should augment existing medical infrastructure in village Higher literacy and awareness more utilization and hence increasing costs Moral Hazard Ex-ante presence of insurance decreases preventive care measures Ex-post Unnecessary treatments sought due to presence of cover Protect RSBY from cost escalation while preventing rationing of health care Adverse selection Draw of individuals from riskier pool furthers gender bias Raises claim ratios and premium Solutions Bring entire population under scheme / offer lifelong insurance instead of annual insurance

Contd.

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Long-term projections & conclusions Demographic changes falling fertility rate and increasing longevity Predominant diseases and salient causes for mortality on developing countries to be replaced by noncommunicable diseases (NCDs) NCDs have higher treatment costs Higher incidence probability due to extensive tobacco use, occupational risks, etc. NCDs early stage progressive, advanced progressive and stable. RSBY applicable only for early stage progressive Cost escalation inevitable. Premium needs to be re calculated periodically (Rs. 750 has already been overshot in certain places like Kerala) Rather than relying on PPP to supplement the programme, govt. should look towards developing health infrastructure to augment the programme

Hospitalization patterns in RSBY : Evidence from MIS

Effects: Absence of Health Insurance
Absence of health insurance Poor financial access to treatment

Future productivity

Financial shocks

Poverty

Facts
Overall utilization rate 2.8% : Rural utilization rate 2.3% Lowest 40 % of income distribution (NSS 60th round) : 1.7% Weak correlation between utilization rate and conversion ratio District with higher level of literacy higher utilization rate 38% of villages have more than zero utilization rate or location of village relative to empanelled hospitals Average utilization rate being 4.3 % in villages Elder population being major user Utilization higher for villages with individuals who have already used RSBY

Caveats
Not representative of entire country Districts are at different points in their policy periods NSS is for 2004: significant change in demand and supply since then

Keeping the health in Health Insurance

A review of VimosEWA's hospitalisation claims data provides an indication of how RSBY is likely to develop

Key Issues with Implication on Indias health system

Trends likely to be seen in implementation of RSBY A high percentage of claims for preventable illness 1 2 3 4 Unnecessary expenditure on medicines Increasing hysterectomies Inequitable claims patterns

Evaluating the RSBY: Lessons from an Experimental Information campaignDas and leino
IEC had no impact on enrollment, but households which were part of the survey sample and therefore received information closer to enrollment period were 60% more likely to enroll There is little evidence that the Insurance Company selectively enrolled healthier households. Instead hospital claims were lower for households who received the IEC and for households who received both the survey and the IEC, suggesting that marginal household enrolled was in fact healthier. Results:
Enrolment Utilization Profits Char. Of enrolled households

Three corrective steps for more effective national programme

To ensure that health insurance plays intended role:

1 2 3

Appropriate investment in prevention Community involvement- Evidence based learning Strengthened public sector

An Outline of Steps to Overhaul Healthcare India

Areas of Focus:

EQUITY to achieve health security for all

The Rights Approach

The Right for Healthcare Primary, Secondary and Tertiary levels of institution (T.N. model)

QUALITY of Health Facilities

Bismarck Model
State ensures everyone for Healthcare Private Sector provides the services Mechanism to audit quality of services Rights Approach is fulfilled

PrivatePublic Mix Quality Assured Healthcare

India has a mix of public and private healthcare institutions Govt. to evolve a policy regarding the involvement of private sector in providing the healthcare as citizens right

Standards available but not always ensured. Simple elements: Medical Records, Auditing of Diagnosis, Lab Investigations

The Way Forward:

Raising Healthcare Reforms above party politics Have a National Commission, a national vision and mission To focus on the Social Justice in health rather than Capitalist Promotion of private enterprises

3 models of financing healthcare: Beveridge (UK), Bismarck(Canada) and Inequity Model(India) India needs to move towards Bismarck Model - RSBY is a step Health Healthcare responsibility State govt. vs. Disease care Financing Prevention Central govt. Revisit constitutional divisions

Thankyou