Moving Toward Universal Health Coverage R A S H T R I Y A S W A S T H Y A B H I M A Y O J A N A (R S B Y) 1 India

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1 Moving Toward Universal Health Coverage R A S H T R I Y A S W A S T H Y A B H I M A Y O J A N A (R S B Y) 1 India I. Basic Demographic and Health Statistics II. Impetus for Reform III. Summary of RSBY IV. Funding V. Population Coverage, Enrollment, and Communication VI. Benefits Package VII. Service Delivery System VIII. Provider Payment Mechanisms I. Technology. Monitoring and Evaluation I. The Way Forward Basic Demographic and Health Statistics The following table presents a brief overview of some key health and demographic statistics in India i : Table I: Selected Demographic and Health Statistics, India, 2006: India (2006) Gross national income per capita (PPP international $) 2460 Population (in thousands) total 1,151,751 Per capita total expenditure on health (PPP int. $) 109 Private expenditure on health as percentage of total expenditure on health 80.4 Infant mortality rate (per live births) both sexes 57 Life expectancy at birth (years) female 64 Life expectancy at birth (years) male 62 Maternal mortality ratio (per live births) 450 Impetus for Reform Health financing in India: Health care in India is financed through various sources, including individual out of pocket payments, central and state government tax revenues, external aid, and profits of private companies. National Health Accounts data shows that central, state, and local governments together account for only about 20% the total health expenditure in India, with greater than 75% of the health spend comprised of un pooled, out of pocket expenditures. ii This level of out of pocket expenditure is one of the highest in the world. External aid to the health sector, either to the government or via NGOs, accounted for negligible 2% of the total health expenditure. Health Delivery in India: In India, the government is both a financer as well as a provider of health care. Households, particularly poor households, are expected to seek care in the grossly under resourced network of government health services. Not surprisingly, due to uneven quality of care, and high absenteeism, patients often shift away from public health services to private health services for their care. Studies show that about 72% of outpatient care and about 40 60% of inpatient care is sought from the private health sector. iii This has implications for lower income patient communities. About 6% of patients who require hospitalization do not seek health care because they cannot afford it. iv Among those who seek hospital care, about 25 40% of patients have to borrow or sell their assets to meet their medical expenses. v All these figures are aggregate, the picture is worse if one disaggregates along the divides of urban / rural; male / female; upper quintile / lower quintile; upper caste / lower caste etc. Building a More Equitable Health System: The Government of India recognized inequities in its health delivery and financing infrastructure and has introduced various measures to solve it. One measure was to increase the budgetary 1 This case study was compiled by the Results for Development Institute with inputs from Nishant Jain, GTZ India and the Ministry of Labour and Employment in India.

2 allocations for health care. The National Rural Health Mission (NRHM) promises to increase the government spending on health care from the current 0.9% of GDP to 3% of GDP. vi However, just increasing the budget for health is not a solution in itself, and it has been seen that absorptive capacity of the public health care system is not adequate; even the current level of spending by the government is not being properly utilized. The government has introduced various demand side financing mechanisms to provide financial protection for vulnerable populations. Health insurance schemes like the Universal Health Insurance Scheme (UHIS) launched by the Ministry of Finance in 2003, the Sanjeevani Scheme launched by the Punjab government in 2005, and the Chief Minister s health insurance scheme launched by the Assam Government in 2004 are some examples. vii However, most of these schemes have been dissolved due to poor policy design, lack of clear accountability at the state level, lack of sustained efforts in implementation, weak monitoring and evaluation, unclear roles and responsibilities of different stakeholders, and/and poor awareness among beneficiaries about the schemes. There are exceptions to this, for example Aarogyasri, which is a health insurance scheme launched by the Andhra Pradesh state government that is thriving to date. Learning from the experiences of other major government and non government health insurance schemes in India, the Government of India decided to launch another health insurance scheme. The government realized that there are three main characteristics of their target audience (below the poverty line families) that needed to be taken into consideration in the design of this new insurance program. First, the population is poor and therefore cannot pay cash upfront and take reimbursement later. Second, the population is largely illiterate so they cannot fill out registration forms. Third, some of the target population is migrant, so they need a scheme which is able to provide transportable benefits. Taking all these characteristics into consideration, a scheme was designed that can provide benefits to the target population. The Ministry of Labour and Employment (MoLE) launched the Rashtriya Swasthya Bima Yojana (RSBY) to provide health insurance benefits to the below the poverty line (BPL), populations. It was launched in 2008 and is being implemented by the respective state governments. RSBY plans to cover all the entire BPL population in India (approx 300 million people) by Summary of RSBY The objectives of RSBY are to: o Provide financial protection from health care expenses on hospitalization o Improve access to quality health care o Provide beneficiaries the power to choose from a national network of providers o Provide a scheme which even the illiterate can use easily Beneficiaries under RSBY are entitled to hospitalization coverage up to Rs. 30,000/ (approximately USD700) for most diseases that require hospitalization. There are fixed package rates for a large number of surgical interventions. Preexisting conditions are covered from day one and there is no age limit. Coverage extends to five members of the family which includes the head of household, spouse, and up to three dependents. Beneficiaries need to pay Rs. 30/ (less than USD1) as a registration fee, while the central and state governments pay the premium to the insurer selected by the state government on the basis of a competitive bidding (the technically qualified lowest bid is selected). Some of the most noteworthy aspects of RSBY include: Empowering beneficiaries: RSBY provides freedom of choice to the patient in the selection of hospitals: They can access any public or private provider in the network across the country. Business model for all stakeholders: The scheme is designed as a business model, with incentives built in for each stakeholder: o Insurers: The insurer is paid a premium for each household enrolled in RSBY, therefore giving the insurer an incentive to enroll as many households as possible from the BPL list. o Hospitals: A hospital has the incentive to provide treatment to large number of beneficiaries as it is paid per beneficiary treated. Even public hospitals have an incentive to treat beneficiaries under RSBY as

3 money from the insurer will flow directly to the public hospital. Insurers, in contrast, will monitor participating hospitals in order to prevent unnecessary procedures or fraud resulting in excessive claims. o Intermediaries: The inclusion of intermediaries, such as NGOs and MFIs, was intentional since they have a greater stake in assisting BPL households. Intermediaries will be paid for the services they render in reaching out to the beneficiaries. o Government: Including public sector providers in the RSBY delivery network creates healthy competition between public and private providers which in turn provides incentives for public providers to improve their service delivery. SmartCard: Every beneficiary family is issued a biometric enabled SmartCard containing their fingerprints and photographs. All the hospitals empanelled under RSBY are IT enabled and connected to the server at the district level. This will ensure a smooth data flow regarding service utilization periodically. The SmartCard also ensures that only true beneficiaries can use sevices, reducing fraud. Portability: One key feature of RSBY is that a beneficiary who has been enrolled in a particular district will be able to use his/her SmartCard in any RSBY empanelled hospital across India. This makes the scheme beneficial to the many poor families that migrate from one place to the other. Cash less: RSBY transactions are completely cashless. Beneficiaries do not pay cash for any services unless they exceed the annual allowance of Rs. 30,000/. Provider to insurer dealings are also paperless, as all claims are processed and paid electronically. To date, RSBY has: Started in 23 States of India Issued million SmartCards to 10 million families Covered 40 million people Empanelled over 2500 hospitals Treated more than 350,000 hospitalization cases Funding Funding for RSBY comes from central and state governments: 75% (90% in case of Jammu & Kashmir and North eastern States) of the premium comes from the central government 25% (10% in case of Jammu & Kashmir and North Eastern States) of the premium comes from the state government The insurance premium is determined at the state level based on an open tender process. Premiums for the scheme vary from state to state and district to district, but at present are in the range of Rs. 400 (USD8) to Rs. 600 (USD12). Indian Insurance Regulatory Development Authority (IRDA) registered insurers compete in competitive bidding; the organization that fulfils technical criteria and has the lowest premium is chosen. The state and central governments pay the agreed upon premium to the insurance company commensurate with the number of BPL families enrolled. The insurer bears all the risk of the scheme and though the state governments provide support to the insurer(s), it is the responsibility of the insurer to operationalize the scheme on the ground. Beneficiaries pay a small amount (Rs. 30, less than one US dollar) as registration fee which is aggregated at the State level and can be used to take care of some administrative costs associated with scheme. Population Coverage, Enrollment, and Communication RSBY aims to provide coverage for all BPL families. Annually, an electronic list of eligible BPL households is provided to insurers by each participating state s MoLE. An enrollment schedule for each village, along with dates, is prepared by the insurance company with the help of district officials. The insurance companies are provided a maximum of four months to enroll BPL families in each district.

4 To communicate and market the RSBY scheme and enrollment camps, insurance companies are required to hire intermediaries to provide grassroots outreach prior to enrollment. (These organizations could also be used to provide assistance to members in utilizing services after enrollment.) In addition, the BPL list is posted in each village at the enrollment station and prominent places prior to the enrollment camp. The date/location of the enrollment camp are also publicized in advance. Mobile enrollment stations are established at local centers (e.g., public schools) at each village at least once a year. These stations are equipped by the insurer with hardware to collect biometric information (fingerprints) and photographs of household members to be covered, as well as a printer to print SmartCards. The SmartCard, along with an information packet describing benefits, hospitals in network, and other relevant information is provided to all enrollees once they have paid the Rs. 30/ registration fee. The process normally takes less than 10 minutes. A government official from the district (field key officer FKO) needs to be present at the camp and must insert his/her own government issued SmartCard and provide his/her fingerprint to verify the legitimacy of the enrollment. This way each enrollee can be tracked to a particular government official. The details of each BPL family who is authenticated by the FKO gets transferred to the FKO s SmartCard; the data is also transferred from the FKO s card to the government server at the district level. In addition to the FKO, an insurance company/smartcard agency rep is present at the enrollment camp. At the end of the enrollment camp, a list of enrolled households is sent to the state nodal agency by the Insurer. The list of enrolled households is maintained centrally and the insurer is paid once data provided from the insurer and FKO card has been reconciled. The SmartCard given to each enrolled household also contains a new national unique ID for each family a program the Government of India is implementing nationwide. Benefits package RSBY beneficiaries are covered for hospitalization expenses of up to Rs. 30,000/ per family per year. The family can include up to five members (including a husband, a wife, and three dependents). Most of the surgical and medical conditions for which hospitalization is necessary are covered in the scheme. Package rates for 727 inpatient surgical procedures, including maternity and newborn care have been pre defined. In addition, beneficiaries are covered for outpatient surgeries which can be done on an outpatient basis. The benefit also includes one day pre and five day posthospitalization expenses. There is also a transportation benefit that provides Rs. 100 per visit to the beneficiary; total transport assistance cannot exceed Rs. 1000/ per annum and it is part of the total Rs. 30,000/ coverage. All pre existing diseases are covered from the first day of enrollment with some exclusions. RSBY does not cover: OPD expenses, or expenses in hospitals which do not lead to hospitalization Congenital external diseases Drug and alcohol induced illness Sterilization and fertility related procedures Service Delivery System As of October 2009, 2067 hospitals (1516 private hospitals and 551 public hospitals) were included in the RSBY delivery network. Providers are empanelled as in network by the state selected insurance company based on prescribed criteria. A health care provider empanelled by any of the insurers in RSBY gets automatically empanelled by all the other insurers. After an insurance company is selected by the state 2, the insurance company is tasked with empanelling/certifying both public and private care providers in the program. The process is based on prescribed criteria (e.g., the service providers 2 It is important to note here that many states have separately bid out districts or clusters of districts to obtain diversity in the insurers engaging in RSBY work across the state. But a single district can only be covered by one insurer, so there is no overlap of jurisdictions covered by insurers.

5 should possess specified basic facilities, like: have at least 10 inpatient medical beds; have specified medical and surgical facilities and diagnostic facilities, etc.). In addition, hospitals must agree to need to install necessary hardware and software to be able to process beneficiaries SmartCard transactions. They must also set up a dedicated RSBY desk with trained staff. The insurer must empanel enough hospitals in each district so that beneficiaries do not need to travel great distances to get to health care services. For empanelment of public hospitals, the insurer needs to coordinate with the respective health department of the state. Once a hospital is empanelled, a nationally unique hospital ID number is generated so that transactions can be tracked at each hospital. Each empanelled hospital is connected with the district server of the insurance company and thus able to transfer data related to hospitalization on a daily basis. Provider Payment Mechanisms The process for reporting and paying claims is designed to be simple and cashless from the perspective of the provider and beneficiary. In general, the process looks as follows: 1. A patient comes to a provider to receive care and goes straight to the RSBY help desk; the patient s identity is verified via fingerprints 2. The patient visits the doctor who assess his/her health condition; doctor prescribes a treatment 3. Assistant at RSBY help desk checks whether procedure is in the list of pre specified packages. Procedures are priced/paid to the provider on a case based payment system a. If procedure is on list, appropriate prescribed package is selected, patient is scheduled for procedure, and the amount to be paid out is blocked b. If not on list, help desk checks with insurer to price and get approval to conduct procedure, patient is schedule for procedure, and the pre determined amount to be paid is blocked 4. In patient treatment is provided to the beneficiary. 5. Upon release of beneficiary from hospital, SmartCard is swiped again with fingerprint verification a. Beneficiary is paid by the hospital Rs. 100/ as transportation expense at time of discharge b. The pre specified cost of procedure is deducted from the amount available on the card 6. After rendering service to patient, hospital sends an electronic report and claim to the insurer/tpa 7. The insurer/tpa reviews the records and information and makes payment to the hospital (electronically) within a specified time period (agreed upon between insurer/tpa and hospital) At present there are no quality standards being utilized by RSBY, but the national team is working with states and insurers to develop an incentive based quality management system for providers (e.g., a system where hospitals are graded according specific quality parameters and hospitals with better quality are paid at a higher rate by insurers). Institutional Structures There are many stakeholders involved in the oversight and execution of RSBY at both the national and state levels. One key stakeholder for administrative functions is the insurer. Once a state has agreed to implement RSBY, a nodal department is selected by the State. The nodal department designate sets up a nodal agency which is responsible for implementing RSBY. The nodal agency seeks bids from registered public or private insurance companies. The financial bid is essentially an annual premium per enrolled household. Technically qualified insurer(s) with the lowest bid is/are selected as the state s RSBY insurer. A state can seek bids from multiple insurers for various districts. Selected insurers are compensated on the basis of the number of SmartCards issued (i.e. households covered). Each contract is specified on the basis of an individual district in a state, with the insurer agreeing to set up an office in each district where it operates. While more than one insurer can operate in a particular state, only one insurer can operate in a single district at any given point in time.

6 The insurer must agree to cover the benefit package prescribed by the central MoLE through a cashless facility that in turn requires the use of SmartCards which must be issued to all members. This requires that a sub contract be arranged with a qualified Third Party Administrator/SmartCard provider. The insurer must also agree to engage intermediaries with local presence (e.g., NGOs) in order to provide grassroots outreach and assist members in utilizing the services after enrolment. The insurer must also build a list of empanelled hospitals that will participate in the cashless arrangement. These hospitals must meet certain basic minimum requirements (e.g., size and registration) and must agree to set up a special RSBY desk with SmartCard and fingerprint reader and train the hospital staff. The list should include public and private hospitals. The insurer must also establish a separate Project Office for implementing the scheme and coordinating activities with the state nodal agency in the state capital. The insurer will have appropriate people in their own/tpa, state, and district offices to perform the following functions: Operate a 24 hour toll free call center Manage district kiosks for post issuance modifications to SmartCards Management info system functions, including collecting, collating, and reporting data on a real time basis Generating reports, in predefined format, at periodic intervals, as decided between insurer and state nodal agency IT related functions which include running the local website/updating data regularly Pre authorization function for non package surgical interventions Claims settlement Organizing Health camps Publicity for enrollment and post enrollment Grievance and dispute resolution Feedback functions As of January 2010, eleven public and private insurance companies were engaged in insuring RSBY beneficiaries across 23 states. Since in the initial phases of RSBY, the focus was on stabilizing processes and operations, insurer contracts were set for one year. Now that processes and basic operations have been ironed out and stabilized, the contract period has been extended to a maximum period of three years. However, even three year contracts are subject to annual renewal based on insurer performance, with annual performance goals defined by the government at the time of initial contract signing. The table below summarizes the roles and responsibilities of all organizations involved in operationalizing RSBY at the state and national level: Table II: RSBY Institutional Roles and Responsibilities, 2009: Central Govt State Nodal Agency Oversight of scheme Financing scheme Setting parameters (benefits package, empanelment criteria, BPL criteria, etc.) Hardware specifications (e.g, systems, SmartCard, etc.) Contract management with Insurer Accreditation/Empanelment of providers Insurer/TPA NGOs/Other Partners Providers of Care

7 Collecting Registration Fees Enrollment Financial management/planning Actuarial analysis Setting rate schedules for services/reimbursement rates Claims processing and payment Outreach, Marketing to beneficiaries Service delivery Developing clinical information system for monitoring/eval Monitoring state level utilization and other patient information Monitoring national RSBY information Customer service Training Technology The use of technology in RSBY is one of the highlights of the scheme and it is one of a handful of schemes in the developing world where technology has been leveraged in this way. RSBY uses following technologies: SmartCard Technology A SmartCard is given to each BPL family at the time of enrollment in the scheme. The SmartCard is prepared and printed on the spot in the village by the insurer and handed over to the beneficiary. This SmartCard can be used by the beneficiary in any empanelled hospital across India to obtain treatment. Biometric Technology Fingerprints of all beneficiaries are collected during enrollment at the village level. One thumb impression of each of the household beneficiaries is stored in the SmartCard. This fingerprint is used to verify the identity of the beneficiaries at the hospital. Key Management System Another unique feature of the scheme is its key management system which helps in reducing fraud and improves accountability. A government officer called a Field Key Officer (FKO) needs to be present at the enrollment station and his/ her role is to verify each beneficiary family using his/ her own SmartCard and fingerprints. This ensures that the correct beneficiary is issued the card by the insurer. Online data transfer RSBY has been able to operationalize a paperless scheme with the help of technology. Claims are submitted online by hospitals and so insurers can make online payments to hospitals. A robust backend data management system is being developed for RSBY which will ensure smooth flow of data from across India to both the state and central governments in real time. The aim of the scheme is to use technology not only for controlling fraud and monitoring utilization, but also to find innovative solutions to insurance related prolblems. For example, enrollment software has been designed to ensure that male heads of households must insure their spouses. In addition, since the scheme aims to provide quality treatment to all beneficiaries, technology has been implemented to ensure that every beneficiary receives needed treatment. For example, if a patient is not in a condition to validate his/her identity at the hospital then any family member who is on the SmartCard can validate the identity of the patient by providing his/ her finger print.

8 Currently, the Government of India is scrutinizing how the SmartCard can be used for other social sector schemes and how the RSBY technology platform can be used to provide other services to the below the poverty line population. Monitoring &Evaluation One of the key strengths of RSBY is the real time monitoring and evaluation system that is enabled by the program s extensive technology backbone. The scheme s management information system was built centrally for all state led RSBY schemes to enable the collection of standardized information on all daily transactions at hospitals. Data from all districts flow to the central government at periodic intervals. This information is uploaded through an internet/phone line to a database on a district server. A separate set of pre formatted tables are generated for the insurer and for the state and central government respectively. The collection of this information allows the insurer to track claims, transfer funds to the hospitals, and investigate claims in the case of suspicious claim patterns through on site audits. Governments are able to monitor utilization of the program by members and to some extent, begin to measure the impact of the program. The central government posts much of this data online on the RSBY website. Enrollment, hospitalization, and claims data are analyzed at the national level regularly and shared with state nodal agencies. In addition, the government of India is planning to produce periodic reports on selected indicators to be shared with all the stakeholders in the near future. RSBY is one of the few government sponsored schemes where a concurrent evaluation is being done by both central and state governments. The Government of India and a few state governments have already begun to conduct evaluations of RSBY and the results are positive. The World Bank and GTZ together are developing a survey instrument which will be prescribed by the Government of India for the evaluation of RSBY schemes across India. This is being done to improve comparability of studies across implementing states. The tender document of the scheme has a provision whereby each state government is required to evaluate the performance of its RSBY scheme. The Way Forward RSBY has been able to reach more than 8 million families in just over eighteen months. The Government of India intends to covers a total of million people in next four years. In addition, the scheme may be extended to additional groups (e.g., unorganized workers) in coordination with other government agencies, ministries, and departments. The experience of the scheme in the field has been quite encouraging since its inception. More and more people are not only enrolling, but utilization of services is increasing, as well. In any health insurance scheme, a critical point in improving utilization is building awareness about the scheme. RSBY is no exception: In districts where awareness campaigns have been organized, claims ratios are higher, whereas in districts where awareness campaigns have not been effectively organized, claims ratios are very low. Data shows that claims ratio are increasing slowly as awareness about the scheme is increasing among the beneficiaries. This underscores the importance of maintained focus on information dissemination and awareness campaigns. To improve the efficiency of implementation and ensure that the scheme benefits are utilized by beneficiaries, the government is planning to organize a nationwide capacity building exercise for various stakeholders. It is also planning to engage in large scale IEC and BCC activities to disseminate information about the scheme and its benefits to the target population. The government is also in the process of designing a quality management system for health care providers. This will encourage providers to improve their quality as they will be incentivized through quality and performance driven payments; hospitals with higher assessed quality will be graded higher and thus eligible for higher reimbursements from insurers.

9 i World Health Organization National Health Accounts. India ii Ministry of Health & Family Welfare. National Health Accounts, India. New Delhi: Government of India, 2006 : iii Ministry of Health & Family Welfare. National Health Accounts, India. New Delhi: Government of India, 2006 : iv National Sample Survey Organisation. Morbidity, Health care and condition of the aged. New Delhi: Government of India, 2006 : v van Doorslaer E, O'Donnell O, Rannan-Eliya RP, Samanathan A, Adhikari SR, Garg CC, et al. Effect of payments for health care on poverty estimates in 11 countries in Asia: an analysis of household survey data. Lancet 2006; 368: vi Ministry of Health & Family Welfare. National Rural Health Mission: Mission document. New Delhi: Government of India, 2005 : vii 1 Devadasan N, Jain Nehal. An inventory of health insurance products in India. Bangalore: Institute of Public Health; 2008:

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