How To Improve Health Care In India

Transcription

1 Healthcare: Reaching out to the masses PanIIT Conclave 2010 kpmg.com/in

2 1 Introduction Current state of healthcare in India Over the last few decades, there has been a tremendous improvement in the quality of healthcare services in India. This is illustrated by the significant improvement in healthcare indicators such as life expectancy at birth, infant mortality rates, maternal mortality rate, etc. over this period. Life expectancy at birth (years) Male Female Male Female Source: World Health Statistics 2010 Infant mortality rate Maternal mortality ratio Per 1000 live births Per live-births The improvement in the healthcare indicators is a direct result of the improved penetration of healthcare services in terms of the increase in the number of government and private hospitals in India. There is a noted increase in the number of allopathic doctors with recognized medical qualifications, who have registered with state medical councils. Number of Physicians (Allopathic)

3 2 It has been observed that there is a In spite of this significant development, Demand and supply analysis I: widespread effort to improve the considerable gaps continue to exist in International benchmarking accessibility of healthcare amenities to the demand for and supply of quality India rates poorly on even the basic every strata of society. The fact that a healthcare. This paper highlights these healthcare indicators when major part of India is rural cannot be gaps through: benchmarked against not just the ignored and indispensable services I. International benchmarking developed economies, but also against such as healthcare need to be made II. Identifying the urban semi-urban the other BRIC nations. This can be available to all. and rural disparity attributed to the poor healthcare infrastructure reflected in the low bed III. Identifying the inter-state disparity. density ratio, low doctor density ratio, and poor healthcare spending. Developed Economies Emerging Economies Indicator Year India US UK Japan Brazil Russia China Life expectancy at birth (years) Infant mortality rate (probability of dying by age 1 per 1000 live births) Maternal mortality rate (per births) Hospital bed density (per population) Doctor density (per population) Births attended by skilled health personnel (percent) NA Source: World Health Statistics 2010

4 3 India is facing a serious challenge in matching the supply of healthcare resources with the growing demand on account of population growth, improving socio-economic drivers, and the increasing disease burden of lifestyle diseases. Further, a major fraction of the Indian population lacks access to even basic amenities such as clean water and sanitation. Developed Economies Emerging Economies Indicator Year India US UK Japan Brazil Russia China Population using improved sanitation (percent) Source: World Health Statistics 2010 Demand and supply analysis II: Urban semi-urban and rural disparity The following table highlights the disparity in healthcare indicators between the rural and urban population. This can be attributed to the lack of uniformity in healthcare resources available in rural and urban India. This has also been dragging down the overall India average. Indicator (2007) Rural Urban Crude death rate Infant mortality rate Neo-natal mortality rate Post-natal mortality rate Peri-natal mortality rate Still birth rate Healthcare penetration has for a long Some other alarming facts about status The primary reasons for undertime been concentrated in urban areas, of healthcare infrastructure in rural developed infrastructure in the semiparticularly in metropolitan cities such 3 areas vis-à-vis urban areas are: urban and rural areas are the lack of as Mumbai, Delhi, Chennai and Kolkata Rural doctors to population ratio is investment incentives for private sector and other Tier I cities. lower by six times investment, inefficiencies in the public Rural beds to population ratio is healthcare system and lack of a quality While 70 percent of the Indian lower by 15 times human resource pool and supply and population lives in semi-urban and rural Seven out of ten medicines in rural distribution infrastructure. areas, 80 percent of the healthcare areas are substandard / counterfeit 1 infrastructure is built in urban areas. Sixty six percent of the rural For instance, there are 369,351 population lack access to critical government beds in urban areas and a medicine 2 mere 143,069 beds in rural areas. Thirty one percent of the rural population travels for over 30 kilometers for medical treatment. 1 Vaatsalya Hospitals, 2 National Health Profile Healthcare in Rural India: Challenges, Rural Technology & Business Incubator, IITM, Chennai, March 2008

5 4 Rural areas also suffer from the lack of basic amenities such as electricity, appropriate drainage and sewage, etc., which further contribute to poor hygiene and increased susceptibility to diseases. Although there have been various government initiatives to supply healthcare amenities to the rural population and also the slum dwelling urban population, these efforts are clearly not sufficient. Distribution of households having safe drinking water facilities in India (percent) Distribution of households having electricity in India 2001 (percent) Rural Urban Rural Urban Rural Urban Total Hence, the National Rural Health ease the burden of tertiary care centers living in slums characterized by 4 Mission was initiated in 2005 in order in the cities by providing equipment overcrowding, poor hygiene and to resolve the issues of accessibility and training primary care physicians in sanitation and the absence of civic and affordability of healthcare to the basic surgeries. 7 services. population below the poverty line and the lower and middle classes, in rural The government of India is also India. The primary focus of this initiative providing a five-year tax holiday for new is on 18 states that have low public hospitals (in Tier II and III towns) health indicators and/or inadequate commissioned in the period April 2008 infrastructure. These include Arunachal to March 2013, in the Union Budget Pradesh, Assam, Bihar, Chhattisgarh, , in order to boost investment Himachal Pradesh, Jharkhand, Jammu 6 in this sector. & Kashmir, Manipur, Mizoram, Meghalaya, Madhya Pradesh, Nagaland, The National Urban Health Mission Orissa, Rajasthan, Sikkim, Tripura, focuses on the healthcare needs of the 5 Uttaranchal and Uttar Pradesh. Through urban poor, particularly the slum 4 Ministry of Health and Family Welfare the Mission, the government is working dwellers in urban areas. Nearly oneto increase the capabilities of primary third of India s urban population (~100 medical facilities in rural areas, and million people) are estimated to be 5 NRHM Document 2009 on Rural Healthcare System in India 6 Union Budget Urban Health Resource Center

6 5 Demand and supply analysis II: Inter-state disparity India is a diverse country with 28 states and seven union territories, each receiving different densities of rainfall, and experiencing different weather conditions. There is also a difference in the socio-economic status of people, literacy levels, living conditions and political situations. These factors play a significant role in the difference in the healthcare status and resources across states. For instance, female life expectancy in Kerala is the highest and approximately 16 years more than that in states such as Uttar Pradesh and Bihar. The female infant mortality rate in Madhya Pradesh is approximately 7.2 times more than that in Kerala. Similarly, the maternal mortality rate in Rajasthan is almost thrice that in Maharashtra, as indicative in the table. States such as Uttar Pradesh, Bihar, Orissa, and Madhya Pradesh rank poorly when compared with Kerala, Maharashtra, Tamil Nadu, Gujarat, and Andhra Pradesh. States Life expectancy (Years) Infant mortality rates (per 1000 live births) Male Female Male Female Maternal mortality ratio (per 100,000 live births) mortality Punjab Bihar Uttar Pradesh Rajasthan Gujarat Maharashtra West Bengal Karnataka Madhya Pradesh Orissa Kerala State/UT wise number of government hospitals and beds in rural and urban areas (including CHCs) in India State/UT Rural Hospitals Urban Hospitals Total Hospitals Projected Population as on reference period (In Number Beds Number Beds Number Beds thousand) Average Population Served Per Govt. Hospital Average Population Served Per Govt. Hospital Bed Reference Period Punjab Bihar NA NA NA NA Uttar Pradesh Rajasthan Gujarat Maharashtra West Bengal Karnataka Kerala

7 6 There is also a significant disparity in number of hospitals and hospital beds serving the population across states. Evidently, the average population served per government hospital bed in states such as Uttar Pradesh and Bihar is much higher when compared with Kerala or West Bengal. This indicates that the ease of availability of healthcare facilities to a person in Kerala is much greater as compared to a person in Uttar Pradesh. Case study I: Status of healthcare in Nalanda (Bihar) Nalanda district, a university town of Bihar, has been in the news for its increasing number of hunger deaths. In a study of 593 districts in the country, Nalanda ranked 509 in health 8 indicators. In a field visit to Nalanda in May 2010, 9 World Vision India observed : High out-of-pocket fees, even at public health facilities, were preventing people from accessing services. There were indications of debt bondage to landowners, due to health costs Few families had child immunization cards In one particular village of roughly 400 beneficiaries, inaccessible by road, there was no doctor, no private medical provider, no dais, and only 1 visiting accredited social health activist Virtually no access to family planning, and no involvement of adolescent girls in area welfare centers. Case study II: Maternal mortality in Assam Assam has the country's highest rate 10 of maternal mortality. The main reason for this is observed to be insurgency, affecting accessibility of healthcare services. The involvement of the government healthcare agencies and other stakeholders is also reportedly insufficient. Most northeastern women are anemic and the children are highly prone to mumps measles rubella and other infectitious diseases resulting from weak immunity. This could be likely attributed to a combination of reasons that interplay including social issues, insurgency, slow development, lack of infrastructure, inadequate manpower resources in healthcare system. Case study III: Malnutrition in India The World Bank estimates that India is globally ranked 2nd in the number of children suffering from malnutrition, after Bangladesh, where 47 percent of the children exhibit a degree of 11 malnutrition. The number of underweight children in India is among the highest in the world. Under-nutrition among children and women in Bihar is much higher than the national level with 54.4 percent children being underweight and 81 percent anemic. More than half of children (56 percent) under age five are 12 stunted or too short for their age. Children in rural areas are more likely to be malnourished; however, even in urban areas, almost half of children under age five years suffer from chronic 13 under nutrition (48 percent). Vitamin A deficiency can contribute to a higher risk of dying from measles, diarrhea, or malaria. The Government of India recommends that children under three years receive vitamin A supplements every six months, starting at age nine months. However, only one in three last-born children age months were given a vitamin A supplement in the six months prior to 14 the NFHS 3. 8 MoHFW, Ranking and Mapping of Districts based on socio-economic and demographic indicators (2006) 9 World Vision India India Statistics 10 National Health Profile World Vision India India Statistics 12 World Vision India- India statistics- Bihar fact sheet 13 World Vision India- India statistics 14 National Family Health Survey (NFHS-3, )

8 7 State of public healthcare infrastructure In a developing country like India, the primarily attributed to the poor public sector has a critical role in healthcare expenditure by the ensuring healthcare delivery to all government. The public sector accounts sections of the society. According to for a mere 26 percent of the total the Planning Commission, outpatient 1 healthcare expenditure. India s public services are percent costlier and health spending has increased from inpatient services percent 0.22 percent of GDP in to 1.05 costlier than public healthcare. Hence, percent during the mid 1980s and the role of the public sector in ensuring stagnated at a mere 1 percent of the accessibility cannot be emphasized 2 GDP in the recent years. The per capita enough. government spending is significantly However, the current status of lower than the other BRIC nations. healthcare infrastructure in India and the huge regional disparity can be Indicator India US UK Japan Brazil Russia China Total expenditure on health as a percent of GDP (2007) Government expenditure as a percent of total health expenditure (2007) Private expenditure as a percent of total health expenditure (2007) Per capita total expenditure on health (PPP int. USD) Per capita government expenditure on health at average exchange rate (USD 2007) Per capita government expenditure on health (PPP int. USD 2007) Source: World Health Statistics However, the government of India aims to increase healthcare expenditure to 3 percent of GDP by World Health Statistics National Health Profile 2009, World Health Statistics Department of Health and Family Welfare Annual Report FY10

9 8 Primary healthcare infrastructure The primary healthcare infrastructure has a three tier system with Sub Centers, Primary Health Centers (PHCs) and Community Health Centers (CHCs) spread across rural and semiurban areas. The tertiary care comprising multi-specialty hospitals and medical colleges are located almost exclusively in urban regions. The Sub Center is the most peripheral contact point between the Primary Healthcare System and the community. Hence, manpower is an important prerequisite for the efficient functioning of this set-up. However, as per the table below, there is a significant shortage of healthcare manpower in sub centers and primary health centers. Shortfall - Percentage of shortfall as compared to requirement based on existing infrastructure at Sub Centers and PHCs (As on March, 2008) Percenrage Health Worker (Female)/ Auxiliary Nurse Midwife Health Worker (Male) Lady Health Visitor/ Health Assistants (Female) Health Assistant (Male) Doctors at PHC Source: NRHM Document 2009 on Rural Healthcare System in India Vacancy position - percentage of sanctioned post vacant at PHCs (as on March, 2008) Percentahe Health Worker (Female)/ Auxiliary Nurse Midwife Health Worker (Male) Lady Health Visitor/ Health Assistants (Female) Health Assistant (Male) Doctors at PHC Source: NRHM Document 2009 on Rural Healthcare System in India Even out of the sanctioned posts, a considerable percentage of posts are vacant across all the levels.

10 9 Need for standardization of healthcare infrastructure The lack of standardization of healthcare infrastructure raises serious concerns about quality. It is observed that the standard of service in terms of cost, diagnostic procedures and therapeutic treatments differs with different providers. This disparity increases with the urban-rural and interstate divide, resulting in low customer satisfaction, unethical practices such as longer hospital stays, expensive treatments and drugs. One of the most effective approaches to cope with this disparity is to bring in standardization of protocols as well as costs through accreditation. Accreditation offers several advantages such as providing higher efficiency, accountability, and better governance. It can potentially greatly benefit patients and their safety due to increased credibility. It encourages continuous improvement of the hard infrastructure as well as upgradation of the medical and para-medical staff. In India, the National Accreditation To further encourage application for Board for Hospitals and Healthcare accreditation, India can consider Providers (NABH), a constituent board offering attractive fiscal incentives, like of Quality Council of India (QCI) set up several developed countries. with the cooperation of the Ministry of Health & Family Welfare and the Indian industry, sets standards for hospitals. A complete set of standards have been drafted by Technical Committee of the NABH for evaluation of hospitals for 4 grant of accreditation. Although accreditation in India is voluntary, several Indian hospitals are increasingly seeking accreditation from national as well as global agencies. No. of Indian Hospitals - Accredited and Applicants National Accreditation Board for Hospital and Healthcare Providers NABH Accredited 51 NABH Applicants 358 Joint Commission International Accredited 16 Source: Quality Control of India Website

11 10 Need to use information technology The use of Information Technology (IT) can play a very important role in enhancing the healthcare delivery mechanisms. While IT applications in the healthcare space have been increasing in India, they are still quite limited when compared with developed countries. Some areas where technology is being applied are hospital management systems, decision support systems that improve diagnosis and treatment, telemedicine and Picture Archiving and Communication System (PACS). Telemedicine, which is the use of IT for delivering health services and information over distances, has a substantial scope for growth in India. The use of telemedicine can greatly aid in dealing with the shortage of healthcare staff and improving the penetration of healthcare infrastructure and resources in the underserved semiurban and particularly rural areas. Various private hospitals have adopted telemedicine services while some have also developed PPPs for the same; these include Apollo, AIIMS, Arvind Hospitals, etc. Organizations such as Asian Heart Institute (AHI) and Indian Space Research Organization (ISRO) 5 have plans in this space. However, the current healthcare scenario in the country calls for the implementation of a large scale / nationwide telemedicine programme with a specific focus on the underserved states. Use of IT in healthcare improves patient care by enabling systems and processes to be introduced and monitored repeatedly. However, lack of standardization and regulations in the sector have been the major roadblocks in adopting IT solutions. Also, the fragmented nature of the Indian healthcare system has considerably slowed down the adoption of IT in the sector. Need to upgrade medical education infrastructure Despite rapid development of medical However, despite this rapid growth, this There is also a shortage of nurses in education infrastructure, the demandinsufficent supply of medical personnel is grossly the country. It is expected that, to meet supply gap of medical professionals to meet the estimated the global average of 2.56 nurses per continues to widen. requirement of doctors as seen in the 1000 population in the coming 15 years, table below. India needs to add 1500 nursing Medical education infrastructure in the 10 colleges. country has witnessed rapid growth during the last 19 years. The number of Category Current Required medical colleges in India has been growing at a very high rate rate, and Physicians has more than doubled between FY92 6 and FY10. Correspondingly, the Dental surgeons number of medical admissions (Bachelor of Medicine and Bachelor of Surgery) has increased by around times. As of FY10, India had Further, estimates indicate that around approximately 300 medical colleges, 10 percent of medical graduates go 290 colleges for Bachelor of Dental abroad in pursuit of post graduation Surgery and 140 colleges for Master of 8 courses.it is also estimated that Dental Surgery admitting 34,595, approximately 60,000 Indian physicians and 2,644 students annually work in countries like US, UK and respectively. 9 Australia. 5 Netscribes Hospital Market-India, February National Health Profile National Health Profile 2009, KPMG Analysis 8 The Hindu, Medicine for medical education, November 16, The Times of India, India short of 6 lakh doctors, World health report 2006

12 11 Medical personnel concentrated in modern teaching methods. All this 15 billion by FY15. The growth of the urban areas emulates into a static medical market is being driven by the improving The demand-supply gap of medical education system. Therefore, socioeconomic and demographic resources is more prominent in rural strengthening faculty development environment, favorable regulatory areas. Around 74 percent of the programmes is critical for capacity environment as well as significant graduate doctors in India work in urban building in medical education in India. marketing push by insurance settlements which account for only 28 companies. It is important to note that all these percent of the population. Hence, the challenges require a massive expansion However, the growth will also depend population in rural areas remains largely of the education facilities with a on the ability of the key stakeholders 11 unserved. Moreover the skewed continuous focus on upgrading the viz. government, regulators, healthcare countrywide distribution of these quality of existing infrastructure. It providers, insurance companies, institutes results in widening this gap therefore requires concerted efforts of NGOs/SHGs, TPAs, distribution channel even further. Sixty one percent of the the public as well private sector. partners, health centers and the media medical colleges are in the six states of Maharashtra, Karnataka, Kerala, Tamil Nadu, Andhra Pradesh and Puducherry, while only 11 percent are in Bihar, Need for health insurance penetration Jharkhand, Orissa and West Bengal and 12 the north-eastern states. The students With limited public healthcare funding, out-of-pocket spending has been forced studying in more developed states are unlikely to serve their semi-urban or and become the only option for India. rural areas after graduation where the As already stated earlier, the public potential of fee income is lower as sector plays a small role in healthcare compared with urban areas. financing. Hence, the private sector has Further, the benefits of healthcare in a a pivotal role in financing the healthcare tertiary care setting at reasonable expenditure in India, with out-of-pocket prices is available only to those patients expenditure accounting for a who lie within the catchment area of disproportionate 90 percent funding of the medical colleges, most of which are the private expenditure on health. Thus, 12 set up in the urban areas. the spending on healthcare is largely determined by an increase in the Lastly, almost 70 percent of the purchasing power of people. This medical colleges set up in the last five makes healthcare elusive for the lower 12 years are in the private sector, where and middle income group, which the economic motivation is overbearing accounts for a majority section of the other social objective and fees are total population. Therefore, health higher and unaffordable. insurance has a critical role in improving access to healthcare services in India. Increasing penetration of medical Lack of qualified faculty base insurance would also result in an The quality of medical education is increased demand for quality defined by the availability and quality of healthcare services. teachers. The shortage of teachers is The penetration of health insurance is estimated at approximately increasing over the years. The health 12 percent in medical colleges. The insurance industry is the fastest growth in the number of teachers has growing segment in non-life insurance not been commensurate to the surge in segments. The Indian health insurance the number of medical institutions over industry is valued at INR 51 billion and the last few years, thereby bringing has grown at a compounded annual down the teacher-student ratio. The growth rate of around 37 percent shortage is more severe in the pre- 13 (between FY02 and FY08). clinical and para-clinical areas. Besides this, there is also the quality aspect In spite of this, the coverage of health that cannot be ignored. There are insurance in India is merely around limited formal teacher training percent of the total population. programmes and the absence of a Overall, the health insurance industry in monitoring mechanism for faculty India is expected to grow at a CAGR of learning. As a result, most medical percent till FY15 to reach the college teachers remain untrained in market size of approximately INR 280 to strengthen the industry. 11 Task Force on Medical Education for the National Rural Health Mission 12 The National Medical Journal of India Vol. 23, No. 3, CII KPMG Health Insurance Summit 2008 Report 14 Crisil Research Annual Hospital Review CII KPMG Health Insurance Summit 2008 Report

13 12 Conclusion Public-Private Partnership The all inclusive way forward In light of the current status of 2. Achieve economies of scale and Through the partnerships, it is healthcare in India, a Public-Private possible cost reduction by possible to provide the public with Partnership (PPP) approach appears as standardizing the services good quality, high-tech care at probably the only all inclusive way throughout the initiative affordable prices. forward that will address all the issues 3. Utilizing the existing capacity of the stated in this background note. A PPP system: It is thus much faster to is a synergistic model to bring together The areas where private sector implement, as very little the social objectives (of the contribution can prove very beneficial infrastructure development is government) of universal healthcare are: needed (in many instances). The access and affordability and the effort is to make use of the existing 1 Infrastructure Development - business objective of running a facilities, wherever feasible Development and strengthening of profitable healthcare facility (industry). healthcare infrastructure that is 4. Create synergy between the public While the public sector contributes in evenly distributed geographically and and private systems thereby terms of infrastructure development, at all levels of care reducing the duplication of efforts land acquisition, financing, etc., the and wastage of funds 2 Management and Operations - private party brings in its knowledge Management and operation of and expertise of project management 5. Targeting the poor: By focusing more healthcare facilities for technical and operational efficiency. on the primary care aspect of efficiency, operational economy and healthcare and making available Public-private partnerships have distinct quality good quality healthcare services at advantages and help to achieve desired affordable prices, it is possible to 3 Capacity Building and Training - health outcomes. provide acceptable and sustainable Capacity building for formal, informal public healthcare even to the poorest and continuing education of professional, para-professional and 1. Creating competition: 6. Flexibility in action: The country is ancillary staff engaged in the delivery passing through a phase of health a. Competition between the PPP of healthcare and demographic transition. initiative facilities with other However, this transition of health is 4 Financing Mechanism - Creation of healthcare providers would make not uniform throughout the country. voluntary as well as mandated thirdeven the private facilities available to While a few states are in early party financing mechanisms the poor through reduction in their stages of demographic transition, costs 5 IT Infrastructure - Establishment of and still have a high birth rate, low national and regional IT backbones b. Greater choice of services would be utilization of public healthcare, etc., and health data repositories for available to the poor few states on the other end of the ready access to clinical information spectrum, have already reached c. Better quality of services can be replacement level of population 6 Materials Management - achieved by setting up of standard growth, having efficient public Development of a maintenance and guidelines for the initiative healthcare delivery services, etc. supply chain for ready availability of participants. Thus a basic minimum Thus by developing models involving serviceable equipment and level of quality of healthcare services PPP and taking into cognizance the appliances, and medical supplies and would be maintained. The competing specific needs of the states, it is sundries at the point of care. private healthcare providers would possible to address the disparity in try to improve the quality as well, to healthcare needs increase/ retain their clientele 7. The demographic transition has also In summary, through this initiative, been accompanied by a the private providers may have to technological revolution in the compete with public sector providers country with newer techniques, to act as agents for providing public instruments and expertise available healthcare to the poor. for healthcare service delivery.

14 13 Implementation of public-private partnership: Case studies Initiative Name About the Project How will it help? Ayush Graham Bhawali Project, Nainital Run the project on Build -Operate-Transfer (BOT) mode Government will provide land measuring 10 acres to set up the Ayush Gram at Bhawali, Nainital Emami Limited, will be responsible for: - Managing Out-Patient and In-Patient Departments - Interacting with local community in growing and managing the herbal garden - Installing a latest version of any licensed hospital management application software - Installing a latest version of any licensed drug manufacturing unit application software - Maintaining detailed records of medicinal plants in Herbal Garden Conceived by the Government of Uttarakhand, it is the first of its kind in India, to provide Ayurvedic, Unani and Homeopathy services, cultivation center for herbs and also as center for health tourism in the form of Wellness Centers Will also aid in maximizing service availability and reduction of operations and management cost for the government Telemedicine initiative by Narayana Hrudayalaya in Karnataka With connections by satellite, this project functions in the Coronary Care Units (CCU) of selected district hospitals that are linked with Narayana Hrudayalaya hospital Each CCU is connected to the main hospital to facilitate investigation by specialists after ordinary doctors have examined patients If a patient requires an operation, s/he is referred to the main hospital in Bangalore; otherwise s/he is admitted to a CCU for consultation and treatment Provides access to underserved or unserved areas Improve access to specialty care and reduce both time and cost for rural and semi-urban patients Facilitate in timely diagnosis and treatment Emergency Ambulance Services scheme in Tamil Nadu This scheme is part of the World Bank aided health system development project in Tamil Nadu Seva Nilayam has been selected as the potential non-governmental partner in the scheme This scheme is self-supporting through the collection of user charges Government supports the scheme only by supplying the vehicles Seva Nilayam recruits the drivers, train the staff, maintain the vehicles, operate the program and report to the government - It bears the entire operating cost of the project including communications, equipment and medicine, and publicizing the service in the villages, particularly the telephone number of the ambulance service. The major cause for the high maternal mortality is a non-medical cause - the lack of adequate transport facilities to carry pregnant women to health institutions for childbirth, especially in the tribal areas The scheme is designed to reduce the maternal mortality rate in the rural areas of Tamil Nadu Community Health Insurance scheme in Karnataka Karuna Trust in collaboration with the National Health Insurance Company and Government of Karnataka has launched a community health insurance scheme. It covers the Yelundur and Narasipuram Taluks Scheme is fully subsidized for Scheduled Castes and Scheduled Tribes who are below the poverty line and partially subsidized for non-sc/st BPL Poor patients are identified by field workers and health workers who visit door-to-door to make people aware of the scheme Auxillary Nurse Midwives and health workers visiting a village collect its insurance premiums and deposit them in the bank Annual premium is INR 22, less than INR 2 a month If admitted to any government hospital for treatment, an insured member gets INR 100 per day during hospitalization INR 50 for bedcharges and medicine and INR 50 as compensation for loss of wages up to a maximum of INR 2500 within a 25-day limit Extra payment is possible for surgery. Improve access and utilization of health services, to prevent impoverishment of rural poor due to hospitalization and health related issues Establish insurance coverage for outpatient care by the people themselves. Source: CII-KPMG Report on 'The Emerging Role of PPP in Indian Healthcare Sector, 2008

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