A Step Towards Universal Coverage in India Example of RSBY

Dr. Nishant Jain 06.12.2013

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 Government is both Financial and Service Provider in Health Sector in India Government spends only 1% of GDP on Health Government is suppose to provide free health care to the population across India with their own infrastructure at different levels However, the ground level situation is very different
People spend on an Average Rs. 3000 (USD 50) even when they are hospitalised in a Government hospital Though the facilities per se are free but a lot of these expenditure is related to the medicines, diagnostic tests, food, transportation etc.

Role of the Government in India

To take care of these expenditures people often have to borrow money or sell assets 7.6% of households fall BPL due to healthcare payments.
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 Benefits

What is RSBY

Hospitalisation cover with a limit per family per annum on a family floater basis (Upto five family members) All hospitalisation is covered and for 1400 surgical packages including Maternity & Newborn Care rates are pre-defined All Pre-existing Diseases to be covered Pre and post hospitalisation Expenses covered Transport Allowance

Sources of funding for program

Rs. 30 (US$ 0.5) per family per year from Beneficiaries 100% premium shared between Central and State Government

Both Public and Private providers can be empanelled Beneficiary can get cashless treatment in empanelled hospital
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 State Government set up an independent nodal agency to implement the scheme Insurance Company is selected through an open tendering process A list of potential beneficiaries is prepared based on defined criteria for different categories Insurance Companies need to go the field and enroll beneficiaries in the village after taking fingerprint and photo
A smart card is printed and given on the spot and a Government representative authenticates it by his/ her smart card and fingerprint

Main Processes Involved

A beneficiary can go to any public and private empanelled hospital and get cashless treatment through smart card Data flows every day from each hospital to the insurer and Govt.
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RSBY Smart Card

Smart Card with embedded chip which stores details: Fingerprint and photographs (up to five members) Other details like Name, Age, Gender, Relationship etc. of up to five family members Unique relationship number across country Insurance Policy Details Transaction Details
www.rsby.gov.in
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SS DD BB VVV YY 00000 #
District Village Serial No.

Enrollment Station

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Innovative Use of Technology

RSBY uses different technologies to effective reach its objectives Biometric Technology for identification of beneficiaries and reduce fraud Smart Card technology to ensure that benefits can be provided electronically even in cases where there is no regular internet facility available and provide portability of benefits Web based services to ensure that data is transferred securely and all the activities are transparent Mapping and GIS services to track developments in the field on a regular basis Mobile Technology for Outpatient Benefits
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Current Status of RSBY Implementation in India

RSBY Coverage
Round 1 Round 2 Round 3 Round 4 Round 5

Cards issued App. 37.5 million People enrolled Appr. 136 million Number of People benefitted till now Appr. 6.3 million Number of Hospitals Empanelled Appr. 11,000 States and UT where Service delivery has started Twenty Eight Number of Insurance Companies Involved Seventeen

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700

Premium Trends in RSBY per family per year

573 518 515 482 449 593 504 492 461 448 527 451 423 449 433 404

600

500

400

388 358 276 253

314
300

276

200

100

0 Average Premium for Fresh Districts in 2008 Round 1 Average Premium for Fresh Districts in 2009 Round 2 Average Premium for Fresh Districts in 2010 Round 3 Average Premium for Fresh Districts in 2011 Round 4 Average Premium for Fresh Districts in 2012 Round 6 Average Premium for Fresh Districts in 2013 (incl freshly tendered)

Round 5

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Hospitalisation Ratio
Hospitalisation Ratio
6.00% 5.04% 5.00%
100% 90%

Gender Wise Hospitalization Ratio

4.00%
80% 70%

42%

42% 54%

3.00% 2.20% 2.00% 1.00% 0.00% Round 1 completed (345 disticts) Round 2 completed (252 districts) Round 3 (81 districts) 1.90%

60%
50% 40% 30% 20% 10% 0% Round 1 Male Hospitalization Ratio Round 2 Round 3 58%

58%
46%

Female Hospitalization Ratio

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298 Districts where Two Years has been Completed 364 Districts where One Year has been Completed
120.00% 100.00% 80.00% 60.00% Money Left with the Insurance Company 24% 40.00% 20.00% -1.26% 0.00% -20.00% Expenditure by Insurance Company 76% Expenditure by Insurance Company Money Left with the Insurance Company 101.26%

121 Districts where Three Years has been Completed

120.00% 100.00% 80.00% 60.00% 104.40%

40.00% 20.00%
0.00% -20.00% Expenditure by Insurance Company -4.40% Money Left with the Insurance Company

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Benefits for Beneficiary in RSBY

Health is a state of complete physical, mental and social well-being (WHO definition)
Improved access to Health care Reduction in OOPE

Physical
Improved Quality Care

Reduction in indebtedness Mental Security Migrant workers Family is covered

Beneficiary

Mental

Scheme is working well even in Naxalite districts

Social

Improved gender utilisation Providing Social Identity

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Evaluations of the Scheme

RSBY is being evaluated by third party agencies since 2009. Key Results from Latest Evaluation (2012) 90% of the enrolled and hospitalized respondents, spent no money at the hospital for the last policy period In comparison to this non enrollees spend on an average Rs. 17,000 (USD 320) per year from their own pocket 90% of beneficiaries were satisfied with the scheme More than 94% of beneficiaries said that they will enroll even next year even if they had not used hospitalisation services
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In the worst extremists affected areas also RSBY has been able to provide benefits to people Healthy Competition between Public and Private Hospitals
Incentives for staff of public hospitals from Insurance money Public hospitals are earning more and more through RSBY Setting up of Hospitals by Private sector in remote areas

Success So Far

Increase in capacity of private hospitals

Improvement in quality of services provided at the hospitals Delivery of services with almost no leakages Use of IT ensure that Insurance Company and Government gets data daily from the Hospitals
This data is analysed for patterns/ spikes/ Frauds and action taken and more than 250 hospitals have been de-empanelled till now
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www.rsby.gov.in

Beneficiary Data Preparation Improving Enrollment Information dissemination Capacity Building Prevention, Early Detection of Fraud and Abuse Improving Quality of Health Care Linking Primary Care with inpatient benefits

Challenges

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RSBY and Provision of Outpatient Care

RSBY started with providing only inpatient care through a network of empanelled public and private health care providers In 2011 two experiments on providing Outpatient benefits to RSBY beneficiaries were started

In both the experiments, the provision of Outpatient benefits is done through the intermediation of Insurers
Now more experiments on providing OPD has started

Initial results are quite positive and cost of inpatient care has come down where outpatient care is covered
At present Primary Care experiments are being designed including prevention and promotion
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www.rsby.gov.in

Private Insurance Government Employees

Curative Continuum

Extension and Expansion of RSBY

Tertiary Care

Secondary Care

Primary Care/ Outpatient

RSBY Partially Subsidised/ Non-Subsidised

Other Occupational Groups e.g Taxi drivers

Informal Workers e.g. NREGS, Construction worker, Domestic workers, other categories of workers

Common Storage Area - Family demographic details - Biometric details of RSBY family

RSBY Fully Subsidised

Below Poverty Line (30%)

RSBY related data Health Card related data NREGS Data Life and disability data Food Subsidy Scheme Data
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Future Focus Areas for RSBY

For expenditures beyond Rs. 30,000 different State Governments are linking with other funds/ schemes
RSBY provides them a platform to transparently deliver this Government of India has designed an Quality management system so as to encourage hospitals to improve quality

Improving the quality of service at the hospitals

Capacity Building at each levels for all the stakeholders Provide Primary care benefits including prevention integrated with RSBY Store Health related data on the smart card Use the Smart Card for other targeted interventions Cooperating with Countries which are interested in RSBY
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www.rsby.gov.in

Learnings for Us
RSBY uses following to effective reach its objectives
Create a dedicated body responsible for design and implementation Keep provision for flexibility later as design may change with experience Focus on details and develop details for each process Effective use of Technology Smart card provided a good solution to our scenario where connectivity is not always there and need to prevent frauds and leakages Without partnership with Private Sector e.g. Insurance Companies, IT Companies and Hospitals Development of Business model so that everybody has incentive to work towards this Initially keeping it low profile helped

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If you believe you have a reasonably good UHC plan it is better to start than keep waiting perfect design (often the biggest enemy of good is best) We must leverage the private sector and their strengths as they can compliment in the efforts of the Government Buy-in of stakeholders is very important for success From fixing Targets to a model of developing Business models for Social sector schemes is the way forward Generate regular evidence to feed into policy design and keep improving Technology today has power to change Focus should be on ease of access for Beneficiary than easy of implementation for Government
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Learning for Others

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Thank You
nishant.jain@giz.de

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