Moving Towards Universal Coverage in India - Rashtriya Swasthya Bima Yojana (RSBY)

1. Moving Towards Universal Coverage in India - Rashtriya Swasthya Bima Yojana (RSBY) Dr. Nishant Jain

2. Role of the Government in Health Insurance • Very Low penetration of Health Insurance (Less than 100 million people covered with health insurance till 2007) • Objectives of Government Funded Health Insurance • Gradual Shift From Supply Side Financing to Demand Side Financing • Strengthening Public Health Care by bringing competition and incentives • Providing Power of Choice to the Beneficiaries in terms of treatment • Reduce OOPE on health care • A health insurance scheme (RSBY) was designed keeping in mind the characteristics of the beneficiaries • RSBY was designed as a “Business Model” for a social sector initiative

3. Birth of RSBY • Why RSBY designed such a way? • Design a scheme based on the characteristics of the target segment • Poor, Largely illiterate, Often migrant in nature • It was doubly risky as none of the Govt. funded smart card initiative or health insurance had worked well in India in the past • Scheme was not forced on the State Governments it was marketed to them and it took lot of time and effort • It was decided to start the scheme in few districts in few States but the larger picture was kept in mind • Financial planning was done not only for the first stage but projections were prepared for the full scaled up model

4. What is RSBY • Benefits • Cover for Hospitalisation Expenses of Rs. 30,000/- (US$ 650 ) per family per annum on a family floater basis (Upto five family members) • 1020 pre-defined surgical packages including Maternity & Newborn Care • Cover for Day Care Surgeries • All Pre-existing Diseases to be covered • 1 day pre and 5 day post hospitalisation Expenses • Transportation costs (Rs.100 per visit) with overall limit of Rs.1000 (US$ 22) • Sources of funding for program • Rs. 30 (US$ 0.65) per family per year from Beneficiaries • 75% of Premium from Central Government • 25% of Premium from State Government • Both Public and Private providers can be empanelled • Beneficiary can get cashless treatment in empanelled hospital

5. 13. Submission of Data to State and Central Govt. www.rsby.gov.in 3. Upload on website after verification 4. Selection through tendering Government of India State Nodal Agency Insurance Company 9. Submission of data and bill 10. Payment to Insurer 1. Prepare in given format Beneficiary Data 2. Send for verification 12. Claim Process 5. Empanelment Health Care Providers FKO 7. Enrollment of Beneficiaries Setting-up BPL Beneficiaries 5. Setting-up 7. Verification of Smart Card District Kiosk Call Centre 8. Download of FKO Data at DKM server 6. Issuance of FKO Card Awareness Health Camps 11. Utilisation of Services DKM

6. Key transfer Verification by FKO by fingerprint and smart card FKO Card RSBY Card Data of Beneficiary family

7. Enrollment Station

9. Stakeholders and their Roles

13. 40 rue de Lille

15. Current Status of RSBY Implementation in India • Cards issued – App. 32.3 million • People enrolled – App. 110 million • Number of People benefitted till now – App. 4 million • Number of Hospitals Empanelled – App. 10,100 • States where Service delivery has started – Twenty Five • Number of Insurance Companies Involved – Fourteen

16. PREMIUM TRENDS in RSBY

17. Conversion Ratio

18. High for all the districts Large variations across districts Less variation across Districts

19. Hospitalisation Ratio • Access to hospitals have increased for RSBY beneficiaries • Districts which have finished two years have higher hospitalisation • There is huge variations across different States

20. Hospitalisation Ratio

21. 295 Districts where One Year Completed 95 Districts where Two Years Completed

22. Hospitalization (Round1) vs. Enrolment (Round 2) • Hospitalization in Round 1 is correlated with Enrolment in Round 2. • The average hospitalization for districts where enrolment increased significantly is 63% more than that of districts where enrolment decreased significantly • Districts with large BPL population and above 2.7% hospitalization in round 2 should be ready for a higher or maintained enrolment in round 3. • Districts with hospitalization less than 2% have to be made more aware if higher enrolment is desired in the next round.

23. Male - Female Distribution

24. Success So Far – Improving Access • Improvement in access to Healthcare for targeted segment • In the worst naxalite affected areas also RSBY has been able to provide benefits to people • There is a marked improvement in utilisation by women in the scheme (more than 60% usage by women in northern States) • Out of pocket expenditure for health is coming down (Six times lesser OOPE for RSBY beneficiaries than non-RSBY) • State Governments are improving their BPL list because RSBY is bringing out the discrepancy • Able to provide social identity to people

25. Success So Far • Competition between Public and Private Hospitals • Incentives for staff of public hospitals from Insurance money • Hospital retains the insurance money in the hospital and can be used for the hospital by the hospital. • Increase in capacity of private hospitals • Setting up of Hospitals by Private sector in remote areas • Use of IT ensure that Insurance Company and Government gets data daily from the Hospitals • This data is analysed for patterns/ spikes and strong action taken against errant hospitals • Cashless & paperless transaction for people • paperless claim process for hospitals

26. Success So Far • Using Smart Card and Biometric technology successfully for a social sector scheme at this large scale and thereby • Reducing Frauds/ errors • Improving targeting and • Stopping leakages • Portability of Smart Card across India • Migrant workers are now able to get benefit anywhere in India (Split card) • Unique IDs are given to each RSBY empanelled hospital • Almost Real time data available from all over India • Standardised Templates and documents at Central level

27. Satisfaction Level of Beneficiaries from RSBY

28. Survey Results – Gujarat • More than 80% of beneficiaries had to spend less than one hour at the enrollment station • 92% of the beneficiaries told that RSBY staff at help desk was polite and helpful • 89.7% of beneficiaries that were enrolled but had not used the scheme said that they will enroll next year. • 98.3% of beneficiaries that had used the RSBY card said they will enroll next year also. • 83%of respondents said that they will recommend the same hospital to their relatives where they received treatment under RSBY. • 88.9% of respondents who used RSBY said their out of pocket expenditure on health came down because of RSBY

29. Survey Results – Himachal Pradesh • 86% of enrolled beneficiaries were aware of RSBY • 90% of the beneficiaries who were sick used RSBY card for availing treatment • 85% of people went to hospitals through referrals • Only 43% of hospitals had separate help desk for RSBY and in other cases it was combined with existing reception • 97% of the respondents reported that staff at the help desk was polite and helpful • Only in 5% of cases transport allowance was provided • 88% of respondents reported that they were provided food at the hospitals • 89% said that they will avail the facility in the same hospital again

30. Survey Results – Chhattisgarh • 98% of the respondents view that behaviour of staff at help desk is polite. • 77.8% of respondents who were hospitalised were provided free food during hospitalisation; • 95.1% of hospitals had separate RSBY help desk and 97% of the respondents reported that staff at the help desk was polite and helpful • Only in 67.2% of cases transport allowance was provided • 88% of respondents reported that they were provided food at the hospitals • The home delivery was reduced by 35% amongst respondents

31. Challenges • Beneficiary Data Preparation • Improving the quality of data • Building on the previous year enrolled data for next year • Updating the BPL data • Preparing data for new categories • Improving Enrollment • Informing and motivating families to come and enroll • Improving average family size • Which intermediaries to engage for this purpose • Capacity building. • Designing different capacity building materials for different stakeholders • Organising separate training workshops for different stakeholders

32. Challenges • Information dissemination • Designing and Implementing effective communication strategies • Ensuring that beneficiaries are enrolled and know how to use the benefits of RSBY • Collecting feedback from beneficiaries • Coordination with PACS Programme of DFID in Selected States • Early Detection/ Prevention of fraud. • Closely monitoring the hospital’s performance and trends • Identify early hospitals engaged in malpractices • Strict action against errant hospitals • Incentivising better performing hospitals

33. Future Plan • RSBY is being extended to many other categories which will be partially or fully sibsidised • NREGS Beneficiaries • Building and Construction Workers • Railway Porters • Postmen • Domestic Workers • Street Vendors • Beedi Workers

34. Extension and Expansion of RSBY Tertiary Care Private Insurance Secondary Care Government Employees Other Occupational Groups e.g Taxi drivers RSBY Partially Subsidised/ Non-Subsidised Primary Care/ Outpatient Curative Continuum NREGS Workers Domestic Workers B&C Workers Street Vendors Below Poverty Line (30%) RSBY Fully Subsidised

35. 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 • Improving the quality of service at the hospitals • Government of India has designed an Quality management system • Evolving a robust back-end data base management • Capacity Building at each levels for all the stakeholders • Cover OPD linked with RSBY (Experiments going on) • Store Health data on the smart card with proper security • Use the Smart Card for other targeted interventions and provide subsidies like Life Insurance, Food Subsidy

36. Future of RSBY Smart Card…….? • Common Storage Area • Family demographic details • Biometric details of RSBY family RSBY related data Health Card related data PDS Data Life and disability data MNREGS Data

37. Thank You nishant.jain@giz.de