Healthcare Financing System in India (Global Health Presentation)

We presented at the Healthcare Department, City, University of London, UK (as part of the Global Health Project).

1. Healthcare Financing System in India: RSBY 1 Lead: Dr Sharanya Rajan Dr Mina Maallah Adriana Desoto Ana Milena Quintero Anoosha Anoosha Marya Salhab (Plasman, 2016)

2. Describe the Country 2 (Boeing, 2016)

3. Demographic Profile of India Population : 1,266,883,598 (July 2016 est.) 29 States ,7 Union territories , 640 districts and 5924 Sub-Districts Geographical area: 3,287,263 sq km Birth rate : 19.3 births/1,000 population (2016 est.) Death rate : 7.3 deaths/1,000 population (2016 est.) Maternal Mortality Rate: 174 deaths/100,000 live births (2015 est.) Infant Mortality Rate : 40.5 deaths/1,000 live births Life Expectancy at Birth : 68.5 years (male: 67.3 years/female : 69.8 years) (2016 est.) Total Fertility Rate : 2.45 children born/woman (2016 est.) {Central Intelligence Agency, 2016) 3

4. Demographic Profile of India Physician Density : 0.7 physicians/1,000 population (2012) [1] Hospital Bed Density : 0.7 beds/1,000 population ( 2011 ) [1] Literacy Rates : Total population: 71.2%, Male: 81.3%, Female: 60.6% (2015 est.) [1] Total GDP : 2.074 trillion dollars (2015) [2] Health expenditure per capita (current US$) : 74.9 [2] Health expenditure, total (% of GDP) : 4.69 [2] Out-of-pocket health expenditure (% of total expenditure on health) : 62.42 [2] 4 [1] (Central Intelligence Agency, 2016) [2] (World Bank, 2016) (Planet, 2016)

5. Political Bearing on India ’ s Healthcare Financing India became an Independent country in 1947. The first government led by Prime Minister Nehru. Two mandatory government sponsored health insurance schemes legislation on social security for workers in India were made: - 1948, Employee State Insurance Scheme (ESI) - 1954, Central Government Health Scheme (CGHS) ( Dash and Muraleedharan , 2011) 5 Pre colonial and colonial period: No governement health schemes. Only private insurances existed. It was not popular among Indian population as they were charged high premiums.

6. Political Bearing on India ’ s Healthcare Financing 1973 - Prime Minister Indira Gandhi nationalized insurance companies . This led to amalgamation of 107 insurers forming a central holding company called The General Insurance Corporation (GIC). They had four large subsidiaries which provided voluntary health insurance schemes (Anita, 2014) . National Insurance Corporation New India Assurance Company Oriental Insurance Company United Insurance Company 1983 - First Health policy (Health for all by 2000) ( Yojana , 2016) 6

7. Political Bearing on India ’ s Healthcare Financing 1991- India was in a severe economic crisis , India approached the IMF for a loan, and the IMF granted what is called a ‘structural adjustment’ loan, which brought a new policy known as Liberalization, Privatization and Globalization Policy initiated by Finance Minister DR. Singh ( Kumar, 2013) 2002 - National health Policy , recommended that the health spending as a proportion of GDP should be doubled from 1 per cent to 2 per cent within a period of 10 years ( Yojana, 2016) 2003 - Universal Health Scheme was launched by the BJP government under Prime Minister Vajpayee for providing financial risk protection to the poor. This scheme was not successful (Anita, 20 08 ) . 200 8 - Rashtriya Swasthya Bima Yojna was launched by Prime Minister Manmohan Singh along with Anil Swarup, the junior Ministry of Labour and Employment officer committed to a national expansion. The scheme was put together because the poor were becoming poorer. (Fan, 2013). 7

8. Political Bearing: Reduce OOP Spending 8 May 2014 – BJP government came into power in India led by P.M Modi. Goal: “ provide health assurance to all Indians and to reduce the out-of-pocket spending on health care ” with the help of state governments . Focus on key determinants of health—sanitation and drinking water —to reduce water-borne diseases. Fig. 2: BJP government initiatives. (Sharma, 2015) (Sharma, 2015).

9. Socio-Economic Determinants Economic indicator: 32% of population living below the poverty line. Employment: 29650.00 people (Trading Economics, 2016) Unemployed: 44.79 million people (Trading Economics, 2016) 1 billion people still have extreme poverty. 2billion people have no access to energy services. Social indicator: Religion: religious ethnicities limit the diagnosis/treatment of diseases. Ex: Muslim women and HPV Education: 750 million can ’ t read. gender issues: inequity is barrier in progress in health and develop in India. Ex: some women not allowed to leave the house without their husband. Location problems: cut off areas and ecologically vulnerable area where the large section of the population lives. (Mukhopadhyay, 2011) 9 India has experienced: Sustained economic growth, fast demographic transition, increase in communicable and non communicable diseases, and an imbalanced resource allocation with much variation between states. (T et al., 2016) Catastrophic health spending associated with: High poverty level, low coverage of health insurance, difficulty in accessing health centers, poor public health system. ( Mohanty et al., 2016)

10. 10 (Govpreneur, 2016) Urban and Rural Health Indicators

11. Health Background and Healthcare Financing India is undergoing a dramatic demographic, societal, and economic transformation, but the health status of the citizens is lagging behind [1] . There has been substantial advances in life expectancy and disease prevention since the middle of the 20th century, but the Indian health systems provide little protection against financial risk [1] . High out of pocket payments (OOPs)for health followed by severe financial catastrophe especially for the people who are affected with non-communicable diseases, which keep increasing: for example there is an increase in diabetes mainly because consumption of carbohydrates is too high. (Nair,2016) . Communicable diseases are now very high: HIV (2.4 million cases) [2] and TB (2.2 million cases) [3] . It is now clearly indicated that the poor have much higher levels of mortality, malnutrition and fertility than the rich. The poor-rich risk ratio is 2.5 for infant mortality, 2.8 for under-five mortality, 1.7 for underweight children . [1] [1] (Mukhopadhyay, 2011) [2] (World bank, 2016) [3] ( TBFACTS.ORG. , 2016) 11

12. Public health spending: India spends less on health care than other middle income countries. India is ranked 184 out of 191 countries for public health spending. Government funds 75% of the current health insurance scheme. The rest is funded by state governments. Health Background and Healthcare Financing Out Of Pocket spending (OOP): OOPs represented 58% : one of the highest in the world. OOPs are an increasingly large share of household budgets (Kumar et al., 2011) 12

13. Drugs are the biggest component of OOPs: 72% (Kumar et al., 2011) Health insurance drug coverage is minimal. For example: paracetamol is covered but antibiotics are not. OOPs on drugs are high because: (OECD Economic Surveys: India, 2014 ) Indispensable medicines are most of the time out of stock in public hospitals. The median availability of key indispensable generic medicines is: 22% in public sector 77% in private sector Shortage in public sector makes patients turn to private sector and spend out of their pockets. Health Background and Healthcare Financing: Drugs and OOPs 13

14. Historical Emergence of Rashtriya Swasthya Bima Yojana (RSBY) 4.7% of the country ’ s GDP is spent on healthcare [1] Most people were and still are using private healthcare (Smith, 2005) Increase in out-of-pocket expenses for health services [2] Health costs has actually led to poverty [2] Started with Prime Minister , Manmohan Singh ’ s, vision [3] RSBY was introduced in April 2008 by the Ministry of Labour and Employment [2] Rashtriya Swasthya Bima Yojana means “ National Health Insurance Program ” [3] Responsibility transferred to Ministry of Health and Family Welfare in 2015 [1] Expanded from families below the poverty line to other informal groups (Rashtriya Swasthya Bima Yojana, 2016) Covers about 120 million people in India [2] 14 [1] (Devadasan et al., 2013) [2] (Marten et al., 2014) [3] (Fan, 2013)

15. Who Is Covered? Those below the national poverty line (BPL) and other groups are eligible for coverage [1] Voluntary [1] Covers a household size of up to 5 members [1] No age limit [1] Enrollment fee of about 30 rupees (US $0.60) per family per year [1] Enrolled families receive a smart card of membership and are covered about 30,000 rupees (US $600) per family per year for hospitalizations [3] Floater basis [3] 15 (Hooghlyonline.in, 2016) [1] ( Devadasan et al., 2013) [2] (Marten et al., 2014) [3] ( Rashtriya Swasthya Bima Yojana , 2016)

16. Smart Cards For each family Paperless Given on the spot Has their fingerprints and photos Makes sure that they are the ones using the services and not others who are not covered People may not know how to read or sign their own name 16 (Rashtriya Swasthya Bima Yojana, 2016) (Correspondent, 2016)

17. Funds for RSBY 25% state funded and 75% government-funded scheme (Dasgupta et al., 2013) Each district in India is managed by one insurance company (Fan, 2013) Each year, insurance companies must win competitive bidding (Fan, 2013) Bids from private and public insurance companies (Dasgupta et al., 2013) Premium (regular payments, usually monthly, for health coverage) is subsidized mostly by the Government of India and the State Governments and paid directly to the insurance company (Devadasan et al., 2013) About Rs. 687 – 825 (US $10 – 12) 17

18. RSBY Scheme (Devadasan et al., 2013) 18

19. District BPL lists provided by the state government State Nodal Agency (SNA) is set up by the state government at each district Diseases Package List will be defined by the government Cashless facility  Smart Card Freedom of choice both public and private hospitals are empanelled under the RSBY package list. Field Key Officer (FKO) Floater basis Using the smart card in any RSBY empanelled hospital across India Easy access to health services At the enrolment site smart cards are printed and handed over to the family after collecting registration fee of Rs.30 per card (No money is returned at the end of the year) nationally unique hospital ID number After rendering the service to the patient, the hospital needs to send an electronic hospitalization data to the insurer to claim expenses  (Rashtriya Swasthya Bima Yojana, 2016) Funds and Risk Pooling 19

20. (United Nations Office Development, 2011) Funds and Risk Pooling 20

21. Insurers – The insurer is paid premium for each household enrolled for RSBY Hospitals – is paid per beneficiary treated. Insurers monitor participating hospitals to prevent unnecessary procedures or fraud resulting in excessive claims. Intermediaries –   The intermediaries will be paid for the services they render in reaching out to the beneficiaries .  (Rashtriya Swasthya Bima Yojana, 2016) (SK Infotech, 2016)  Incentives to Encourage The RSBY System 21

22. (Singh et al., 2016) Catastrophic Expenditure Among Hospitalized Cases in Shaheed Bhagat Singh District of Punjab, India, 2014 22

23. Consultation and medicine which leads to hospitalization. Pre-existing disease that leads to hospitalization. Hospitalization for both medical and surgical procedures , including the day care surgical procedures. Transportation expense up to Rs.100 per hospitalization and Rs.1000 per year Food only for the person who is hospitalized is covered in the package rate. The hospital will also provide medicines and other assistances for patient till five days after discharge.    (Rashtriya Swasthya Bima Yojana, 2016) What Healthcare Services are Covered? 23

24. All expenses related to the delivery of the baby in the hospital. A new-born is covered under RSBY since birth automatically. Out Patient Department is not covered in RSBY. Medicines and tests which do not lead to hospitalization need to be paid by the beneficiary. Medical hospitalization for less than 24 hours is not covered. Transportation expense which exceed Rs.100 per hospitalization will be covered by the beneficiary.  (Rashtriya Swasthya Bima Yojana, 2016) What Health Services are Not Covered? 24

25. How is the System Equitable? Covers BPL families and more recently expanded to include other non- BPL but socio-economically disadvantaged groups (Nandi et al., 2015) Portability of the smart card (Basu, 2010) . Patients are able to access hospitals outside district; power of choice. (Organization for Economic Co-operation and Development, 2014) Public-Private Partnership (PPP) (Basu, 2010) Decreased OOP spending which may otherwise be financially disastrous and increased use of healthcare services which may be otherwise unattainable (Sinha, 2013) . 25

26. How is the System Inequitable? Low enrollment and lack of availability of hospitals in remote rural areas (Sinha, 2013) . Enrollment inequalities among more disadvantaged groups (Baru et al, 2010) . Only covers inpatient services. The increase in non communicable diseases in India can be largely addressed in the outpatient setting (primary/diagnostic level). (Taneja and Taneja, 2016) Many people may decide not to use primary health services, because they cannot afford either the direct costs for consultations, medicines and diagnostic tests, or the indirect costs, such as for transport and special food. Outdated BPL household list. May sometimes exclude eligible households and include undeserving households; leakage. (Organization for Economic Co-operation and Development, 2014) 26

27. Non-registration in Karnataka (Berg et al., 2011) 27

28. Quality of Care and Efficiency Considered an efficient health financing system since it is funded by general taxes (Sinha, 2015) . Shortage of qualified health care workers throughout India. Biggest shortage in the rural north (Organization for Economic Co-operation and Development, 2014) . Problems with reimbursements (Nandi et al., 2015) Delay in settling bills Partial reimbursement Problems with smart card technology. (Dasgupta et al., 2013) Insufficient training in operation of the smart-card technology. Technology improperly installed. Incorrect information stored on the card 28

29. Efficiency There is a suggestive evidence that RSBY resulted in increased OOP level both on inpatient and outpatient OOP because of the complementarity between both services. (Karan et al., 2015) The effect of the scheme on the total OOP is almost negligible ( 0.2 %to 0.4% ) (Karan et al ., 2015) While the RSBY has managed to include the poor under its umbrella, it has provided only partial financial coverage. Nearly 60% of insured and admitted patients made OOP payments. (Devadasan et al., 2013) 29

30. Out-of-pocket expenditures among patients enrolled in RSBY in Patan District, 2010-2011 (Devadasan et al., 2013) Number of patients who had to make OOP payments (%) Direct expenses before admission 180 (35%) Direct expenses during admission 299 (58%) Direct expenses after discharge 216 (42%) Indirect expenses 489 (94%) 30

31. Healthcare Financing Challenges and Advantages in India Advantages: Large population able to generate revenue through general taxes to contribute towards scheme ( Sinha , 2011) . Young population. Private hospitals are also empanelled, 75% ( Sinha , 2011) . Pre-existing conditions are covered. 31

32. Healthcare Financing Challenges and Advantages in India Challenges: Increase in non communicable and chronic diseases: not enough public funds available to promote the program treatments and patients don ’ t have enough money too. (Nandi et al., 2015) Low and uneven spending on public health. Substantial differences in health care services between states (Organization for Economic Co-operation and Development, 2014) Nearly 60% of hospitalized patients made OOP payments (Devadasan et al., 2013). The effect of the scheme on the total OOP is almost negligible ( 0.2 %to 0.4% ) (Karan et al ., 2015). Outpatient coverage is essential Choice of health facility is limited Delay in getting the transportation charge Issues with quality of BPL data: (Bollineni, 2012) . Unsustainable Result: Many people may decide not to use health services (Devi Nair, 2014) 32

33. Empanelled Hospitals in RSBY-Lack Quality A list of empanelled hospitals under RSBY give people an opportunity to access public and private healthcare. Some of these empanelled hospitals lack adequate health infrastructure which nullifies any benefits RSBY could have generated for the poor population. Hospitals have to meet certain requirements to become empanelled under the RSBY system since the rural poor can only access subsidized care . Less number of health facilities are available in proximity to the villages, which makes the RSBY program ineffective. Almost two thirds of rural villagers in India must travel more than three miles to reach any inpatient hospital has profound implications for the health of the rural poor and increasing the OOPs. 33 (Upneja, 2015)

34. Stepwise Inclusion/Exclusion of Eligible Population Among the Selected Households of Maharashtra  34 (Thakur, 2016)

35. Conclusion Goals for the Future of RSBY Improve targeting [2] Better monitoring [2] Expand to full population coverage [2] Better educate beneficiaries [2] Improve benefits package [2] RSBY could be the blueprint for universal health insurance [1] [1] (Dror et al., 2012) [2] (Devi Nair, 2014) 35

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