…………… a journey called RSBY
STRUCTURE OF THE PRESENTATION
• What was the context and why social security?• Why Health Insurance?• What is the Scheme?• How is it different from the other schemes?• What has happened so far?• How has the scheme been perceived?• What are the challenges for the future?
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Workforce In India• 470 million workforce
in India
• More than 94% of workers are in the informal sector
• India's unorganized sector is one of the largest in the post-industrial world
WHY SOCIAL SECURITY?
• Absence of a meaningful social security arrangement is not merely a problem for individual workers, it has wider ramifications in the economy and the society.
• From an economic point of view, it debilitate workers’ ability to contribute meaningfully and efficiently.
• Low earning power, coupled with vulnerabilities, lead to poverty that also reduces aggregate demand.
• Socially, it leads to disaffection and dissatisfaction, especially when a small segment of the society is well endowed and seen as prospering.
• Government of India is working towards providing social security to the workers
Major Needs of Unorganised Sector workers
• Employment Security• Health Security• Maternity Security• Old Age Security
RECENT INITIATIVES TO PROVIDE SOCIAL SECURITY TO THE UNORGANIZED SECTOR WORKER
• Employment Security through National Rural Employment Guarantee (NREGA)
• Health Security through Rashtriya Swasthya Bima Yojana (RSBY)
• Aam Aadmi Bima Yojana• Indira Gandhi Old Age Pension Scheme• Unorganized Workers’ Social Security Act, 2008
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HEALTH INSURANCE COVERAGE VERY LOW
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
1 2 3 4 5 6 7 8 9 10
income decile
per
cen
t o
f w
ork
ers
cove
red
health insurance
OOP = 83% of total health spending in India
Data for All- India 2004
OUT OF POCKET (OOP) EXPENSES AND INDEBTEDNESS IN INDIA
(Amount in $US)
ALL INDIA POOREST
1. Average OOP Payments made per hospitalization in Govt. facilities
70 54
2. Average OOP Payments made per hospitalization in private facilities
158 115
3. %age of people indebted due to OP Care
23 21
4. %age of people indebted due to IP Care
52 64
SOURCE: NSSO, GOI
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SOME OF THE KEY ISSUES WHILE CONSIDERING A HEALTH INSURANCE SCHEME
• Whether “adverse selection” gets taken care of ?• What is the likely incidence of “moral hazard” and who bears the cost
thereof?• Whether the scheme is sustainable or would it require sustained
aggressive driving by individuals? Should the scheme be market driven or ‘bureaucrat’ driven?
• Are the systems secure?• Can benefits be claimed outside the State?• Is there a subjective criteria to deny entry or benefits to the beneficiary?• Will the benefits be delivered seamlessly?
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CHARACTERISTICS OF UNORGANIZED SECTOR WORKERS
• Poor• Illiterate• Migratory
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RASHTRIYA SWASTHYA BIMA YOJANA
The Scheme
• Total sum Insured of Rs 30,000 ( U.S. $ 650) per BPL family (a unit of five) on a family floater basis
• Pre-existing diseases covered
• Coverage of health services related to hospitalization and certain procedures which can be provided on a day-care basis
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RASHTRIYA SWASTHYA BIMA YOJANA
Benefits
• Cashless coverage for hospitalization with few exceptions.
• Provision of Smart Card.• Provision of pre and post hospitalization expenses.• Transport allowance @Rs.100(U.S.$ 2.2) per visit up
to a ceiling of Rs. 1000 (U.S. $ 22) as part of the benefits.
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FUNDING
• Contribution by GOI : 75% of the estimated annual premium.• Contribution by the State Governments: 25% of the annual
premium. • Additional benefits can be provided by the State Government but
the cost has to be borne by the State.• Beneficiary to pay Rs. 30 (U.S.$ 0.65) per annum as Registration Fee.• Administrative cost to be borne by the State Government.• Cost of Smart Card to be borne by the Central Government @ Rs.60
(U.S.$1.30) per beneficiary
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Insurance Company
State Nodal Agency
Health
Care Providers 7.
Enr
ollm
ent o
f
Benefi
ciarie
s
FKO
7.
Verification
of Smart
CardBPLBeneficiari
es
Government of India
BPL Data
www.rsby.in
5. Empanelment
District
Kiosk
DKM
Call Centre
5. Setting-up
Setting-up
1. Prepare
in given
format
2. Send
for verificatio
n
3. Upload on
website after
verification 4. Selection through tendering
6.
Issu
an
ce o
f FK
O C
ard
8.
Dow
nlo
ad
of
FKO
Data
at
DK
M
serv
er
9. Submission of data and bill
10. Payment to Insurer
11. Utilisation of Services
12. Claim Process
AwarenessHealth Camps
SMART CARD
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16
BP
L D
AT
A M
AN
AG
EM
EN
T S
OF
TW
AR
E
KEY MANAGEMENT SYSTEM SOFTWARES
CARD OPERATING SYSTEM SOFTWARE
EN
RO
LM
EN
T S
OF
TW
AR
E
DA
TA
TR
AN
SM
ISS
ION
SO
FT
WA
RE
TR
AN
SA
CT
ION
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FT
WA
RE
DIS
TR
ICT
KIO
SK
SO
FT
WA
RE
10
8
7
1
632
4
5
SMART CARD, I.T. APPLICATIONS & RSBY
ENROLMENT DATA DOWNLOAD SOFTWARE
BA
CK
-EN
D D
AT
A M
AN
AG
EM
EN
T S
OF
TW
AR
E
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INITIAL CHALLENGES
• Acceptability by the States and other Stakeholders• Earlier experience with Health Insurance Schemes• Improving Enrollment Conversion Ratio
– BPL data issue– Migration, Death, Awareness
• Increasing Hospitalisation– Awareness– Availability of Hospitals in rural areas and their willingness to join
• Availability of hardware and software to support• Capacity of Government and Private players.• Moral Hazard• Evolving a win-win situation for everybody
WHAT WAS REQUIRED TO BE DONE DURING THE INITIAL PHASE?
• Insurance related Tasks.
• Information Technology related Tasks.
• Marketing of the Scheme.
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TASKS DURING THE INITIAL PHASEInsurance and Medical Services Related Activities
• Issue of Guidelines.• Preparing Draft Tender Document to be issued by the State
Governments.• Preparing Draft Contract Document between States and
Insurance Companies.• Standardizing Medical Procedures and the Costs thereof.
(States can modify the price list)• Preparing Draft MOU between Centre and the States.• Guidelines for evaluating the process and the outputs.
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TASKS DURING THE INITIAL PHASE Information Technology Related Issues
• Standardization of Smart Card specifications.• Standardization of Smart Card Handling Devices
specifications.• Preparation of Enrolment software for issue of Smart Cards.• Standardization of software specifications for transacting
business with smart cards.• Evolving IT package for settlement of claims.• Evolving MIS for monitoring and evaluation.• Evolving Key Management System (KMS) with a view to
providing security.• Putting in place a Software Certification System.
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TASKS DURING THE INITIAL PHASE Marketing of the Scheme
• Within the Central Government
• State Governments
• Insurance Companies
• Health Service Providers
• Smart Card Service Providers
• Intermediaries
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HOW IS RSBY DIFFERENT?
• IT used to reach the poor on a large scale.• The BPL families are being empowered with a choice. They can
choose from among several hospitals (both public and private) for treatment.
• A ‘business’ model for a social sector scheme. (Fortune at the bottom of the pyramid)
• Key Management System (KMS) to make the scheme foolproof.• Simple front end but extremely complex back end.• Paperless.• Validity of the smart card throughout the country.
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ENROLMENT KIT
FIRST RECIPIENT OF SMART CARDVillage: Chappar; District: Yamunanagar; State: Haryana
•
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RSBY - Enrollment
WHERE DID IT ALL BEGIN?
Current Status of Implementation of RSBY
…. since its roll out from 1.4.08Category Numbers
Number of People Covered 75 million
Number of people benefitted 700,000
Number of States Started the Process
26
Number of States Distributing Smart Cards
22
Number of States where Policy has Started
22
Number of Insurance Companies involved
11
Number of Smart Cards Distributed
18.5 million
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INITIAL INDICATIONS
• Improvement in access to Healthcare. Health infrastructure being set up in remote areas by the private sector.
• Public Sector hospitals competing and improving performance to gain access to flexible funds and incentives.
• Penetration in the areas affected by extremist activities.• Marked improvement in utilization by women in the scheme (more than
60% usage by women in a number of Districts)• Out of pocket expenditure for health is coming down (Six times lesser
OOPE for RSBY beneficiaries than non-RSBY)• For expenditures beyond Rs. 30,000 ( US $ 650), State Governments
linking with other schemes• Below Poverty Level (BPL) lists improving on account of exposure• Disease profiling in each District
Note: Estimate based on monthly hospitalizations; includes multiple procedures within same household in case of RSBY
Note: 78 districts are sorted by male utilization rate (blue line). If female utilization rate (red dot) is higher than male one, then red dot is above blue line.
Note: Estimates are based on ALL districts with RSBY program, both completed and in progress
Public sector hospitals must play key role in RSBY and can benefit from RSBY as well
In Kerala government hospitals, revenue from RSBY is used for:•75% earmarked for KMC to fill critical gaps
• Improving hospital environment• Providing additional
consumables and maintaining equipments
• Building and acquiring capacity• Covering operational expenses
of ambulance service
•25% on incentivizing staffsOutcome:•Better equipped to provide more patient friendly services and to compete with private hospitals
BURN-OUT RATIO FOR 92 DISTRICTS WHERE ONE YEAR COMPLETED
A. Total Premium Paid: Rs. 299.80 CrB. Service Tax Paid by Ins. Co.: Rs. 37.19 CrC. Expenditure on Smartcard : Rs. 52.96 CrD. Paid To Hospital: Rs. 181.75 CrE. Balance with the Ins. Co.: Rs. 27.90 Cr
27.9
37.19
52.96
181.75
12.40 %
17.67 %
60.63 %
9.30 %
B+C+D X 100
A
Burn Out Ratio: 90.70 %
PERCEPTIONS ABOUT THE SCHEME
• Evaluation• In the Media• The International Agencies
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……….evaluation surveys
Beneficiary Response to the Treatment Provided in the Hospitals
SOURCE: Evaluation Survey in Kerala by The Research Institute, Rajagiri College of Social Sciences
Beneficiary Response to the Overall Experience at the Hospitals
SOURCE: Evaluation Survey in Kerala by The Research Institute, Rajagiri College of Social Sciences
Health Status Percent
Has improved
completely89.8
No improvement 0.9
Partially improved 9.3
Total 100.0
Service Delivery – Health Status Post RSBY Treatment
Source: Survey conducted by The Research Institute Rajagiri College of Social Sciences 2009
BENEFICIARY RESPONSE IN DELHI
• In 88.4 per cent hospital visits the respondents said that there was a RSBY help desk at the hospital.
• About 83.51 per cent of the patients were attended by the staff within 15 minutes.
• In 94.85 cases the staff at the RSBY help-desk was polite and helpful
Source: Survey organised by GTZ and World Bank in Delhi, 2009
BENEFICIARY RESPONSE IN DELHI
• 92% of beneficiary said that they would recommend others especially their relatives and friends to join the scheme.
• 94 percent patients would have gone to a public hospital in the absence of RSBY
Source: Survey organised by GTZ and World Bank in Delhi, 2009
………..…..in the media
“For the nation, it is the best Diwali present amidst all the gloom in the marketplace”
BBC
• It’s a government effort and it seems to be working. • The biggest change that this card has brought about is that it
has brought money into hands of people. So no hospital, public or private, can afford to ignore even the poorest of patients.
• The government seems to have a winning model with the first market driven welfare scheme where all the players, the insurance companies, hospitals and patients get to benefit.
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……….international agencies
The World Bank
• “……congratulate you on the growing success of the Rashtriya Swasthya Bima Yojana (RSBY). Increasingly, the scheme is being seen as a model of good design and implementation with important lessons for other programs”
• “The experience with the design and implementation of the Rashtriya Swasthya Bima Yojana (RSBY) in particular, is one of the most promising efforts in India to bridge this gap by providing health insurance to millions of poor households. The program is now internationally recognized for its innovative approach to harnessing information technology to reach the poor.”
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Bill Gates Foundation
• “The process was very efficient”• “……….quite impressed to see a system
where an SMS is sent……..whenever a patient presents at an empanelled hospital”
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RECOGNITION BY UNDP AND ILO
• The scheme has been selected for publication in a document “Sharing Innovative Experiences: Social Protection Floor Success Stories” being brought out by UNDP
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WHY DID RSBY HAPPEN and ARE THERE ANY LESSONS?
• Rare opportunity to visualize, conceptualize, articulate, implement and evaluate the scheme by a dedicated core group.
• Conceptually and operationally very different. (Out-of-the-box thinking)• Attempt to understand the consumer. (Beneficiary is the key)• Focus on operational issues. (Proof of pudding lies in eating it)• Flexibility to evolve. (All answers are not known up-front)• Marketing of the scheme. (No imposition) • A business model for a social sector scheme. (Value for every stake holder.)• No targets, only processes and estimates. (Processes are critical)• Little monitoring, more facilitation. (Partnership)• Appropriate and extensive use of IT applications. (The smart card revolution) …………and a fabulous team that never lost hope and enjoyed the journey as
positive energy kept the members upbeat.
The Challenges Ahead
• Sustaining the momentum .• Finding a lasting solution to the problems relating to BPL data• Evolving a robust back-end data base management.• Reaching out to the beneficiaries.• Ensuring quality.• Taking RSBY beyond BPL beneficiaries.• Capacity building at various levels of operation.• Preventing fraudulent claims.• Using the Smart Card platform for delivering other benefits
to the poor.
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……….we haven’t arrived as yet but the journey so far has been extremely enjoyable.
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