Experience of RSBYIndia’s Health Insurance Scheme for UnorganizedSector WorkersChangqing SunSouth Asia Human Development
Structure of Presentation• Background• RSBY Program• Progress So Far• Challenges and Next Steps
Low coverage & high OOP & low outcomesOut of Pocket (OOP) expensesINDIA POORESTAverage OOP perhospitalization inGovt. faci...
Health Care System in India• Gaps in access toquality care, financialprotection, efficiency– Low public spending– Equity– ...
Rationale behind RSBY design1. Beneficiary perspective– Poor  reimbursement model unlikely work– Illiterate  simple and ...
Rationale behind RSBY design2. Aligning incentives– State government seeks best technical and financial bid anddoes not kn...
Rationale behind RSBY design3. Adapting based on evidence - examples– Rules and software were changed to allow enrolment o...
What is RSBY?RASHTRIYA SWASTHYA BIMA YOJANA (www.rsby.gov.in)• a demand-side, voucher-like intervention• Objective: provid...
Key parameters of RSBYDescription Comments/caveatsBenefitscoveredCost of hospitalization for 725+ procedures atempanelled ...
InsuranceCompanyState NodalAgencyHealth CareProvidersFKOBPLBeneficiariesGovernmentof IndiaBPL Datawww.rsby.inDistrictKiosk...
ENROLMENT KIT
INITIAL CHALLENGES• Acceptability by the States and other stakeholders• Earlier experience with Health Insurance Schemes• ...
Current Status• Cards issued – App.34.8 million• People enrolled – App.120 million• Number ofhospitalization casestill now...
Encouraging Signs1.Operation– Implemented in 500 out of 600+ districts with very diverseconditions, e.g. weak/no so weak p...
Note: Estimate based on monthly hospitalizations; includesmultiple procedures within same household in case of RSBY0.00 0....
Participation by Gender61% 55% 53%39% 45% 47%0%20%40%60%80%100%Round 1 Round 2 Round 358% 58%46%42% 42%54%0%20%40%60%80%10...
PREMIUM TRENDS in RSBY607 600533 5273475094924514265185134124825504890100200300400500600700Average Premiumfor Fresh Distri...
Current Priority Areas• Out-Patient benefits – pilots• Extend to more categories – NREGS workers, B&Cworkers, railway port...
Extension and Expansion of RSBYBelow Poverty Line (30%)Government EmployeesPrivate InsuranceB&CWorkersDomesticWorkersNREGS...
The Challenges Ahead• Institution building• Finding a lasting solution to poverty targeting• Evolving a robust back-end da...
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Labor Markets Core Course 2013: India's Health Insurance Scheme for Unorganized Sector Workers

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Labor Markets Core Course 2013: India's Health Insurance Scheme for Unorganized Sector Workers

  1. 1. Experience of RSBYIndia’s Health Insurance Scheme for UnorganizedSector WorkersChangqing SunSouth Asia Human Development
  2. 2. Structure of Presentation• Background• RSBY Program• Progress So Far• Challenges and Next Steps
  3. 3. Low coverage & high OOP & low outcomesOut of Pocket (OOP) expensesINDIA POORESTAverage OOP perhospitalization inGovt. facilities ($US)70 54Average OOP perhospitalization inprivate facilities ($US)158 115% of people indebteddue to OP cost23 21% of people indebteddue to IP cost52 64• 90+% labor force belongsto unorganized sectors• HI coverage is very lowand concentrated in theupper income groups• OOP expenses are veryhigh and result in extremecoping mechanismsExpansion of social security coverage is a high priority for theGovernment (Unorganized Workers Social Security Act, 2008)
  4. 4. Health Care System in India• Gaps in access toquality care, financialprotection, efficiency– Low public spending– Equity– Accountability in publicprovision– Weakly regulated privatesupply0204060801000 2 4 6 8 10OOPas%ofHealthExpenditurePublic Health Expenditure as % of GDP• Initiatives for Universal Healthcare Coverage,including government sponsored HIs
  5. 5. Rationale behind RSBY design1. Beneficiary perspective– Poor  reimbursement model unlikely work– Illiterate  simple and no “fine print”– Migratory  portable– Smart card ‘front end’• Cashless and paperless• Requires direct contact with household and named policy– Pre-existing conditions covered– Interoperability across country– Low, but non-zero cost– Choice of hospital including private
  6. 6. Rationale behind RSBY design2. Aligning incentives– State government seeks best technical and financial bid anddoes not know the true cost of provision– Insurers compete revealing the best information availableon the premium required for insurers to maximizeenrolment– Hospitals see RSBY members as potential revenue sourceand try to attract their business and to encourageoverconsumption (or worse)– Insurers have an incentive to monitor hospitals to minimizeclaims based on unwarranted procedures
  7. 7. Rationale behind RSBY design3. Adapting based on evidence - examples– Rules and software were changed to allow enrolment ofdependents not present on original BPL list; rules for infantsadopted along with addition of maternity care– Indicative treatment “package price” list has been revisedbased on feedback from hospitals– Data submission standards and schedules have beencontractually mandated for insurance companies– Enrolment period shortened from 6 to 4 months– Inter-insurance claim settlement mechanism to allow use ofempanelled hospitals by all RSBY members
  8. 8. What is RSBY?RASHTRIYA SWASTHYA BIMA YOJANA (www.rsby.gov.in)• a demand-side, voucher-like intervention• Objective: provide effective, catastrophic healthinsurance to a potential population of 60 million poorhouseholds• National government responsible for policy & standardssetting and state government responsible forimplementation• Risk pooling and contracting at district level• Participation of private sector – insurance and healthcare providers• Smart card centered IT platform – biometric verification,digital transaction, daily data uploading
  9. 9. Key parameters of RSBYDescription Comments/caveatsBenefitscoveredCost of hospitalization for 725+ procedures atempanelled hospitals up to 30,000 rupees perannum per household plus 100 rupees transportcost per visit up to 1000 rupees.Pre-existing conditions arecovered; minimal exclusions;certain day-care proceduresallowedEligibilitycriteriaMust be on the official state BPL list; limited to fivemembers of the household including householdhead, spouse and three dependentsAll enrolled members must bepresent to be enrolled; infants arecovered through motherPremiumand fees30 rupee registration fee per household perannum paid by household;Per household premium payment determinedthrough competitive bidding process;Average premium for activedistricts is around 560 rupeesPolicyperiodOne year starting the month after first enrolmentin a particular districtEnrolment can take place overfour monthsFinancing 75%/25% Government of India/State Government The ratio is 90%/10% in Northeaststates and Jammu and Kashmir
  10. 10. InsuranceCompanyState NodalAgencyHealth CareProvidersFKOBPLBeneficiariesGovernmentof IndiaBPL Datawww.rsby.inDistrictKioskDKMCallCentre4. Selection through tendering6.IssuanceofFKOCard8.DownloadofFKODataatDKMserver9. Submission of data and bill10. Payment to InsurerAwarenessHealthCamps
  11. 11. ENROLMENT KIT
  12. 12. INITIAL CHALLENGES• Acceptability by the States and other stakeholders• Earlier experience with Health Insurance Schemes• BPL Data• Increasing utilization– 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
  13. 13. Current Status• Cards issued – App.34.8 million• People enrolled – App.120 million• Number ofhospitalization casestill now – App. 5.2million• Number of HospitalsEmpanelled – App.11,000• States where Servicedelivery has started –28• Number of InsuranceCompanies Involved –Fifteen
  14. 14. Encouraging Signs1.Operation– Implemented in 500 out of 600+ districts with very diverseconditions, e.g. weak/no so weak public provision, evenoperational in districts affected by left-wing extremism;– Enhancements by State Governments, e.g. expanding coverageand/or benefits2.Beneficiaries– Improvement in access to health care for targeted segment incomparison to NSSO Data– High satisfaction and renewal rate– Utilization biased actual in favor of women– Out of pocket expenditure for health is coming down3.Providers– Competition between public and private hospitals– Incentives for staff of public hospitals and for public hospitals tospend on facility, capacity/services, inventory, etc– Private hospitals increase capacity & set up new facilities inremote areas4.Public health– Disease profiling and better monitoring
  15. 15. Note: Estimate based on monthly hospitalizations; includesmultiple procedures within same household in case of RSBY0.00 0.50 1.00 1.50 2.00 2.50 3.00 3.50NSS 60-poorest 40%NSS 60 AverageYeshashwiniRSBYPercentage of Members Hospitalized
  16. 16. Participation by Gender61% 55% 53%39% 45% 47%0%20%40%60%80%100%Round 1 Round 2 Round 358% 58%46%42% 42%54%0%20%40%60%80%100%Round 1 Round 2 Round 3Enrollment Utilization
  17. 17. PREMIUM TRENDS in RSBY607 600533 5273475094924514265185134124825504890100200300400500600700Average Premiumfor Fresh Districts in2008Average Premiumfor Fresh Districts in2009Average Premiumfor Fresh Districts in2010Average Premiumfor Fresh Districts in2011Average Premiumfor Fresh Districts in2012 (incl freshlytendered)InINRRound 1 Round 2 Round 3 Round 4 Round 5
  18. 18. Current Priority Areas• Out-Patient benefits – pilots• Extend to more categories – NREGS workers, B&Cworkers, railway porters, postmen, etc.• Awareness among beneficiaries• Quality of health care services – grading system startedin 800 hospitals in 16 districts• Fraud prevention, detection and control• Integrate Weaver’s and Artison’s HI schemes with RSBY• Evaluation studies to generate evidence• Leverage RSBY smart card for other social securityprograms– Life and Disability Insurance for the poor (MoF)– Public Distribution System (Chattisgarh)– Social Pension and NREGS – pilots (MoRD)
  19. 19. Extension and Expansion of RSBYBelow Poverty Line (30%)Government EmployeesPrivate InsuranceB&CWorkersDomesticWorkersNREGSWorkersRSBYFullySubsidisedOther OccupationalGroups e.g Taxi driversRSBYPartiallySubsidised/Non-SubsidisedPrimary Care/ OutpatientSecondary CareTertiary CareCurativeContinuumStreetVendors
  20. 20. The Challenges Ahead• Institution building• Finding a lasting solution to poverty targeting• Evolving a robust back-end data management system• Reaching out to the beneficiaries.• Ensuring quality of services• Taking RSBY beyond BPL beneficiaries• Capacity building at various levels of operation.• Preventing fraudulent claims.• Using the Smart Card platform for delivering otherbenefits to the poor.

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