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Dr Suraj Chawla
JR, Department of Community Medicine,
            PGIMS, Rohtak
Contents

 Health Insurance
    Definition
    Milestones
    Essentials
    Functions
    Basic elements
    Risks & Risk management
 Social Health Insurance
    Central Government Health Scheme (CGHS)
    Employees' State Insurance (ESI)
    Rashtriya Swasthya Bima Yojana (RSBY)
Contents

   Private health insurance – Mediclaim
   Community health insurance
   Health Insurance – The Way Ahead
   Pillars of change and Enablers for growth
   References
Health Insurance

 According to ILO “the reduction or elimination of the uncertain
  risk of loss for the individual or household by combining a larger
  number of similarly exposed individuals or households who are
  included in a common fund that makes good the loss caused to
  any one member”
 Simply, in a health insurance programme, people who have the
  risk of a certain event contribute a small amount (premium)
  towards a health insurance fund.
 This fund is then used to treat patients who experience that
  particular event (e.g. hospitalisation).
Health Insurance: Milestones

 Social security in India for medical emergencies is as old as the
  Indian civilisation.
 However, health insurance as we know it today was introduced
  only in 1912 when the first Insurance Act was passed.
 The current version of the Insurance Act was introduced in 1938.
 In 1972 the insurance industry was nationalised and private
  insurance companies were brought under the umbrella of the
  General Insurance Company (GIC).
Health Insurance: Milestones

 The winds of liberalisation that blew across India in the 1990s
  affected the insurance industry also.
 Private and foreign companies were allowed to enter the
  market in 1999 with the passage of the Insurance Regulatory
  Development Authority (IRDA) bill.
Indian Health Scenario

 Total Expenditure on health in India is 6% of GDP
 Government spending is less than 20% against the average
  spending of 30-40 % in other developing countries
 Indian health insurance industry stands at INR 10,500 crores
 Currently, in India only eight million people (about 0.8% of the
  total population) are covered under Mediclaim, whereas in
  developed nations like USA about 75% of the total population
  are covered under some insurance scheme.
 Health insurance industry in India is one of the fastest growing
  segments and with more and more private companies in the
  sector, the situation may change soon
Health Insurance Premium

     Source: IRDA official site


                                  10,500
                                  Crores
Essentials in Health Insurance

 Prepayment and risk pooling: Individuals or families pay when
  they are healthy and are able to pay. However, when they are
  affected by illness, the insurance fund can be used to finance
  their healthcare needs.
 Health insurance functions when there are large numbers
  enrolled. This is because with large numbers, the chances of
  adverse events are reduced and so is the outflow from the
  insurance fund.
Essentials in Health Insurance

 Solidarity: A successful health insurance programme requires
  people to contribute, knowing fully well that their contribution
  may not help them directly, but will help others who require
  the support.
 Without this value, a health insurance programme is likely to
  fail as people will insist on withdrawing at least their
  contributions from the fund. This will destroy the concept of
  health insurance.
 Yet another value, rarely talked about is one of equity. A
  health insurance programme should ideally promote both
  horizontal equity and vertical equity. This promotes cross-
  subsidy between equals and also between unequals.
Functions

A health insurance programme usually has two main functions:
1. To increase access to healthcare
2. To protect households from high medical expenses at the time
   of illness
Basic elements in a health insurance programme
Risks in Health Insurance Programme

 There are three main risks that are peculiar to health insurance:
 Adverse selection – Normally we expect that both the healthy
  and sick would enrol in a health insurance programme.
  However, if poorly designed, there is a chance that the sick will
  enrol in larger numbers as compared to the healthy. Thus the
  programme becomes unviable as the outflow exceeds the
  inflow.
 Cream skimming (risk selection) – This is the opposite of
  adverse selection and occurs when insurance companies
  selectively choose low-risk individuals and reject the high-risk
  individuals.
Risks in Health Insurance Programme

 Moral hazard – This takes place when the fact of being insured
  changes the behaviour of the patient or the provider. There are
  two types of moral hazard.
 In the supply side moral hazard, we find that the provider
  tends to intervene unnecessarily or charge higher bills for an
  insured patient.
 In the demand side moral hazard, the patient tends to demand
  more care, or indulges in risky behaviour, because of the
  insurance status.
Managing risks in a health insurance
              programme

 Moral hazard – This takes place when the fact of being insured
  changes the behaviour of the patient or the provider. There are
  two types of moral hazard.
 In the supply side moral hazard, we find that the provider
  tends to intervene unnecessarily or charge higher bills for an
  insured patient.
 In the demand side moral hazard, the patient tends to demand
  more care, or indulges in risky behaviour, because of the
  insurance status.
Types of Health Insurance

          Health Insurance Plans


                                   Community Based /
Private           Social            Micro Insurance
Social Health Insurance
Social Health Insurance

 There are two mandatory and contributory health insurance
  schemes in India – the Central Government Health Scheme
  (CGHS) for the government of India‟s civil servants and the
  Employees' State Insurance Scheme (ESIS) for the low-paid
  industrial workers.
 Here the eligible people contribute through a payroll tax
  towards a specific health fund. This fund then finances specific
  benefits for them.
 Rashtriya Swasthya Bima Yojana (RSBY) for BPL families is
  recent addition in social insurance.
Central Government Health Scheme (CGHS)

  The CGHS was introduced in 1954 as a contributory health
   scheme to provide comprehensive medical care to the central
   government employees and their families.
  Currently, there are approximately 5.5 million beneficiaries. The
   staff contributes a nominal amount (ranging from Rs 30 to Rs
   300 per month) from their salaries.
  It provides service through following categories of systems:-
     Allopathic
     Homeopathic
     Indian System of Medicines
CGHS Beneficiaries

Besides Central Government employees, the scheme also provides
services to:
 Members and Ex-members of Parliament
 Judges of the Supreme Court and High Court (sitting and
   retired)
 Freedom Fighters
 Central Government Pensioners, Employees of Autonomous
   bodies
 Ex-Governors and Ex-Vice-Presidents of India
CGHS Facilities

The benefit package includes both outpatient care and
hospitalisation. The medical facilities are provided through
Wellness Centres and polyclinics.
 248 Allopathic dispensaries
 19 polyclinics
 78 Ayush dispensary/units
 3 Yoga Centres
 65 Laboratories
 17 Dental Units
 Also uses the facilities of the government and approved private
  hospitals to provide inpatient care and reimburses the expenses
  to the patient.
CGHS - Problems

 Equity – In a country where the government spends about 1.1%
  of the GDP on healthcare, it is unacceptable that a sizable
  amount of this goes to the better-off section of the society.
 Demand side moral hazard – It is noted that more than 80% of
  the hospitalised patients are self-referred. It appears that most
  patients prefer to bypass the dispensaries and directly avail of
  specialist services.
 Poor quality care – There are regular complaints about long
  waiting periods, inadequate supply of medicines and
  equipment and unhygienic conditions
 High out-of-pocket expenditure
Employees' State Insurance Scheme

 Established in 1948, the Employees‟ State Insurance Scheme
  (ESIS) is an insurance system, which provides both cash and
  medical benefits. It was conceived as a compulsory social
  security benefit for workers in the formal sector.
 The Employees‟ State Insurance Corporation (ESIC) manages
  the scheme and is a corporate semigovernment body headed
  by the Union Minister of Labour as Chairman and a Director
  General as the chief executive.
 Number of insured persons covered under the ESI Scheme
  reached 16 million in 2010-11.
Employees' State Insurance Scheme

 The Act compulsorily covers:
  (a) all power-using non-seasonal factories employing 10 or
  more persons;
  (b) all non-power-using factories employing 20 or more
  employees, and
  (c) service establishments like shops, hotels, restaurants,
  cinemas, road transport and newspapers.
Employees' State Insurance Scheme

 Act does not include employees of Indian navy, military or air
  force; or whose wages exceed Rs. 15000 or as prescribed by the
  Central Government.
 To avail of the sickness benefit, the employee has to have
  worked for 78 days prior to the sickness. Similarly, to avail of
  the maternity benefit, the woman has to have worked for 70
  days prior to the sickness.
Employees' State Insurance Scheme

Contribution :-
 State Governments share 1/8th of expenditure on medical
  treatment and attendance (7/8 being borne by the ESIC).
 Employees pay on an average 1.75% of the wages and
  employers contribute 4.75% of the wage bill. The employee
  who is getting daily wage of less than Rs. 70.00 shall be
  exempted from payment of contribution.
Employees' State Insurance Scheme

Benefits :-
1) Sickness Benefit:
 At the rate of 50% of the daily average wage is given to the
    employee for a maximum period of 91 days in one year. In
    diseases like tuberculosis, leprosy, fracture, malignancy etc, the
    sickness benefits are extended to two year.
2) Maternity Benefit:
 At the rate of full wages for a period of 84 days in case of
    pregnancy and 6 weeks in case of miscarriage or MTP.
Employees' State Insurance Scheme

3) Disablement Benefit :-
 In cash, 72% of the wages is given to the temporary disabled
   person during the period of disablement. In case of permanent
   disablement, the payment is made at the same rate for the
   whole of his life in the form of pension.
4) Dependent Benefit :-
 Widow or adopted child (up to the age of 18 years or till the
   daughter get married) of the diseased person gets the cash
   payment may be in the form of pension.
Employees' State Insurance Scheme

5) Funeral Benefit :-
 An amount of Rs. 5000 is paid to the eldest surviving member
   for the funeral purpose.
6) Medical Benefit :-
 All member of the worker gets the medical cover including the
   Outdoor treatment, domiciliary treatment facilities by the
   panel system, specialist services, ambulance services, and indoor
   services.
ESIS-Problems

 Less than half the enrolees use the ESIS facilities because of the
  low quality of care
 Many of the staff are not aware of the benefits. The employers
  also do not disseminate the information to their staff.
 There is duality of control, with both the ESIC and the State
  governments trying to establish superiority
 Poor penetration in rural areas
Universal Health Insurance Scheme

 Government of India launched the Universal Health Insurance
  Scheme (UHIS) in 2003
 Standard Mediclaim product with an annual cover of Rs
  30,000 for a family
 Scheme marketed by the public sector insurance companies
  and was targeted at the BPL population.
Reasons for failure:
 Lack of willingness of Insurers/other stake holders
 Improper identification system of beneficiaries
 Inadequate coverage / benefits
Now superseded by RSBY
Rashtriya Swasthya Bima Yojana
            (RSBY)

 The RSBY is a project under the Ministry of Labour and
  Employment
 Started in April, 2008 and has been implemented in 25 states
  including Haryana
 Scheme will be implemented by the State Government in a
  phased manner and entire country is to be covered in 2012-13.
 Total sum insured of Rs 30,000 per BPL family on a family
  floater basis
 A total of 23 million families have been enrolled as of February
  2011
Rashtriya Swasthya Bima Yojana
            (RSBY)

 Pre-existing diseases to be covered from day 1
 Coverage of health services related to OPD and hospitalization
 Cashless coverage of all eligible health services in public as well
  private hospitals
 Provision of Smart Card
 Provision for transport allowance (actual with limit of Rs.100
  per visit) but subject to an annual ceiling of Rs.1000
FUNDING-RSBY

 Contribution by GOI : 75% of the estimated annual premium of
  Rs 750, subject to a maximum of Rs. 565 per family
 Contribution by the State Governments: 25% of the annual
  premium and any additional premium beyond Rs 750
 Every "below poverty line" (BPL) family holding a yellow ration
  card pays Rs 30 registration fee to get a biometric-enabled
  smart card containing their fingerprints and photographs.
 Administrative cost to be borne by the State Government
 Cost of Smart Card to be borne by the Central Government. An
  additional amount of Rs.60 per beneficiary would be available
  for this purpose
RSBY- Facts

 In the Union Budget for 2012-13, the government made a total
  allocation of about 1100 crores towards RSBY.
 Although meant to cover the entire BPL population,(about
  37.2 per cent of the total Indian population according to the
  Tendulkar committee estimates) it had enrolled only around 10
  per cent of the Indian population by March 31, 2011.
 The scheme has won plaudits from the World Bank, the UN
  and the ILO as one of the world's best health insurance schemes.
  Germany has shown interest in adopting the smart card based
  model for revamping its own social security system.
Private Health Insurance
Private Health Insurance

 A voluntary health insurance wherein people can enroll and
  purchase the insurance product of their liking, paying a risk-
  rated premium
 Both public and private insurance companies market a variety
  of health insurance products
 Out of these „Mediclaim‟ is the most sold product
Mediclaim

 Introduced in 1986
 A voluntary health insurance scheme offered by the public
  sector (and since 1999 the private sector) health insurance
  companies
 Anybody (3 months to 80 years) who can afford the risk-rated
  premium is eligible to join the scheme
 The premium depends on the age, risk and the benefit
  package opted for
 The subscribers are usually the middle and upper class,
  especially as there is a tax benefit in subscribing
Insurance Regulatory Development
            Authority (IRDA)

 A regulatory body, controlled by the Indian
  Government, governing insurance companies
  across India
 The headquarters of IRDA -located at Hyderabad
Aims:
 To protect the interests of the policyholders, and
 To regulate, promote and ensure orderly growth
  of the insurance industry
Third Party Administrator (TPA)

A TPA is a specialized health service provider, introduced by the
IRDA, rendering the following broad-spectrum services:

 Networking with hospitals

 Facilitating hospitalization processes

 Claim processing and settlement
Claim Disputes/Grievances

 Ombudsman is a special court
  constituted under IRDA for
  addressing grievances associated
  with Insurance claims.

 The claimant can approach the
  Ombudsman for resolving claim
  issues.
Strengths of the Mediclaim policy

 The only voluntary health insurance policy in the country
  currently, with about > 8 million subscribers
 Provides protection against catastrophic health expenditure
 Easily available in most insurance companies
 Is being modified to make it customer friendly
Private Health Insurance: Issues & challenges

                Faced by Insurance Companies
     Key Issues                       Description
 Limited Influence    Limited healthcare delivery network
  over healthcare
  delivery          
                    Insufficient data on consumers & disease
  mechanism         patterns, absence of standardization of
 High claim ratio  healthcare costs & significant levels of
                    frauds leading to under-pricing of
                    insurance products and higher value of
                    claims
 Limited product  Insufficient data on Indian consumers &
  development       disease patterns and limited control of
                    healthcare delivery network resulting in
                    limited product and pricing innovation
Private Health Insurance: Issues & challenges

                        Faced by TPAs
     Key Issues                         Description
 Limited influence Varying treatment costs across providers due
  over healthcare    to limited bargaining power
  delivery network   Lack of standardization & accreditation in
                     most healthcare facilities leading to difficulty in
 Funding support    judging the authenticity of procedures & costs
                    Limited funding support from the Insurance
                     company impacting the claims disbursement
                     time
                    Delays and issues in claims processing
                     leading to negative perceptions by insurance
                     companies & consumers about TPAs
Private Health Insurance: Issues & challenges

                Faced by Healthcare Providers
     Key Issues                        Description
 Pricing demands  Lack of standardization and
  from Insurance    accreditation norms for healthcare
  companies         resulting in unreasonable pricing
                    demands by insurance companies
 Lack of          Low health insurance penetration and
  affordability     lack of affordability of the consumers
                    in the cities and rural areas to support
                    the investment in healthcare
                    infrastructure in these areas
Community Health Insurance
Community health insurance

 “any not-for-profit insurance scheme aimed primarily at the
informal sector and formed on the basis of a collective pooling of
health risks, and in which the members participate in its
management.”
 While the CHI movement is vibrant in Africa, it is slowly picking
   up momentum in India.
Characteristics of CHI in India

 Initiated by NGOs / CBOs

 Mainly to improve access to health care

 The members varies from 1000+ to more than 2 million
Models of CHI

3 basic models of CHI
 Provider model (Direct Model)
 Insurer model (Mutual Model)
 Linked model
Provider (Direct )model


       Hospital




      Community
Insurer (Mutual) model


NGO             Hospital




      Community
Linked model


NGO           Hospital




  Community
Yeshasvini

 Organized by the Yeshasvini Trust, Karnataka
 Eligibility – Cooperative farmers and their families
 Premium – Rs 120 + 30 per person per year
 Benefit – any surgery up to Rs 1 lakh per hospitalization and 2
  lakh per patient per year
 Providers – Empanelled hospital > 300
 Administration by TPAs
Karuna Trust

 Initiated in September 2002
 Organized by Karuna Trust, Karnataka
 Eligibility – BPL families in talukas where Karuna trust works
 Premium – Rs 20 per person per year
 Benefit – hospitalization expenses upto Rs 2500; loss of wages
  upto Rs 1500; payment to the doctors upto Rs 1500
 Providers – Only government hospitals
 First year > 60,000 members, now around 100,000.
Performance of CHI

   Able to reach out to the weaker sections of society
   Provide some form of health security
   Has improved access to health care
   Has protected households, but only partially
   Has not improved quality of care for the patient
   Many of them require external subsidies
CHI- Conclusions

 An useful tool to improve access to health care and protect
  families from impoverishment
 But there are some pre-conditions that need to be met –
    Trustworthy organization
    Good quality providers
    Community with some means
    Managerial skills
Health Insurance – The Way Ahead

 Creating awareness on Rights & Responsibilities
 Standardization of Cost
    TPAs
    Health Providers
 Increased Tax benefit
 Removal of Service Tax
 Gradation of Health service providers
 Pool for Senior Citizen
Health Insurance – The Way Ahead

 Renewability / Portability
 Compulsory Health Benefits for organized sector
 Government role on mass healthcare initiatives
Pillars of change and Enablers for growth

  Pillars of Change    Enablers for Growth    Outcome
      • Consumer         • Product & Pricing • Healthy
         Awareness            Innovation       Vibrant
 •      Standardization   • Technology          India
   of Health care costs • Channel Innovation
    and Accreditation
           norms
     • Healthcare
       Infrastructure
• Data & Information
          Exchange
References

 Planning and Implementing Health Insurance Programmes in
  India; Dr. N. Devadasan; Institute of Public Health Bangalore,
  India,In collaboration with the WHO India Country Office:
  Website www.iphindia.org Email: mail@iphindia.org
 Central Government Health Scheme mohfw.nic.in/cghs.htm
 Employees State Insurance Scheme of India. Citizens Charter.
  New Delhi: Employees State Insurance Corporation; 2006(cited
  March 1, 2010). p.1-8. Available from:
  http://esic.nic.in/citizen_charter.htm
 http://en.wikipedia.org/wiki/Employees%27_State_Insurance
References

 Issues in Micro Health Insurance in India – Role of Government :
  India Insurance
  ifmr.ac.in/cmf/internship/june0508nishantjain.ppt
 Department of economic and statistical analysis,Haryana 2010;
  publication no. 946 ;deptt. website: www.esaharyana.gov.in
 Government of Haryana , economic survey of Haryana, 2009-
  2010;issued by: department of economic and statistical analysis
  Haryana
 http://www.medindia.net/slideshow/health-insurance.asp#4
 http://en.wikipedia.org/wiki/Rashtriya_Swasthya_Bima_Yojana
THANK

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Health insurance in India- Dr Suraj Chawla

  • 1. Dr Suraj Chawla JR, Department of Community Medicine, PGIMS, Rohtak
  • 2. Contents  Health Insurance  Definition  Milestones  Essentials  Functions  Basic elements  Risks & Risk management  Social Health Insurance  Central Government Health Scheme (CGHS)  Employees' State Insurance (ESI)  Rashtriya Swasthya Bima Yojana (RSBY)
  • 3. Contents  Private health insurance – Mediclaim  Community health insurance  Health Insurance – The Way Ahead  Pillars of change and Enablers for growth  References
  • 4. Health Insurance  According to ILO “the reduction or elimination of the uncertain risk of loss for the individual or household by combining a larger number of similarly exposed individuals or households who are included in a common fund that makes good the loss caused to any one member”  Simply, in a health insurance programme, people who have the risk of a certain event contribute a small amount (premium) towards a health insurance fund.  This fund is then used to treat patients who experience that particular event (e.g. hospitalisation).
  • 5. Health Insurance: Milestones  Social security in India for medical emergencies is as old as the Indian civilisation.  However, health insurance as we know it today was introduced only in 1912 when the first Insurance Act was passed.  The current version of the Insurance Act was introduced in 1938.  In 1972 the insurance industry was nationalised and private insurance companies were brought under the umbrella of the General Insurance Company (GIC).
  • 6. Health Insurance: Milestones  The winds of liberalisation that blew across India in the 1990s affected the insurance industry also.  Private and foreign companies were allowed to enter the market in 1999 with the passage of the Insurance Regulatory Development Authority (IRDA) bill.
  • 7. Indian Health Scenario  Total Expenditure on health in India is 6% of GDP  Government spending is less than 20% against the average spending of 30-40 % in other developing countries  Indian health insurance industry stands at INR 10,500 crores  Currently, in India only eight million people (about 0.8% of the total population) are covered under Mediclaim, whereas in developed nations like USA about 75% of the total population are covered under some insurance scheme.  Health insurance industry in India is one of the fastest growing segments and with more and more private companies in the sector, the situation may change soon
  • 8. Health Insurance Premium Source: IRDA official site 10,500 Crores
  • 9. Essentials in Health Insurance  Prepayment and risk pooling: Individuals or families pay when they are healthy and are able to pay. However, when they are affected by illness, the insurance fund can be used to finance their healthcare needs.  Health insurance functions when there are large numbers enrolled. This is because with large numbers, the chances of adverse events are reduced and so is the outflow from the insurance fund.
  • 10. Essentials in Health Insurance  Solidarity: A successful health insurance programme requires people to contribute, knowing fully well that their contribution may not help them directly, but will help others who require the support.  Without this value, a health insurance programme is likely to fail as people will insist on withdrawing at least their contributions from the fund. This will destroy the concept of health insurance.  Yet another value, rarely talked about is one of equity. A health insurance programme should ideally promote both horizontal equity and vertical equity. This promotes cross- subsidy between equals and also between unequals.
  • 11. Functions A health insurance programme usually has two main functions: 1. To increase access to healthcare 2. To protect households from high medical expenses at the time of illness
  • 12. Basic elements in a health insurance programme
  • 13. Risks in Health Insurance Programme  There are three main risks that are peculiar to health insurance:  Adverse selection – Normally we expect that both the healthy and sick would enrol in a health insurance programme. However, if poorly designed, there is a chance that the sick will enrol in larger numbers as compared to the healthy. Thus the programme becomes unviable as the outflow exceeds the inflow.  Cream skimming (risk selection) – This is the opposite of adverse selection and occurs when insurance companies selectively choose low-risk individuals and reject the high-risk individuals.
  • 14. Risks in Health Insurance Programme  Moral hazard – This takes place when the fact of being insured changes the behaviour of the patient or the provider. There are two types of moral hazard.  In the supply side moral hazard, we find that the provider tends to intervene unnecessarily or charge higher bills for an insured patient.  In the demand side moral hazard, the patient tends to demand more care, or indulges in risky behaviour, because of the insurance status.
  • 15. Managing risks in a health insurance programme  Moral hazard – This takes place when the fact of being insured changes the behaviour of the patient or the provider. There are two types of moral hazard.  In the supply side moral hazard, we find that the provider tends to intervene unnecessarily or charge higher bills for an insured patient.  In the demand side moral hazard, the patient tends to demand more care, or indulges in risky behaviour, because of the insurance status.
  • 16. Types of Health Insurance Health Insurance Plans Community Based / Private Social Micro Insurance
  • 18. Social Health Insurance  There are two mandatory and contributory health insurance schemes in India – the Central Government Health Scheme (CGHS) for the government of India‟s civil servants and the Employees' State Insurance Scheme (ESIS) for the low-paid industrial workers.  Here the eligible people contribute through a payroll tax towards a specific health fund. This fund then finances specific benefits for them.  Rashtriya Swasthya Bima Yojana (RSBY) for BPL families is recent addition in social insurance.
  • 19. Central Government Health Scheme (CGHS)  The CGHS was introduced in 1954 as a contributory health scheme to provide comprehensive medical care to the central government employees and their families.  Currently, there are approximately 5.5 million beneficiaries. The staff contributes a nominal amount (ranging from Rs 30 to Rs 300 per month) from their salaries.  It provides service through following categories of systems:-  Allopathic  Homeopathic  Indian System of Medicines
  • 20. CGHS Beneficiaries Besides Central Government employees, the scheme also provides services to:  Members and Ex-members of Parliament  Judges of the Supreme Court and High Court (sitting and retired)  Freedom Fighters  Central Government Pensioners, Employees of Autonomous bodies  Ex-Governors and Ex-Vice-Presidents of India
  • 21. CGHS Facilities The benefit package includes both outpatient care and hospitalisation. The medical facilities are provided through Wellness Centres and polyclinics.  248 Allopathic dispensaries  19 polyclinics  78 Ayush dispensary/units  3 Yoga Centres  65 Laboratories  17 Dental Units  Also uses the facilities of the government and approved private hospitals to provide inpatient care and reimburses the expenses to the patient.
  • 22. CGHS - Problems  Equity – In a country where the government spends about 1.1% of the GDP on healthcare, it is unacceptable that a sizable amount of this goes to the better-off section of the society.  Demand side moral hazard – It is noted that more than 80% of the hospitalised patients are self-referred. It appears that most patients prefer to bypass the dispensaries and directly avail of specialist services.  Poor quality care – There are regular complaints about long waiting periods, inadequate supply of medicines and equipment and unhygienic conditions  High out-of-pocket expenditure
  • 23. Employees' State Insurance Scheme  Established in 1948, the Employees‟ State Insurance Scheme (ESIS) is an insurance system, which provides both cash and medical benefits. It was conceived as a compulsory social security benefit for workers in the formal sector.  The Employees‟ State Insurance Corporation (ESIC) manages the scheme and is a corporate semigovernment body headed by the Union Minister of Labour as Chairman and a Director General as the chief executive.  Number of insured persons covered under the ESI Scheme reached 16 million in 2010-11.
  • 24. Employees' State Insurance Scheme  The Act compulsorily covers: (a) all power-using non-seasonal factories employing 10 or more persons; (b) all non-power-using factories employing 20 or more employees, and (c) service establishments like shops, hotels, restaurants, cinemas, road transport and newspapers.
  • 25. Employees' State Insurance Scheme  Act does not include employees of Indian navy, military or air force; or whose wages exceed Rs. 15000 or as prescribed by the Central Government.  To avail of the sickness benefit, the employee has to have worked for 78 days prior to the sickness. Similarly, to avail of the maternity benefit, the woman has to have worked for 70 days prior to the sickness.
  • 26. Employees' State Insurance Scheme Contribution :-  State Governments share 1/8th of expenditure on medical treatment and attendance (7/8 being borne by the ESIC).  Employees pay on an average 1.75% of the wages and employers contribute 4.75% of the wage bill. The employee who is getting daily wage of less than Rs. 70.00 shall be exempted from payment of contribution.
  • 27. Employees' State Insurance Scheme Benefits :- 1) Sickness Benefit:  At the rate of 50% of the daily average wage is given to the employee for a maximum period of 91 days in one year. In diseases like tuberculosis, leprosy, fracture, malignancy etc, the sickness benefits are extended to two year. 2) Maternity Benefit:  At the rate of full wages for a period of 84 days in case of pregnancy and 6 weeks in case of miscarriage or MTP.
  • 28. Employees' State Insurance Scheme 3) Disablement Benefit :-  In cash, 72% of the wages is given to the temporary disabled person during the period of disablement. In case of permanent disablement, the payment is made at the same rate for the whole of his life in the form of pension. 4) Dependent Benefit :-  Widow or adopted child (up to the age of 18 years or till the daughter get married) of the diseased person gets the cash payment may be in the form of pension.
  • 29. Employees' State Insurance Scheme 5) Funeral Benefit :-  An amount of Rs. 5000 is paid to the eldest surviving member for the funeral purpose. 6) Medical Benefit :-  All member of the worker gets the medical cover including the Outdoor treatment, domiciliary treatment facilities by the panel system, specialist services, ambulance services, and indoor services.
  • 30. ESIS-Problems  Less than half the enrolees use the ESIS facilities because of the low quality of care  Many of the staff are not aware of the benefits. The employers also do not disseminate the information to their staff.  There is duality of control, with both the ESIC and the State governments trying to establish superiority  Poor penetration in rural areas
  • 31. Universal Health Insurance Scheme  Government of India launched the Universal Health Insurance Scheme (UHIS) in 2003  Standard Mediclaim product with an annual cover of Rs 30,000 for a family  Scheme marketed by the public sector insurance companies and was targeted at the BPL population. Reasons for failure:  Lack of willingness of Insurers/other stake holders  Improper identification system of beneficiaries  Inadequate coverage / benefits Now superseded by RSBY
  • 32. Rashtriya Swasthya Bima Yojana (RSBY)  The RSBY is a project under the Ministry of Labour and Employment  Started in April, 2008 and has been implemented in 25 states including Haryana  Scheme will be implemented by the State Government in a phased manner and entire country is to be covered in 2012-13.  Total sum insured of Rs 30,000 per BPL family on a family floater basis  A total of 23 million families have been enrolled as of February 2011
  • 33. Rashtriya Swasthya Bima Yojana (RSBY)  Pre-existing diseases to be covered from day 1  Coverage of health services related to OPD and hospitalization  Cashless coverage of all eligible health services in public as well private hospitals  Provision of Smart Card  Provision for transport allowance (actual with limit of Rs.100 per visit) but subject to an annual ceiling of Rs.1000
  • 34. FUNDING-RSBY  Contribution by GOI : 75% of the estimated annual premium of Rs 750, subject to a maximum of Rs. 565 per family  Contribution by the State Governments: 25% of the annual premium and any additional premium beyond Rs 750  Every "below poverty line" (BPL) family holding a yellow ration card pays Rs 30 registration fee to get a biometric-enabled smart card containing their fingerprints and photographs.  Administrative cost to be borne by the State Government  Cost of Smart Card to be borne by the Central Government. An additional amount of Rs.60 per beneficiary would be available for this purpose
  • 35. RSBY- Facts  In the Union Budget for 2012-13, the government made a total allocation of about 1100 crores towards RSBY.  Although meant to cover the entire BPL population,(about 37.2 per cent of the total Indian population according to the Tendulkar committee estimates) it had enrolled only around 10 per cent of the Indian population by March 31, 2011.  The scheme has won plaudits from the World Bank, the UN and the ILO as one of the world's best health insurance schemes. Germany has shown interest in adopting the smart card based model for revamping its own social security system.
  • 37. Private Health Insurance  A voluntary health insurance wherein people can enroll and purchase the insurance product of their liking, paying a risk- rated premium  Both public and private insurance companies market a variety of health insurance products  Out of these „Mediclaim‟ is the most sold product
  • 38. Mediclaim  Introduced in 1986  A voluntary health insurance scheme offered by the public sector (and since 1999 the private sector) health insurance companies  Anybody (3 months to 80 years) who can afford the risk-rated premium is eligible to join the scheme  The premium depends on the age, risk and the benefit package opted for  The subscribers are usually the middle and upper class, especially as there is a tax benefit in subscribing
  • 39. Insurance Regulatory Development Authority (IRDA)  A regulatory body, controlled by the Indian Government, governing insurance companies across India  The headquarters of IRDA -located at Hyderabad Aims:  To protect the interests of the policyholders, and  To regulate, promote and ensure orderly growth of the insurance industry
  • 40. Third Party Administrator (TPA) A TPA is a specialized health service provider, introduced by the IRDA, rendering the following broad-spectrum services:  Networking with hospitals  Facilitating hospitalization processes  Claim processing and settlement
  • 41. Claim Disputes/Grievances  Ombudsman is a special court constituted under IRDA for addressing grievances associated with Insurance claims.  The claimant can approach the Ombudsman for resolving claim issues.
  • 42. Strengths of the Mediclaim policy  The only voluntary health insurance policy in the country currently, with about > 8 million subscribers  Provides protection against catastrophic health expenditure  Easily available in most insurance companies  Is being modified to make it customer friendly
  • 43. Private Health Insurance: Issues & challenges Faced by Insurance Companies Key Issues Description  Limited Influence  Limited healthcare delivery network over healthcare delivery  Insufficient data on consumers & disease mechanism patterns, absence of standardization of  High claim ratio healthcare costs & significant levels of frauds leading to under-pricing of insurance products and higher value of claims  Limited product  Insufficient data on Indian consumers & development disease patterns and limited control of healthcare delivery network resulting in limited product and pricing innovation
  • 44. Private Health Insurance: Issues & challenges Faced by TPAs Key Issues Description  Limited influence Varying treatment costs across providers due over healthcare to limited bargaining power delivery network  Lack of standardization & accreditation in most healthcare facilities leading to difficulty in  Funding support judging the authenticity of procedures & costs  Limited funding support from the Insurance company impacting the claims disbursement time  Delays and issues in claims processing leading to negative perceptions by insurance companies & consumers about TPAs
  • 45. Private Health Insurance: Issues & challenges Faced by Healthcare Providers Key Issues Description  Pricing demands  Lack of standardization and from Insurance accreditation norms for healthcare companies resulting in unreasonable pricing demands by insurance companies  Lack of  Low health insurance penetration and affordability lack of affordability of the consumers in the cities and rural areas to support the investment in healthcare infrastructure in these areas
  • 47. Community health insurance “any not-for-profit insurance scheme aimed primarily at the informal sector and formed on the basis of a collective pooling of health risks, and in which the members participate in its management.”  While the CHI movement is vibrant in Africa, it is slowly picking up momentum in India.
  • 48. Characteristics of CHI in India  Initiated by NGOs / CBOs  Mainly to improve access to health care  The members varies from 1000+ to more than 2 million
  • 49. Models of CHI 3 basic models of CHI  Provider model (Direct Model)  Insurer model (Mutual Model)  Linked model
  • 50. Provider (Direct )model Hospital Community
  • 51. Insurer (Mutual) model NGO Hospital Community
  • 52. Linked model NGO Hospital Community
  • 53. Yeshasvini  Organized by the Yeshasvini Trust, Karnataka  Eligibility – Cooperative farmers and their families  Premium – Rs 120 + 30 per person per year  Benefit – any surgery up to Rs 1 lakh per hospitalization and 2 lakh per patient per year  Providers – Empanelled hospital > 300  Administration by TPAs
  • 54. Karuna Trust  Initiated in September 2002  Organized by Karuna Trust, Karnataka  Eligibility – BPL families in talukas where Karuna trust works  Premium – Rs 20 per person per year  Benefit – hospitalization expenses upto Rs 2500; loss of wages upto Rs 1500; payment to the doctors upto Rs 1500  Providers – Only government hospitals  First year > 60,000 members, now around 100,000.
  • 55. Performance of CHI  Able to reach out to the weaker sections of society  Provide some form of health security  Has improved access to health care  Has protected households, but only partially  Has not improved quality of care for the patient  Many of them require external subsidies
  • 56. CHI- Conclusions  An useful tool to improve access to health care and protect families from impoverishment  But there are some pre-conditions that need to be met –  Trustworthy organization  Good quality providers  Community with some means  Managerial skills
  • 57. Health Insurance – The Way Ahead  Creating awareness on Rights & Responsibilities  Standardization of Cost  TPAs  Health Providers  Increased Tax benefit  Removal of Service Tax  Gradation of Health service providers  Pool for Senior Citizen
  • 58. Health Insurance – The Way Ahead  Renewability / Portability  Compulsory Health Benefits for organized sector  Government role on mass healthcare initiatives
  • 59. Pillars of change and Enablers for growth Pillars of Change Enablers for Growth Outcome • Consumer • Product & Pricing • Healthy Awareness Innovation Vibrant • Standardization • Technology India of Health care costs • Channel Innovation and Accreditation norms • Healthcare Infrastructure • Data & Information Exchange
  • 60. References  Planning and Implementing Health Insurance Programmes in India; Dr. N. Devadasan; Institute of Public Health Bangalore, India,In collaboration with the WHO India Country Office: Website www.iphindia.org Email: mail@iphindia.org  Central Government Health Scheme mohfw.nic.in/cghs.htm  Employees State Insurance Scheme of India. Citizens Charter. New Delhi: Employees State Insurance Corporation; 2006(cited March 1, 2010). p.1-8. Available from: http://esic.nic.in/citizen_charter.htm  http://en.wikipedia.org/wiki/Employees%27_State_Insurance
  • 61. References  Issues in Micro Health Insurance in India – Role of Government : India Insurance ifmr.ac.in/cmf/internship/june0508nishantjain.ppt  Department of economic and statistical analysis,Haryana 2010; publication no. 946 ;deptt. website: www.esaharyana.gov.in  Government of Haryana , economic survey of Haryana, 2009- 2010;issued by: department of economic and statistical analysis Haryana  http://www.medindia.net/slideshow/health-insurance.asp#4  http://en.wikipedia.org/wiki/Rashtriya_Swasthya_Bima_Yojana
  • 62. THANK

Editor's Notes

  1. A union of interests, purposes or sympathies among members of a group. horizontal equity is the idea that people with a similar ability to pay taxes should pay the same or similar amounts. Vertical equity usually refers to the idea that people with a greater ability to pay taxes should pay more
  2. A government appointee who investigates complaints by private persons against the government