…………… 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?

2

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

6

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

8

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?

9

CHARACTERISTICS OF UNORGANIZED SECTOR WORKERS

• Poor• Illiterate• Migratory

10

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

11

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.

12

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

13

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

15

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

SO

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

119

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.

19

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.

20

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.

21

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

22

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.

23

ENROLMENT KIT

FIRST RECIPIENT OF SMART CARDVillage: Chappar; District: Yamunanagar; State: Haryana

•

25

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

28

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

35

……….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.

51

……….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.”

53

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”

54

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

55

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.

57

……….we haven’t arrived as yet but the journey so far has been extremely enjoyable.