Revamping of Rashtriya
Swasthya Bima Yojana to launch Universal Health Assurance Scheme in India:
Lessons from the France State Health Care System
ONKAR SINGH MEENA
World Health Organization Report 2010
states that 150 million people each year suffer financial hardship due to out
of pocket expenditure on health and 100 million annually are pushed into
poverty as a result. “About 44.5 percent of Private Expenditure on health in
the world comes from out of pocket expenditure which is 86 % estimated for
India. Health Expenditure in the world is 10.1 % of GDP as per WHO reports of
2012. Health Statistics for India shows very high Private and Out of pocket
expenses. There is need to raise additional funds for health, reduce financial
barriers and increase financial risk protection through prepayment and pooling,
use the available funds more equitably and efficiently. Private Prepaid Plan
contributes only 4.7 % of the total private expenditure on health in India
which is very low compared to European countries” (1)
Comparative health statistics of France and
India is provided in Table below:-
Indicator
|
France
|
India
|
Population (in million as in 2011)
|
63.9
|
1240
|
Total Fertility Rate per woman
|
1.98
|
2.51
|
Population below 15 years of age
|
18.26%
|
29.43 %
|
Population above 60 years age
|
23.82 %
|
8.1 %
|
Crude Birth Rate per 1000
|
12.4
|
20.7
|
Crude Death Rate
|
8.7
|
7.9
|
Per Capita Government Expenditure on
health (PPP Int $)
|
3135
|
43.8
|
Per capita expenditure on health (PPP,
Int $)
|
4128
|
156.9
|
Private Pre Paid Plan as % of total
health expenditure
|
59.7
|
4.7
|
Out of pocket expenditure as % of
Private Expenditure on health
|
32.1
|
86
|
Government expenditure on health as %
of total expenditure on health
|
77
|
33.1
|
Health Expenditure as % of GDP
|
17.8
|
4.1
|
Health Expenditure as % of State
Budget
|
15.9
|
9.7
|
Physicians per 10000 population
|
34.47
|
6.49
|
Midwife and Nursing per 10000
population
|
3.06
|
9.96
|
Public Expenditure on general
medicines
|
35 to 65 %
|
22.1 %
|
It is clear from the health statistics
that Indian health care system depends on private health financing, most out of
pocket expenditure on medical treatment, medicines as well as social security
compared to France where most of the health finance comes from Public
expenditure and prepaid plans.
2. France Health Care System (2)
World Health Organization (WHO)
compared different health care systems in the world and came up with the
findings that the French Health Care System is one of the best in terms of affordability,
accessibility, sustainability and universal acceptance by the people. Health
Care in France is characterized by judicious mix of Public and Private health
care providers under effective regulations on uniform treatment rates fixed
annually by Health care Providers and the State, freedom of choice to select
providers and efficient National Health Insurance funded from Public finances
and contributory statutory health insurance and volunteer health insurance
schemes implemented in tandem with the State Health Systems. There is system of
powerful government role in assuring universal coverage and regulating the
health system.
2.1
The Medical Care Institutional Framework in France
1. General Practitioners / physicians
free to work in Clinique or Public facility.
2. Specialists and Public Hospitals
providing high end treatment at the approved rates. Private Hospitals can
charge uniform rates as per package.
3. Network of Centres for Health
check-ups and occupational health services in unorganized enterprises.
2.2
Basic Health Care System in France provides:-
·
financial coverage for comprehensive services ranging from
inpatient hospital care to outpatient services, maternity care, prescription
drugs (including homeopathic products),thermal cures in spas, long-term care,
cash benefits and, to a lesser extent, dental and vision care.
·
As a general rule, French patients pay the full fees
directly to health care providers and subsequently obtain partial or more
rarely full reimbursement from their health insurance funds. The amounts
reimbursed to patients under French national health insurance are calculated on
the basis of negotiated rates (uniform rates approved by the State) minus a
copayment, depending on the kind of service.
1. 2.3 Statutory Health Insurance schemes and
Universal Health Care (5) under Social security protection has three
statutory health insurance namely General National Health Insurance
Scheme for salaried workers covers 80 of the Population, Health Insurance
Scheme for farmers, administrative personnel in agriculture and their
salaried workers covers 9 % of the Population, Health Insurance Scheme for
Self employed covers 6 % of the population and Universal Health Insurance
(CMU Protection) for unemployed, poor households below threshold household
income levels. At present those below 9534 Euro per annum are entitled for
free basic health care insurance. Threshold level is determined as per the
size of the family and ranges between 8593 Euro for one member household to
18045 Euro for four members above 16 years of age. Children are included in
their parent’s card. The threshold household income levels are decided by
Government each year.
2. Social Security Systems of Public
funds, as discussed above, pays 70 % of the Official GP fees and 65 % of the
prescribed medicines in France. Top Up Health Insurance or Volunteer Health
Insurance Schemes at state determined rates of premium can be obtained to
take care of rest of the health expenditure. These rates are range from Euro
100 up to 16 years of age to Euro 500 above 60 years of age. The Universal
Health Coverage Act 1999 has launched Universal Health Coverage Scheme to
those who are unemployed, poor having income below threshold household income
level (called as Couverture Maladie Universelle or CMU (3) and implemented by
Public Health Authority (Caisse Primarie d’Assuarnce Maladie or CPAM(5,6). CMU
is the contributory health insurance with premium calculated at the rate of 8
% of the income of household above threshold income level.
|
2.3 Carte Vitae2 or Health Card (4): - A Smart
card having electronic chip and photo is issued to all individuals above 16
years of age by the Insurance providers under the administrative arrangements
of CPAM or Public Health Authority. This card can be used to access health care
in any of the Public or Private health care providers and reimbursements of the
payments are authorized on the card electronically. Health Card contains all
personal details, medical records in the chip. This card can be used to access
services at GP, Specialists, Public Hospitals or Private Hospitals, Diagnostics
and Pharmacy through the strong IT network available uniformly. In case of CMU
Carte Vitae (5) no payments are required to be made as these are credited to
health care providers directly and in case of VHI and other Private Health
Insurance Schemes.
3.
Critical analysis of the France Health Care System:-
Strengths
a.
State regulations of
cost of treatment rates, pharmacy and medical care both OPD and IPD through
participatory negotiations accepted by all health care providers. No difference
of health care standards in private as well as public facilities.
b.
Equity in the standards
of treatment and rates irrespective of social status, wealth and employment
category. All the citizens are provided the same health care uniformly.
c.
High public financing
under social security protection.
d.
Integrated IT support
network and service providers network.
e.
Direct payment by the
patient and freedom of choice of selection.
f.
Efficiency in service
delivery and value of money.
Limitations
a. High
rates of contribution to premium for top up health insurances.
b. High
Public finances increasing burden on the State exchequer.
c. Extra
Billing for tertiary care and specialists fees for diseases not included in 32
identified in the basic health care thereby increasing Out of pocket expenses.
d. Resistance
by Physicians and pharmacy against official rates fixed by the state.
e. Private
Health Insurance requirement for some of the health care not included in CMU,
VHI and Basic Health Care Systems.
In general, the health
care system of France has high level of satisfaction of the France people and
rated as the one of the best systems in Europe and undoubtedly the ranked one
of the best in the world.
4. Scope of revamping
the Rashtriya Swasthya Bima Yojana (RSBY) in the context of France Health Care
System
RSBY
scheme launched in 2008 was initially designed to target only the Below Poverty
Line (BPL) households, but has recently been expanded to cover a number of
non-BPL categories of informal sector workers, including street vendors,
domestic workers, beedi workers, building and construction workers, and most
importantly the workers who have worked for more than 15 days under MGNREGS.
Government of India and the State Governments are co-financing the premium cost
for enrolled beneficiaries. The program has the target to cover 70 million (7) households
by the end of the Twelfth Five Year Plan (2012-17). Its service delivery model
– demand financing, freedom of choice among accredited Government and Private
hospitals, and cashless service reimbursable to provider on a pre-determined
package price basis, could become a strong pillar for the universal health care
system.
The
beneficiaries under RSBY are entitled to hospitalization coverage up to Rs.
30,000/- for most of the diseases that require hospitalization. The government
has even fixed the package rates for the hospitals for a large number of
interventions. Pre-existing conditions are covered from day one and there is no
age limit. The coverage extends to five members of the family which includes
the head of household, spouse and up to three dependents. As of now the scheme
is operational in 398 districts of 25 states. There are 10116 hospitals
empanelled across these states out of which 5941 are private sector hospitals
and 4175 are public sector hospitals. During FY 2013-14 approximately 25
million families were in possession of active RSBY cards (8).
4.1
RSBY caters to only one fifth of the population in India and provides only IPD
health care of select packages which is limited to only Rs 30000 per annum. The
scheme failed to achieve the outcomes. There is need to revamp the scheme to
make it universal to health coverage. Some of the limitations/ weaknesses of
RSBY are as follows:-
1. It
covers only 20 % of the population.
2. Sub
optimal coverage of health cost as only IPD up to Rs 30000 per family of 5 is
reimbursed. Tertiary care and long duration treatment not covered.
3. IT plate form is not integrated with all
health care providers, all public hospitals providing basic free treatment,
pharmacy and other medical facilities as a result of which its use is limited.
4. Poor
accessibility and geographical distribution of facilities.
5. Lack
of transparency and vigilance on use.
6. Lack
of efficiency
7. Not
inclusive.
8. No
convergence with NRHM and other health programmes.
9. Multiple
Health Insurance schemes with different standards of treatment and rates and
multiple implementing authorities make the implementation of these schemes and
efficiency very poor.
4.2
Taking lessons from the France all the benefits under National Rural Health
Mission, National Public Health Programmes, and Social Security protection
schemes for unorganized sectors, different social groups and employees can be
integrated through the Universal Health Coverage Cards on the same IT network.
Basic health care under NRHM and other health schemes, social security
protection can be provided to users in any of the health care provider across
the country using the Universal Health Card on the integrated IT network and
top up package can be paid from the Statutory Health Insurance schemes. All the
health schemes for employees by Central Government and State Governments,
contributory health Insurance by employers, social security health schemes can
be merged with the revamped RSBY and implemented through integrated system.
Patient will access the health care provider of choice, whether private or
public and will not be required to pay within the entitled basic health care
package available under NRHM and other health programmes and access health
insurance treatment costs to get the packages not covered under the basic
health programmes. Premium of BPL and other weaker sections below threshold
income level to be determined by the State Governments can be paid by the
Central and State Government as per the existing funding pattern and those for
employees can be paid from the contribution from the employer and the employee.
Standard of treatment packages for all health insurance schemes in the country
can be fixed uniformly for the States irrespective of income levels so as to
ensure equity and equal opportunity to all. Treatment package must include OPD
as well as IPD packages. Public Health Authority integrating all the Public
social security and health schemes can be constituted to implement the scheme.
References:
1.
Internet Source Official website of World Health Organisation, World Health
Statistics 2014 at http://www.who.int/gho/countries/fra/en/
This data
extract has been generated by the Global Health Observatory of the World Health
Organization. The data was extracted on
2014-07-30 14:03:20.0.
2. Internet
Source “The French Health Care System” retrieved on 1st August 2014
at http://about-france.com/health-care.htm
3.
Internet source Official website of France Government http://www.ameli.fr/assures/soins-et-remboursements/cmu-et-complementaires-sante/cmu-complementaire/une-complementaire-sante-gratuite.php
retrieved on 1st August 2014.
5.
Internet source Official website of France Government on Social and health
retrieved on 1st August 2014 at http://vosdroits.service-public.fr/particuliers/N418.xhtml
6. World
Health Organisation, Health Systems In Transition (HiT): France 2010 Report
retrieved from http://www.civitas.org.uk/nhs/download/france.pdf
on 1st August 2014.
7. Planning commission document
retrieved from http://planningcommission.nic.in/news/pre_pov2307.pdf
8. Rashtriya Swasthya Bima Yojana Operational
Manual 2014 page 9-13 retrieved on 1st August 2014 from Official
website of RSBY, http://rsby.gov.in/Docs/Guidelines%20for%20Revamp%20of%20RSBY%20-Operational%20Manual%20for%20Phase%20I%20%28Released%20on%2016th%20July%202014%29.pdf.
