Some thoughts on turning around of RSBY in West Bengal

Some thoughts on Turning around of Rashtriya Swasthya Bima Yojana (RSBY) in West Bengal

 

1.     Introduction

Implementation of RSBY was shifted from Director ESI under Labour Department to Health & Family Welfare Department of West Bengal Government on 23^rd September 2013. The scheme is sponsored by Ministry of Labour & employment Government of India and State Budget in 75:25 sharing pattern for payment of premium. BPL and MGNREGA beneficiaries in all districts of West Bengal including Kolkata are covered under the scheme which assures cashless free treatment up to Rs 30000 per family in any of the enlisted 726 hospitals throughout West Bengal for the family of 5 members enrolled. Biometric smart card containing 64 Kb chips are used just like ATM cards to access the indoor services in the enrolled hospitals which are connected to online network and operates on common Transaction Software.

1.1 There were 56 lakhs families enrolled under the scheme in September 2013 insured under RSBY in 18 districts excluding Kolkata. Annual rates of premium were Rs 459 per family per annum in most of the districts and Rs 430 in few districts.

1.2 Free indoor treatment services were being provided through the network of 521 hospitals including 20 Government hospitals enlisted with the scheme. 97000 patients accessed free indoor treatment, mainly surgical interventions from March to September 2013, with monthly average of 14000 patients.

1.3 RSBY health insurance policy is renewed after 12 months at the same rates on three year rate agreement with the Insurance Companies subject to fulfilment of performance clauses of the agreement.

1.4 At district level one ADM in the District Administration implements the scheme assisted by Third Party Administrators (TPA) appointed by Insurance Companies and District Grievance Redressal Committee (DGRC) acts as arbitrator and authority to resolve public grievances. Enrolment of families and issue of RSBY smart cards online is done by the Field Key Officer (FKO) appointed by ADM through IT based network connected system having proper authentication. This is one of the best delivered services in public sector with strong IT plate form.

1.5 TPAs conduct medical audits of treated patients and action of de-empanelment of hospitals and new enlistment is done by them as per agreements. 

2.     Major initiatives and interventions in last one year to strengthen RSBY in West Bengal  

2.1 State Nodal Authority of RSBY set up wef 23^rd September 2013. In addition to erstwhile team of SNA transferred from ESI Directorate, dedicated medical audit teams under the Technical Officer (Senior West Bengal Health Service Cadre medical officer) were notified. There is Medical Audit team in each district headed by Dy CMOH-1 and comprises of specialists from surgery, gynaecology, orthopaedic and eye surgeon from the Government hospitals. System of medical audit by TPAs strengthened and accountability of health care providers improved.

2.2 Package rates of treatment were revised adding new packages for indoor as well as day care treatment. Now, there are more than 1460 packages of surgical and general medicine treatment compared to 1200 last year. Rates of all the packages have been revised and technical changes were made in the packages as per the current rates and treatment guidelines. Expert Committee comprising of Medical College Professors and Specialists examined all the packages and their recommendations accepted by the SNA and Insurance Companies. Now, the rates and packages are uniformly followed in all 726 hospitals in the State wef 1^st April 2014. These packages are lucrative to health care providers and cover all the treatment costs, thereby reducing out of pocket expenses. For example, General Medicine admission charges increased from Rs 500 per day to Rs 750 per day. Similarly, charges of ICU increased from Rs 1000 per day to Rs 1500. Most of the packages have been revised upwards. Number of cases of refusal to admission by hospitals decreased substantially and rate of hospitalisation has increased thereby ensuring access to card holders.

2.3 In terms of the Policy of the health & family welfare department, Government Hospitals from Medical College Hospitals to State General Hospitals were compulsorily enlisted under RSBY as health care providers. There are 104 Government hospitals under RSBY now and numbers of private hospitals have increased from 501 to 602 in last one year. RSBY helpdesk comprising of minimum 5 Rogi Sahayaks in secondary hospitals and 8 in Tertiary care hospitals have been supported from RSBY fund in Government hospitals facilitating admission & treatment of RSBY card holders. There has been sharp increase in treatment claims in Government Hospitals from merely Rs 1.8 Crores last year to Rs 14 Crores this year. Government hospitals have been allowed to retain this income from RSBY and utilise for the benefit of patient services in hospitals.

2.4 Rs 100 per patient each admission and maximum of Rs 1000 per annum is paid for transport allowance under the scheme. Extra Rs 200 per patient and maximum of Rs 2000 per annum has been allowed by SNA in Government hospitals wef 1^st April 2014.

2.5 DGRC were activated and District Level Implementation Committees were constituted for better service delivery and ownership of the scheme. Workshops at each district with block and municipal level functionaries, health care providers and TPAs were organised twice in the year. Regional workshops with hospitals were organised facilitating claim settlement and grievance Redressal thereby improving the hospitalisation. Fortnightly review meetings at SNA with Insurance Companies and TPAs have been effective in monitoring Programme Outcome.

2.6 Fresh competitive biddings were conducted in 11 districts last year for selection of Insurance Companies. Premium rates came down to Rs 185 to Rs 245 per family per annum. This provided annual savings of Rs 103 Crores each year due to low premium rates. This is in addition to increase in free treatment reimbursement due to better access and revision of packages. Enrolment of families completed in record three months from January to March 2014. RSBY cards with female as head of family were issued for the first time in any State in the country. West Bengal has 60.16 lakhs live smart cards as on date. This is the highest number of cards in any state in the country.

3.     Achievements and outcomes 

3.1 These interventions have contributed in improving the access and outcome of the RSBY programme in West Bengal in last one year. Enrolment increased by four lakhs and number of lives insured increased by 23 lakhs. There are 209 lakhs persons insured under RSBY in West Bengal.

3.2 Total 3.10 lakhs patients availed free indoor treatment in enlisted hospitals in last one year. Claims of treatment of Rs 210 Crores were generated during the period. There has been increase in rate of hospitalisation per month and substantial decrease in rates of premium.

3.3 Network of enlisted hospitals widened and introduction of Government Hospitals improved access to quality health care. This has also benefitted these hospitals by ensuring sustained revenue for maintenance of patient services. It is projected that at least Rs 20 Crores will be generated by Government hospitals in the current year which will help them financially. Helpdesk in all hospitals will directly helps then patient in these hospitals.

3.4 Projections on outcome and financial benefits are depicted in the table below :- 

Trends of Patient hospitalisation and benefits under RSBY in West Bengal in 2014-15
Number of Patients hospitalised and got free indoor treatment from Feb to April 2014	64850
Total Premium liability to be paid (in Rs lakhs)	4590
Per month Premium in Rs lakhs	2295
Total value of free treatment in Rs lakhs	3674
Per month benefits (in Rs lakhs)	1837
Net savings per month in Rs lakhs	-458
Total savings in Rs lakhs	-916
Number of Patients hospitalised and got free indoor treatment from April to August 2014	147150
Total Premium liability to be paid (in Rs lakhs)	5400
Per month Premium in Rs lakhs	1080
Total value of free treatment in Rs lakhs	9726
Per month benefits (in Rs lakhs)	1945.2
Net savings per month in Rs lakhs from April to August 2014	865.2
Total savings in Rs lakhs from April to August 2014	4326
Annual savings projected at current trends in Rs lakhs	10382.4
Annual Premium liability projected in Rs lakhs	12960
Annual free treatment projected at current trend in Rs lakhs	23342
Current trend of free indoor treatment per month in numbers	29430
Annual free indoor treatment projected at current trend in numbers	353160
Net annual free treatment cost with 94 % claim settlement in Rs lakhs	21942
Net annual savings to the State in current year with these projections in Rs lakhs	8982

 Conclusion:

RSBY performance has substantially improved in last one year in West Bengal, which has been appreciated by MoLE. Improvement in quality of outcome, reduction of cost of services and net benefits to the BPL and MGNREGA families under RSBY is West Bengal can be easily understood from the facts depicted herein. There is lot of scope to take it forward and improve the outcomes.

Revamping of Rashtriya Swasthya Bima Yojana to launch Universal Health Assurance Scheme in India: Lessons from the France State Health Care System

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 %

 Source : World Health Organisation, Health Statistics 2014 retrieved from www.who.int

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 1^st 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.

4. Internet Source http://www.ameli.fr/index.php retrieved on 1st August 2014.

5. Internet source Official website of France Government on Social and health retrieved on 1^st 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 1^st 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.

New assignment as Secretary to State Government after working as District Magistrate in Nadia and Burdwan.

State Govt posted me as Secretary in Health department yesterday. After getting supertime scale of IAS I was promoted to Secretary in January 2013. It's pride to get status as Secretary to the State Govt., more challenges and opportunities to serve the people.
It has been wonderful experience to work in the field as ADM in Coochbehar and Hooghly from 2001 to 2006. Thereafter District Magistrate Nadia from October 2006 to March 2010 and Burdwan from March 2010 to August 2013, completing 82 months uninterrupted. I feel satisfied about my assignments in the field as District Officer. Intensive touring, interaction with cross section of society and adoptive innovative approaches has been very helpful to give me great satisfaction. I sincerely thank all those associated, colleagues and general public for their love, affection and encouragement.
Team Burdwan blog title is changed now onwards but team spirit will always remain.