Moving Towards Universal Coverage in India

Disclaimer: The views expressed in this paper/presentation are the views

of the author and do not necessarily reflect the views or policies of the
Asian Development Bank (ADB), or its Board of Governors, or the
governments they represent. ADB does not guarantee the accuracy of
the data included in this paper and accepts no responsibility for any
consequence of their use. Terminology used may not necessarily be
consistent with ADB official terms.

www.rsby.gov.in

Dr. Nishant Jain

10.10.2016

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Role of the Government in India

Government is both financier and Service Provider in Health
Government spends only 1% of GDP on Health
Government is suppose to provide free health care to the
population with their own infrastructure at different levels
However, the ground level situation is very different
People spend a lot even when they are hospitalised in a Government
hospital
Though the facilities per se are free but a lot of these expenditure is
related to the medicines, diagnostic tests, food, transportation etc.

To take care of these expenditures people often have to borrow

money or sell assets
7.6% of households fall BPL due to healthcare payments
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Rationale for Insurance Mechanism

Supply side mechanism alone is not able to solve issues related
to health care delivery in India
Countries across the world are moving towards a mix of supply
side and demand side financing for health
Private sector can be engaged more effectively through this
system
Even public sector can be engaged more effectively through
purchasing of services and provision of performance based
incentives
Quality of services can be improved in absence of legal systems
as the purchaser can push for quality
Beneficiary gets power to choose the hospital to get the
treatment and money follows the beneficiary
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Birth of RSBY
Why RSBY was designed such a way?
Design a scheme based on the characteristics of the target segment
Poor, Largely illiterate, Often migrant in nature

It was doubly risky as none of the Govt. funded smart card

initiative or health insurance had worked well in India in the past
Scheme was not forced on the State Governments it was
marketed to them and it took lot of time and effort
It was decided to start the scheme in few districts in few States
but the larger picture was kept in mind
Financial planning was done not only for the first stage but
projections were prepared for the full scaled up model

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 Benefits

What is RSBY

Cover for Hospitalisation Expenses of Rs. 30,000/- (US$ 500 ) per family
per annum on a family floater basis (Upto five family members)
All hospitalisations are covered and rates are fixed in advance for 1500
surgical packages including Maternity & Newborn Care
Cover for Day Care Surgeries
All Pre-existing Diseases to be covered
Pre and Post hospitalisation Expenses
Transportation Allowance

Sources of funding for program

Rs. 30 (US$ 0.5) per family per year from Beneficiaries
100% of Premium shared between Central and State Government

Both Public and Private providers can be empanelled

Beneficiary can get cashless treatment in empanelled hospital
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Main Processes Involved

State Government set up an independent nodal agency to
implement the scheme
Insurance Company is selected through an open tender
A list of targeted beneficiaries is prepared based on defined
criteria
Insurance Companies need to go the field and enroll
beneficiaries in the village after taking fingerprint and photo
A smart card is printed and given on the spot and a Government
representative authenticates it by his/ her smart card and fingerprint

A beneficiary can go to any public and private empanelled

hospital and get cashless treatment through smart card
Data flows every day from each hospital to the insurer and
Govt.
www.rsby.gov.in
Paperless claim settlement process for the hospitals
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RSBY Smart Card

Smart Card with embedded chip
which stores details:
Fingerprint and photographs
(up to five members)

Other details like Name,

Age, Gender, Relationship
etc. of up to five family
members

State

Block

Year of generation

Checksum

SS DD BB VVV YY 00000 #
District

Village

Serial No.

Unique relationship number

across country

Insurance Policy Details

Transaction Details
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Key transfer
Verification by FKO by
fingerprint and smart card

FKO
Card

RSBY
Card

Data of Beneficiary family

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Enrollment Station

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Innovative Use of Technology

RSBY uses different technologies to effective reach
its objectives
Biometric Technology for identification of
beneficiaries and reduce fraud
Smart Card technology to ensure that benefits
can be provided electronically even in cases
where there is no regular internet facility
available and provide portability of benefits
Web based services to ensure that data is
transferred securely and all the activities are
transparent
Mapping and GIS services to track
developments in the field on a regular basis
Mobile Technology for Outpatient Benefits
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Current Status of RSBY Implementation in India

RSBY Coverage
Round 1
Round 2
Round 3
Round 4
Round 5

www.rsby.gov.in

Cards issued App. 41.3 million

People enrolled Appr. 140
million
Number of People benefitted till
now Approx. 10.2 million
Number of Hospitals Empanelled
10,725
States and UT where Service
delivery has started Twenty One
Number of Insurance Companies
Involved Seventeen

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Benefits for Beneficiary in RSBY

Health is a state of
complete physical, mental
and social well-being
(WHO definition)

Improved access to Health

care

Reduction in OOPE

Physical
Improved Quality Care

Reduction in indebtedness

Beneficiary

Mental

Mental Security

Migrant workers Family is

covered

Scheme is working well

even in Naxalite districts

Social

Improved gender utilisation

Providing Social Identity

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Success So Far Improving Access

Improvement in access to Healthcare for targeted segment

In the worst conflict areas also RSBY has been able to
provide benefits to people
Access to health care RSBY enrolled families is higher
There is a marked improvement in utilisation by women in
the scheme (more than 60% usage by women in northern States)
Out of pocket expenditure for health is coming down (Six
times lesser OOPE for RSBY beneficiaries than non-RSBY)
State Governments are improving their BPL list because
RSBY is bringing out the discrepancy
Able to provide social identity to people

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Success So Far

Competition between Public and Private Hospitals

Increase in capacity of private hospitals

Setting up of Hospitals by Private sector in remote areas
Use of IT ensure that Insurance Company and Government
gets data daily from the Hospitals

Incentives for staff of public hospitals from Insurance money

Hospital retains the insurance money in the hospital and can be
used for the hospital by the hospital.

This data is analysed for patterns/ spikes and strong action taken
against errant hospitals

Cashless & paperless transaction for people

paperless claim process for hospitals

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Success So Far

Using Smart Card and Biometric technology successfully

for a social sector scheme at this large scale and thereby

Portability of Smart Card across India

Reducing Frauds/ errors

Improving targeting and
Stopping leakages
Migrant workers are now able to get benefit anywhere in India
(Split card)

Unique IDs are given to each RSBY empanelled hospital

Almost Real time data available from all over India
Standardised Templates and documents at Central level

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Results from latest Evaluation

Panel evaluation across four States
The median annual income for RSBY eligible households
was only INR 10,000 (USD 167)
Data showed that access to health care was substantially
higher in the case of RSBY enrolled families (60% more)
52 % of the RSBY households incurred OOPE on
cumulative hospitalization costs (median was Rs. 50/ USD 0.82)
In Non-RSBY households, 96% reported OOPE on
cumulative hospitalisation costs (median was INR 500/ USD 8.2)
The willingness to enroll in RSBY as expressed by RSBY
eligible households, by both enrolled and non-enrolled, was
very high (95%) across all the 4 States
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RSBY : Challenges
Policy Level
Issues

Low coverage limit Rs. 30,000 (USD 500)/ family/

year
Limit of 5 members in the family size
Use of old BPL list (2001) led to low enrolment

Implementation
Issues

Disjointed IT system
Issuance of Smart Card by Insurance Companies
led to issues in the field

Other
Challenges
www.rsby.gov.in

Absence of dedicated agency at National level

Lack of awareness about the scheme in various
districts
Frauds/ Abuse
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RSBY : Learning
IT Architecture
Centralised IT System Key to Success
Standardisation of Processes and documents across all states
Portability of schemes across states

Smart Card
Fool proof authentication in an offline environment

Other Learning
Evaluation studies found that hospitalization rate for RSBY
beneficiaries were higher and OOP were lower than non RSBY
Beneficiaries
Best mode for awareness was found to be inter personal
communication and use of health workers like ASHA and ANMs
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Next Generation Reforms

RSBY has shifted from Ministry of Labour and Employment
to Ministry of Health and Family Welfare from April 2015
RSBY will continue to be implemented in the existing form
till March 2017
Honble Prime Minister has announced that a New Health
Protection Scheme with a cover of Rs. 100,000 (USD
1,666) will be launched
The proposed scheme will replace RSBY and will also
converge various other Central Government funded health
insurance schemes
Proposed scheme will also provide a platform of
convergence with various State Government funded health
insurance schemes

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PROPOSED SCHEME
Proposed National Health Protection Scheme (NHPS) will be
launched from 01.04.2017
NHPS will be based on two core principles
Convergence
Holistic Approach
Scheme to provide a common platform for health protection/
insurance services to various Central Govt. and State Govt.
funded schemes
Dedicated National Health Authority (NHA) to be set up to
manage the proposed scheme
Policy direction to be given by MoHFW ; responsibility for
implementation lies with States / UTs
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PROPOSED SCHEME: SALIENT FEATURES

Target
Population

Benefit
Package

Convergence
Power

Power to Poor
Families

About 80 million poor and economically weak families (400 million persons)
Beneficiary identification based on deprivation and occupational criterion of
Socio Economic Caste Census database
A higher insurance coverage of Rs. 100,000 (USD 1,666) per family per year
for Secondary and Tertiary care procedures
Transport allowance
Covers Pre and Post hospitalization expenses
Additional cover of Rs. 30,000 (USD 500) per senior citizen

States and other central ministries can use this platform for their schemes
Flexibility to expand the scheme both vertically and horizontally by the States/
UTs
Co-branding between Central and State with the proposed scheme
No limit on family size for enrolment
Families have power to choose any empanelled private or public hospitals for
treatment

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PROPOSED SCHEME: SALIENT FEATURES

Preventive Care

Implementation
Model

Strengthening of
Public Health
Facilities

Platform for Non

Poor

Comprehensive
Approach to
Health care

Screening for hypertension, diabetes and cancers

Health and wellness check for beneficiaries above 35 years once in three
years

National Health Authority to be set up at National Level

States/ UTs to set up / identify State Health Authority
Scheme to be implemented through Insurance Company /
Public health care facilities to retain claim amount
Use of claim amount to improve infrastructure and as incentives to performers
Once stable, the platform will be opened for non-poor families
They will be allowed to pay full premium and join scheme in groups
Development of Referral systems
Real time monitoring through IT systems to prevent over hospitalisation, frauds,
abuses etc.
Quality based grading of Public and private health facilities will be explored

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NHPS : MAJOR CHALLENGES

Challenges in Convergence
11 States are implementing their own schemes with higher packages in addition to
RSBY
10 states who are implementing their own scheme (3 more States have announced
schemes)
Convergence of all these State schemes on NHPS IT Platform

Developing a Robust, flexible and interoperable IT Platform

IT system based on Aadhaar as far as possible
Alternate mechanisms to provide services to such persons who do not have Aadhaar
A system that is able to handle intermittent connectivity issues

Beneficiary Identification
Using SECC Data and filling out incomplete details
Techniques to be employed for field verification

Setting up of State Health Authority

23 Tackling issues of infrastructure, human resources, budget

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The Road Ahead

NHPS will be launched from 01.04.2017
This scheme will act as lever to
improve the functioning of public health facilities
Improve quality of care being provided

It will reduce fragmentation by converging various

schemes
It also aims to create linkage with primary care to
provide continuum of care

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Thank You
nishant.jain@giz.de

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