Presentation is a case about cutting the risk fragmentation and having a universal pool for Health Insurance as one of the tools for achieving UHC in India.

1. Universal Health Coverage and
Role of Health Insurance
A CASE STUDY FROM INDIA

2. Universal health coverage (UHC)
Described by the Director-General of the
World Health Organization (WHO), Margaret
Chan, as ‘the most powerful concept that
public health has to offer’, Universal health
coverage (UHC) has risen to the top of the
global health agenda. At its core, UHC is about
the right to health.
UHC means that all people get the treatment
they need without fear of falling into
poverty.
Universal health coverage (UHC) has the
potential to transform the lives of millions of
people by bringing life-saving health care to
those who need it most.
This requires a strong, efficient, well-run health system which is robust and responsive.

3. Three Dimensions to consider - UHC

4. Health Financing & UHC goals
Service
Delivery
Revenue
Raising
Pooling
Purchasing
Benefits
Stewardship/
Governance/
Oversight
Health Financing within the overall health system
Quality
Financial
protection
and equity
in finance
Utilization
relative to
need
Transparency
accountability
Efficiency
Equity in
Resource
Distribution
UHC Intermediate Objectives Final Coverage Goals
Creating
Resources

5. Revenue Raising
Objectives
Service
Delivery
Revenue
Raising
Pooling
Purchasing
Benefits
Stewardship/
Governance/
Oversight
Creating
Resources
Guiding
Objectives for
Revenue Raising
Policy
Raise adequate
revenues in order
to make progress
for UHC
Move towards
a predominant
reliance on
public source
Equity in Finance.
Make sure the
financial burden is
shared fairly across
society
Ensure stable
and predictable
flow of funds to
health sector

6. Earmarking
Earmarking funds for the health sector
iS an effort to increase and stabilize
levels of public funding, although the
evidence is mixed about its
effectiveness due to, offset by reduced
discretionary allocations during the
budget process.
Analysis has shown that what is most
important to increase public funding
for health, is that it is a political
priority for the government, rather
than measures such as earmarking.

7. Pooling
Service
Delivery
Revenue
Raising
Pooling
Purchasing
Benefits
Stewardship/
Governance/
Oversight
Creating
Resources

8. Purchasing
Health systems need to increasingly purchase
health services in a strategic way, for progress
to be made towards UHC.
This means allocating and spending funds
based on information about provider
performance, as well as the health needs of
the population they serve.
Service
Delivery
Revenue
Raising
Pooling
Purchasing
Benefits
Stewardship/
Governance/
Oversight
Creating
Resources

9. Purchaser Provider Split
The primary motivation for introducing
PPS is the concern that strategic
purchasing is very difficult to do when
the same organization pays for and
delivers health services.
This is the case in many countries
where the Ministry of Health plays
both roles.
Efficiency and quality improvements in
service delivery can be made by
separating the two functions and
having an agency dedicated to
purchasing services.

10. Financial Protection ?

11. Trends in Out of Pocket Spending on Health in
India, 1987-2004Source:MahalAetal.;2011
Expenditure Category/Year
Urban Population Rural Population
Poorest 20% Richest 20% Poorest 20% Richest 20%
Outpatient Expenditure/visit
(INR)
1987 58 110 60 96
1996 126 252 121 227
2004 231 482 213 338
Inpatient Expenditure/ visit
(INR)
1987 801 1781 653 1059
1996 864 8182 1052 5305
2004 4705 16910 4071 8375
Per Capita Expenditure(INR)
1987 1000 4532 760 1497
1996 2848 12624 2093 6744
2004 4967 24676 2997 10926

12. How much spending is
"adequate"
Further analysis in 2015 updated
these estimates to $86 per capita,
stressing more clearly than
previous estimates that this is the
amount which governments need
to spend.
The analysis also noted that
countries would find it difficult to
get close to universal health
coverage, if public spending on
health is less than 4-5% of GDP.

13. How much do countries rely on public
revenue sources?

14. Catastrophic and Impoverishing
payments
Catastrophic payments are greater than a given proportion of total household
expenditure (or income); Impoverishing payments are when a household is
pushed below, or further below, the poverty line.

15. Poverty Estimates – Planning commission
India 2013
For 2011-12, for rural areas the national poverty line using the Tendulkar methodology is
estimated at Rs. 816 per capita per month and Rs. 1,000 per capita per month in urban areas.
Thus, for a family of five, the all India poverty line in terms of consumption expenditure would
amount to about Rs. 4,080 per month in rural areas and Rs. 5,000 per month in urban areas.
These poverty lines would vary from State to State because of inter-state price differentials.

16. Or is it ?

17. The National Rural Health Mission (NRHM) launched by
the Government of India in 2005 seeks to provide
accessible, affordable and quality health care to the rural
population, especially the most vulnerable.
Despite significant progress especially since the launch of
NRHM, challenges remain:
The availability of health care services provided by the
public and private sectors taken together is inadequate;
The quality of healthcare services varies considerably in
both the public and private sector as regulatory standards
for public and private hospitals are not adequately defined
and, are ineffectively enforced; and
The affordability of health care is a serious problem for
the vast majority of the population, especially at the
tertiary level.
According to NSSO (2005-06) estimates most
people accessed private providers for outpatient
care—78% in rural areas and 81% in urban areas.
For inpatient care, 58% of Indian people in rural
areas and 62% in urban areas accessed private
health facilities.
What has been India’s response ?

18. Health Insurance

19. Health Insurance - Status
Most of these schemes cover only in-patient
care, mainly at the tertiary level.

20. https://india.gov.in/spotlight/rashtriya-swasthya-bima-yojana
Eligibility
•Unorganized sector workers belonging to BPL category and their family members (a family unit of five) shall be the beneficiaries under the
scheme. The beneficiaries will be issued smart cards for the purpose of identification.
Benefits
The beneficiary shall be eligible for such in - patient health care insurance benefits as would be designed by the respective State Governments based on the
requirement of the people/ geographical area. However, the State Governments are advised to incorporate at least the following minimum benefits in the
package / scheme:
•The unorganized sector worker and his family (unit of five) will be covered.
•Total sum insured would be Rs. 30,000/- per family per annum on a family floater basis.
•Cashless attendance to all covered ailments
•Hospitalization expenses, taking care of most common illnesses with as few exclusions as possible
•All pre-existing diseases to be covered
•Transportation costs (actual with maximum limit of Rs. 100 per visit) within an overall limit of Rs. 1000.
Funding Pattern
•Contribution by Government of India: 75% of the estimated annual premium of Rs. 750, subject to a maximum of Rs. 565 per family per annum. The cost of
smart card will be borne by the Central Government.
•Contribution by respective State Governments: 25% of the annual premium, as well as any additional premium.
•The beneficiary would pay Rs. 30 per annum as registration/renewal fee.
•The administrative and other related cost of administering the scheme would be borne by the respective State Governments
•Till March 25, 2013, the scheme had 34,285,737 Smart Cards and 5,097,128 hospitalization cases.

21. Critiques of the Scheme

22. Unorganized sector workers belonging to BPL category

23. India’s RSBY insurance schemes (with 110 million people enrolled) and Cambodia’s
Health Equity Funds are good examples of attempts to selectively cover the destitute
and poor as often they have no resources to access health care.
However, there is a growing perception that these special schemes for the poor
provide inferior and often inadequate coverage, so that ‘services for the poor
become poor services’.

24. Here we are !

25. Equity in resource distribution
Service
Delivery
Revenue
Raising
Pooling
Purchasing
Benefits
Stewardship/
Governance/
Oversight
Quality
Financial
protection
and equity
in finance
Utilization
relative to
need
Transparency
accountability
Efficiency
Equity in
Resource
Distribution
UHC Intermediate Objectives
Creating
Resources

26. How fair is revenue raising in the USA?
Overall the picture in the USA is
clear, that despite having some
revenue sources which are mostly
fair or progressive, the effect is out-
weighed by the high volume of
regressive payments, making the
overall picture highly unfair.
It will be interesting to repeat this
analysis in light of the Affordable
Care Act signed into law in 2010,
which aims amongst other things to
make health insurance premiums
more progressive.

27. Fiscal Context
The "fiscal context"
in a country,
significantly affects
the ability of a
government to
mobilize public
revenues overall,
which in turn
affects the level
available to fund
health services.

28. The Road Ahead: An
Integrated Model
Integrated Model
CGHS
ESIS
RBSY
National Health Mission (NHM)
Primary health care

29. Conclusion
Combined
ESIS-RSBY-
CGHS
CGHS - Civil
servants
ESIS-
Organized
sector
RSBY-
Unorganized
/ poor Creating a ready
pool of about 138
million population
with a staggering
budget of roughly
Rs. 40,000 million
with a per capita
expenditure of Rs.
290 per annum.
This would offer a
tremendous value
for money for all
the stakeholders -
payer, purchaser,
provider and
beneficiary.
This would also
ensure efficient
allocation and
utilization of funds.
National Health Mission

30. thanks !