Dr. P. Boregowda Executive Director, SAST A Workshop on Universal Health Coverage in India: Karnataka Case Study Organised by University of Chicago August 18th 2015 Proposed approach for RSBY implementation in Karnataka Dr. P. Boregowda Executive Director, SAST

Existing health schemes in Karnataka Name of scheme Coverage Characteristics of the scheme ESIS 80 lakh individuals Mainly for workers in the formal sector. Comprehensive cover of primary, secondary and tertiary conditions. Yeshasvini 34 lakh individuals Only for members of the cooperative societies in Karnataka. Covers surgical procedures upto a limit of Rs 150,000 per patient per year Vajpayee Arogyasree Scheme (VAS) 113 lakh households For all citizens of Karnataka with a BPL card. Covers tertiary care expenses upto Rs 150,000 per family per year. Rajiv Arogya Bhagya (RAB) 34 lakh families For all citizens of Karnataka with an APL card. Covers tertiary care expenses upto Rs 150,000 per family per year. Patient is expected to pay 30% of the final bill Jyothi Sanjeevini Scheme 6 lakh families State government employees and their dependents, covers tertiary care expenses no financial cap per family RSBY 64 lakh families For all citizens of Karnataka with a BPL card. Hospitalization expenses up to Rs 30,000 per family per year.

Suvarna Arogya Suraksha Trust IMPLEMENTATION of Health Schemes Special Purpose Vehicle in 2009 ‘‘Suvarna Arogya Suraksha Trust’ (SAST) under the Department of Health & Family Welfare as per the provisions of the Indian Trust Act, 1882. The Chief Minister - Chief Patron The Minister for Health & Family Welfare & The Minister for Medical Education – are member patrons SAST Governing Bodies Board of Trustees. Executive Committee Empanelment & Disciplinary Committee

For Govt/aided School Children For State Govt. Employees Schemes implemented by SAST to achieve universal health coverage in tertiary sector SAST Schemes VAS RAB JSS RBSK RAB For Govt/aided School Children For BPL For APL For State Govt. Employees BPL-Below Poverty line population APL-Above Poverty line population

SAST Approach in Tertiary Care High Cost Tertiary Diseases-Cashless treatment facility to identified seven tertiary ailments. Public – Private Partnership. Treatment in well equipped Super Specialty Hospitals hitherto unavailable to BPL families. Providing Financial Security & Better Health Outcomes. The Vajpayee Arogyashree scheme was evaluated by the World Bank which found that there was 64% reduction in out of pocket expenditure for the beneficiary and mortality was reduced by 68% among BPL families. 12.3 % households more likely to use tertiary care for covered conditions under VAS. They concluded that “Insuring poor households for efficacious but costly & underused health services significantly improves population health in India” (Sood N et.al, BMJ 2014;349:g5114 doi: 10.1136/bmj.g5114 (Published 11 September 2014).

Population Coverage in % Preamble To provide Health Security to the people of Karnataka, SAST, an autonomous body was established to implement the following Tertiary care schemes on a project mode. About 93% of Total Karnataka population is being covered by SAST, balance 7% covered under other Government & Private Insurance. Thus Karnataka Is the first state in the country to move towards UHC in Tertiary Sector. Scheme Name Year Target population Population Coverage in % Vajpayee Arogya Shree (VAS) 2009-10 All BPL families in Karnataka 69% Rajiv Arogya Bhagya (RAB) 2014-15 All APL families in Karnataka 19% Jyothi Sanjeevini (JSS) All State Government Employees and their dependents . 5% Mukhya Manthrigala Santhwana Scheme(MSS) Accident Victims on the roads in the territory of Karnataka 100%

Expenditure– Rs. Crores Scheme Utilization Yearly, the number of BPL beneficiaries has increased by nine fold. More than nine fold increase in number of beneficiaries. Total Beneficiaries Inception – March-15 is 94937 Expenditure– Rs. Crores The total Trust expenditure is Rs. 545.76 Cr of which claims serviced amounts to Rs.491.18 Cr constituting about 90 % of the total Trust expenditure. Unlike Insurance mode, under Health Assurance, maximum amount is spent towards servicing of claims as Administrative cost is less than 10 %. Economy & Focus on access to more beneficiaries.

Proposed approach for RSBY implementation through SAST

RSBY Status update Karnataka The RSBY has been functional in Karnataka for the past 6 years. Started as a pilot in five districts, it currently provides coverage to 64 lakh BPL families across the state. Enrolment is satisfactory (57%), utilisation is very low with an average claim size of Rs. 6210 and consequently the claims ratio is also low. Out of the 722 hospitals empanelled 34% are public hospitals and the remaining 66% belong to the private sector.

Implementation status of RSBY overtime in Karnataka Phase Pilot Roll-out Current Year (2009-10, 2010-11) (2011-12, 2012-13, 2013-14) (2014-15, 2015-16) No. of districts 5 30 No. of insurance companies 1 3 4 Premium rate 475 369(360-403) 194(163-219) Eligible number of families 3,81,381 40,76,638 1,12,87,697 Enrolled Families 1,61,116 (42%) 17,45,461 (43%) 63,88,199 (57%) Enrolled Individuals 4,99,460 54,10,929 1,98,03,417 Utilization-families (Percentage) 3841(2%) 64401(4%) 18,929(0.3%) Utilization rate per 100 beneficiary (%) 0.8 1.2 0.1 Amount reimbursed 1,53,07,582 29,73,25,245 10,79,83,061 Hospitals 151 640 722

Average claims ratio for the year 2013-14

Rationale for the approach Efficiency gains and continuity of care It is more efficient to have a primary health care scheme (NHM), a secondary health care scheme (RSBY) and a tertiary health care scheme (VAS, JSS & RAB) under one umbrella. This ensures continuity of care as well as better use of scarce resources. Stengthening of public health facilities The Health Department will promote more use of the public health facilities under RSBY, which means that there will be additional fund flowing into the ARS funds of these facilities. These funds in turn can be used to strengthen the facility as well as motivate the staff to improve their performance. Better Scheme management The Health Department will be able to better manage the scheme as it has technical knowledge through IT platform led pre-authorisations and claims settlement. It will ensure that unnecessary procedures will not be undertaken, quality care will be provided and patient’s health improved. This will include a strong gate keeping mechanism.

SWOT analysis of SAST, Department of Health, Government of Karnataka, to take over the scheme Strengths Weakness Service objective of increasing access to care Enrollment and IEC retained with MOLE Well developed IT system –end to end solutions   Strong Gatekeeping mechanisms-two level Implementing support agency in place with 25 doctors at the trust level we have 15 doctors for final approval Presence of 496 Arogyamitras at field level-CHC, TH, DH and each empanelled hospital Trained manpower available Experience in implementing similar schemes for tertiary care Quality assurance and grievance redressal systems in place Opportunities Threats To increase efficiency by bringing all of schemes under one umbrella for implementation Lobby by insurance companies Continuum of care- empanelled hospitals available for tertiary care and referral mechanisms can be worked out. Primary health care implemented by Directorate of health hence Policy changes at the government level better synergies with Ministry of Health Regulation of the private sector delivery of health care A vast network of health care staff including ASHAS of the directorate of health can be channelized for IEC activities and follow-up care

Strategy of Implementation- Assurance or Insurance mode Particulars Assurance mode-through SAST Insurance mode Motive Service – Welfare of people Profit – Tendency towards less utilization, more profit Enrolment Criteria Automatic – Voluntary Enrolment Rate Automatic - 100 % Optional (Real needy families may miss out) Scheme Administrator SAST with support of ISA Insurance company through single or multiple TPAs Premium No premium – GoK releases funds to Trust Advance premium to be paid to insurance company Administrative Cost 7.5 % - 10 % included in unit cost 20 % included in unit cost Provider payment Case based OOP & Co payment Nil for all schemes except for RAB Yes Financial Security Cashless Treatment Unpredictable Gate Keeping Yes – Two tiered checks of all preauths & claims before approval Only by TPA Pre existing Diseases Covered Flexibility of making changes in the scheme Can be done & implemented with immediate effect Time consuming plus additional premium. Medical Audit No Grievance redressal Death Audit Not clear

Steps in shifting The strategies for shifting need to be carefully considered. The options are: Big bang approach – orders are passed to shift the RSBY to SAST and the SAST takes over as and when the insurance companies contract ends. The advantage of this is that the SAST will start operations as soon as possible and strengthen the existing RSBY and improve it in the best possible manner. Phased approach- may not be desirable Other than the financial, technical and managerial advantages, there is a distinct probability that Karnataka would be one of the first state to have transitioned successfully and will add to the prestige of Karnataka at the national level

Summary The SAST that is currently managing the VAS, JSS and RAB through the trust model will be able to manage the transition and ensure that the RSBY is successfully operational in the shortest period possible. The Government of India has recognized the organization structure of SAST and has been recommending all the states to follow the SAST model for implementation of Rashtriya Swasthya Bima Yojana. This is truly a significant recognition of the successful implementation of the schemes by Suvarna Arogya Suraksha trust. It has the necessary human resources and the technical knowhow to manage it. If done well this will be a great achievement and will show the way for other states in the country. By strengthening the health services, the people of Karnataka will benefit considerably.

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