Health Financing Reforms in India Linking to Africa July 9, 2015

Health Financing in India: The Landscape Outline Health Financing in India: The Landscape Current Reforms and Practices in India Synergies and Relevance to Africa Health Financing Support Program About ACCESS Health Core Functions of Health Finance Support Program (DFID Supported) Emerging themes and Potential Linkages The way forward 2

28 states, 7 union territories Population: 1.25 billion Background: India 28 states, 7 union territories Population: 1.25 billion 29% of population urban, 71% rural Lower-middle income country GDP Per Capita 1,498 US$ 270 million people below-poverty-line 4

Life expectancy at birth: 66 years Health Indicators Life expectancy at birth: 66 years Infant mortality (per 1,000 live births): 58 Child malnutrition (% of children under 5): 44 Under-5 mortality rate (per 1,000 live births): 72 Maternal mortality ratio (per 100000 live births): 450 Hospitalization: 2.5 per 100 population Out patient care: 0.5 incidence per person per year 5

Low Public Expenditure and high OOP payment High OOP payment AT THE POINT AND TIME OF USE! 6 Source: Ministry of Health & Family Welfare. National Health Accounts, India. New Delhi, 2009

Strategic options High OOP Limits Access Improve access Abolish user charges and improve public health facilities High OOP Increase in poverty Reduce tax base Low allocation for health sector Variable Standards of public services & high use of private health providers Limits Access Health Insurance covering private provider Reduce poverty Increase allocation to health sector Increase tax base 7

Options chosen by government Improve access Abolish user charges and improve public health facilities Reduce Access High OOP Increase in poverty Reduce tax base Low allocation for health sector Dysfunctional public services & high use of private health providers Health Insurance (RSBY) Reduce poverty Increase allocation to health sector (NRHM) Increase tax base 8

National Health Insurance Scheme (RSBY) Claims & Reimbursement (smart card) Registration fee – Rs 30 BPL families BPL Families (37M Families) Public and Private Providers CARE Hospitalisation expenses Select day care procedures Max $667 family floater Transportation costs Max $2.5 per trip and totally $25 Pre - hospitalization (1 day) & Post hospitalisation (5 days) expenses Minimum exclusions Insurance company Central government State government Premium 75% 25% started in the year 2008; Source: N. Devadasan et al. Rashtriya Swasthya Bima Yojana: an overview. IRDA journal (2008) 9

Health Financing Reforms in India Policy Practices Public financing for Health through Insurance Universal Health Coverage: Increasing geographic and population coverage Engaging Private Sector and designing innovative PPP models Developing Primary care integrations models Implementation Practices (supply and demand side) Enrolment: Use of Smart card technology Designing package rates and costing studies Claims: Review and Data Monitoring 10

Successful Innovations Use of information technology in Aarogyasri allowing for online payments (faster than managed in the US) Pre authorization with medical experts reviewing diagnosis before guaranteeing reimbursements to MANAGE FRAUD, Ongoing analytics to identify fraud and improve the program (e.g. introduced guidelines for hysterectomies) 11

ACCESS Health International A non-profit think tank and advisory group Dedicated to improving access to high quality, affordable healthcare in low, middle, and high income countries Advise national and regional governments and the private sector on the design and management of healthcare finance and delivery systems 12

Quality Access To improve health outcomes Health Financing Support Program WHAT To improve health outcomes HOW By ensuring better use of public funds Access Financial and geographic Quality Improved accountability WHY For improved equity and effectiveness in the health system As per the Draft National Health Policy 2015, less than 20% of primary health care needs are addressed in the public sector 13

Health Financing and Support Programme Information Hub for Health Financing Designed to support better use of secondary data to inform decision makers on reform progress on an ongoing basis. On-demand Support Fund Builds peer to peer linkages between the increasing numbers of experienced professionals in India and representatives from countries designing and implementing health financing reforms. Complements ongoing activities Linking activities of PPP and primary healthcare models. aligned with other international activities under the Joint Learning Network. 14

Health Financing & Integration with Primary Health Care, Quality & Public Private Collaboration in Health 15

Snapshot of the Program Investments, technology and innovations 16

Management and Payments Functional Model The three core functions of Governance, System Management and Performance Monitoring are separated in our model to increase accountability for improved access and health outcomes GOVERNANCE (Led by Government) State and district level governance to ensure effective leadership and execution of: Stewardship Contracting / Procurement Monitoring Finance SYSTEM MANAGEMENT (Independent agency/ Consortium) PERFORMANCE MONITORING (Third-party agency) An autonomous agency that ensures data driven decisions through: Monitoring Quality Verification Audits Outcome measurement Research studies Community Engagement Service Delivery Management and Payments CHC Performance-linked payments and block-level capitation PHC or equivalent PHC or equivalent Integrated information technology, including patient records Existing public clinics upgraded to offer a broader, comprehensive range of primary care (e.g. NCD), and drugs and diagnostics in Hub and Spoke model Pro-active, universal registration and screening of families to ensure access and awareness Community feedback and grievances collected Quality assurance through clinical protocols and training Family Health Teams set up for task-shifting and coordination of care Private providers contracted to fill gaps Focus on outcomes, with tracking and reporting of data 17

Value Proposition for Governments and Private Sector MARKET INTELLIGENCE Trusted Advisor Policy Reforms Center of Competency Structured processes for PPP Lifecycle Capacity Building and Handholding Facilitator Active communication of opportunities Match opportunities to private innovations and ideas Orient private sector for government engagement GOVERNMENT PRIVATE SECTOR Partnering for Progress Initiative OPPORTUNITIES DATA Information Repository 18

Costing of Health Services Health Financing Support Program Emerging Technical Areas for collaboration (connecting with emerging themes in workshop) Private Sector Integration including primary care, public private partnerships and Quality of Care Costing of Health Services Performance Review and Data Monitoring (e.g. claims) Capacity Building by peer-peer knowledge sharing across countries Integrated Knowledge Hub 19

Step2: Present a portfolio of solutions and expertise in India The Way Forward Step 1: Understand the current reform efforts and priorities (e.g PPP Policies and Guidelines, etc) Step2: Present a portfolio of solutions and expertise in India Step 3: Study visit to India Step 4: Jointly develop a work plan for the Collaboration 20

Thank you Key Contacts Siddhartha@accessh.org Bhavesh.Jain@accessh.org Rohini.Rao@accessh.org Thank you 21