1. La couverture sanitaire des pauvres, quelles leçons tirées des expériences internationales pour le RAMED? Expérience de Inde M. P.V. Ramesh

2. India - Profile  7 th Largest country in Area  2 nd most Populous Country (1.21 billion)  4th Largest national economy by GDP in PPP terms  29 states and 7 UT

3. 3 th Largest State by Area 5 th most Populous State 3 rd biggest GSDP Andhra Pradesh

4. IndicatorIndia AP PopulationPopulation (in million)1,210.284.7 Decadal growth rate (2001 to 2011)17.6%11.1% 0-6 yr population (% of total population)13.110.2 Sex RatioAll Ages (females/1000 males)940992 0-6 years914943 Health indicators Crude Birth Rate (per 1000 population)20.918.4 Crude death Rate (per 1000 population)7.877.5 Total Fertility Rate (TFR)2.61.8 Life expectancy (in years)63.763.1 Literacy rate 74.0467.7 Demographic Profile: India / AP

5.  Population of 84.7 million; wide social & economic diversity  One of the fastest growing States in South India  Growth averaging 8 -9 % pa / 5 years  Produces 15% of health human resources in India  Health Care costs – 5% GSDP; 80% out-of pocket  Has a vibrant private health sector & extensive public health network  Hyderabad: Hub of medical tourism  Bifurcated into two States in June 2014; Andhra & Telangana Andhra Pradesh – Context

6. District Hospital -17 Area Hospitals- 117 Community Health Centre (CHC)-309 A 30 bedded Hospital/Referral Unit for 4-10 PHCs with Specialized services Primary Health Centre (PHCs): 1,624 1. Supports 6-12 Sub-Centres 2. Manned by: 2 MOs, 3 Nurses, 1 Lab technician, 1 Pharmacist, and Support Staff Sub Centres: 12,285 1. One for every 5,000 population/3,000 in tribal / hilly areas 2. Staffed by two ANMs & one MPHA (M) Medical College Hospitals & Specialized Hospitals Medical College Hospitals & Specialized Hospitals Public Health Care Delivery

7. Accredited Social Health Activists (ASHA): 70,700 Auxiliary Nurse Mid-Wife22,400 Staff Nurses 8,000 Medical officers6,900 Multi-Purpose Health Workers 7,700 Other Para-Medical27,800 Public Health Workforce

8.  High IMR / MMR / Malnutrition & Disease Burden  Inadequate Financial Allocation; High out-of-pocket expenses  Access constraints: – Regional, Social, Geographic Disparities – Physical access - Distance, Inadequate Transportation, Remote areas – Urban Orientation – Non availability of Doctors & other professionals, where required  Governance Issues: – Sub-optimal governance effectiveness – Poor Accountability and Responsibility – No system for Support, Facilitation and capacity development – Lack of Community / client orientation – Inadequate-integration with nutrition, rural development and poverty alleviation efforts – Poor Management of Human Resources  Tribal Areas & Vulnerable Social Groups – A long way Behind Challenges facing the Health System in 2007

9. Health System Reform-Key Components  Health Governance System Reform  Revitalization of Primary Health System & Referral System  Comprehensive Maternal and Child Health and Nutrition Action Plan  Community Participation & Demand Generation Strengthened  Synergy and Integration with nutrition and poverty alleviation programs  Customized strategies for tribal areas and vulnerable groups  Targeted Interventions for adolescent girls, disabled, school children, elderly, etc.  Public-Private Partnerships: Emergency Transport System; Arogya Sri – Community Health Insurance System  Rationalized procurement system for medicines and equipment  Effective Health Management Information System

10. Arogya Sri - Community Health Assurance Scheme

11. Aarogyasri – Key Features Launched in 2007 to ‘ensure lifesaving inpatient care affordable for below-poverty- line population’ Covers 19.7 million families (78 million) below poverty line population holding ‘White ration card’ (annual income of $1,000 per family in rural: $ 1,200 in urban) - 80% of population No enrolment fee; all persons with white card entitled for coverage State Government responsible for oversight, operations and financing from general revenues and $0.10 health cess on every liquor bottle sold ($200 + $ 80 million) Aarogyasri Health Care Trust responsible for Implementation, Monitoring and Evaluation

12. Aarogyasri …2 Covers 942 surgical and therapeutic interventions; Cashless Service to the Patient All public health facilities and Empanelled Private Health facilities provide services Not fee for service; package rate determined for each surgical / therapeutic procedure that includes the cost of health camps, diagnostic procedures, follow-up medication, in addition to the main therapeutic / surgical intervention Annual coverage of $ 2,500 (additional $ 1,000 for serious ailments like cancer, etc.)

13. Arogya Sri….3  4,500 Arogya Mitras (Health-Friends) facilitate patient identification, linkage with the hospital and follow-up  Robust IT Platform enables real time management and monitoring of every patient; network hospitals share patient histories, diagnostic tests, treatment, follow-up medication with the Trust (procedures video recorded and uploaded)  Aarogyasri has a sophisticated system for pre- authorization; data submitted by the hospitals is reviewed by the Trust doctors before hospital is authorized to treat the patient..  Payment is made only after an expert panel carefully reviews all claims before the Trust approves them.  Standard treatment protocols have been prepared in collaboration with the NICE of UK.

14. Aim & Implementation AIM Financial protection to ‘Below Poverty Line’ (BPL) population for medical treatment requiring Hospitalization IMPLEMENTATION Public – Private - Partnership (PPP) Mode AAROGYASRI HEALTH CARE TRUST EXECUTING AGENCY NETWORK HOSPITALS SERVICE PROVIDER PRIMARY HEALTH SYSTEM PATIENT IDENTIFICATION HEALTH WORKERS AAROGYAMITHRAS SOFTWARE COMPANY TECHNOLOGY SOLUTIONS

15. Aarogyasri Implementation Patient Records BPL Data Medicines Inventory Health Camps Data Inventory Patients Feedback Financial Data NW Doctors Trust Trust Doctors Banks Citizens Bed Capacity Follow Up PATIENT Network Hospital Preauthorization Admission Preliminary Verification Monitoring Claim Processing Billing Diagnosis Trust Administration /Insurance Company Payments Claims Aarogya- Mithras Treatment PHC’S/ CHC’S AREA HOSPITAL DIST HOSPITALS DIRECT HEALTH CAMPS ACCIDENT SITES CM CAMP OFFICE CALL CENTER PHC’S/ CHC’S AREA HOSPITAL DIST HOSPITALS DIRECT HEALTH CAMPS ACCIDENT SITES CM CAMP OFFICE CALL CENTER Treated Patient Registration Aarogyasri MIS Aarogyasri Service Intelligence