PUBLIC HEALTH DELIVERY SYSTEMS : A STUDY OF RAJIV AROGYA SRI HEALTH INSURANCE PROGRAMME

Transcription

1 PUBLIC HEALTH DELIVERY SYSTEMS : A STUDY OF RAJIV AROGYA SRI HEALTH INSURANCE PROGRAMME T. Yadagiri Rao* K. Seetharama Rao** In this paper an attempt is made to discuss about nature of Health Sector Reforms (HSR) funded by World Bank in Andhra Pradesh in the Section I. As part of HSR the government of AP has introduced Rajiv Arogyasri Health Insurance Scheme (RAHIS) to provide quality medical and health services to the people of Below Poverty Line (BPL). In Section II the basic features of RAHIS has been explained. Implementation of RAHIS in Warangal district has been analyzed taking 900 patients as sample during three years, i.e from one of the networking Hospital located in the district head quarters in Section III. The social status and other details of 900 patients, already treated, have been explained in this section apart from their experiences and opinions. Section IV consists of Conclusion and Suggestions related to providing quality of health services to disadvantaged groups of the state. I The evolution of the health systems is largely shaped by the culture, history, norms and clientele satisfaction. As per National Family Health Survey (NFHS-II) data, an overwhelming majority of clients are satisfied by the services delivered by the public health systems. May be the expectations are low or may be our people are so courteous. But we have the report from Transparent International ranked organization the health system in India is the most corrupt system. The Government has taken several steps for improving the public health care institutions and strengthening the primary health care infrastructure. However, the situation is compounded by severe resource constraints - financial, technical and human power related, which has resulted in policy makers as well as programme managers at differing levels being faced with difficult choices. In such a situation, attempts are being made through various reform initiatives to ensure that the health needs of the people are met one of the major reform initiatives underway is the Secondary Health System Strengthening Project funded by the World Bank in seven states including Andhra Pradesh. The projects include strengthening First Referral Units/Community Health Centres (FRUs/CHCs) and district hospitals so as to improve the availability of emergency care services to patients, to reduce overcrowding at district and tertiary care hospitals, Many state governments in India had recourse to Health Systems Development Project (HSDP) loans from the World Bank for carrying out Health Sector Reforms (HSR), of which one of the key policies has been to raise public spending on health care from the abysmally low levels. The HSDP seeks to develop strategic management capacity; strengthen performance, accountability, and efficiency; and build implementation capacity. Further, it seeks to improve clinical service quality by renovating and expanding district, sub district, and community hospitals and improving access to services. * Associate Professor, Department of Public Administration and HRM, Kakatiya University, Warangal, , A.P. drtyrao@gmail.com ** Professor, Department of Public Administration and HRM, Kakatiya University, Warangal, , A.P. ksrrao027@yahoo.com 1

2 The governments of the reforming states have agreed to accept the terms and conditions of funding agencies to implement HSRs. These are: (i) to enhance the overall size of the health budget; (ii) to redress imbalances in public expenditure between secondary and tertiary care levels; (iii) to safeguard the operations and maintenance components of current expenditure allocations for the secondary health-care sector; (iv) to charge user fees for selected services; and (v) to address workforce issues. The Third Phase of APERP, initiated in January 2007, that sought to support the state's HSRs program. Within AP there are regional, social and gender disparities. Health outcomes are worst among Scheduled Castes (16% of population) and Scheduled Tribes (7% of population), especially those living in rural areas in North tribal and South drought prone districts, and for women. Effective delivery of quality basic health services is hampered by demand and supply side issues, including poor health infrastructure and staffing. The reform history in health sector in the State can be traced to Andhra Pradesh First Referral Health System Project (FRHSP), one of the first World Bank aided health system projects in the country. This project, launched in 1995 had been implemented by AP Vaidya Vidhana Parishad (APVVP). Agencies like World Bank and Department for International Development (DFID) are supporting the reform process in the State. The Bank supported the AP Economic Restructuring Project which included improvement of primary health care as one of the component. The priority of reforms focus on improved access to quality and responsive health services, strengthened governance and management in health sector, improved institutional mechanisms for community participation and systems for accountability; and strengthened financial management systems. The government of Andhra Pradesh [GoAP 1999] Vision 2020 document identifies a seven-point set of priorities for health sector reform: i) providing universal access to primary healthcare; ii) encouraging private investment in tertiary healthcare; iii) focusing on specific programmes to promote family planning; iv) focusing on improving health levels in disadvantaged groups and backward regions; v) ensuring a strong prevention focus; vi) enhancing the performance of the public health system; and viii) formulating a state Information Education and Communication (IEC) programme to broadcast information on preventive healthcare. The Government of Andhra Pradesh is embarking on a major health sector reforms to improve health care delivery in the State. DFID has expressed its willingness to support these initiatives with a grant of 100 Million pounds over the next five years ( ). The reform initiative will include measures to improve the effectiveness and accountability of public health services, measures to focus on community centric preventive healthcare system and enhance access to quality healthcare for major diseases to the poorer sections of the population. The major reforms underway are classified under these categories and the activities are noted below: (I) Reorganization and restructuring of existing government health care system Establishment of Andhra Pradesh Vaidya Vidhana Parishad (APVVP) (II) Changes in health system organisation, delivery and Management Public Private Partnership (PPP) (III) Changes in financing methods Sukhibhava Scheme (Improvement of Institutional Delivery Services Scheme) (IV) Reforms related to human resources (V) Involving community in health service delivery and Provision (VI) Reforms to quality of care 2

3 Management of Urban Health Centers by NGOs Under the World Bank assisted Andhra Pradesh Urban Slum Health Care Project (APUSHCP), 192 urban health centers (UHCs) have been established in 74 municipal towns in 21 districts covering 1848 slums. After withdrawal of support by the World Bank, the project has been funded by the state government since The outcomes of the project show marked improvement in ANC coverage, institutional deliveries, post natal care and immunisation in the slum population. II Rajiv Arogya Sri Health Insurance Scheme (RAHIS) Annual Government Public Health insurance scheme, to serve people of poor from the serious ailments is now attracting the nation, as this programme highly successful. This scheme provides financial support to families of BPL upto 2 lakhs per anum for treating serious ailments. It is proposed to cover the entire state by 2nd October 2008 with the government paying the insurance premium for all the beneficiaries. An amount of Rs.450 crores are provided to implement the scheme during Apart from Rajiv Arogya Sri Health Insurance Scheme, under the Sukhibhava Scheme, a cash assistance of Rs.300 (Rs 200 towards transportation charges and Rs 100 for food and incidental expenses) is paid to pregnant women belonging to below poverty line families who come to government hospitals for delivery services. This assistance is payable only to those women with no living children or with one living child. There is a felt need in the State to provide financial protection to families living below poverty line for the treatment of major ailments such as cancer, kidney failure, heart and neurosurgical diseases etc., requiring hospitalization and surgery. Government hospitals lack the requisite infrastructure facility and the specialist pool of doctors to meet the statewide requirement for the treatment of such diseases. Large proportions of people, especially below poverty line borrow money or sell assets to pay for the treatment in private hospitals. Health Insurance could be a way of removing the financial barriers and improving access of poor to quality medical care. There is need for providing financial protection against high medical expenses and negotiating with the providers for better quality medical care. Government of Andhra Pradesh has accordingly implemented a Community Health Insurance Scheme by name Rajiv Aarogyasri in Anantapur, Mahabubnagar, Srikakulam as Phase I project, East Godavari, West Godavari, Chittoor, Nalgonda and Ranga Reddy as Phase II, Medak, Karimnagar, Kadapa, Prakasam and Nellore as Phase III, Hyderabad, Adilabad, Kurnool, Vizianagaram and Visakhapatnam as Phase IV. Government after careful assessment of the scheme has now decided to expand the scheme with some modifications. Accordingly the Fifth phase expansion is planned from July 2008 in five districts viz. Nizamabad, Warangal, Khammam, Guntur and Krishna. In order to operate the scheme professionally in a cost effective manner, Public Private Partnership (PPP) is envisaged between the Insurance Company, the private sector hospitals and the State agencies. State government/ Trust will guide the Insurance Company in establishing network of hospitals, fixing of treatment protocol and costs, treatment authorization, claims scrutiny and any other related work, such that the cost of administering the scheme is kept at the lowest, while making full use of the resources available in the Government system. Private hospitals fulfilling minimum qualifications in terms of availability of inpatient medical beds, pathological laboratory, latest equipments, operation theatres etc. and a track record in the treatment of the specified diseases can be enlisted for providing treatment to the BPL families under the scheme. Premium under this scheme will 3

4 be borne by the Government / Trust, i.e. Rajiv Arogyasri Trust specially established for this purpose. Since April 2007 under Rajiv Aarogyasri Scheme 2, 193 health camps were conducted screening 36,49,197 people. In total 27,90,840 cases were registered, 15,85,549 out patients and 8,91,288 in patients were given treatment. The total number of preauthorisations were 7,81,391 and surgeries/therapies were 7,73,528 and the amount preauthorized for surgeries/therapies was 2, crores. The persons in the Below Poverty Line (BPL) category holding white ration cards get free medical treatment for 887 identified diseases. They can also avail free/cashless treatment at 320 identified private and government hospitals. The scheme provides health insurance of Rs. 1.5 lakhs to each BPL person At any time of the day 250 patients will be waiting to be treated under this RAHS in Andhra Pradesh. The main objective is to improve access of BPL families to quality medical care for treatment of identified diseases involving hospitalization, surgeries and therapies, through an identified network of health care providers. The scheme is intended to benefit below poverty line (BPL) population in all the districts of the State covered in five phases. All eligible families in these districts will be provided with Rajiv Aarogyasri Bhima Health Cards. These Health Cards/ BPL Ration card will be basis for identification of Beneficiary under the scheme. As per the scheme, the family means members as enumerated and photographed on the Rajiv Aarogyasri Health Card/ BPL Ration Card. The photograph indicated in the Health Card/ BPL Ration Card will be taken as the proof for determining the eligibility of the beneficiary. GoAP / Trust will provide the details of each BPL family covered under the Scheme through the Health Card to the insurer. This Health Card will be a part of enrollment / identification for availing the health insurance facility. The scheme will provide coverage for meeting expenses of hospitalization and surgical procedures of beneficiary members up to Rs.1.50 lakhs per family per year, in any of the network hospitals. The benefit on family will be on floater basis i.e. the total reimbursement of Rs.1.50 lakhs can be availed of individually or collectively by members of the family in one year. Beneficiaries approach nearby PHC/Area Hospitals/District Hospital/Network Hospital. Aarogyamithras placed in the above hospitals facilitate the beneficiary. If beneficiary visits any other PHC/Government hospital other than the Network Hospital, the doctors will give him a referral card to the Network Hospital after preliminary diagnosis. The Beneficiary may also attend the Health Camps being conducted by the Network Hospital in the Villages and can get the referral card based on the diagnosis The Aarogyamithras at the Network Hospital examine the referral card and BPL ration card and facilitates the beneficiary to undergo preliminary diagnosis and basic tests. The Network Hospital, based on the diagnosis, admits the patient and sends preauthorization request to the Insurance company and to the Aarogyasri Health Care Trust. Specialists of the Insurance Company and the Trust examine the preauthorization request and approve preauthorization if all the conditions are satisfied. The Network Hospital extends cashless treatment/surgery to the beneficiary. Network Hospital after discharge forwards the original bill, discharge summary with signature of the patient and other relevant documents to Insurance Company for settlement of the claim. Insurance Company scrutinize the bills and gives approval for the sanction of the bill. Network hospital will provide follow-up free consultation and medicines supplied by the Trust for the patients undergoing treatment under the scheme for a period of one year from eleventh day of discharge. 4

5 Method of Implementation of the Scheme The entire scheme will be implemented through insurance firm. An MoU has been signed by the CEO of AHCT on behelf of GoAP with Star Health and Allied Insurance Firm. The contact point would be PHC and Government hospitals in the District, where Insurer will have a help desk known as Aarogyasri Help Desk. The desk will be managed by a Aarogyasri Health Coordinator (AHC) to be appointed and paid by the Insurer. Aarogyasri Help Desk at PHC / Government Hospitals will refer patients on the recommendation of the PHC/Government Doctors to one of the Network Hospitals or hospital of the BPL family member's choice with in the network. At the Network Hospital Insurer will establish Aarogyasri Assistance Counters and will facilitate the referred BPL family member to go through the tests and there after if needed for the surgical treatment. White Ration Card (BPL Card) holders can also directly approach Aarogyasri Assistance Counters at the Network Hospital for examination and treatment. For treatment of poly-trauma and burn cases Insurer will refer to the network of hospitals closer to the people preferably at the mandal level. The Aarogyasri Assistance Counters at the network hospitals will facilitate cashless transaction and formalities connected with discharge of patient and enable forwarding the bills for payment to the Hyderabad zonal Office of Insurer. Not withstanding whatever stated above, if a patient gets admitted directly in a network hospital and fulfills all the criteria for the benefits under the scheme, his/her case will be considered without any objections. A toll-free number will be made available at Hyderabad where any complaints can be registered. The insurer shall keep track of the complaints and report on the action taken to the Central Grievance Committee. The beneficiaries can also send telegrams to CEO of the Trust/ Zonal Office of the Insurer. The details of toll-free Numbers/addresses will be made available with Aarogyasri Help Desks in the network of Hospitals. The implementation of the programme is regularly monitored by the district level and state level monitoring committees. Unique Features of the Policy The scheme will encompass all the family members of the BPL families. All the family members whose photographs and details appear on white ration card are the eligible for benefit. The members are insured against surgeries on KIDNEY, HEART, BRAIN, CANCER, BURN INJURIES and ACCIDENTS (other than those covered by MV Act.). The scheme envisages cashless transaction. Patient gets admitted, operated and discharged without paying any money. Immediate Pre and post operative expenditure included in packages, so as to minimize the other financial expenses to the patient. Scheme is introduced in Mahboobnagar, Anatapur, Srikakulam three backward districts of the state on pilot basis and later it is expanded to all the districts of the State. Entire premium will be paid by the government for the first year. Preexisting diseases are also covered from day one. 5

6 III About Referral Hospital Jaya Hospital located in the district head quarters of Warangal is a one of the big multi-specialty hospital established in 1976 as small nursing home and steadily developed into a most significant MSH. The hospital has put in more than three decades of medical service track record in providing quality treatment to the patients. This hospital has been included in the networking hospitals since inception of RAHIS. As per the information given by the Hospital Management, on an average of in patients and out patients are given treatment in a month to various ailments under arogyasri scheme by this hospital. This hospital is a First Referral Unit (FRU) to many PHCs, CHCs and small nursing homes located in different mandal and division level head quarters of the district. With regard to infrastructure facilities available in the hospitals are; beds, 59 super speciality doctors as consultants apart from regular duty doctors in the hospital, 350 nursing and para-medical staff, more than 100 regular and part-time technicians and laboratory staff, 5 ICU wards (belonging to surgical, medical, neurological, cardiological, neo-natal, pulmonological branches), 2 Trauma and poly-trauma units, 120 administrative, nontechnical and ministerial staff. The hospital is fully equipped with latest investigative electronic equipments like CT scan and other advanced machinery. In the year 1988, the hospital management has established a nursing college as its auxillary unit which provide nursing services as part of training to the nursing students, mostly female nurses. In a way it is a teaching hospital to nursing course students. A separate ward and Help Desk/Assistance counter is maintained for Rajiv Arogyasri Scheme patients in this hospital to facilitate and give special attention to the beneficiaries of the scheme. RAHIS Beneficiaries from this Hospital during After examining hospital records of patients, who were given treatment under RAHIS over a period of three years, i.e. from , in total 900, every year 300, case sheets were analyzed in consultation with hospital staff and doctors. As per the data analyzed during these three years average 46.5 per cent men, 42.5 per cent women and around 11 per cent children were enrolled as both in patients and out patients under the scheme to take treatment for different diseases. More than 62 per cent belongs to rural areas and nearly 38 per cent from urban areas in the registered beneficiaries. Out of the enrolled beneficiaries nearly 32 per cent were treated as in patients and remaining was given out patient treatment. With regard to social status of the beneficiaries on an average 13 per cent from other castes, 47 per cent from backward classes/castes, 24 per cent from scheduled castes and remaining 16 per cent from scheduled tribes during these three years. Generally, the health condition of SCs and STs is most precarious and vulnerable to major diseases like kidney failures, lung infections, heart problems and gastroenterology cases. With regard to nature of ailments of respondents, 12 per cent are with heart diseases, 17 per cent are with lung and chest diseases, 9 per cent are suffering from cancer, 7 per cent are effected by kidney infections and failures, 12 pe rcent are burning cases and remaining 43 per cent with other severe ailments like accident cases (not covered in MV Act, with severe head injurieis), neurological cases, viral fevers and so on. 6

7 Public Opinion These are some of the typical and critical opinions of different sections of the people about the implementation of Aarogyasri health insurance scheme. I heard a lot about this programme, many poor people lives were saved through this programme. I hope this programme would continue with more transparency to the expectations of our people, what ever political party comes into power they should continue this. This is the best of all programmes until today by a ruling government in India. In NIMS hospital the treatment is very much neglected for Aarogyasri patients, and they are not giving the medicine also. This is very bad news to patients because they do not have the money to purchase the medicines, am also one of the people in that PHC Aarogyamithras has to meet all the beneficiaries who are all got benefited under the scheme within ten days from the date of discharge and motivate them to undergo follow up visit and treatment so that the patient can completely get the benefit of the scheme and which in turn the motive of the scheme get fulfilled No doubt, this is Apara Sanjeevini project to protect the lives of poor people, but there are certain management failures in this project at different levels. Women health should be given top priority, this health scheme should offer treatment for her eligible disease whether it may be laproscopic or open surgery, you should see that she should be cured of her illness, we should accept that because of illiteracy, ignorance, most of the women were not able to come for screening that is why by the time they come to hospitals, we the doctors are finding abdominal tumors in advanced state (not fit for laproscopic surgery) hence there is a definite need to include open surgeries in this health scheme I am getting treated for Ewings sarcoma after chemo, started radiation, I am happy that this scheme is completely free for needy and poor people. Hope for its continuity and long life Another major critical opinion about this scheme is that the private corporate hospitals are major beneficiaries of this scheme, without providing expected quality of medical and health services to poor people. If government strengthens the preventive and PHC sectors, the health conditions of rural poor would undergo a definite change in turn reduce the burden of government to spend on health insurance schemes. IV Conclusion RAHIS is definitely a novel and innovative programme as part of HSRs aimed at providing quality medical and health services to persons of BPL category. This is very popular scheme among poor people of A.P. and widely known as Apara Sanjeevini and 7

8 there is popular demand from the people to continue the programme more effectively and transparently. However, there are certain management failures in proper implementation of this scheme. The enrolment of beneficiaries is on higher side and the facilities and service available to them is not up to their level of expectations. The proper examination of the data provided by the hospital, selected for study, reveals that nearly 5 7 per cent of claims and false due to misuse of the scheme in collusion with hospital management and insurer. There is a sort of dissatisfaction among the beneficiaries of the scheme that, step motherly treatment is given to RAHIS patients in the referral hospitals mainly corporate hospitals. This is mainly because of hospital management s suspicion about the delay and other litigations from the insurer to clear the claims, as expressed by the patients and their relatives. References 1. Devishetti : Will there a health for all? Special Anniversary Issue, India Today, December Kaveti Nambison : Towards Effective Rural Health Care. Hindu, May, Ramesh Bhatt and Somen Shah : Health Insurance not Panacea. Economic and Political Weekly, Vol. 39, August I. Rambrahmam and S. Sudhakar Babu : Public Private Partnership and Evolving National Health Policy for a Cautious Approach. Indian Journal of Public Administration, July-September, K.V. Narayana : Public and Private Mix in the Medical Care in Andhra Pradesh. Report of Centre for Economic and Social Sciences, Hyderabad, K.V. Narayana : Size and Nature of Health Care System. Andhra Pradesh Development Economic Reforms and Challenges Ahead, Centre for Economic and Social Sciences, Hyderabad, Ambumani Das : Minister for Health and Family Welfare, Government of India. An Interview with India Today on National Rural Health Mission, Vol. 32, No. 30, July GoAP, Hyderabad from states-ii. 8