Reaching the informal sector.
In 2007, the state of Andhra Pradesh launched the Aarogyasri health insurance scheme, gradually extending coverage for catastrophic, inpatient care to the entire below-poverty-line population statewide. One year later at the national level, the Ministry of Labour and Employment launched RSBY to provide health insurance benefits to BPL populations.
In 2007, the state of Andhra Pradesh launched the Aarogyasri health insurance scheme, gradually extending coverage for catastrophic, inpatient care to the entire below-poverty-line (BPL) population statewide. Similar programs are now being adopted in neighboring states based on the Aarogyasri model. Aarogyasri in the state of Andhra Pradesh was initiated with the objective to reduce the catastrophic expenditure for hospital care among the BPL population. One year later at the national level, the Ministry of Labour and Employment (MoLE) launched the Rashtriya Swasthya Bima Yojana (RSBY) program to provide health insurance benefits to BPL populations with the focus to increasing access to care for the BPL population. It is being implemented by state governments in 23 different states, with plans to cover the entire BPL population in India. These programs are similar in several ways, from both a design and implementation perspective. To this point, they have both targeted the BPL populations within their respective geographies. Both programs provide inpatient benefits and have defined lists of covered procedures. This indicates an emphasis on preventing catastrophic health expenditures, by covering many of the most expensive and complex procedures.
Both programs are entirely cashless, with no required co-payments at the point-of-service. Aarogyasri requires no member contribution whatsoever, while RSBY has made the decision to charge beneficiaries a small registration fee. These fees have proven to increase the perceived value of the scheme, and increase utilization as beneficiaries feel that they have “bought into” the scheme and therefore are entitled to receive services from it.
Both programs are financed through general government revenues. RSBY is financed through a mix of central and state government revenues, while Aarogyasri is financed entirely at the state level with no support of the central government. Both schemes have included both public and private sector hospitals, and in fact, the majority of hospitals in each case are private. The inclusion of private hospitals has given beneficiaries access to many state-of-the-art facilities that they otherwise would not be able to afford.
Both programs have also made use of commercial insurers for administrative functions, including enrollment, collections (where necessary), provider management, and claims processing and reimbursement. In both cases, the selected insurer is paid a defined premium from the government per beneficiary, and carries the actuarial risk of program beyond that point. Aarogyasri program in Andhra Pradesh is administered in-house from within the trust with no commercial insurer anymore.
The RSBY program is unique in its involvement of local NGOs in the process of building awareness, and identifying and enrolling targeted beneficiaries. RSBY uses “enrollment camps”, or defined periods for enrollment into the scheme, at a district level. RSBY has also used innovative technology to aid enrollment and claims processing, particularly through use of SmartCards. SmartCards are issued, one per family, at the time of enrollment and include information, including fingerprints and photographs, on all enrolled members of the family.
The Aarogyasri program is unique in its use of Aarogya Mithras, health workers who serve as patient advocates and first points of contact for beneficiaries seeking care. There are presently over 4,000 Aarogya Mithras, with one located in each primary health center, to help guide beneficiaries through the process of seeking care and inform them about the available benefits. Aarogyasri also employs robust technology, including enrollment cards that store vital beneficiary information as well as patient visit records.
Impact: Cross-Country Knowledge Sharing
India has been the member of the Joint Learning Network since its inception in 2010 and with the new governance structures of the network have informally institutionalized a JLN country core groups comprised of representatives from the government sponsored health insurance programs from the state and central level. ACCESS Health International has been nominated by the Country Core Group to serve as the secretariat in the coordination and facilitation role.
RSBY and Aarogyasri hosted a delegation from Ghana in 2011 to exchange knowledge on India’s experience with ICT, claims processing, biometric membership ID’s, and subscriber authentication at the provider site.
Ghana’s National Health Insurance Authority received follow-up support from Arogyasri to establish a call center and RSBY on biometric ID’s. Ghana established their call center in early 2012 and began rolling out biometric ID cards in early 2014.
Expanding access to health insurance is an important part of an overall strategy to achieve universal health coverage (UHC). Nigeria will need to make crucial decisions if access and financial protection in the context of health are to be expanded to cover the majority of the population. The Health Policy
The review indicates that UHC interventions in low- and middle-income countries improve access to health care. It also shows, though less convincingly, that UHC often has a positive effect on financial protection, and that, in some cases it seems to have a positive impact on health status. The review also
This paper summarizes the literature on the impact of state subsidized or social health insurance schemes that have been offered, mostly on a voluntary basis, to the informal sector in low- and middle-income countries. A substantial number of papers provide estimations of average treatment on the treated effect for insured
Country Core Group Members
Dr Sandeep Korey
Deutsche Gesellschaft für Internationale Zusammenarbeit