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SERIES:

         SOCIAL SECURITY EXTENSION
          INITIATIVES IN SOUTH ASIA




                                    INDIA:
                         STATE GOVERNMENT SPONSORED
                      COMMUNITY HEALTH INSURANCE SCHEME
                                        (ANDHRA PRADESH)




              “EXPANDING ACCESS TO MOST EXPENSIVE HEALTH CARE SERVICES”




                                            ILO Subregional Office for South Asia




Decent Work for All                                           Asian Decent Work Decade
INTRODUCTION

The fourteenth Asian Regional meeting of the ILO recently organized in Busan, Republic of South
Korea (August 29th – September 1st) endorsed an Asian Decent Work Decade (2006-2015), during
which concentrated and sustained efforts will be developed in order to progressively realize decent
work for all in all countries. During the proceedings, social protection was explicitly mentioned as a vital
component of Decent Work by a number of speakers including the employers and workers
representatives. The need to roll out social security to workers and their families in the informal
economy, to migrant workers and to non regular workers in the formal economy was also perceived as
a major national social policy objective. The need to enter into a more intensive dialogue with respect to
the design and financing of national social security systems to equip them to cope with the new
requirements and challenges of a global economy also emerged as a major outcome of the meeting.

The challenge of providing social security benefits to each and every citizen has already been taken up
in India. In 2004, the United Progressive Alliance (UPA) Government pledged in its National Common
Minimum Programme (NCMP) to ensure, through social security, health insurance and other schemes
the welfare and well-being of all workers, and most particularly those operating in the informal economy
who now account for 94 per cent of the workforce. In line with this commitment, several new initiatives
were taken both at the Central and at the state level, focusing mainly on the promotion of new health
insurance mechanisms, considered as the pressing need of the day. At the same time, and given the
huge social protection gap and the pressing demand from all excluded groups, health micro-insurance
schemes driven by a wide diversity of actors have proliferated across all India. While a wide diversity of
insurance products has already been made available to the poor, health insurance is still found lagging
behind in terms of overall coverage and scope of benefits, resulting in the fact that access to quality
health care remains a distant dream for many.

Given this context, the ILO’s strategy was to develop an active advocacy role aiming at facilitating the
design and implementation of the most appropriate health protection extension strategies and
programmes. Since any efficient advocacy role has to rely on practical evidence, the ILO first engaged
a wide knowledge development process, aiming at identifying and documenting the most innovative
approaches that could contribute to the progressive extension of health protection to all. One such
innovative and promising approach is the “rare care” health insurance scheme fully sponsored by the
Government of Andhra Pradesh which extends its benefits to all poor.


BACKGROUND

There was a felt need in Andhra Pradesh to provide
financial protection to poor families for the
treatment      of    major   ailments    requiring
hospitalization and surgery.

On the one hand, Government hospitals often do
not have the requisite facility and the necessary
pool of specialists to meet state wide requirements
for the treatment of such diseases. On the other
hand, large proportions of people cannot afford to
pay for treatment in private hospitals or needed to
borrow money of even sell their meagre assets to
access these facilities.

Like many other states, Andhra Pradesh already set up a State Assistance Fund targeting the poorest
segments of the population and aiming at meeting their hospitalization expenses for surgical
procedures. Responding to individual demands, financial assistance to a tune of Rs. 10.72 crore was
disbursed during the period from May 2005 to December 2006. This amount fully covered the
expenditures related to surgical procedures performed for a total of 38,001 cases. From the experience
gained it was felt that the time had come to institutionalize an insurance mechanism that could enhance

                                                                                                    2
the operational efficiency of the scheme, extend its benefits to a broader segment of the population and
improve the overall quality of health care services.

To achieve these goals, the Government of Andhra Pradesh was the first to collaborate with the
Ministry of Health, Government of India, in the framework of the National Rural Health Mission (NRHM)
insurance development plans. In order to operate the scheme professionally in a cost effective manner,
public-private partnership had to be promoted between the State agencies, the private sector hospitals,
the insurance companies and Third Party Administrators. A Public-private Trust had to be set up to
assist the insurance company in establishing a network of hospitals applying pre-determined tariffs on
all services covered under the scheme.

The planned partnership was to cover all issues pertaining to the preparation and implementation of the
insurance scheme such as: the accreditation conditions, the fixing of treatment protocols, tariffs,
treatment procedures, claims processing and scrutiny and monitoring and reporting mechanisms. This
partnership also had to ensure making full use of resources available in the Government system.

Private hospitals fulfilling minimum qualifications in terms of availability of in-patient medical beds, staff,
laboratory equipments, operation theatres etc, and having a track record in the treatment of specified
diseases could be enlisted for providing treatment to families covered under the insurance scheme. The
special Trust to be set up by Government of Andhra Pradesh should assist the insurance company /
TPA / groups of beneficiaries and co-ordinate with all other actors such as Medical and Health
Department, District Collectors, Civil Supplies Department etc.

Inspired by the Guidelines published in 2006 by the Ministry of Health and Family Welfare to support
the NRHM venture into health insurance, the Government of Andhra Pradesh was also dedicated to
collaborate actively with community based organizations, such as the Federations of Self Help Groups,
which had already expressed their interest for the setting up of a health insurance scheme that could
address the needs of their huge membership. The full design and preparation phase of the Rajiv
Aarogyasri Community Health Insurance Scheme was completed in early 2007.


TARGET POPULATION
Like in many other states, the Government of Andhra Pradesh was first considering to cover the Below
Poverty Line population. According to the Planning Commission estimates, the total Below Poverty Line
population of the state amounted to 12.6 million in 2004. A major issue is the divergence in the statistics
on the magnitude of BPL households between the central and sate Governments
                                                                The central government usually projects
                                                                the BPL population based on the NSSO
                                                                date, The state governments, on the
                                                                other hand, prepare the list of BPL with
                                                                the help of data collected from all the
                                                                households in a locality. In 2005, while
                                                                looking for a cost-sharing arrangement in
                                                                relation to a first health insurance
                                                                attempt, this BPL figure issue stalled the
                                                                negotiations initiated with The Central
                                                                Government. Based on this experience,
                                                                the Government of Andhra Pradesh
                                                                decided to go its own way and to rely
                                                                only on State resources which allowed it
                                                                to broaden the coverage of its health
                                                                insurance initiative. As a result, the new
                                                                planned scheme would now cover all
                                                                people availing the ration card, which
                                                                included both the BPL population (pink
                                                                card) and the APL population (white
                                                                card).


                                                                                                       3
This new approach should ultimately result in covering about 70% of the entire population of the
state. To this end, the Trust went on the fast track when launching the successive phases of its
implementation plan.

Phase I (March 2007)

                     Districts                  No of BPL Families              Total BPL Population
 1        Anantapur                                              870,616                        3,134,218
 2        Mahaboobnagar                                          781,777                        2,814,397
 3        Srikakulam                                             664,233                        2,391,239
          Total                                               2,316,426                         8,339,854

Phase II (December 2007)

                    Districts                   No of BPL Families              Total BPL Population
 1        East Godavari
 2        West Godavari
 3        Nalgonda
 4        Ranga Reddy
 5        Chittoor
          Total                                               4,813,000                        16,700,000

Phase III (April 2008)

                       Districts                No of BPL Families              Total BPL Population
 1        Karimnagar
 2        Kadapa
 3        Medak
 4        Nellore
 5        Prakasam
          Total                                               3,487,000                        12,300,000

          Grand Total:                                      10,616,000                        37,339,000


ORGANIZATION

To implement the scheme, the State Government set up the Aarogyashri Health Care Trust under the
chairmanship of the Chief Minister of the State. With technical assistance from specialists in the field of
insurance and health, a competitive bidding process was prepared by the Trust. As a result, a
partnership was entered into with Star Alliance and Allied Insurance Company, the first stand-alone
health insurance company operating in the country.

With regard to the implementation of the scheme, the role of the Trust is to serve as a regulator and
assist the beneficiaries, supervise the Insurance Company and coordinate with Health and Medical
Department, District Administration, Rural development Department and federations of Self Help
Groups.

At the local level, each federation of Self Help Group appoints health workers (also known as Arogya
Mitras) to work in close coloration with the insurance company and ensure interface with the target
group. These health workers are each assigned to a specific hospital where they welcome and advise
the insurance card holders and organize the registration process.

In order to inform all stakeholders as well as the common people, the Asrogyasri has established a very
good online information management system. Any one can easily access the information on the
progress of the scheme in several phases. They can also access disaggregated data on number of
people screened in a health camp, people availing referral services, amount spent, etc. The public can
also find out the health providers who are empanelled by districts and locations. All this information,
updated on a day-to-day basis, would help the people to avail health care facilities


                                                                                                   4
THE INSURANCE PLAN

Eligibility                                                            General Overview

The scheme is open to the whole family without any       Starting date           April 2007
age bar. Family means head of the family, spouse,        Ownership profile       GoAP Trust
dependent children and dependent parents. Any            Target group            All ration card holders
addition of family member during the currency of the     Outreach                13 districts of Andhra
one-year policy shall not be considered. Such                                    Pradesh
additions shall be included at the time of renewal of    Intervention area       Rural, semi-urban
the policy.                                              Risks covered           Single risk: Health
                                                         Premium Insured/Y       Rs 0
Plan Benefits                                            Co-contribution         Rs 249 (GoAP)
                                                         Total premium           Rs 249
The insurance plan only covers listed critical           No of insured           36,700,000
illnesses and major surgeries up to a sum insured of     Percentage of women 51%
Rs. 150,000 per family per year on a floater basis.                 Operational Mechanisms
Additional amount of Rs. 50,000 is available as a
buffer for excess expenses on an individual case         Type of scheme        Partner-agent
basis and all diagnostic tests to be conducted as per    Insurance company     Private
standard protocols are free of cost                      Insurance year        Fixed year
                                                         Insured unit          Whole family
In addition to a list of some 270 surgical procedures,
                                                         Type of enrolment     Voluntary/automatic
the scheme covers the following critical illnesses:
                                                         One-time enrolment    No
                                                         fee
        Heart
                                                         Premium payment       -
        Lungs
        Liver                                            Waiting period        No
        Pancreas                                                   Scope of Health Benefits
        Cancer
        Burns                                            Tertiary health care
        Neuro-surgery
        Paediatric congenital malformations              Hospitalization                  No
                                                         Deliveries                       No
In early 2008, the Trust decided to extend the           Access to medicines              No
coverage to all cases of poly-trauma and cochlear        Primary health care              No
implant surgery for children below 6 years, and to                  Level of Health Benefits
provide follow-up medicines to the beneficiaries
undergoing surgeries under the scheme. These             Surgical procedures      Rs. 150,000
medicines will be made available for free at all         Additional buffer        Rs. 50,000
public Teaching / District Hospitals.                                    Service Delivery

The scheme also covers pre-existing diseases and         Health prevent./educ.    No
provides free transportation in case of referral from    programmes
a health camp. Additional features include: simple       Prior health check-up    No
procedures, e-authorization, packages for end-to-        Tie-up with H.P.         Yes
end-treatment and 24 hour toll free help line. Free      Type of health prov.     Private and public HP
food must also be provided by the hospital to each       Type of agreement        Formal agreement
patient till discharge                                   No of associated HP      74
                                                         TPA intervention         No
Premium Rate                                             Access to health care    Pre-authorization and
                                                         services                 referral
Premium was first set at Rs. 300 per family per year     Co-payment:              No
at no cost to the family. The premium registered a       HC payment modality      Pure cashless
slight decline when negotiating its next expansion       Additional financial     Free food, free
phases with insurance companies and stands now           benefits                 transportation
at Rs. 249 per family per year (Plus Service Tax)        Additional Non-          Health camps, free
fully paid by the Government of Andhra Pradesh           financial benefits       screening, dedicated
                                                                                  reception desk
                                                                                                  5
Plan Distribution

Database and photographs in electronic format of BPL families were already in the ration cards issued
by the Civil Supplies Department. The Trust will provide the details of each BPL family covered under
the scheme electronically though the white ration card. This card will be a part of enrolment /
identification for availing the health insurance facility.




Service Delivery

The scheme is presently associated with 74 hospitals spread across the State. All hospitals (whether
private or public) associated with the scheme should comply with the following minimum criteria:

    Minimum of 50 in-patient medical beds              Maintaining complete record as required on
    Fully equipped and engaged in providing            day to day basis and be able to provide
    medical and surgical facilities along with         necessary records of the insured patient to
    diagnostic facilities i.e. Pathological test and   the insurer or his representative
    X-ray, E.C.G…                                      Using ICD and OPQS codes for Drugs,
    Fully equipped operation theatre                   Diagnosis, Surgical procedures, etc.
    Fully qualifies doctors should be physically in     Having sufficient experience
    charge round the clock

They should also be in a position to provide the following additional benefits to insured: substantial
discounts on diagnostic tests and medical treatment and minimum of 10-12 free health camps per year


MAIN ACHIEVEMENTS

Coverage

The scheme was initiated in three districts of Andhra Pradesh, covering already about 8 million people.
Over a one-year period, the scheme expanded to ten new districts adding a total of 29 million people
under its cover.


                                                                                               6
Services Provided

Health Camps

As mentioned in the first status report released by the scheme, 1,053 mega health camps could be
organized in the three districts covered in Phase I (01/04/2007 – 31/03/2008), These camps allowed for
people to be screened by medical officers before being immediately referred to network hospitals if
need be. Some 175,000 people were screened with more than 15,000 being referred for pre-
authorization and final approval before treatment.

During its first one-year phase, referral cases in                                   Percentage of Referrals
the three districts ranged between 8.7% and
9.1% of the population screened.                            9.1

                                                             9

                                                            8.9
                N° Camps     N° Screen        N° Refer.     8.8
Anantapur             421          76,228          6,697    8.7
Mahabubnagar          346          47,036          4,241    8.6
Srikakulam            286          52,302          4,764
                                                            8.5
Total               1,053         175,566         15,702                Anantapur           Mahabubnagar          Srikakulam




Surgeries Performed

As total of 11,484 surgeries were performed during Phase I, most of these related to cardiac problems
(41% of interventions). The corresponding cost for the scheme amounted to a total of Rs. 515 million,
meaning an average claims cost of Rs. 44,800.

The 11,484 surgical interventions performed fell
                                                                                          Surgeries Performed
into the following categories:
                                                           5000
                                                           4500
                                                           4000
                                                           3500
                        N°          % Total     Cum.%      3000
1. Cardiac              4,712          41.0         41.0   2500
2. Neuro                2,850          24.8         65.8   2000
                                                           1500
3. Cancer               2,434          21.2         87.0
                                                           1000
4. Renal                    674         5.9         92.9   500
5. Polytrauma               671         5.8         98,7     0
                                                                   Cardiac       Neuro      Cancer     Renal    Polytrauma     Burns
6. Burns                    143         1.3        100.0


Gender-wise Distribution of Interventions

Only 11% of all surgical interventions were                                  Gender-wise Distribution of Surgeries
performed on children

                                                                                    11%


                                                                                                                                  48%
                  N° Surgeries                %
Male                        5,453                  47.5
                                                                  41%
Female                      4,746                  41.3
Children                    1,285                  11.2
Total                    11,484                   100.0



                                                                                                                                       7
CHALLENGES
The insurance plan has still to address the following key challenges:

        The total number of beneficiaries appears to be very limited as compared to the overall figure of
        insured in the first three districts. This number could raise to new peaks once everyone is
        aware of the existence of the scheme
        A mechanism allowing for a systematic appraisal of the quality of services provided under the
        scheme should reach all beneficiaries
        There is still a need to strengthen the medical audit capacities and to report on all interventions
        covered under the scheme
        At this early stage, the long-term financial implications of the planned extension of the scheme
        to the whole state cannot be fully measured
        The involvement of an insurance company in the management of such a scheme may still be
        questioned over time


THE LINKAGE EXPERIENCE

Developing efficient partnership arrangements is already seen as a key element for the successful
implementation of any health insurance scheme. Evidence also suggests that building efficient linkages
between community-based initiatives and government programmes in order to exploit their respective
strengths is another major requirement. This necessary synergy may be developed at various levels.

              Scope of Linkages                    The first partnership arrangements developed over
                                                   less than a year by this ambitious health insurance
Financing:                                         initiative are still expected to expand over the years
                                                   to come. However, the innovative arrangements that
Operations:                                        were already concluded with a broad network of
Service Delivery:                                  health providers (including fixed concessional tariffs),
                                                   as well as with the insurance company (with stop-loss
Governance:                       No               and profit limitation provisions) deserve a special
Policy Planning:                  No               attention when comparing with other government
Legal Framework:                                   sponsored health insurance schemes


1. Financing

The full cost of the running of the scheme is borne by the Government of Andhra Pradesh. There is no
contribution coming in the form of either a yearly premium or a one-time registration fee from the
insured.

2. Operations

The scheme benefits from the active support provided at all levels by the Ministry of Health. It also
relies on the active support of Federations of SHGs spread across the whole state.

3. Service Delivery

The scheme has succeeded to develop efficient partnership arrangements with a broad network of
private hospitals guaranteeing a high-level quality of health care services. These facilities have agreed
to apply standard rates for all procedures covered under the scheme, resulting in some decrease in the
treatment costs. Although still in small number, several public hospitals have been associated with the
scheme.

4. Governance

The administration of the scheme is left to a Trust regrouping only public department representatives.
So far, there is no direct involvement of any other key actor.
                                                                                                   8
5. Policy Planning

The Government of Andhra Pradesh is keen that the scheme should rapidly extend to all other districts.
This goal is now expected to be reached by the end of 2008. If this is going to happen, several years
will be required before drawing the full lessons – including the financial ones - of an extension initiative
of this magnitude. There is thus still a long way before developing a working model that could be
replicated in other states.

It is noteworthy to mention that in the case of Rajasthan, also willing to develop a similar scheme in the
NRHM framework, the original orientation has evolved over time towards an intervention that would be
more along the lines of the new scheme promoted by the Ministry of Labour and Employment (targeting
only the BPL population and covering hospitalization expenses).

6. Legal Framework

The scheme falls under the partner-agent model as described by the Micro-insurance Regulations
issued in November 2005 by the Insurance Regulatory and Development Authority (IRDA) of India. It is
therefore under regulation of the IRDA and would be considered as fulfilling Star Health & Alliance’s
obligations to the rural sector.


CONCLUSION

The innovative health insurance experience conducted in Andhra Pradesh has succeeded to become
the largest in India in its first year of operation. Already scaling up to reach a total of 38 million, it is
expected to further expand in order to cover the whole state by the end of the year. This amazing pace
of development was never experienced before and many new implementation challenges will have to
be addressed over the next few months. Special credit must be given to the Government of Andhra
Pradesh for the transparency of all activities and the importance it set on opening wide communication
channels not only with key stakeholders but also with the public at large. This particular feature should
be used to develop more in-depth analysis with a focus on relations with health providers (in the
absence of a Third Party Administrator) and with the self-help groups and their federations working at
the grassroots level. At this still early stage, a better understanding of these relations could already
prove very helpful to determine and facilitate similar initiatives in other states.

                         To learn more, contact:


                         Shri. Babu. A., I.A.S, Chief Executive Officer
                         Aarogyashri Health Care Trust, 3rd Floor, Municipal Complex, Sultan Bazar
                         Koti, Hyderabab – 500 001, Andhra Pradesh

                            : (040) 2465 2540 / 2465 2478

                         Dr. S.P. Goswamy, National Consultant, Health Insurance
                         Ministry of Health & Family Welfare, Government of India
                         ½ Taj Apartments, Rao Tula Marg, Motibagh, New Delhi
                         E.mail: drspgoswamy@yahoo.com

                            : (011) 98183 12179




                                                                                                     9

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Andra health scheme

  • 1. SERIES: SOCIAL SECURITY EXTENSION INITIATIVES IN SOUTH ASIA INDIA: STATE GOVERNMENT SPONSORED COMMUNITY HEALTH INSURANCE SCHEME (ANDHRA PRADESH) “EXPANDING ACCESS TO MOST EXPENSIVE HEALTH CARE SERVICES” ILO Subregional Office for South Asia Decent Work for All Asian Decent Work Decade
  • 2. INTRODUCTION The fourteenth Asian Regional meeting of the ILO recently organized in Busan, Republic of South Korea (August 29th – September 1st) endorsed an Asian Decent Work Decade (2006-2015), during which concentrated and sustained efforts will be developed in order to progressively realize decent work for all in all countries. During the proceedings, social protection was explicitly mentioned as a vital component of Decent Work by a number of speakers including the employers and workers representatives. The need to roll out social security to workers and their families in the informal economy, to migrant workers and to non regular workers in the formal economy was also perceived as a major national social policy objective. The need to enter into a more intensive dialogue with respect to the design and financing of national social security systems to equip them to cope with the new requirements and challenges of a global economy also emerged as a major outcome of the meeting. The challenge of providing social security benefits to each and every citizen has already been taken up in India. In 2004, the United Progressive Alliance (UPA) Government pledged in its National Common Minimum Programme (NCMP) to ensure, through social security, health insurance and other schemes the welfare and well-being of all workers, and most particularly those operating in the informal economy who now account for 94 per cent of the workforce. In line with this commitment, several new initiatives were taken both at the Central and at the state level, focusing mainly on the promotion of new health insurance mechanisms, considered as the pressing need of the day. At the same time, and given the huge social protection gap and the pressing demand from all excluded groups, health micro-insurance schemes driven by a wide diversity of actors have proliferated across all India. While a wide diversity of insurance products has already been made available to the poor, health insurance is still found lagging behind in terms of overall coverage and scope of benefits, resulting in the fact that access to quality health care remains a distant dream for many. Given this context, the ILO’s strategy was to develop an active advocacy role aiming at facilitating the design and implementation of the most appropriate health protection extension strategies and programmes. Since any efficient advocacy role has to rely on practical evidence, the ILO first engaged a wide knowledge development process, aiming at identifying and documenting the most innovative approaches that could contribute to the progressive extension of health protection to all. One such innovative and promising approach is the “rare care” health insurance scheme fully sponsored by the Government of Andhra Pradesh which extends its benefits to all poor. BACKGROUND There was a felt need in Andhra Pradesh to provide financial protection to poor families for the treatment of major ailments requiring hospitalization and surgery. On the one hand, Government hospitals often do not have the requisite facility and the necessary pool of specialists to meet state wide requirements for the treatment of such diseases. On the other hand, large proportions of people cannot afford to pay for treatment in private hospitals or needed to borrow money of even sell their meagre assets to access these facilities. Like many other states, Andhra Pradesh already set up a State Assistance Fund targeting the poorest segments of the population and aiming at meeting their hospitalization expenses for surgical procedures. Responding to individual demands, financial assistance to a tune of Rs. 10.72 crore was disbursed during the period from May 2005 to December 2006. This amount fully covered the expenditures related to surgical procedures performed for a total of 38,001 cases. From the experience gained it was felt that the time had come to institutionalize an insurance mechanism that could enhance 2
  • 3. the operational efficiency of the scheme, extend its benefits to a broader segment of the population and improve the overall quality of health care services. To achieve these goals, the Government of Andhra Pradesh was the first to collaborate with the Ministry of Health, Government of India, in the framework of the National Rural Health Mission (NRHM) insurance development plans. In order to operate the scheme professionally in a cost effective manner, public-private partnership had to be promoted between the State agencies, the private sector hospitals, the insurance companies and Third Party Administrators. A Public-private Trust had to be set up to assist the insurance company in establishing a network of hospitals applying pre-determined tariffs on all services covered under the scheme. The planned partnership was to cover all issues pertaining to the preparation and implementation of the insurance scheme such as: the accreditation conditions, the fixing of treatment protocols, tariffs, treatment procedures, claims processing and scrutiny and monitoring and reporting mechanisms. This partnership also had to ensure making full use of resources available in the Government system. Private hospitals fulfilling minimum qualifications in terms of availability of in-patient medical beds, staff, laboratory equipments, operation theatres etc, and having a track record in the treatment of specified diseases could be enlisted for providing treatment to families covered under the insurance scheme. The special Trust to be set up by Government of Andhra Pradesh should assist the insurance company / TPA / groups of beneficiaries and co-ordinate with all other actors such as Medical and Health Department, District Collectors, Civil Supplies Department etc. Inspired by the Guidelines published in 2006 by the Ministry of Health and Family Welfare to support the NRHM venture into health insurance, the Government of Andhra Pradesh was also dedicated to collaborate actively with community based organizations, such as the Federations of Self Help Groups, which had already expressed their interest for the setting up of a health insurance scheme that could address the needs of their huge membership. The full design and preparation phase of the Rajiv Aarogyasri Community Health Insurance Scheme was completed in early 2007. TARGET POPULATION Like in many other states, the Government of Andhra Pradesh was first considering to cover the Below Poverty Line population. According to the Planning Commission estimates, the total Below Poverty Line population of the state amounted to 12.6 million in 2004. A major issue is the divergence in the statistics on the magnitude of BPL households between the central and sate Governments The central government usually projects the BPL population based on the NSSO date, The state governments, on the other hand, prepare the list of BPL with the help of data collected from all the households in a locality. In 2005, while looking for a cost-sharing arrangement in relation to a first health insurance attempt, this BPL figure issue stalled the negotiations initiated with The Central Government. Based on this experience, the Government of Andhra Pradesh decided to go its own way and to rely only on State resources which allowed it to broaden the coverage of its health insurance initiative. As a result, the new planned scheme would now cover all people availing the ration card, which included both the BPL population (pink card) and the APL population (white card). 3
  • 4. This new approach should ultimately result in covering about 70% of the entire population of the state. To this end, the Trust went on the fast track when launching the successive phases of its implementation plan. Phase I (March 2007) Districts No of BPL Families Total BPL Population 1 Anantapur 870,616 3,134,218 2 Mahaboobnagar 781,777 2,814,397 3 Srikakulam 664,233 2,391,239 Total 2,316,426 8,339,854 Phase II (December 2007) Districts No of BPL Families Total BPL Population 1 East Godavari 2 West Godavari 3 Nalgonda 4 Ranga Reddy 5 Chittoor Total 4,813,000 16,700,000 Phase III (April 2008) Districts No of BPL Families Total BPL Population 1 Karimnagar 2 Kadapa 3 Medak 4 Nellore 5 Prakasam Total 3,487,000 12,300,000 Grand Total: 10,616,000 37,339,000 ORGANIZATION To implement the scheme, the State Government set up the Aarogyashri Health Care Trust under the chairmanship of the Chief Minister of the State. With technical assistance from specialists in the field of insurance and health, a competitive bidding process was prepared by the Trust. As a result, a partnership was entered into with Star Alliance and Allied Insurance Company, the first stand-alone health insurance company operating in the country. With regard to the implementation of the scheme, the role of the Trust is to serve as a regulator and assist the beneficiaries, supervise the Insurance Company and coordinate with Health and Medical Department, District Administration, Rural development Department and federations of Self Help Groups. At the local level, each federation of Self Help Group appoints health workers (also known as Arogya Mitras) to work in close coloration with the insurance company and ensure interface with the target group. These health workers are each assigned to a specific hospital where they welcome and advise the insurance card holders and organize the registration process. In order to inform all stakeholders as well as the common people, the Asrogyasri has established a very good online information management system. Any one can easily access the information on the progress of the scheme in several phases. They can also access disaggregated data on number of people screened in a health camp, people availing referral services, amount spent, etc. The public can also find out the health providers who are empanelled by districts and locations. All this information, updated on a day-to-day basis, would help the people to avail health care facilities 4
  • 5. THE INSURANCE PLAN Eligibility General Overview The scheme is open to the whole family without any Starting date April 2007 age bar. Family means head of the family, spouse, Ownership profile GoAP Trust dependent children and dependent parents. Any Target group All ration card holders addition of family member during the currency of the Outreach 13 districts of Andhra one-year policy shall not be considered. Such Pradesh additions shall be included at the time of renewal of Intervention area Rural, semi-urban the policy. Risks covered Single risk: Health Premium Insured/Y Rs 0 Plan Benefits Co-contribution Rs 249 (GoAP) Total premium Rs 249 The insurance plan only covers listed critical No of insured 36,700,000 illnesses and major surgeries up to a sum insured of Percentage of women 51% Rs. 150,000 per family per year on a floater basis. Operational Mechanisms Additional amount of Rs. 50,000 is available as a buffer for excess expenses on an individual case Type of scheme Partner-agent basis and all diagnostic tests to be conducted as per Insurance company Private standard protocols are free of cost Insurance year Fixed year Insured unit Whole family In addition to a list of some 270 surgical procedures, Type of enrolment Voluntary/automatic the scheme covers the following critical illnesses: One-time enrolment No fee Heart Premium payment - Lungs Liver Waiting period No Pancreas Scope of Health Benefits Cancer Burns Tertiary health care Neuro-surgery Paediatric congenital malformations Hospitalization No Deliveries No In early 2008, the Trust decided to extend the Access to medicines No coverage to all cases of poly-trauma and cochlear Primary health care No implant surgery for children below 6 years, and to Level of Health Benefits provide follow-up medicines to the beneficiaries undergoing surgeries under the scheme. These Surgical procedures Rs. 150,000 medicines will be made available for free at all Additional buffer Rs. 50,000 public Teaching / District Hospitals. Service Delivery The scheme also covers pre-existing diseases and Health prevent./educ. No provides free transportation in case of referral from programmes a health camp. Additional features include: simple Prior health check-up No procedures, e-authorization, packages for end-to- Tie-up with H.P. Yes end-treatment and 24 hour toll free help line. Free Type of health prov. Private and public HP food must also be provided by the hospital to each Type of agreement Formal agreement patient till discharge No of associated HP 74 TPA intervention No Premium Rate Access to health care Pre-authorization and services referral Premium was first set at Rs. 300 per family per year Co-payment: No at no cost to the family. The premium registered a HC payment modality Pure cashless slight decline when negotiating its next expansion Additional financial Free food, free phases with insurance companies and stands now benefits transportation at Rs. 249 per family per year (Plus Service Tax) Additional Non- Health camps, free fully paid by the Government of Andhra Pradesh financial benefits screening, dedicated reception desk 5
  • 6. Plan Distribution Database and photographs in electronic format of BPL families were already in the ration cards issued by the Civil Supplies Department. The Trust will provide the details of each BPL family covered under the scheme electronically though the white ration card. This card will be a part of enrolment / identification for availing the health insurance facility. Service Delivery The scheme is presently associated with 74 hospitals spread across the State. All hospitals (whether private or public) associated with the scheme should comply with the following minimum criteria: Minimum of 50 in-patient medical beds Maintaining complete record as required on Fully equipped and engaged in providing day to day basis and be able to provide medical and surgical facilities along with necessary records of the insured patient to diagnostic facilities i.e. Pathological test and the insurer or his representative X-ray, E.C.G… Using ICD and OPQS codes for Drugs, Fully equipped operation theatre Diagnosis, Surgical procedures, etc. Fully qualifies doctors should be physically in Having sufficient experience charge round the clock They should also be in a position to provide the following additional benefits to insured: substantial discounts on diagnostic tests and medical treatment and minimum of 10-12 free health camps per year MAIN ACHIEVEMENTS Coverage The scheme was initiated in three districts of Andhra Pradesh, covering already about 8 million people. Over a one-year period, the scheme expanded to ten new districts adding a total of 29 million people under its cover. 6
  • 7. Services Provided Health Camps As mentioned in the first status report released by the scheme, 1,053 mega health camps could be organized in the three districts covered in Phase I (01/04/2007 – 31/03/2008), These camps allowed for people to be screened by medical officers before being immediately referred to network hospitals if need be. Some 175,000 people were screened with more than 15,000 being referred for pre- authorization and final approval before treatment. During its first one-year phase, referral cases in Percentage of Referrals the three districts ranged between 8.7% and 9.1% of the population screened. 9.1 9 8.9 N° Camps N° Screen N° Refer. 8.8 Anantapur 421 76,228 6,697 8.7 Mahabubnagar 346 47,036 4,241 8.6 Srikakulam 286 52,302 4,764 8.5 Total 1,053 175,566 15,702 Anantapur Mahabubnagar Srikakulam Surgeries Performed As total of 11,484 surgeries were performed during Phase I, most of these related to cardiac problems (41% of interventions). The corresponding cost for the scheme amounted to a total of Rs. 515 million, meaning an average claims cost of Rs. 44,800. The 11,484 surgical interventions performed fell Surgeries Performed into the following categories: 5000 4500 4000 3500 N° % Total Cum.% 3000 1. Cardiac 4,712 41.0 41.0 2500 2. Neuro 2,850 24.8 65.8 2000 1500 3. Cancer 2,434 21.2 87.0 1000 4. Renal 674 5.9 92.9 500 5. Polytrauma 671 5.8 98,7 0 Cardiac Neuro Cancer Renal Polytrauma Burns 6. Burns 143 1.3 100.0 Gender-wise Distribution of Interventions Only 11% of all surgical interventions were Gender-wise Distribution of Surgeries performed on children 11% 48% N° Surgeries % Male 5,453 47.5 41% Female 4,746 41.3 Children 1,285 11.2 Total 11,484 100.0 7
  • 8. CHALLENGES The insurance plan has still to address the following key challenges: The total number of beneficiaries appears to be very limited as compared to the overall figure of insured in the first three districts. This number could raise to new peaks once everyone is aware of the existence of the scheme A mechanism allowing for a systematic appraisal of the quality of services provided under the scheme should reach all beneficiaries There is still a need to strengthen the medical audit capacities and to report on all interventions covered under the scheme At this early stage, the long-term financial implications of the planned extension of the scheme to the whole state cannot be fully measured The involvement of an insurance company in the management of such a scheme may still be questioned over time THE LINKAGE EXPERIENCE Developing efficient partnership arrangements is already seen as a key element for the successful implementation of any health insurance scheme. Evidence also suggests that building efficient linkages between community-based initiatives and government programmes in order to exploit their respective strengths is another major requirement. This necessary synergy may be developed at various levels. Scope of Linkages The first partnership arrangements developed over less than a year by this ambitious health insurance Financing: initiative are still expected to expand over the years to come. However, the innovative arrangements that Operations: were already concluded with a broad network of Service Delivery: health providers (including fixed concessional tariffs), as well as with the insurance company (with stop-loss Governance: No and profit limitation provisions) deserve a special Policy Planning: No attention when comparing with other government Legal Framework: sponsored health insurance schemes 1. Financing The full cost of the running of the scheme is borne by the Government of Andhra Pradesh. There is no contribution coming in the form of either a yearly premium or a one-time registration fee from the insured. 2. Operations The scheme benefits from the active support provided at all levels by the Ministry of Health. It also relies on the active support of Federations of SHGs spread across the whole state. 3. Service Delivery The scheme has succeeded to develop efficient partnership arrangements with a broad network of private hospitals guaranteeing a high-level quality of health care services. These facilities have agreed to apply standard rates for all procedures covered under the scheme, resulting in some decrease in the treatment costs. Although still in small number, several public hospitals have been associated with the scheme. 4. Governance The administration of the scheme is left to a Trust regrouping only public department representatives. So far, there is no direct involvement of any other key actor. 8
  • 9. 5. Policy Planning The Government of Andhra Pradesh is keen that the scheme should rapidly extend to all other districts. This goal is now expected to be reached by the end of 2008. If this is going to happen, several years will be required before drawing the full lessons – including the financial ones - of an extension initiative of this magnitude. There is thus still a long way before developing a working model that could be replicated in other states. It is noteworthy to mention that in the case of Rajasthan, also willing to develop a similar scheme in the NRHM framework, the original orientation has evolved over time towards an intervention that would be more along the lines of the new scheme promoted by the Ministry of Labour and Employment (targeting only the BPL population and covering hospitalization expenses). 6. Legal Framework The scheme falls under the partner-agent model as described by the Micro-insurance Regulations issued in November 2005 by the Insurance Regulatory and Development Authority (IRDA) of India. It is therefore under regulation of the IRDA and would be considered as fulfilling Star Health & Alliance’s obligations to the rural sector. CONCLUSION The innovative health insurance experience conducted in Andhra Pradesh has succeeded to become the largest in India in its first year of operation. Already scaling up to reach a total of 38 million, it is expected to further expand in order to cover the whole state by the end of the year. This amazing pace of development was never experienced before and many new implementation challenges will have to be addressed over the next few months. Special credit must be given to the Government of Andhra Pradesh for the transparency of all activities and the importance it set on opening wide communication channels not only with key stakeholders but also with the public at large. This particular feature should be used to develop more in-depth analysis with a focus on relations with health providers (in the absence of a Third Party Administrator) and with the self-help groups and their federations working at the grassroots level. At this still early stage, a better understanding of these relations could already prove very helpful to determine and facilitate similar initiatives in other states. To learn more, contact: Shri. Babu. A., I.A.S, Chief Executive Officer Aarogyashri Health Care Trust, 3rd Floor, Municipal Complex, Sultan Bazar Koti, Hyderabab – 500 001, Andhra Pradesh : (040) 2465 2540 / 2465 2478 Dr. S.P. Goswamy, National Consultant, Health Insurance Ministry of Health & Family Welfare, Government of India ½ Taj Apartments, Rao Tula Marg, Motibagh, New Delhi E.mail: drspgoswamy@yahoo.com : (011) 98183 12179 9