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Challenges of State Governments in Implementing

National Health Insurance

National Health Insurance for Universal

Health Coverage, Manila, Philippines
Asian Development Bank
Sunil Nandraj
Advisor, MOHFW, GOI
India

Scope of the Presentation

Challenges
Policy level
Population coverage and Benefit package
Provision of Services
Financing
Governance
Capacities

Addressing the Challenges

Policy Level

Funding by state governments (part payment 25% under RSBY or independent

schemes states ability for long term funding questionable and sustainability In
many states schemes were closed down

Increased privatization and shifting role of government from provisioning to

purchasing care abdicating its role in health care services

Multiplicity of schemes by various entities and levels- Many states implementing HI

schemes either as independent schemes or under RSBY
Viewed as a
solution to address health problems affecting the state

Implementing mechanisms differ - Some schemes are implemented through

insurance companies (e.g. RSBY) while some States are implementing directly
through a independent body (e.g. Kerala, Karnataka)
Creating parallel structures within the state
Many states due to lack of capacity to set up independent body forced to go with
insurance companies

Cont

Separation of purchaser and provider function when government are providing

care, how feasible ?

Health Insurance as a financing mechanism or as main stay in the context of

health sector reforms being undertaken Delhi

Mid course corrections becomes a challenge for the states

Change in the central government bring about uncertainty and disruptions in

continuation and sustainability eg. RSBY shifting from Labour to Health

Since multiple schemes are being implemented separately, there is high level of
inefficiency e.g. Karnataka

Political
Political parties are different at the centre and states
Branding (name of the scheme)
Taking credit (centre or state) - political and election issue

Population Coverage Benefit Package

National and State interests - Who is to be covered, what benefit package

who decides ?
Population coverage - Overlapping & fragmentation - RSBY covers BPL
while many States cover beyond BPL eg. Kerala, Delhi wants to include
entire population
Multiple benefit packages resulting in varied types of care providedKarnataka covers critical illness
Amount covered differs Kerala provides beyond RSBY Rs. 1 Lakh
Needs of people vary Disease burden, top ups eg. Delhi (critical care,
accident)

Migration Portability State level schemes portability is an issue

especially with migrating populations
In Delhi, high proportion of in-migration

Provision of Services

Availability and accessibility of health facilities

Availability of private / public hospitals especially in rural and remote areas
Private only available where there is a paying capacity
Private hospitals providing the range of benefit package Majority of them 10 to
30 bedded hospitals
Availability of HR (doctors etc.), diagnostic services
Different types of hospitals mostly mom-pop entities, system of functioning
family run business, absence of systems e.g.. information & record keeping,
dependent on visiting consultants, medical equipment poor, quality of care
provided questionable, issue of HR
No special preference for utilizing public hospitals
Empanelment of hospitals each scheme has different criteria for empanelment
Black listing of hospitals one scheme blacklists, another scheme continues
Denial of care across various schemes is a major issue
STGs and protocols differ between schemes
Less attention to improving quality of care and outcomes

Financing

Resources for Health Insurance

Additional funding from finance dept. or from the already meager health
budget
Partly funded by the state not interested in joining the NHI scheme
e.g. Delhi
Varied Claim to Premium Ratio - Data from state schemes shows variation
in Claim to Premium ratio. While it is more than 100% in a large number of
States it is quite low.
Fixing premiums Issues between state schemes and central scheme
Cartelization and competition between insurance companies
Standardization of package rates among multiple schemes - Karnataka
Delay in reimbursement to Hospitals
Delay in payment of premium to insurance companies
States having other forms of purchasing care Mohalla (neighborhood)
clinics, special / specific funds
Convergence with the national health insurance scheme is a challenge

Governance

Management structures and process - Clarity in roles between National & State
governments

Dominant & unregulated private health sector - Accountability and transparency of

private health services in the absence of regulation, lack of data and information

Multiplicity of data - various entities collecting various data at various points control,
access & analysis Kerala & Karnataka

Fragmented research & evaluation

Information Technology different software platforms between schemes, multiplicity

of smart cards

Low awareness of schemes Information on who is covered and what is covered

under what scheme in multiple schemes is an issue resulting in low uptake than
expected - Karnataka and Kerala

Capacities

Health officials moving from traditional functions disease control, managing

hospitals and centre etc. to health insurance functions which is highly technical

Human resources to design and undertake HI, dependent on external

consultants No specialized cadre at the state / central level

Human resources at the state and district level dependent on insurance

companies Kerala

Technical capacities - Negotiating with insurance companies, developing benefit

package, costing, STGs, empanelment of hospitals etc is weak

Monitoring capacity weak in states - Kerala and Karnataka

Detection of frauds and taking action
Undertaking medical and clinical audits

Addressing the Challenges - Kerala

All India level Government has approved a modified form of National Health Insurance
Scheme

Assessment of who is covered under which scheme and their utilization (OP, IP, maternity
etc.) prerequisite for undertaking UHC

Identification of various financial protection schemes including benefit packages in the state

Convergence of financial risk protection schemes at the facility level

Single criteria for empanelment of hospitals

Single smart card

Centralized information system at District and State level

STG, Protocols & care pathways standardized

Thank you
Acknowledge
Nishant Jain GIZ, New Delhi