Voluntary health insurance schemes or privatefor-profit schemes:
The CGHS and ESIS were the only forms of insurance until the introduction of Voluntary Health Insurance in 1986 and they covered only formal sector employees.
The vast majority of the population received care from either the public health facilities or fee-for-service private sector. This scenario changed drastically in the last three years with state governments announcing their new health insurance schemes specifically targeting the poor.
The Rajiv Aarogyasri Scheme (RAS), the first of this class targeting below-thepoverty-line population of Andhra Pradesh was introduced in 2007. In 2009, approximately 20.4 million families and 70 million beneficiaries were covered by the scheme, which is about 85 percent of the total population of the state.
It is interesting to observe that a scheme, which was originally planned to be focussed on BPL families, went ahead to cover almost the entire population of the state. This scheme is considered to be one of the pioneering effort in terms of achieving equity and universalism in a limited sense. Rajiv Aarogyasri or Aarogyasri is a program of the Government of Andhra Pradesh. It covers those below the poverty line. The government issues a Aarogyasri card and the beneficiary can use it at government and private hospitals and get services free of cost.[13,14,15]
Rajiv Aarogyasri is the flagship scheme of all health initiatives of the State Government with a mission to provide quality healthcare to the poor. The aim of the Government is to achieve "Health for All". In order to facilitate the effective implementation of the scheme, the State Government set up the Aarogyasri Health Care Trust under the chairmanship of the Chief Minister.
The Trust is administered by a Chief Executive Officer, an IAS Officer. The trust, in consultation with the specialists in the field of healthcare, runs the scheme.
On similar lines, other state governments have introduced or are in the process of introducing insurance schemes targeting poor households. Notable among these are Kalaignar health insurance scheme that currently covers 55 million people in Tamil Nadu (2009) changed and upgraded to Amma kapitu thittam(2012) and Vajapayee Arogyasri Karnataka (2009).
Vajapayee Arogyasri currently in its pilot phase in the Gulbarga division of Karnataka covers any 5 members of family holding a BPLcard. As of September 2009 the scheme covered 1.6 million people. The scheme is designed to extend coverage to 6.3 million BPL families each year in a phase wise manner.
On the other hand, the commercial or private health insurance provided by publicly and privately owned General Insurance companies have typically served only the better offpopulations. Although private health insurance has grown at the rate of 40% per annum, it has not been able to permeate into a large part of population owing to high premiums, very low awareness, and poor back-end infrastructure (FICCI, 2009). With 'Mediclaim' as the only health insurance policy sold for a long time, the industry has also been marred by lack of innovation.
The Yeshasvini scheme in Karnataka (2003) is an example of government subsidized voluntary health insurance scheme, targeting the poor. Yeshasvini targets more than 12 million people registered in cooperative societies in Karnataka. The representation is stronger in the rural sector where Primary Agriculture Cooperative Societies (PACS), rural credit and savings cooperatives, sugarcane production and dairy cooperatives account for about 8.2 million people.
The RSBY (2008), which is on the other end of the spectrum, is also voluntary in enrolment, was initiated by the Central Government (Ministry of Labour and Employment) as a national health insurance scheme targeting the BPL population. The scheme currently covers approximately 80 million individuals across the country (RSBY2011), which is approximately 27% of the target population.
Indian Journal of Peritoneal Dialysis
In private insurance, buyers are willing to pay the premium to an insurance company that insures them for health related expenses. The main distinction is that the premiums are set at different levels, as per age, pre-existing conditions, which are based on assessment of risk status of the consumer (or of the group of employees) and the benefits are provided, according to the preset premium paid to the insurance company.
In the public sector, the General Insurance Corporation (GIC) and its four subsidiary companies (National Insurance Corporation, New India Assurance Company, Oriental Insurance Company and United Insurance Company) provide voluntary insurance schemes.
The most popular health insurance cover offered by GIC is Mediclaim policy
• Mediclaim policy: It was introduced in1986. It reimburses the hospitalization expenses for illness or injury suffered by the insured, whether the hospitalization is domiciliary or otherwise. It does not cover outpatient treatments. Government has exempted the premium paid by individuals from their taxable income. Because of high premium it has served only to affordable class, urban tax payer segment of population.
• Some of the various other voluntary health insurance schemes available in the market are :- Asha deep plan II , Jeevan Asha plan II, Jan Arogya policy, Raja Rajeswari policy, Overseas Mediclaim policy, Cancer Insurance policy, Bhavishya Arogya policy, Dreaded disease policy, Health Guard, Critical illness policy, Group Health insurance policy, Shakti Shield etc.
• At present Health insurance is provided mainly in the form of riders. There are very few pure health insurance policies under voluntary health insurance schemes.
2. Mandatory health insurance schemes or government run schemes (namely ESIS, CGHS) Employer State Insurance Scheme (ESI):
Enacted in 1948, the employers' state insurance (ESI) Act was the first major legislation on social security in India. The scheme applies to power using factories employing 10 persons or more and non-power and other specified establishments employing 20 persons or more.
It covers employees and the dependents against loss of wages due to sickness, maternity, disability and death due to employment injury. It also covers funeral expenses and rehabilitation allowance. Medical care comprises outpatient care, hospitalization, medicines and specialist care.
These services are provided through network of ESIS facilities, public care centers, non-governmental organizations (NGOs) and empanelled private practitioners. The ESIS is financed by three way contributions from employers, employees and the state government.
Even though the scheme is formulated well there are problem areas in managing this scheme. Some of the problems are :-
* Large numbers of posts of medical staff remain vacant due to high turnover and low remuneration compared to corporate hospitals.
* Rising costs and technological advancement in super specialty treatment.
* Management information is not satisfactory.
* The patients are not satisfied with the services they get
* Low utilization of the hospitals
* In rural areas, the access to services is also a problem
All these problems indicate an urgent need for reforms in the ESIS Scheme.
• Central Government Health Insurance Scheme (CGHS):-
Established in 1954, the CGHS covers employees and retirees of the central government and certain autonomous and semi autonomous and semi-government organizations. It also covers Members of Parliament, Governors, accredited journalists and members of general public in some specified areas. Benefits under the scheme include medical care, home visits/care, free medicines and diagnostic services.
These services are provided through public facilities with some specialized treatment (with reimbursement ceilings) being permissible at private facilities. Most of the expenditure Indian Journal of Peritoneal Dialysis is met by the central government as only 12% is the shareof contribution.
* The CGHS has been criticized from the point of view of quality and accessibility. Subscribers have complained of high out of pocket expenses due to slow reimbursement and incomplete coverage for private health care (as only 80% of the cost is reimbursed if referral is made to private facility, when such facilities are not available with the CGHS).
* Andaman: CAPD was initiated in the year 2002, and free CAPD bags and accessories were supplied from medical store s of GB.Pant Hospital. For all these patients catheter was implanted at mainland(Chennai or Kolkata) and the prescription was given by the Nephrologist. This year CAPD Programme has been launched in the Andaman & Nicobar Islands.
With the launching of CAPD programme at G.B. Pant Hospital, patients from Islands are no longer required to go to mainland for CAPD catheter implantation and prescription. The catheter can be implanted by the trained surgeon at G.B. Pant Hospital, Port Blair and prescription of CAPD and follow up can be done by the trained physician and technician.
The Dialysis unit at G.B. Pant Hospital has been functioning since 2002 and is performing more than 500 Dialysis in a month. CAPD fluid which costs around Rs. 20,000- 25,000/- per month. Initiation of CAPD Programme in Andaman will benefit a large number of patients of ESRD requiring Dialysis who are spread across many Island in Archipelago.[16]
• Universal Health Insurance Scheme (UHIS):-
For providing financial risk protection to the poor, the government announced UHIS in 2003. Under this scheme, for a premium of Rs. 165 per year per person, Rs.248 for a family of five and Rs.330 for a family of seven , health care for sum equivalent to Rs. 30,000/- was provided. This scheme has been made eligible for below poverty line families only. To make the scheme more saleable, the insurance companies provided for a floater clause that made any member of family eligible as against mediclaim policy which is for an individual member. In spite of all these, the scheme was not successful.
The reasons for failing to attract rural poor are many :-
* The public sector companies who where required to implement this scheme found it to be potentially loss making. To meet the target, it is learnt that several field officers pay the premium under fictitious names.
* Identification of eligible families is a difficult task a Poor find it difficult to pay the entire premium at one time for future benefit, foregoing current consumption needs. a Paper work required to settle the claims is cumbersome a Deficit in availability of service providers a Set back due to health insurance companies refusing to renew the previous year's policies.
In 2004, the government also provided an insurance product to the Self Help Group (SHG) for a premium of Rs.120 and sum assured of Rs.10000/-. However, the intake is negligible. The reasons for poor intake are similar to those cited above.
3. Insurance offered by NGOs/Community based health insurance(CBHI)
Community based schemes are typically targeted at poorer population living in communities. Such schemes are generally run by charitable trusts or non-governmental organizations (NGOs). In these schemes the members prepay a set amount each year for specified services. The premia are usually flat rate (not income related) and therefore not progressive.
The benefits offered are mainly in terms of preventive care, though ambulatory and inpatient care is also covered. Such schemes tend to be financed through patient collection, government grants and donations. Increasingly in India, CBHI schemes are negotiating with for profit insurers for the purchase of custom designed group insurance policies. a CBHI schemes suffer from poor design and management. Often there is a problem of adverse selection as premiums are not based on assessment of individual risk status.
These schemes fail to include the poorest of the poor.
Indian Journal of Peritoneal Dialysis
They have low membership and require extensive financial support. Other issues are related to sustainability and replication of such schemes. a Some of the popular Community Based Health Insurance schemes are: - Self-Employed Women's Association (SEWA), Tribuvandas Foundation (TF), The Mullur Milk Co-operative, Sewagram, Action for Community Organization, Rehabilitation and Development (ACCORD), Voluntary Health Services (VHS) etc.
4. Employer based schemes
Employers in both public and private sector offers employer based insurance schemes through their own employer. These facilities are by way of lump sum payments, reimbursement of employees' health expenditure for out patient care and hospitalization, fixed medical allowance or covering them under the group health insurance schemes.
The Railways, Defense and Security forces, Plantation sector and Mining sector run their own health services for employees and their families.
In India, currently any form of insurance including the CHGS, ESIS, Government Sponsored Schemes and Private Health Insurance together covered approximately 302 million individuals or 25 percent of India's population in 2010[17]. State wise percentage penetration of health insurance in figure 1.
Central and State Government Peritoneal Dialysis
Initiatives for the future:
Central and state government need to do clinical evidence based study to find the economical viability and quality of life of both rural/urban areas. The objectives of the study are mainly need to focus on
1. Cost comparison between maintenance hemodialysis and chronic peritoneal dialysis, and
2. Quality of life and rehabilitation of patients.
The study should be unbiased. If the report favours chronic peritoneal dialysis then Government need to take PD as a first choice therapy. Central and state government need to tie-up with Indian PD fluid manufacturer for the overall control of cost of PD bags, accessories and PD catheters.
In future, there will be zonal-wise PD manufacturing company and later state-wise manufacturer that will further reduce the cost burden to the government. Government should enact policy to fruitfully employee young and healthy dialysis patients who can empower the employment sector of the country.
In Conclusion: There should be a rethinking in terms of dialysis therapy following the examples of Mexico, Hongkong and Thailand as a Peritoneal Dialysis First Policy in India.
The combined efforts of central government and state government health insurance policies engagement with large private health insurance partners will enhance and broaden dialysis therapy to a large section of the nearly 200000 incidental ESRD patients every year in India.
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