India Software

[Margurite Vizarro]

Mainlypublic providers, salaried. Many private providers, regulated and unregulated, paid FFS. In principle, gatekeeping in public system but largely not functional, none in private system. Patient registration not required.

Historically, there have been several government-funded health insurance schemes intended to improve coverage for specific population groups, with variations across states. One important scheme aimed at reducing financial catastrophe and vulnerability for lower-income populations is the National Health Insurance Program (Rashtriya Swasthya Bima Yojana, or RSBY), launched in 2008. As of 2016, some 41 million families were enrolled in RSBY.2 However, evidence indicates that the scheme has not significantly reduced out-of-pocket spending. It is now being subsumed under the PM-JAY.

At the federal level, the Ministry of Health and Family Welfare has regulatory power over the majority of health policy decisions but is not directly involved in health care delivery. The ministry comprises two departments:

At the state level, the Directorates of Health Services and the Departments of Health and Family Welfare are responsible for organizing and delivering health care services to their populations. These include all medical care, from primary care and pharmacies to secondary and tertiary hospital care. These state bodies are also responsible for the following:

At the district level, Panchayati Raj (local governance) institutions are responsible for grassroots governance and administration in rural villages. These government bodies play a significant role in establishing primary health centers, and contribute to various social policies in such areas as education, agriculture, and transportation.6

Role of public health insurance: Total public and private health expenditures as a percentage of GDP are estimated at 3.9 percent, significantly lower than the world average of 9.9 percent.7 The public sector accounts for approximately one-quarter of health expenditures.

There are various public insurance schemes, including RSBY, which provides hospital coverage for most diseases and pre-existing health conditions for individuals living below the poverty line (with a family cap of five members). Outpatient care, primary care, and high-level tertiary care are not included.

Funding for the public insurance schemes is divided between the central and state governments. For instance, most states are contributing a 40 percent share to the cost of the National Health Protection Scheme, with the central government providing the remaining 60 percent.

Funding for the National Health Protection Scheme has been allocated under the existing budget for the RSBY, which has doubled from 2018 to accommodate expanding public insurance costs.9 To further support these initiatives, the cess (levy) on income tax was increased from 3 percent to 4 percent, to collect an estimated INR 110 billion (USD 1.54 billion) annually.10

The states also run their own health schemes, mostly along the lines of RSBY. In addition, public sector undertakings (state-owned enterprises) and autonomous government bodies like central and state universities offer health coverage to their employees.

Another important health coverage scheme is the Central Government Health Scheme, organized and run by the Ministry of Health and Family Welfare for current and retired central government employees and their dependents.11 There are no income or wage requirements to be eligible. Coverage includes health care services for allopathic, homeopathic, and alternative medicine treatments.12 Approximately 3.6 million beneficiaries were registered under this scheme as of late 2019.13 Similar schemes exist for railway and defense employees.

In 2013, the RSBY was extended to mine workers, while certain groups of plantation workers were subsumed under the Aam Admi Bima Yojana (AABY), a government social security scheme administered through the Life Insurance Corporation of India that provides death and disability coverage from ages 18 to 59.

Many public hospitalization schemes partner with public and private insurance companies to run the plans. The PM-JAY has offered private sector hospitals incentives to increase supply in underserved areas by providing access to funding and land for hospital construction in urban-rural and rural cities.17

The Insurance Regulatory and Development Authority Act of 1999 allowed for private companies to enter the health insurance market.18 The 1999 act also allowed for individuals who are not eligible for sponsored insurance schemes to purchase a private policy. Private insurance now accounts for nearly 4.4 percent of total current health expenditures.19

A significant proportion of the population faces impoverishment due to lack of insurance and high out-of-pocket expenditures. An estimated 8 percent of the population is being pushed below the poverty line as a result of high out-of-pocket payments.22

The launch of the National Health Protection Scheme aims to insulate lower-income households from high health care costs by offering free care to beneficiaries in private facilities as well as public facilities.

However, the impact of the scheme will depend on demand as well as supply factors, like the availability of medicines and personnel, health infrastructure, and service quality. It will also depend on how hospitals are reimbursed and on their willingness to offer quality services at the quoted rates.

Safety nets: The various government health coverage programs offer safety nets to different populations, with the government bearing the cost of subsidies. For example, in RSBY and now the National Health Protection Scheme, the federal and state governments share the cost of premiums for each beneficiary, in addition to the cost of health services up to the coverage limit.

The Medical Council of India establishes standards for undergraduate medical education, accredits undergraduate and postgraduate medical education programs, determines equivalencies for foreign medical graduates, and maintains a general directory for all certified physicians.25

Primary care: Under the Health and Wellness Centres program, 150,000 subcenters (the lowest tier of the health system) across the country are being upgraded to provide comprehensive primary health care services, free essential medicines, and free diagnostic services. Nutritional support will also be provided to all beneficiaries with tuberculosis at a rate of INR 500 (USD 7) per month during treatment. Other primary health care providers include primary health centers (PHCs) and community health centers. No patient registration is required.

Under the Health and Wellness Centres program, the subcenter is the first point of contact for patients. It is designed to handle maternal and child health, disease control, and health counseling for a population of 3,000 to 5,000. At least one auxiliary nurse midwife or female health worker, one male health worker, and one additional female health visitor supervise six subcenters.

All medical personnel, including primary and specialty physicians, working at public outpatient or inpatient facilities are paid fixed salaries, which vary based on area of work and level of specialization. Currently, there are no performance-based payment incentives. However, the prime minister announced recently that all accredited social health activists will be enrolled in one of the social security schemes and provided free insurance coverage.

Physicians are allowed to operate private clinics in some states in accordance with regulations determined by the state in which they live and practice. Doctors in states where this is disallowed receive an additional non-practicing allowance payment.26 Some government doctors violate service rules by resorting to private practice during office hours. There is also some evidence that patients have made informal payments to their physicians for services that are supposed to be provided for free, in a bid to improve the quality of their care.27

Outpatient specialist care: Community health centers also provide outpatient specialist care and are required to have four medical specialists (surgeon, general practitioner, gynecologist, and pediatrician) supported by paramedical and other staff. They must also have 30 beds, a laboratory, X-ray services, and other facilities. Each center covers 80,000 to 120,000 people. All outpatient specialized services not provided at community centers are referred to district hospitals.

Administrative mechanisms for direct patient payments to providers: Government or entitlement coverage schemes, such as the Central Government Health Scheme and National Health Protection Scheme, are cashless. Beneficiaries are able to obtain care at facilities enrolled in the schemes by using their smart cards.28

After-hours care by telephone is not well established in India. However, officials are exploring the acceptability and feasibility of mobile phone consultations as a means of improving health care access in rural India and addressing workforce shortages and resource constraints.29

Private sector hospitals and clinics typically provide after-hours care with concomitant fees. Depending on the type of facility, some consultations and services can be provided via telephone or at home.30,31

Hospitals: Patients using the public health system can be referred to a district hospital, which is the terminal referral center. District hospitals offer services similar to community health centers, such as emergency care, maternity services, and newborn care, but serve larger urban centers.32 In total, there were 763 functioning district hospitals in 2015, located largely in the most populous states.33

The research hospitals and education centers funded by the central and state governments offer specialized care in a variety of disciplines, such as ophthalmology, cardiothoracic surgery, neurosciences, trauma, cancer, and drug dependence.34,35 Under the National Health Protection Scheme, some district hospitals will be upgraded to tertiary care facilities to improve access to specialized services and strengthen physician workforce capacity.36

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