RESEARCH AND EVALUATIONS CONDUCTED BY GIZ 2018 19

RESEARCH AND EVALUATIONS CONDUCTED BY GIZ 2018 -19 Dr. Nishant Jain and Dr. Sharmishtha Basu, IGSSP, 30 September 2019 Implemented byby Data collection partners

Presentation Outline ØConceptual Framework for conducting GIZ research ØPrimary study objectives ØResearch and Evaluations conducted by GIZ ØFindings from household survey ØRecommendations from household survey ØFindings from hospital study ØRecommendations from hospital study ØWay forward in setting the research agenda Seite 2 30. 09. 2019 Titel der Präsentation

Conceptual Framework for Conducting GIZ Research PM-JAY Adapted from Levesque et al, 2013 Seite 3 22. 01. 2019 Titel der Präsentation

Primary study objectives To serve as a baseline for Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) To assess the impact of PM-JAY on quality of service delivery and to explore healthcare providers’ experiences with the implementation of the new insurance scheme To assess and understand the impact of PM-JAY on insurance awareness, coverage, health service utilization and financial protection Cross cutting gender focus Seite 4 22. 01. 2019 Titel der Präsentation

Research and Evaluations conducted by GIZ (2018) Completed 1. Evaluating the Performance & Impact of Rashtriya Swasthya Bima yojana (RSBY)/state scheme: findings from seven states in India (2018)- Baseline for PM-JAY 2. Hospital Study on Quality of Care and Implementation Experience Under Government Health Insurance Program(2018)-Baseline for PM-JAY Seite 5 22. 01. 2019 Titel der Präsentation Household survey & FGDs & Key informant interviews Hospital survey & patient exit interviews

Research and Evaluations conducted by GIZ (2019 -2020) Ongoing 3. LITERATURE REVIEW: To map existing evidence and remaining gaps in the area of social health insurance in South Asia, with specific focus on India Mixed methods scoping review 4. PROCESS DOCUMENTATION: To describe implementation processes in selected States transitioning from either no scheme or prior schemes to PM-JAY Document review & Key informant interviews 5. HOUSEHOLD STUDY: To assess and understand the impact of PM-JAY on insurance awareness, coverage, health service utilization and financial protection Household survey & FGDs & Key informant interviews 6. HOSPITAL STUDY: To assess the impact of PM-JAY on quality of service delivery and to explore healthcare providers’ experiences with the implementation of PM-JAY Hospital survey & individual interviews Seite 6 22. 01. 2019 Titel der Präsentation

Study Design Seite 7 22. 01. 2019 Titel der Präsentation

Study Area Hospital Study-2018 Household study-2018 Allahabad Ghazipur Bihar-Patna Muzaffarpur Surat Ahmedabad East Khasi Hills SW Garo Hills Raigarh Bilaspur Gujarat-Surat, Ahmedabad Tumkur Raichur Coimbatore Sivagangai Chattisgarh-Raigarh, Bilaspur

Findings (Household Survey-2018)

Socio Demographic Profile of Households by Health Insurance Status BIHAR CHATTISGARH GUJARAT MEGHALAYA TAMIL NADU KARNATAKA UTTAR PRADESH VARIABLES I NI I NI Male headed households - 95. 3 91. 5 89. 4 82. 1 81. 3 55. 1 64. 8 84. 4 86. 1 79. 2 77. 5 - 91. 1 Mean age Of HH head - 40. 6 47. 8 41. 6 50. 9 48. 4 45. 2 39. 3 52. 0 44. 9 48. 8 47. 4 - 44. 4 Mean year of schooling - 4. 3 5. 7 6. 1 4. 4 4. 1 6. 0 6. 6 5. 5 6. 8 3. 4 3. 5 - 5. 3 Mean HH size - 5. 5 5. 1 4. 5 5. 2 5. 1 4. 3 3. 6 3. 4 4. 1 - 5. 7 Hindu % - 92. 5 97. 8 96. 7 96. 4 7. 5 7. 9 95. 2 94. 9 90. 6 87. 7 - 92. 6 SC/ST% - 56. 2 42. 4 43. 3 64. 5 58. 7 98. 2 98. 8 53. 3 50. 1 65. 4 68. 3 - 65. 0 Non-Insured are also poor families that are eligible for RSBY/ State scheme but decided not to enroll N: Bihar – 2022, Chhattisgarh – 2059, Gujarat – 2021, Meghalaya – 2016, Tamil Nadu – 2080, Karnataka – 2011, UP - 2017

Awareness about RSBY/State health insurance and PM-JAY Seite 11

Household Awareness About RSBY/State Scheme Major sources of information about the scheme – percentage of households by health insurance status Panchayat members/commu nity educators Through friends/neighbou rs 80 70 60 50 40 30 20 10 0 Through friends/neighbo 100 urs Radio Panchayat Newspaper 80 60 40 members/comm unity educators 20 Leaflets/brochur es ANMs ASHA worker AWW Insured Radio Newspaper 0 Leaflets/brochu res ANMs Notworker Insured ASHA AWW

Awareness about PM-JAY Before Launch of the scheme Major sources of awareness about PMJAY – state wise percentage distribution Through 25 20 20 15 ANMs Insured P ka Ka rn at a 4 3 U 6 u N ad ya la M eg ha uj G rh tis at ASHA worker C hh Area committee members ar at 5 6 6 4 5 4 il 7 Ta m 8 10 ga Leaflets/brochure s Pilot started from 15 th August 26 Bi Community educators 30 ha r Panchayat Households aware about PMJAY – percentage distribution by health insurance status Percentages Television friends/neighbour 70 s 60 Radio 50 40 30 Newspaper 20 10 0 This data collection was done couple of months before launch of the scheme 2018) Not insured N: Bihar – 2022, Chhattisgarh – 2059, Gujarat – 2021, Meghalaya – 2016, Tamil Nadu – 2080, Karnataka – 2011, UP - 2017 N (Number of households who are aware of PMJAY): Bihar – 152, Chhattisgarh – 473, Gujarat – 119, Meghalaya – 87, Tamil Nadu – 131, Karnataka – 94, UP - 83

Out of Pocket Expenditure (OOP)

Out of Pocket Expenditure- by Health Insurance Status & Catastrophic Expenditure Mean Bihar Chhattisgarh Gujarat Meghalaya Tamil Nadu Karnataka Uttar Pradesh Not Insured Insured Not Insured Not Insured 8, 494 23, 555 11, 181 9, 264 8, 921 10, 574 8, 562 22, 893 21, 111 14, 523 12, 427 20, 026 Difference between Median insured & not insured 4, 500 10, 000 2, 500 4, 050 5, 000 4, 800 15, 000 6, 000 5, 000 7, 000 (***) (*) Catastrophic Health expenditure (%) 34. 9 47. 1 27. 0 35. 8 30. 2 40. 3 29. 9 65. 9 60. 9 43. 0 37. 2 57. 4 N 731 395 466 441 361 464 469 463 507 546 487 707 (***)-Proportions significantly different at 1%, (**)- Proportions significantly different at 5%, (*)- Proportions significantly different at 10% @Threshold for catastrophic expenditure: Any expenditure that has been 40% and above of the household’s non-food expenditure

Self reported Impacts of Health Expenditure On Family Households who reported that RSBY / State scheme resulted in a decrease of out of pocket expenditure – state-wise percentages 75 80 70 60 60 50 47 43 40 28 30 20 10 0 Chhattisgarh Gujarat Meghalaya Tamil Nadu Karnataka N: Chhattisgarh – 516, Gujarat – 503, Meghalaya – 508, Tamil Nadu – 530, Karnataka – 491

Gender dimension of health insurance

Gender Dimensions of Health Insurance Women’s perception on various issues of health insurance scheme – percentage distribution by health insurance status Chhattisgarh Gujarat Meghalaya Tamil Nadu Karnataka Insured Not insured Insured Not insured The healthcare staffs are friendly towards patients enrolled under RSBY/State health insurance scheme 64. 6 49. 3 39. 4 25. 8 60. 8 24. 8 67. 2 52. 5 34. 2 25. 8 Feel comfortable with the doctor and the nurses who would treat 74. 2 61. 5 50. 0 35. 9 64. 0 40. 0 69. 9 55. 8 40. 7 40. 8 The location of the facility/clinic from residence is convenient 20. 0 21. 8 35. 2 27. 6 21. 9 14. 4 53. 5 36. 7 28. 4 26. 7 The treatment/care provided at the hospital is effective 74. 1 68. 7 43. 5 33. 1 61. 9 43. 7 71. 5 57. 1 38. 5 35. 1 RSBY/state health insurance scheme enables to take decisions regarding health without seeking permission 68. 4 54. 8 40. 6 19. 4 54. 9 22. 5 64. 0 51. 1 33. 4 26. 7 The waiting time at the hospital is same for the RSBY/ state health insurance scheme enrolled patients 22. 5 20. 3 28. 5 16. 6 22. 4 4. 8 10. 2 4. 7 26. 2 21. 7 You feel informed about RSBY/ state health insurance scheme (services covered, how it functions, etc. ) 61. 6 49. 2 39. 8 17. 2 46. 8 20. 6 54. 0 39. 4 34. 1 26. 8 Enrolment in RSBY/ state health insurance scheme improves the households options to access health services 69. 5 55. 0 40. 9 19. 0 55. 7 22. 4 62. 4 47. 1 33. 5 26. 9 Men and women have equal rights to seek proper treatment/hospitalization in case of disease/illness 76. 8 69. 9 59. 7 51. 8 84. 7 62. 1 77. 4 60. 8 54. 9 51. 3 Boys and girls in a family should have equal access to proper medical treatment in case of illness 78. 7 73. 1 58. 4 50. 9 85. 0 64. 7 77. 9 61. 2 53. 8 53. 6 N: Chhattisgarh – 1725, Gujarat – 1946, Meghalaya – 1363, Tamil Nadu – 1460, Karnataka – 1661

Recommendations for PM-JAY • Make enrolment process very simple or remove it • Remove family size restrictions in the scheme • Even insured people are still spending a lot from out of pocket even in public hospitals so a cover of Rs. 30, 000 is insufficient to take care of all the expenses • Provide flexibility to States • Ensure that beneficiaries are informed well about various aspects of the scheme • Choose IEC vehicles carefully based on reach and impact

Recommendations for PM-JAY • More hospitals need to be empaneled at block level as people otherwise have to travel a lot to get access • Strong monitoring of hospitals so that hospitals do not charge money with penalties • Many non-insured families are still going to private hospitals for delivery in spite of Government programmes so better awareness and convergence needed • People should be made aware of grievance redressal mechanisms • Some level of gender empowerment has also happened that can be further strengthened under PM-JAY Seite 20 22. 01. 2019 Titel der Präsentation

Findings (Hospital study-2018)

Empanelment of Hospitals (Field Experience) Empanelment process Reasons cited by hospitals for non-empanelment (perceptions) Ø Low package rates Ø Delayed payments Ø Irrational rejection of claims in other hospitals • Public facilities at CHC level and above, providing secondary and tertiary care services, get empaneled as per Government mandate • Empanelment of hospitals under schemes is time taking process (Gujarat - 2 to 6 months; Chhattisgarh - 3 weeks to 8 months) • All hospitals fulfilled the mandatory criteria for manpower, infrastructure, and had defined processes for storing medical records • In Gujarat, most hospitals (esp. private) empaneled under MA Yojana were NABH accredited • Motivation for hospital empanelment includes social responsibility, service outreach, and profit making Seite 22 22. 01. 2019 Titel der Präsentation

Quality of Care Accreditation: • The insurance schemes do not comprehensively define the process for measuring quality of care, hospitals pursue it voluntarily • In Gujarat, majority empaneled private hospitals are NABH accredited compared to very few in Chhattisgarh Clinical Protocols: • NABH accredited and private corporate hospitals have well-defined STPs/ SOPs and are being followed as well Training & Capacity Building: • In Gujarat, private hospitals have a training schedule and provide trainings • No differentiation in quality of care between scheme and non-scheme patients Patient Satisfaction • Hospitals have grievance redressal mechanism and suggestion and compliant boxes, and emergency grievances are resolved at earliest • Hospitals collect patient feedback at the time of discharge and evaluate in regular meetings and take necessary actions Seite 23 22. 01. 2019 Titel der Präsentation

20 Hospitals in Each State were selected (both empanelled and non-empaneled) Input based indicators Availability of services Availability of functional OT Availability of labor room or obstetric services Infrastructure & equipment Process based indicators HR Availability of Availability floor plan & of doctors signages inside 24*7 facility Sops and guidelines Availability of clinical STP and diagnostic protocols Protocol for biomedical waste segregation Quality grading Accreditatio n of hospital Accessibility Motorable road for patient transport Ramp facility/lift for differently abled A total of 9 indicators were considered and a weighted score is assigned to each indicator to calculate additive index Seite 24 22. 01. 2019 Titel der Präsentation

Gaps and Challenges • Low package rates – difficult to provide quality care • No extra provision in packages in cases of complications Package related Beneficiary related • Long claim settlement cycle • High claim rejections and deductions • Payments made in bulk, details of claim amounts not shared Chhattisgarh: • Missing information – claim/ patient related date from portal Claims related Gujarat: • Long claim settlement cycle, especially in RSBY • High claim rejections and deductions – RSBY Seite 25 22. 01. 2019 Titel der Präsentation Others • Inappropriate/ misbehavior of beneficiaries and relatives • Beneficiaries tend to avoid use their scheme cards in public hospitals to save their sum insured • Lack of awareness among beneficiaries related to scheme and its benefits • Too much documentation and paper work • Unavailability of beds due to increased patient load • Many eligible families are not enrolled in the scheme • Low sum insured (RSBY/MSBY) leading to early exhaustion Gujarat: • High income groups patients also possess MA Yojana card

Recommendations for PM-JAY Implementation experience Rationalization of package rates Quality of care Implementation and enforcement of Standard Treatment Protocols/standard treatment guidelines Reduction in time for empanelment Improved coordination with TPA/IC for speedy document processing and reducing irrational claim rejections Public hospitals should have more flexibility on using scheme funds to upgrade infrastructure and manpower Structured financial management with standard process to ensure efficiency Focused IEB/BCC activities to improve awareness and patient experience Seite 26 22. 01. 2019 Titel der Präsentation Promotion of NABH accreditation of hospitals and mandating accreditation (entry level) for empanelment Incentive based quality accreditation can be promoted Capacity building, training for hygiene practices, and standard bio-medical waste (BMW) process through scheme administration

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