Press Note
“Government Funded Health Insurance Scheme in Maharashtra: Study of Rajiv Gandhi Jeevandayee Aarogya Yojana”
The government of Maharashtra launched the ‘Rajiv Gandhi Jeevandayee Arogya Yojana’ (RGJAY) on 2nd July 2012 to enable access to quality medical care for specialty services specially the ones requiring hospitalization. The scheme was rolled out to provide access to health care for vulnerable populations both the BPL and APL populations without any age restrictions. The scheme provides coverage up to INR one lakh fifty thousand per family per year. About 971 medical procedures were covered under empanelled hospitals in 2014. A unique feature of the scheme was that it covered pre-existing medical conditions from the first day.
As the public health infrastructure is inadequate to meet the health care needs of population, an important operational feature was the roping in of private sector with the objective of increasing access to health care for marginalised population of the state.
CEHAT carried out a study to gain an understanding on the functioning of the schemes, its advantages and limitations. The study provides analysis of various aspects of the scheme including the process of hospital empanelment, the bottlenecks and barriers while accessing the scheme vis-a-vis government guidelines.
Key Findings -
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Of 473 hospitals empanelled in the scheme in 2014, whopping 84% belonged to the private sector. Of these, a high concentration (about 44%) of the private hospitals is found in the six urban centers. Negligible (12%) percent of empanelled hospitals are found in least urbanized districts (12). The scheme brought Private hospitals on board to increase access in remote and rural areas. But gaps in access to health insurance and health care continue.
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Maharashtra having a large private sector presence but specialties such as intervention radiology, medical oncology are almost unavailable in the private sector across many districts. Highly accessed specialties such as radiation oncology are completely absent in the private network hospitals in many tribal and (16 districts) least urbanized district.
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A gap is also noted in the maximum pre-authorizations raised and the specialties available. Maximum pre-authorizations were raised in Medical oncology, nephrology, cardiology and genitourinary system amongst others but the top 5 specialties extensively available in the empanelled hospitals were general surgery, orthopedics, critical care. This is indicative of a mismatch in the empanelment process.
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Nearly 20% of the 971 procedures show that less than 10 preauthorization requests were raised.
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The scheme attempts to provide health care access to patients closer to their homes. But due to the fact that there are insufficiently empanelled private hospitals and an inadequate public sector, patients are compelled to travel to urban areas from rural areas. This inadvertently adds to their financial burden.
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As far as the enrolment is considered, the total eligible families across as per the PDS data, were 20,794,294 during 2015. At the time of the study, merely 2.45% of the families had been enrolled under the scheme in the state.
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One of the reasons could be lack of awareness amongst the beneficiary population about the scheme, validity of the health card in all districts, the benefits of the scheme as well as the medical procedures covered under the scheme. It could be also associated to the limited Information, Education and Communication (IEC) activities carried out through the scheme. Moreover, Aarogyamitras posted at PHCs in phase I, were removed as a cost cutting measure which may have led to the lack of IEC.
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An important and transparent mechanism built in to the scheme is grievance redressal. Analysis of the data showed that more than half of the grievances registered with the RGJAY Society were related to Out of Pocket (OOP) expenditures. The scheme precisely wanted to reduce the burden of OOP for the economically marginalized communities and hence, this appears to be a concern.
Recommendations -
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RGJAY caters to provision of tertiary level surgeries free of cost under the scheme. However, these services are needed by a small fraction of population as compared to outpatient, primary and secondary level services. The scheme needs to rethink and consider expanding the scope of health care services and procedures routinely required, one of which is inclusion of normal delivery. This would be an important step towards Universal Health Coverage.
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The reason for poor utilization of certain procedures should be further explored. This necessitates a need to re-examine the 971 procedures in terms of their utilization and the procedures, which are redundant, should be removed or replaced with more relevant ones.
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In the present mechanism of monitoring of the scheme, there is a need to include assessment of quality of care and ability to access the empanelled hospitals rather than restricting the monitoring to number of beneficiary registrations per hospital.
Considering the structure of the scheme is dependent on the private sector, which is both the implementer and service provider, there needs to be strong monitoring oversight by the public sector. The role of office bearers of the society needs to be made more robust. Comprehensive and stringent guidelines for each stakeholder should be ensured by the RGJAY Society as the administrative body.
Report
