A shining example
The challenge of high morbidity in Kerala was turned into an opportunity through exemplary implementation of RSBY
The good news is that Prime Minister Jan Aarogya Yojana (PMJAY) is being implemented despite some teething troubles. It was made possible on account of a committed team led by the redoubtable Indu Bhushan during the initial years. PMJAY rides on the positives of Rashtriya Swasthya Bima Yojana (RSBY) that was at some point in time dumped by a group of secretaries who had no understanding of this sector. The efficacy of health insurance in general, and RSBY in particular, was actually demonstrated on the field by an outstanding civil servant, Dinesh Arora in Kerala.
This was 2008. Dinesh Arora was posted as Joint Secretary of Health Department and State Mission Director (NRHM) in Kerala. The implementation of RSBY during the next couple of years led to a massive increase in health insurance coverage. Today, the 'Kerala model for development' is often referred to as an example for other countries to follow. It all happened only after many challenges were overcome.
Back in 2008, Kerala was showing several disturbing trends despite better health outcomes on specific indicators. Although mortality was low, morbidity levels were very high in comparison to other states. Thus, the paradox was that on one hand, there were indicators of better healthcare and, on the other, Kerala outstripped all other states in terms of morbidity, especially in chronic illnesses. Increased life expectancy raised additional health issues of the ageing population. Moreover, the unregulated private sector raised healthcare expenditures, making health a commercial commodity purchased by 'ability to pay' rather than a "merit good". Many public facilities remained underutilised, especially at the level of CHC and below. The most disturbing aspect was the large share of out-of-pocket payments for accessing health services.
RSBY, a Government of India health insurance scheme that primarily reimburses secondary-level hospitalisation services, was seen as a window of opportunity. This was a demand-side financing scheme for health, in which the patient or the 'client' becomes the king. The patient could choose to take the services either from the private hospital or from the public hospital. It was a model where the inclusion of private hospitals led to an increase in the ambit of medical service delivery. It parallelly created an environment where public hospitals could compete with private hospitals to provide services free of cost for a particular pre-decided premium paid by the Government. Kerala decided to implement this scheme involving public and private hospitals.
There were apprehensions that most patients would choose private hospitals. These hospitals would have windfall gains as there would be an increase in the number of patients and claims reimbursed. It was also expected that public hospitals, with limited funding and facilities, would lose out to private facilities.
To incentivise the government hospitals, it was decided that the revenue generated through reimbursement of RSBY claims would remain with the hospital development society as an untied fund. The untied fund could be used for human resource development, equipment, and up to 25 per cent could also be used as an incentive to staff. However, there were some initial apprehensions about the scheme and whether it could be considered as a Comprehensive Health Insurance Scheme (CHIS). It had to compete with the private sector where the facilities were better than the government sector.
What followed was no less than a revolution. The revenue generated by empanelled government hospitals became more than that of the empanelled private hospitals. Public health institutions accounted for more than 60 per cent of the caseload and 53 per cent of revenue generated through the scheme. Many taluka hospitals could generate a surplus of Rupees one crore a year. General hospitals could generate a surplus of a few crores. Surgeries and deliveries including caesarean sections started happening in the late hours in public health facilities. The hospital superintendents could decide how to spend money to improve public healthcare facilities as per the local needs and demands. This set up a trend that was different from a cumbersome line-item budget with massive bureaucratic and clerical hurdles. There was now a ready-to-use untied stream of funds available at the local level.
The RSBY scheme ushered in a new set of reforms. Public Relations Officers (PROs) were appointed to improve patient satisfaction. A biomedical officer for scientific waste management, disposal and servicing of equipment was hired. Hospitals became conscious of their quality and branding. Public hospitals started competing not only with private but also with other public hospitals. In the monthly review, one of the criteria for hospitals' performance was the number of claims, patients, and patient satisfaction. The staff of these hospitals started taking pride in their efforts.
On its part, the government, through the National Rural Health Mission, strengthened the supply side provision of public hospitals where patients' footfalls increased. The hospital development committees became functional; decision-making was decentralised, and medical superintendents were held accountable. With the total pool generated, public hospitals got a facelift with more in-patient facilities, renovation of existing hospitals, clean waiting rooms, token-system for appointments, computers, internet, Hospital Management Information System (HMIS) through GIS mapping etc. Accredited Health Social Activists (ASHAs) were attached to these hospitals to enhance outreach activities.
Five public health hospitals in Kerala got accreditation from National Accreditation Board for Hospitals & Healthcare Providers (NABH), which was unthinkable a few years back. Many labs were empanelled before National Accreditation Board for Testing and Calibration Laboratories (NABL). Kerala could disburse claims in a timely manner. A system to check fraudulent practices was put in place. Kerala received the award for best implementation of RSBY among all states for three consecutive years.
These initiatives made the state a torchbearer in the world's most significant government health insurance initiative – Ayushman Bharat PM-JAY. The learnings from Kerala were taken forward by Dinesh Arora. As a part of the founding team of PM-JAY (as the Deputy CEO of NHA), he ensured that the concept and thought that worked so very well in Kerala could now be scaled at the national level. This would enable healthcare facilities for all.
Dinesh Arora and his committed team of officers, which also included P Sukumar, demonstrated that despite challenges and limitations within the government framework, good work can not only be done, it can be scaled through a partnership with the private sector and by taking other stakeholders on board. Initiatives taken in Kerala are being replicated in other parts of the country in the true spirit of Nexus of Good.
Views expressed are personal