RESEARCH AND EVALUATIONS CONDUCTED BY GIZ 2018-19

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

2. Presentation Outline • Conceptual Framework for conducting GIZ research • Primary study objectives • Research and Evaluations conducted by GIZ • Findings from household survey • Recommendations from household survey • Findings from hospital study • Recommendations from hospital study • Way forward in setting the research agenda Titel der Präsentation

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

4. 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 Titel der Präsentation

5. Research and Evaluations conducted by GIZ (2018) Completed • Household survey & FGDs & Key informant interviews 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 • Hospital survey & patient exit interviews Titel der Präsentation

6. 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 Titel der Präsentation

7. Study Design Titel der Präsentation

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

9. Findings (Household Survey-2018)

10. Socio Demographic Profile of Households by Health Insurance Status 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

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

12. Household Awareness About RSBY/State Scheme Major sources of information about the scheme – percentage of households by health insurance status Insured Not Insured

13. This data collection was done couple of months before launch of the scheme 2018) Awareness about PM-JAY Before Launch of the scheme Major sources of awareness about PMJAY – state wise percentage distribution Pilot started from 15th August 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

14. Out of Pocket Expenditure (OOP)

15. Out of Pocket Expenditure- by Health Insurance Status & Catastrophic Expenditure (***)-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

16. Self reported Impacts of Health Expenditure On Family N: Chhattisgarh – 516, Gujarat – 503, Meghalaya – 508, Tamil Nadu – 530, Karnataka – 491

17. Gender dimension of health insurance

18. Gender Dimensions of Health Insurance Women’s perception on various issues of health insurance scheme – percentage distribution by health insurance status N: Chhattisgarh – 1725, Gujarat – 1946, Meghalaya – 1363, Tamil Nadu – 1460, Karnataka – 1661

19. 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

20. 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 Titel der Präsentation

21. Findings (Hospital study-2018)

22. Empanelment of Hospitals (Field Experience) Empanelment process • Reasons cited by hospitals for non-empanelment (perceptions) • Low package rates • Delayed payments • 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 Titel der Präsentation

23. 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 Titel der Präsentation

24. 20 Hospitals in Each State were selected (both empanelled and non-empaneled) A total of 9 indicators were considered and a weighted score is assigned to each indicator to calculate additive index Titel der Präsentation

25. Gaps and Challenges • ​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 Beneficiary related • Low package rates – difficult to provide quality care • No extra provision in packages in cases of complications Package 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 • Gujarat: • Long claim settlement cycle, especially in RSBY • High claim rejections and deductions – RSBY • 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 Claims related Others Titel der Präsentation

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

27. Thank you