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A Rapid Evaluation of the Rajiv Aarogyasri Community Health Insurance
Scheme - Andhra Pradesh
Mala Rao*, Shridhar Kadam**, Sathyanarayana T N*, Rahul Shidhaye*, Rajan Shukla*, Srikrishna Sulgodu Ramachandra*, Souvik Bandyopadhyay*, Anil
Chandran*, Anitha C T*, Sitamma M*, Mathew Sunil George***, Vivek Singh*, Subhashini Sivasankaran*, Veena Shatrugna*
*Indian Institute of Public Health, Hyderabad;**Indian Institute of Public Health, Bhubaneswar;
***Indian Institute of Public Health, Delhi;Public Health Foundation of India
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Background• Poverty and ill-health – a vicious cycle
• Financial protection of poor against OPP– Felt need within state actors – Chief Minister’s Relief Fund (2004-2007): financial
assistance for surgical care for those in need (168.5 crore)
– Institutionalization in form of ‘Rajiv Aarogyasri Community Health Insurance Scheme (RAS)’ introduced in April 2007
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About RAS• Stakeholders
– Government, Private Insurance Company, and health providers (private and government)
– Managed by The Aarogyasri Health Care Trust (AHCT) lead by senior government officials
• For whom? – BPL families (70% of AP population)
• Offers...– Up to Rs. 2 lakh in a year for the treatment of serious illness – The scheme covers 719 surgical and 144 medical
procedures 3
Evaluation questions• Did the scheme succeed in protecting poor households from
catastrophic expenditure required for treatment of serious ailments in AP?
• Did the scheme provide equitable access in regard to age, gender, geographical distribution and medical condition of beneficiaries?
• Does the scheme address the most important health needs of the BPL families?
• How is the scheme perceived by health care providers and BPL families?
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Methods• Literature review • Secondary data• Primary data
– Selection of districts – Visits to network hospitals and health camps– Interviews – Beneficiaries, PHC MOs, RAMCOs,
AAMCOs, MSs, Aarogyamitras– Discussions with DM & HOs and Officials in the
State govt. and Aarogyasri Trust
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Adilabad
Karimnagar
Nizamabad
Medak Warangal
RangareddyHYD Nalgonda
Mahaboobnagar
Kurnool Prakasam
Guntur
Khammam
W.Godavari
Krishna
E.Godavari
Visakhapatnam
SrikakulamV’Nagaram
Anantapur Cuddapah
Nellore
Chittoor
Andhra Pradesh
Districts visited for RAS evaluation
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Beneficiaries characteristics – Age(n= 71549)
13.0
18.1
29.7
25.9
13.4
0.0
5.0
10.0
15.0
20.0
25.0
30.0
35.0
0 to 14 15 to 29 30 to 44 45 to 59 60 and above
Age Group
Pe
rce
nta
ge
be
ne
fic
iari
es
7
54%
46%
Male
Female
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Beneficiaries characteristics – Sex(n= 71549)
50.7
42
7.3
0
10
20
30
40
50
60
Lower Middle High
Standard of living index
Pe
rce
nta
ge
be
ne
fic
iari
es
9
Beneficiaries(Interviewed) characteristics – SES
(n= 217)
Beneficiaries characteristics – Location (n= 71549)
86.7
72.9
13.3
27.1
0
10
20
30
40
50
60
70
80
90
100
Beneficiary Population Beneficiary Population
Rural Urban
Ben
efic
iary
an
d p
op
ula
tio
n p
erce
nta
ge
10
Beneficiaries characteristics – Social groups (n= 71549)
12.4
16.2
2.9
6.6
0
2
4
6
8
10
12
14
16
18
Beneficiary Population Beneficiary Population
SC ST
Per
cen
tag
e o
f B
enef
icia
ry a
nd
Po
pu
lati
on
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Utilization Vis-à-vis Facility/provider type
• 50% of treatments in 30 (of total 353) hospitals– 26 private hospitals: 44% treatments– 4 govt. hospitals: 6% treatments– Majority of them in Hyderabad, Vijayawada,
Guntur, Nellore and Visakhapattnam
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Utilization Vis-à-vis Medical condition (n= 89699)
13
13.4
28.1
23.5
9.7 9.710.6
5.1
0.0
5.0
10.0
15.0
20.0
25.0
30.0
No visit 1 2 3 4 5 and more Noinformation
available
Number of follow up visits
Pe
rce
nta
ge
be
ne
fic
iari
es
Frequency of follow-up visits(n= 217)
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Beneficiaries’ (Interviewed)satisfaction (n= 217)
01
23
45
Sco
res
Trea
tme
nt
Me
dication
Care
Foo
d
Acco
mod
ation
Cle
anline
ss
Doctors
Nurse
s
Hosp
ital
Sco
re g
iven
by
Ben
efic
iarie
s
Distribution of Scores for hospital services indicators
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Age distribution of hospitalizations: NSSO and RAS
0.0
5.0
10.0
15.0
20.0
25.0
30.0
35.0
0 to 14 15 to 29 30 to 44 45 to 59 60 and above
Pro
po
rtio
n o
f H
os
pit
ali
sa
tio
n
Age Group NSSO RAS
NSSO: 16 hospitalizations per 1000 population per year that can be catastrophic
Aarogyasri: 1 beneficiary per 1000 population per year (approx)
16
10
15
20
25
30
35
Be
ne
ficia
rie
s p
er
lac
BP
L p
op
ula
tion
pe
r m
onth
0 50 100 150 200 250Mean distance from Dist HQ to two closest cities catering to majority of RS Beneficiaries
Beneficiaries per lac BPL population per month in a district Fitted values
Utilization vis-à-vis distance from major cities
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Out-Pocket-Payments & reasons• (n= 127 , Median money spent Rs 3600)
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9.8
13
31.7
52
57.7
0 10 20 30 40 50 60 70
Consultation
Others
Diagnosis
Transportation
Medicine
Reasons for additional
money spent
Percentage beneficiaries
Conclusions & Recommendations
• The scheme provides financial protection for the BPL families for identified high cost and low frequency illnesses
• Financial protection through ‘insurance mechanism’ alone is not sufficient
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Conclusions and Recommendations
• Need for strengthening ‘insurance function’ by the government for ensuring the provision of comprehensive, continuous, effective and accessible health services for all.
• Need for developing more coherent, cohesive and integrated health system with integration of preventive, promotive and curative services.
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