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

2

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?

4

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

8

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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