WELCOME TO NATIONAL LEVEL MEETING OF PROJECT DIRECTORS OF RURAL DEVELOPMENT

1. WELCOME TO NATIONAL LEVEL MEETING OF PROJECT DIRECTORS OF RURAL DEVELOPMENT

2. ANDHRA PRADESH PRESENTATION ON Community Managed Health & Life Insurance Total Financial Inclusion Food Security

3. SANJEEVANI “Community Managed Health Insurance”

4. SANJEEVANI • Sanjeevani is a Community based and Communitymanaged Health Welfare Scheme, promoted by Zilla Samakhya, Vishakhapatnam. • This is an initiative to make Healthcare Services accessible to rural Self Help groups ( SHGs) and to promote preventive Healthcare. • Good health is a pre-requisite to human productivity and the development process. A healthy community is the infrastructure upon which an economically viable society can be built.

6. Need for the Scheme • Existing schemes are not pro-poor • Cumbersome Procedure • Uncertainty of coverage of financial shock from health care expenses • Expulsion of pre-existing deceases (Rural poor won’t go for regular check-up of deceases

7. Need for the Scheme • Uniqueness of existing schemes – Insurer, Insured, TPA and Service Providers are un-happy • Existing health care facilities from Govt. institutions not accessed adequately

8. Scope of the Scheme • Hospitalization Cover for Surgeries and Medical Conditions • Free Outpatient Consultations. • Fixed discounts on • - Medicines • - Investigations • Consultation by a lady doctor on specified days.

9. Administration of the Scheme • The scheme will be implemented and administered by Zilla Samakhya, in coordination with the Mandal Samkhaya, and Village Samakhyas.

10. The Role of Zilla Samakhaya • The ZS is responsible for the day-to-day operation of the Scheme and will ensure service standards at provider Network for hospitalization and Diagnostics. • The duties will include, • Maintaining member database • Issuing Photo ID cards to the families covered under the scheme • Creating a network of hospitals to facilitate Cashless treatment to the beneficiaries of the scheme • Facilitating the authorization process with the Network Hospitals • Claims Processing and settlement.

11. Coverage and Premium • Period of operation from 1st May 2007 to 30th April 2008 • Maximum amount payable Per Family Rs. 30,000/- for surgeries ( List provided ). • Maximum amount payable is Rs 5000/- for medical conditions other than surgeries under the Family Package 5. • 10% of Co-Payment by the patient on the final bill. • Premium payable is Rs. 260 per year for a family of 5. • Age Limit: 0-60

12. Features of the Scheme • Out Patient Consultation • PHC level: consultation with lady doctors once in a week free of cost • Network Hospital (NWH): consultation free of cost • Diagnostics: • Basic diagnostics will be done at PHC free of cost • Diagnostics at NWH will be done at a fixed discounted rate. • Quality Medicine • Free of cost at PHC level • 2.  10% Discount rate at NWH • 3. Grossly discount at Drug depots of IKP (Sanjeevani Pharmacy)

13. Features of the Scheme • Contd… • 4. Hospitalization cover: • Cover- Inpatient treatment requiring hospitalization for more than 24 hours. • Cover would include consultation, investigation and room charges, medicines and consumables. • 5. Medical and Secondary and Tertiary Surgical Care • Treatment provided through Referral Network Hospitals only with 100% Cashless facility • 6. Pre existing diseases are covered • 7. Treatment in General ward only

14. Surgeries Covered • The scheme covers more than 1500 surgeries, including all categories of complex and common surgeries, such as • OBG – includes normal delivery, LSCS and Hysterectomy • General Surgery • Gastroenterology • Orthopaedics – includes fracture surgeries • Genito-Urology • Endocrinology • ENT

15. The Team • Case Manager – Role and Responsibilities • Coordinate the referral system of the patient • Regularly visit the Network Hospitals, at least once a week, and ensure that the terms and benefits of the scheme are being properly followed. • Regularly interact with the beneficiaries of the scheme undergoing treatment for feedback. • Inform the Implementing Agency (ZS) about any non-conformance, if any, and follow-up on action taken. • Collate data and statistics from network hospitals on the scheme every week end and Submit it to the ZS

16. The Team • Case Manager – Role and Responsibilities • Randomly verify the operated cases for authenticity of the members. • Verify the authenticity of every case received for pre-authorization and submit report to ZS. • Medical Officer – Role and Responsibilities • Approval of Preauthorization based on necessity of treatment • Liaison with NWH • Quality monitoring of service providers

17. Beneficiary approaches VO Representative VO rep explains scheme Beneficiary goes Network hospital with ID Card, Receipt Medical treatment Admission for Surgery Intimation to TPA/ZS by NWH Patient pays 10% of the bill Pre-Authorization- from TPA/ZS CASHLESS Hospitalization Member signs on the Claim Form Discharge Free OPD Consultation Investigation Special rates Process of Availing Treatment

18. Receipt of claims From NWH Document verification Incomplete Communication To Hospital Complete Claim ID Generation Medical Scrutiny and Claims Processing Claim pending for supporting Documents Approved Claims Submitted To Trust (Weekly) Communication To Hospital Letter Of Settlement To he Bank By ZS Collection of DD Dispatch o hospital Outward Claims Flowchart

19. Progress • Total House Holds Covered sofar : 32,840 • Annual Premium per Family : Rs.260/- • No. of Net working Hospitals : 17 • 4. No. of PHCs & CHCs : 27 • 5. Claims Received (May to December) : 650 • 6. Claims Settled (May to November) : 650 • 7. Claims amount Settled : Rs. 23.50 Lakhs. • Health Cards issued to all families covered under the scheme • 29 Case Managers trained & Positioned in all Mandals&KGH • One Medical Officer trained and positioned.

20. Impact • Free OP : No. of Patients benefited • In Primary Health Centres : 11,325 • In Networking Hospitals : 4,460. • Diagnostic Tests • 20% discount on diagnostic tests • Amount benefited : Rs.1,51,860 • Drugs • 10% discount on drugs • Amount benefited : Rs.98,329

21. Impact • Medical Cases treated • Physical : 373 • Amount : Rs. 9,12,465 • Surgical Cases treated • Physical : 277 • Amount : Rs. 14,37,664

22. Expenditure (From May to December 2007) • Medical Cases

23. Medical Cases Treated

24. Medical Cases Treated

25. Expenditure (From May to December 2007) • Surgical Cases

26. Surgical Cases Treated

27. Surgical Cases Treated

28. Community Managed Life Insurance Scheme

29. Community Based life Insurance Scheme • Objective • Need • Evolution • Implementation • Claim Settlement Process • Impact SERP DRDA

30. Objective • Scheme seeks to offer a risk mitigation measure for the rural poor against sudden death & disability . • The CBO - SHG and their federations VO Mandal Samakhyas and ZS play key role in evolution, implementation of the scheme SERP DRDA

31. Need • Rural poor household having no access to formal Insurance services to cover risks. • Very limited awareness about insurance related risk mitigation options amongst the poor. • High premium coupled with tedious & time consuming claim settlement process. • Participatory community based insurance delivery mechanism meets the needs of the poor more effectively than the provider managed insurance delivery. SERP DRDA

32. Evolution • Initiated dialogue with community on need for community based life & General insurance and risks to be covered. • Dialoging with insurance providers by CBO with facilitation support extended by functionaries. • Finalizing service providers with clear cut MOU between the insurance providers and Zilla Samakhya. SERP DRDA

33. A.P. Level Achievement 2007-08 • Total Members covered : 26,15,540 • Premium Amount collected : Rs.26.68 Crores • Premium Amount paid to • Insurance Company : Rs.21.71 Crores • No. of Claims Received sofar : 7215 • Natural Deaths : 6459 • Accidental Deaths : 756 • Claims settled sofar : 6133 • Natural Deaths : 5515 • Accidental Deaths : 618 • Claim amount settled : Rs.15.73 Crores SERP DRDA

34. District-wise Achievement 2007-08 SERP DRDA

35. District-wise Achievement 2007-08 SERP DRDA

36. Amount collected by CBO” per member Rs. 105/- • TATA – AIG life insurance premium Rs. 61/- • New India Assurance premium Rs. 12/- • Corpus available per member at ZS Rs 32/- • Total 1,00,681 Members covered • Rs. 105.71 Lakhs Amount collected by Zillah Samakhya. • Rs. 61.41 Lakhs Amount paid to TATA-AIG towards life • Insurance • Rs. 12.08 Lakhs Amount paid to New India Assurance • towards general insurance. • Rs. 32.21 Lakhs with ZS. Implementationin Visakhapatnam 2006-07 SERP DRDA

37. Implementation in Visakhapatnam 2007-08 • Amount collected by CBO” per member Rs. 80/- • Life Insurance Corporation Rs. 50/- • National Insurance Rs. 18/- • Corpus available per member at ZS Rs 12/- • Members covered so far as against proposed target of 83,266 members. • Rs. 66.61Lakhs Amount collected by Zillah Samakhya. • Rs. 41.63 Lakhs Amount paid to Life Insurance towards • life insurance. • Rs. 14.98 Lakhs Amount paid to National Insurance towards general insurance. • Rs. 9.99 Lakhs with ZS. SERP DRDA

38. Claim settlement process • Information from affected family to ‘VO’ from SHG. • Verification and Certification by ‘VO’. • Claim submission to Zilla Samakhya through Mandal Samakhya. • Verification by ‘ZS’ monitoring committee. • Claim submission by ZS to insurance company. • Claim settlement by ZS within ‘7’ days of receipt of the claim by ZS pending release of money by insurance company is ZS. • Claim shall reach ZS within ’90’ days of occurrence of the incident. SERP DRDA

39. 2006-2007 • Affordable premium • Immediate claim settlement by Zillah Samakhya. • 357 Claims settled so far against 390 claims received. • Rs. 89.10 Lakhs Amount distributed towards claim settlement. 2007-2008 • 193 Claims settled so far against 235 claims received. • Rs. 73.69 Lakhs Amount distributed towards claim settlement. Impact in Visakhapatnam District SERP DRDA

40. ‘Total Financial Inclusion’

41. General definition of financial inclusion • Accessing to banking services at affordable cost - Opening of ‘no frills account’ - Issue of ‘General Purpose Credit Card’

42. Objective • To address all the financial needs of all households

43. Should we focus on all or should we focus on poor ?

44. The ‘Spread’ of Financial Inclusion Whether urban or rural, the spread is ‘wide’ in non-poor vis-à-vis poor

45. Analysis of financial needs of the poor

46. The Expenditure Portfolio of the Poor • House construction / repairs • farm activities • Working capital • non-farm activities • major • Health problems minor • school education • Children education – • higher education • Marriage purposes • Income generation Activities • Long term investment on land

47. Scale of exp on these items • House repairs/construction-5,000 to 20,000 • Marriage purpose - 20,000 to 50,000 • Health needs - 5,000 to 15,000 • Children higher education - 5000 to 10,000 • Income Generating Assets – 10,000 to 15,000 • Working Capital - 5,000 to 10,000 • Long term investment on land – 30,000 to 50,000

48. Own funds vis-à-vis debt

49. Coping mechanism by the rural poor family • Debt • For smaller needs it is from banks • For larger needs it is from money lenders/mfi Banks Money lenders/friends & relatives

50. Which approach is better to reach the poor? Opening of ‘no frills’ account Issue of general purpose credit card Deepening the credit through SHGs or/and