“ Government Social Health Insurance Scheme”

1. “Government Social Health Insurance Scheme” FAIR Congress - 2019

2. Health Insurance: Health insurance is concerned with access to health care and financial protection against the risk of incurring very high expenditures for such care Social Health Insurance: Is a government-sponsored insurance program, where risks are transferred to and pooled by an organization, often governmental, that is legally required to provide certain benefits

3. History of SHI in Maldives • Prior to 2007 • Health insurance concept was not widely known • 2007 • Private health insurance scheme was introduced for GoM employees (10% of population) • Discontinued in April 2008 • August 2008 • Social health insurance scheme, Madhana was introduced • Composition: GoM employees, absolute poor, pensioners, retirees

4. 2009-2011 Madhana population coverage expanded: senior citizens, opened for voluntary participation, beneficiaries of social assistance included: • Benefit coverage expanded: additional policy introduced to cover treatment from India & Sri Lanka. • By end of December 2011 Madhana had coverage of about 1/3 of the population 2012 • Madhana was replaced by a Universal Social Health Insurance Scheme, Aasandha, which was introduced on January 1, 2012 under the Social Health Insurance Law

5. Aasandha • Aasandha - a national social health insurance scheme for all the Maldivians which covered health services to a maximum of MVR 100,000 per head per year • A premium of MVR 2,750 was paid per person by the Government for whole population • Under this scheme, all the government hospitals, health centers and one private hospital were included to provide health insurance service to Maldivians • Health services which are not available in the Maldives were covered by sending abroad i.e. Sri Lanka & India • The Scheme operated on a fee-for-service direct billing arrangement with providers and did not require beneficiaries to make any payment if the costs were within the specified annuals limits and are covered under the Scheme.

6. Components of Aasandha Scheme

7. Scheme belongs to the National Social Protection Agency (NSPA) • Under an understanding Scheme was handed over to Aasandha Company to implement it • Aasandha Private Limited is a State-Owned Enterprise (SOE) Company which compromise of 100% share by the Government • Scheme is administered by Aasandha Company under the governance of Aasandha Scheme Board and policy guidance of NSPA • All scheme related policies and procedures are formulated by NSPA (endorsing service providers, service types , prices, etc.).

8. Why from ‘Aasandha’ to ‘Husnuvaa’ Aasandha? Overall cover : MVR 100,000 per year Outpatient (including drugs): MVR 10,000 per year Medical Evacuation: MVR 30,000 per year Spectacle: MVR 1,000 (once in two years)

9. Challenges in implementing • Benefit to service mismatch: Unavailability of services such as oncology, nephrology, cardiology, neurology etc. • Benefit to coverage limit mismatch: Specially for high cost /chronic diseases • Coverage exhaustion : Unable to sustain the coverage limit due to high cost of services • Certain Inclusions: Inclusion of definite cost bearing disease in the benefit package such as organ transplants, evacuations, and 100% drug coverage

10. Expenditures of SHI 2009-2014

11. Beneficiaries' of SHI (2009-2014)

12. HUSNUVAA AASANDHA SCHEME – Launched on February 2014 • A universal, Social Health Scheme for the Maldivians / Healthcare Financing Mechanism • No premium collected • No overall limit or sub- limits (except for spectacle) • Must be a Maldivian Citizen

13. Beneficiaries of ‘husnuvaa aasandha’ (2015-2018)

14. Scheme Benefits • All costs related to diagnosis and treatment (including OP and IP) is covered by the scheme. • Any procedure or surgery or treatment not available in the Maldives are sent abroad to an empaneled hospital in Sri Lanka or India • Any condition where it is life threatening or may go into a permanent physical disability is evacuated immediately from one Centre to the other or from one region to another where advanced treatment is available within the country.

15. Airfare ticket (two ways) for the relative travelling for the first time with a patient when travelling abroad • Airfare ticket (one way) for patient and relative during medical evacuation • Airfare ticket four times annually for each patient when travelling abroad • All cost for organ transplant (including donor screening) • All cost for implants • Cost of Cochlear Implants (surgery and implant) • In addition, the relative travelling abroad with patients will get four tickets annually under these conditions: • If the patient is disabled • If the patient is above 65yrs • If the patient is below 18yrs • If patient is travelling on a stretcher

16. Expenditures of ‘husnuvaa aasandha’ (2015-2018)

17. Evacuation expenditure

18. Pharmacy expenditure

19. All government health service providers will give services free of charge under the scheme • Cost of all the services provided by government services providers will be decided by NSPA and Aasandha Company • All private hospitals and clinics must get registered under Aasandha Company to provide services under the scheme • All private hospitals and clinics do take a co-payment from the patients (Aasandha rates are same through out the country) • Pharmacies must also get registered under Aasandha Company in order to provide services under the scheme • Pharmacies can issue medicines included in the Aasandha Master Drug list developed from the ADL • Introduced common price for all medicines covered under the scheme

20. CSC opened 24hrs x 7 days a week • Medical team staff will approve or reject the case based on the documents submitted and as per the rules of the scheme • Hospital will be decided by Aasandha Company • Pre-diagnosis investigations done are not covered by the scheme • Once diagnosed and if the treatment is not available in the Maldives, scheme will cover the cost of care • In an emergency or trauma, all services given in order to save life or prevent disability will be covered by the scheme

21. Treatment for a long-term illness (including medicines) in abroad will not be covered by the scheme • Patients can stay abroad for medical management for a period of two weeks • Scheme will cover the cost of transporting the patient back to Male’ Scheme excludes: • Treatment related to illegal diving problems will not be covered by the scheme • Cost of private room not covered • Special treatment (methadone, detoxification) for those using alcohol or substances not covered • Cosmetic services • Thalassemia • Vaccines • Any treatment related to infertility

22. Total number of service providers - LOCAL

23. Total number of service providers - abroad India Trivandrum – 11 Bangalore – 8 Cochin – 2 Chennai – 2 Vellore – 1 Madurai – 1 Mysore – 2 Coimbatore - 1 Sri Lanka Total - 6 Grand Total: 34

24. Challenges in implementing • Lack of Specialists and Super Specialists at different levels of healthcare delivery system • Health seeking behaviors of people leading to financial wastage within the scheme • Loopholes within the scheme leading to fraud • Service limitations: • 3 main hospitals to serve tertiary care • Lack of specialists and super specialists: oncologist, Rheumatologist, Hematologist • Insufficiency of essential drugs • Service provider inefficiencies • Exceeding cost of the scheme, Problems in sustaining the scheme

25. Can we sustain the scheme?

26. ‘ A Retrospective Study to assess the perception of Senior Managers on sustainability of the ‘Husnuvaa Aasandha’ Scheme in the Maldives ‘ • 10 participants took part in the in-depth interviews of this study • An interviewer-administered structured questionnaire which consists of 13 questions including the demographic data was used • All interviews transcribed and analyzed • Has the scheme been implemented to achieve universal health coverage for the Maldivians? • What could be the major areas of leakages within the scheme as a result of health seeking behaviors of the people? • What could be the changes that need to be brought to the scheme in order to sustain it?

27. Current and looming health care–spending obligations could be challenging for the government to sustain the universal health coverage • A major portion of the scheme money was spent on sending patients abroad for those investigations and treatments that were not available within the country. • According to Aasandha Company, the amount of money spent to send patients abroad for treatment had increased from MVR 139,764,316.50 in 2014 to MVR 175,324,902.04 in 2017 (Aasandha Unpublished Data, 2018). • A large percentage of the total cost was also spent on evacuating patients locally from one Centre to another • A total of MVR 122,728,859.48 was spent only for this service between the years 2014 to 2017 (Aasandha Unpublished Data, 2018).

28. Majority of the respondents agreed that the scheme was not implemented to achieve Universal Health Coverage (UHC) • Services under the scheme are available universally to the whole country but the level of accessibility is different at all levels due to the geographical dispersion of the Islands. • Health seeking behavior of public, and behavior of service providers is causing financial leakages within the scheme - Over prescribing of medicines and investigations - Absence of a proper mechanism to audit and monitor the prices of services provided abroad - Evacuation used as a common transport mechanism - Memo raised for investigations but procedure not performed - Expensive investigations done but reports not collected

29. Diagnostic memo raised but tests not done (IGMH) Diagnostic memo raised but tests not done (Senahiya Hospital)

30. On going and future developments • Implementation of Aasandha ‘Vinavi’ portal through out the country (both public and private) • implementation of set service prices / packaged prices (both local and abroad) • Implementation of E-prescription • Introduce generic drugs • Set standard criteria for the services rendered • The government needs to introduce premiums as an important feature of an Insurance scheme • Special projects to clear long waiting lists for surgeries (TKR project) • Establishing Monitoring and evaluation system • Strengthen data collection and a strong back-up of the data system • Conduct research to identify the areas of wastages within the scheme including prescribing and delivering medicines, emergency evacuations, and referring patients abroad

31. THANK YOU