Rashtriya Swasthya Bima Yojana and Medical Regulation


Rashtriya Swasthya Bima Yojana (RSBY)

It has been estimated that up to 11th Plan only 16% of population was covered by health insurance which has been available mainly to government employees or workers in the organised sector and to a very limited extent through private health insurance. Since poor did not have any insurance for in-patient care, Rashtriya Swasthya Bima Yojana (RSBY) was introduced in 2007, to meet the health insurance needs of the poor.

RSBY provides for ‘cash-less’, smart card based health insurance cover of Rs 30,000 per annum to each enrolled family, comprising up to five individuals. The beneficiary family pays only Rs 30 per annum as registration/renewal fee. The scheme covers hospitalisation expenses including maternity benefit, and preexisting diseases. A transportation cost of Rs100 per visit is also paid. The premium payable to insurance agencies is funded by Central and State Governments in a 75:25 ratio, which is relaxed to 90:10 for the North-East region and Jammu and Kashmir. The maximum premium by the Central Government is limited to Rs 750 per insured family per year.

RSBY was originally limited to Below Poverty Line (BPL) families but was later extended to building and other construction workers, Mahatama Gandhi National Rural Employment Guarantee Act (MGNREGA) beneficiaries, street vendors, beedi workers, and domestic workers.

A general problem with any ‘fee for service’ payment system financed by an insurance mechanism is that it creates an incentive for unnecessary treatment, which in due course raises Costs and premiums. There is some evidence that this is happening and it is necessary to devise corrective steps to minimise it.

The shortcomings of RSBY noted so far include high transaction costs due to insurance intermediaries, inability to control provider induced demand, and lack of coverage for primary health and outpatient care. Fragmentation of different levels of care can lead to an upward escalation towards the secondary level of patients who should preferably be handled at the primary or even preventive stages.

Therefore, there is need to study experience with the RSBY, and with the other state specific insurance schemes, so that suitable corrective measures can be introduced before integrating these schemes into a framework of Universal Health Coverage (UHC).

Health and Medical Regulation

Regulations for food, drugs and the medical profession require lead action by the Central Government not only because these subjects fall under the Concurrent List in the Constitution, but also because the lack of consistency and well enforced standards hugely impacts the common citizen and diminishes health outcomes. Keeping in view the need to place authority and accountability together, the proposed Public Heath Cadre in states would be expected to be the single point for enforcement of all health related regulations. There is also an urgent need to strengthen the regulatory systems in the states, where most of the implementation rests. This would entail the strengthening of and establishment of testing labs and capacity building of functionaries. Such proposals will be part-funded under the National Health Mission (NHM).

Drug Regulation: Pharmaco-vigilance, post-marketing surveillance, Adverse Drug Response Monitoring, quality control, testing and re-evaluation of registered products would be accorded priority under drug regulation.

            Use of generic names or the International Non-proprietary Name (INN) would be made compulsory and encouraged at all stages of government procurement, distribution, prescription and use. To ensure quality, established brand manufacturers would be encouraged to bid for government procurement, but in non-propriety names.

          A National List of Essential Medicines would be made operational with the introduction of Standard Treatment Guidelines, including for AYUSH.

Food surveys would be carried out regularly and their results made public. An annual report on state of food safety would be published.

    Policies to promote production and consumption of healthy food would be developed. Sale and consumption of unhealthy food would be discouraged in general and in schools in particular. Public information campaigns to create awareness on food safety matters will be launched. Regulation of Medical Practice: The provisions for registration and regulation of clinical establishments would be implemented effectively. Government may consider making it mandatory to follow Standard Treatment Guidelines. Gradually under the system, clinical decision-making would be routinely subjected to prescription audits to confirm compliance.

       There is also a need to revise and strengthen the existing regulatory mechanism for medical practice to prevent willful negligence and malpractice. Grievance redressal mechanisms also needs to be put in place. 
                 States will be persuaded to enact/modify legislations as per Central Act under Clause (1) of Article 252 of the Constitution to ensure registration of clinical establishments. To save the girl child, effective enforcement of the provisions of Pre- Conception and Pre- Natal Diagnostic Techniques (Prohibition of Sex Selection) Act and relentless public awareness measures would be put in place.

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