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167x Filetype PDF File size 0.40 MB Source: nhm.gov.in
Framework for developing health insurance
programmes
Some suggestions for States
Ministry of Health & Family Welfare
Government of India
New Delhi
Table of contents
NRHM – The Background 3 – 10
The approach to health insurance for vulnerable groups 11
Section 1
• The framework 12 – 13
• Why health insurance? 14 – 16
• Pre-requisites for a health insurance programme 16 – 17
• Organiser of a health insurance programme 17 – 20
• Communities to be covered 20 – 22
• Defining the benefit package 22 – 24
• The premium 25 – 28
• Empanelling the providers 29 – 32
• Provider payment 32 – 33
• Insurer 33 – 34
• Administration of the programme 34 – 36
• Monitoring 36 – 37
• Managing risks 37
• Values in health insurance 38
Section 2
• Health insurance programme for BPL families 40 – 43
• Health insurance programmes for SHG families 44 – 46
• Health insurance programmes where there are no hospitals 47 – 49
• Revamping the UHIS 50 – 52
Appendices
• Some health insurance terms 54 – 55
• Some health insurance programmes in the NGO / Government 56 – 59
sector
• Prices of some common conditions 60 – 65
• Utilisation rates of some common conditions 66
• Provider payment mechanisms 67 – 69
• Various Insurance Models
BACKGROUND:
th
The Hon’ble Prime Minister launched the NRHM on 12 April, 2005 throughout
the country with special focus on 18 States, including eight Empowered Action Group
(EAG) States, the North-Eastern States, Jammu & Kashmir and Himachal Pradesh.
The NRHM seeks to provide accessible, affordable and quality health care to the
rural population, especially the vulnerable sections. It also seeks to reduce the Maternal
Mortality Rate (MMR) in the country from 407 to 100 per 1,00,000 live births, Infant
Mortality Rate (IMR) from 60 to 30 per 1000 live births and the Total Fertility Rate (TFR)
from 3.0 to 2.1 within the 7 year period of the Mission.
IMPLEMENTATION FRAMEWORK & PLAN OF ACTION FOR NRHM
The key features in order to achieve the goals of the Mission include making the
public health delivery system fully functional and accountable to the community, human
resources management, community involvement, decentralization, rigorous monitoring &
evaluation against standards, convergence of health and related programmes from
village level upwards, innovations and flexible financing and also interventions for
improving the health indicators.
The Diagrammatic Representation of the 5 Main approaches of NRHM is
illustrated below:
NRHM –5 MAIN APPROACHES
COMMUNITIZE
1. Hospital Management MONITOR,
Committee/ PRIs at all levels PROGRESS AGAINST
2. Untied grants to community/ STANDARDS
PRI Bodies 1. Setting IPHS Standards
3. Funds, functions & FLEXIBLE FINANCING 2. Facility Surveys
functionaries to local 3. Independent Monitoring
community organizations 1. Untied grants to institutions Committees at
4. Decentralized planning, 2. NGO sector for public Block, District & State
Village Health & Health goals levels
Sanitation 3. NGOs as implementers
Committees 4. Risk Pooling – money
follows patient
5. More resources for
IMPROVED more reforms INNOVATION IN
MANAGEMENT HUMAN RESOURCE
THROUGH CAPACITY MANAGEMENT
1. Block & District Health 1. More Nurses – local
Office with management skills Resident criteria
2. NGOs in capacity building 2. 24 X 7 emergencies by
3. NHSRC / SHSRC / DRG / BRG Nurses at PHC. AYUSH
4. Continuous skill development 3. 24 x 7 medical emergency
support at CHC
4. Multi skilling
IMPROVING THE PUBLIC HEALTH DELIVERY SYSTEM
Given the status of public health infrastructure in the country, particularly in the
EAG and the North Eastern States, it will not be possible to provide the desired services
till the infrastructure is sufficiently upgraded. The Mission seeks to establish functional
health facilities in the public domain through revitalization of the existing infrastructure
and fresh construction or renovation wherever required. The Mission also seeks to
improve service delivery by putting in place enabling systems at all levels. This involves
simultaneous corrections in manpower planning as well as infrastructure strengthening.
The Mission would provide priority to both these aspects.
A generic Public Health Delivery System envisioned under NRHM from the
Village to the Block Level is illustrated below:
NRHM –ILLUSTRATIVE STRUCTURE Health Manager
BLOCK LEVEL HEALTH OFFICE –--------------- Accountant
Store Keeper
Accredit private 100,000 BLOCK
providers for public Population LEVEL
health goals 100 Villages HOSPITAL Strengthen Ambulance/
Ambulance transport Services
Telephone Increase availability of Nurses
Obstetric/Surgical Medical Provide Telephones
Emergencies 24 X 7 Encourage fixed day clinics
Round the Clock Services;
30-40 Villages CLUSTER OF GPs –PHC LEVEL
3 Staff Nurses; 1 LHV for 4-5 SHCs;
Ambulance/hired vehicle; Fixed Day MCH/Immunization
Clinics; Telephone; MO i/c; Ayush Doctor;
Emergencies that can be handled by Nurses – 24 X 7;
Round the Clock Services; Drugs; TB / Malaria etc. tests
5-6 Villages GRAM PANCHAYAT –SUB HEALTH CENTRE LEVEL
Skill up-gradation of educated RMPs / 2 ANMs, 1 male MPW FOR 5-6 Villages;
1000 Telephone Link; MCH/Immunization Days; Drugs; MCH Clinic
Popu VILLAGE LEVEL – ASHA, AWW, VH & SC
lation
1 ASHA, AWWsin every village; Village Health Day
Drug Kit, Referral chains
PUBLIC HEALTH INFRASTRUCTURE
The Central Govt. has so far supported only the construction/up gradation of sub-
centres. Because of their difficult financial conditions, the States have usually not
provided sufficient funds for construction / up-gradation of Primary Health Centre
[PHC]/Community Health Centre [CHC]/District Hospitals etc. As a result, health
infrastructure is in poor condition in most of the states. NRHM allows the expenditure
for construction subject to the condition that it should not be more than 33% of the total
NRHM outlay in the case of high focus States, and, 25% in the case of non-high focus
States. NRHM also provides for upgradation of District Hospitals.
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