New Delhi: Government-sponsored health programmes such as Central Government Health Scheme (CGHS) and Rashtriya Swasthya Bima Yojana (RSBY) that can serve as change agents for strengthening healthcare and achieving universal health coverage have either failed in implementation or have been ineffective in offering access to healthcare, according to studies done by Public Health Foundation of India (PHFI), an autonomous research and policy development organization.

CGHS provides comprehensive healthcare facilities to central government employees and pensioners and their dependents living in cities covered by the scheme. CGHS facilities are fully funded by budgetary support from the ministry of health, even if a beneficiary avails of treatment in an empanelled private hospital. A study done in the national capital found that delays in payments to private facilities plagued the scheme.

“Empanelled hospitals are reimbursed by the Union health ministry; however a major problem is that there is a delay in the payment to empanelled hospitals," said Raj Panda, author of the study. Panda is an additional professor and senior public health specialist with PHFI.

“There is no separate autonomous fund manager for CGHS, which is a key feature of any self-sustaining health insurance scheme. Details of inflow and outflow of funds at all levels is not available and that raises questions about the planning process of the department in the absence of such basic data," he said.

CGHS covers 25 cities across 18 states and two Union territories. In 2015, CGHS had a beneficiary base of 320,865 with an allocated budget of $241 million when the study was done. The scheme is also plagued by staff shortages. Out of 700 CGHS posts, more than 150 are vacant.

“Medical officers manage wellness centre and polyclinics under CGHS both clinically and administratively. However, officials have many other responsibilities within the system and cannot dedicate full time to scheme oversight and management. There is severe shortfall of human resources which hinders smooth implementation of the scheme," Panda said.

CGHS uses a combination of its own facilities for ambulatory care and purchasing services for inpatient care and advanced diagnostics from its panel of public and private health facilities. CGHS follows a procedure of tendering for defining package rates. However, the rates in the tendering process vary across states. “Empanelment of the hospital under CGHS is done by inviting tenders from private hospitals. However, there are flaws in the process as hospitals quoting lowest bid for particular services are selected and similar rates are applied for the entire country," said Panda.

“At the claims stage, misutilization or fraud can take multiple forms. Prompt disciplinary action is important as a deterrent to fraudulent in claim settlement. There is lack of robust management information systems in the CGHS which compromises the ability of these schemes to purchase effectively, control costs, and measure performance," Panda said.

The ministry of labour and employment launched RSBY in April 2008 to provide insurance coverage for inpatient care to poor families or below poverty line (BPL) families.

PHFI in a separate study found that the scheme did not affect the likelihood and level of inpatient out-of-pocket spending. The researchers also didn’t find any statistically significant effect of RSBY on the level of outpatient out-of-pocket expenditure.

“In contrast, the likelihood of incurring any out-of-pocket spending (inpatient and outpatient) rose by 30% due to RSBY and was statistically significant. Although out-of-pocket spending levels did not change, RSBY raised household non-medical spending by 5%. Overall, the results suggest that RSBY has been ineffective in reducing the burden of out-of-pocket spending on poor households," the study said.

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