Based on the evaluation results, along with considerable challenges encountered with low enrollment and an unacceptably high claim ratio, new enrolment in the CHF was temporarily stopped as of 1 June 2011 to allow SSP to focus on a transition from the present model to one that it believes can promote greater sustainability of the CHF.
In terms of next steps:
- The CHF will focus operations in fewer villages (50) and implement interventions (e.g. more focused grassroots insurance education) to increase penetration through higher enrolment and renewals. SSP believes it can scale up to 70 villages in three years and capture 100,000 members.
- Enrolment will be limited to two low illness periods in the year (e.g. avoid monsoon season) to reduce adverse selection and improve administrative efficiency.
- Ten trained Community Health Volunteers will work with communities to reduce water borne illness and promote basic hygiene and nutrition, in an effort to reduce hospitalizations and claims costs.
- Community governance of the CHF will be strengthened through the CHF Board of Trustees, e.g. by including healthcare providers as advisors. Additionally, community-based Health Governance Groups will be formed to enable greater participation by community members in the oversight of the CHF, and to engage directly with the healthcare provider network to create more visibility and accountability for performance.
- The Government of Maharashtra has launched Rajiv Gandhi Jeevandayee Arogya Yojana (RGSJAY) and Solapur has been selected for a pilot. If the RGSJAY scheme rolls out, SSP could leverage its community experience across multiple districts to facilitate and monitor this scheme.
- Though in first stages of conceptualization, SSP will consider options for a savings mechanism within the communities to help minimize the burden to clients of having to finance the hospital care until reimbursement is made by the insurer.
- The Trust overseeing the CHF will take over direct relationships through its Board, selected advisors and a network of community-based groups to run all facets of the CHF, including setting up and maintaining a contracted healthcare provider network, interfacing with the TPA and insurer, and managing claims and operations. The next step is to resolve a pending backlog of rejected claims to obtain greater claims settlement for legitimate claims, and build a closer working relationship for the future.
- A more robust monitoring and reporting system will be built for claims management and cash handling.
- The discounted pharmacy supply chain will cease.
- The premium will be increased from INR 750 (US$16.70) to INR 860 (US$18.90).
Although it is clear that the initial projections to scale up were overly optimistic and significant progress must be made to address high claims and low enrolment, the rich lessons learned should contribute to further progress toward meeting the objectives of the project. SSP will continue to refine these and other plans with an aim to achieve a sustainable program in approximately five years.
Date of last Learning Journey update: November 2011