|Year : 2015 | Volume
| Issue : 1 | Page : 69-77
Innovative social protection mechanism for alleviating catastrophic expenses on multidrug-resistant tuberculosis patients in Chhattisgarh, India
Debashish Kundu1, Vijendra Katre2, Kamalpreet Singh2, Madhav Deshpande3, Priyakanta Nayak1, Kshitij Khaparde1, Arindam Moitra1, Sreenivas A Nair1, Malik Parmar1
1 World Health Organization Country Office for India, New Delhi, India
2 Rashtriya Swasthya Bima Yojna and Mukhyamantri Swasthya Bima Yojana, State Nodal Agency, Directorate of Health Services; Directorate of Health Services, State Government of Chhattisgarh, Raipur, India
3 Directorate of Health Services, State Government of Chhattisgarh, Raipur, India
|Date of Web Publication||19-May-2017|
D-776, First Floor, C R Park, New Delhi – 110019
Background: Patients with multidrug-resistant tuberculosis (MDR-TB) incur huge expenditures for diagnosis and treatment; these costs can be reduced through a well-designed and implemented social health insurance mechanism. The State of Chhattisgarh in India successfully established a partnership between the Revised National TB Control Programme (RNTCP) and the Health Insurance Programme, to form a universal health insurance scheme for all, by establishing Rashtriya Swasthya Bima Yojna (RSBY) and Mukhyamantri Swasthya Bima Yojana (MSBY) MDR-TB packages. The objective of this partnership was to absorb the catastrophic expenses incurred by patients with MDR-TB, from diagnosis to treatment completion, in the public and private sector. This paper documents the initial experience of a tailor-made health insurance programme, linked to covering catastrophic health expenditure for patients with MDR-TB.
Methods: In this descriptive study, data on uptake of insurance claims through innovative MDR-TB packages from January 2013 to April 2014 were collected. A simple survey of costs for clinical investigation and inpatient care was conducted across two major urban districts in Chhattisgarh. In these selected districts, three health facilities from the private sector and one medical college from the public sector with a functional drug-resistant tuberculosis (DR-TB) centre were chosen by the RSBY and MSBY State Nodal Agency to complete a simple, structured questionnaire on existing market rates. The mean costs for clinical investigations and hospital stay were calculated for an individual patient with MDR-TB who would seek services from the private or public sector.
Results: A total of 207 insurance claims for RSBY and MSBY MDR-TB packages were processed, of which 20 were from private and 187 from public health establishments, covered under the health insurance programme, free of charge. An estimated catastrophic expenditure, of approximately US$ 20 000, was saved through the RSBY and MSBY health insurance mechanism during the study period.
Conclusion: The innovative RSBY and MSBY MDR-TB insurance package is a step towards reducing catastrophic expenses associated with treatment for MDR-TB.
Keywords: catastrophic expenditure, health insurance, MSBY, multi-drug-resistant tuberculosis, public-private partnership, RNTCP, RSBY, social protection
|How to cite this article:|
Kundu D, Katre V, Singh K, Deshpande M, Nayak P, Khaparde K, Moitra A, Nair SA, Parmar M. Innovative social protection mechanism for alleviating catastrophic expenses on multidrug-resistant tuberculosis patients in Chhattisgarh, India. WHO South-East Asia J Public Health 2015;4:69-77
|How to cite this URL:|
Kundu D, Katre V, Singh K, Deshpande M, Nayak P, Khaparde K, Moitra A, Nair SA, Parmar M. Innovative social protection mechanism for alleviating catastrophic expenses on multidrug-resistant tuberculosis patients in Chhattisgarh, India. WHO South-East Asia J Public Health [serial online] 2015 [cited 2019 Jul 22];4:69-77. Available from: http://www.who-seajph.org/text.asp?2015/4/1/69/206624
| Introduction|| |
Tuberculosis (TB) is primarily a disease of poverty. In India currently, there are 1 million so-called missed TB cases, as the majority of these patients are probably seeking care in the private sector and so are missed from public-sector notification. In many high-burden countries such as India, TB patients incur catastrophic expenditure, directly and indirectly, for diagnosis and treatment of their disease. The direct and indirect cost of disease to India is estimated to be US$ 23.7 billion annually. In India, 62 000 multidrug-resistant TB (MDR-TB) cases are estimated to emerge annually among notified pulmonary TB cases, while a similar volume of cases are expected to be managed by the private sector but remain unnotified. These complex cases are more likely to be fatal and unnotified are as much as 100 times more costly to treat, compared with drug-sensitive TB cases. The estimated market for annual TB diagnostics in India is US$ 222 million (in both the public and private sector), of which the non-Revised National TB Control Programme (non-RNTCP; private) sector accounts for at least 62%. In the action framework of the World Health Organization (WHO) End TB Strategy, one of the key targets set for 2035 is that there should be no TB-affected families facing catastrophic costs due to TB., Removal of financial barriers to health-care access is vital to achievement of universal health coverage and prevention of catastrophic expenditures.
A number of social protection schemes are being implemented by the central and state governments of India for improving TB patients’ access to and affordability of health care. The Universal Health Insurance Scheme (UHIS) is one such scheme in the State of Chhattisgarh in India, which provides health insurance coverage and protection to all people to fund medical treatment. UHIS is managed by the National Health Insurance Programme, known as Rashtriya Swasthya Bima Yojna (RSBY) for people below the poverty line and the Chief Minister’s Health Insurance Scheme, known as Mukhyamantri Swasthya Bima Yojna (MSBY), for those who are not included in RSBY (see [Table 1] and [Table 2]). The poverty line is defined as the level of expected income that allows an individual to consume enough food to maintain capacity for labour intact. The RSBY and MSBY already had a Respiratory Medical TB insurance package to cover the expenses of seriously ill TB patients (confirmed bacteriologically or histologically for TB), but this only applies during medical hospitalization (inpatient care basis) for a maximum period of 10 days (see [Table 3]). However, they did not have insurance packages specifically designed for patients with MDR-TB to cover their medical expenses with RNTCP linkages. Also, mechanisms to cover catastrophic expenses for all pre-treatment evaluations, admissions, travel costs, follow-up investigations, ancillary drugs and nutritional support for patients with MDR-TB are not well established within and outside the programme.
|Table 1: Details of the Rashtriya Swasthya Bima Yojna (RSBY) and Mukhyamantri Swasthya Bima Yojna (MSBY) package for poor and non-poor households|
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|Table 2: Details of the innovative Rashtriya Swasthya Bima Yojna (RSBY) and Mukhyamantri Swasthya Bima Yojna (MSBY) MDR-TB package in Round IV|
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Countries in the lower middle income range, such as Brazil, Cambodia, China, Rwanda, Mexico, South Africa and Thailand have adopted national health insurance as models for universal health coverage and a few case-studies demonstrate that integration of TB services with national health insurance has a positive effect on access to services and their quality.
This study discusses the initial experience of linking RSBY and MSBY provision, tailor-made to cover catastrophic health expenditure for patients with MDR-TB; the potential of such linkages for universal health coverage; and challenges and future scope for the national TB control programme. The primary objective of this study is to ascertain (i) the proportion of patients with MDR-TB who are diagnosed from a recognized laboratory in the state, who benefited from the innovative RSBY and MSBY MDR-TB insurance claim packages; and (ii) the number of claims made in both the private and public sector. The study also aimed to estimate the amount of catastrophic expenditure possibly saved due to this innovative social protection mechanism.
| Methods|| |
The State of Chhattisgarh in central India (population 26 million) has 80% of the population living in rural areas, of whom 30% are considered “tribal” (as notified by the Government of India). Chhattisgarh is one of the pioneer states in implementation of various information and communication technology (ICT)-enabled schemes, which includes RSBY, the Centralised Online Real-time Electronic Public Distribution System (Core PDS), and e-Kosh for e-transfer of salaries to government staff.
Under the RNTCP in India, most patients diagnosed with MDR-TB are initially hospitalized for a week or two at drug-resistant TB (DR-TB) centres, established mostly at the medical colleges by the programme, for pre-treatment evaluations, initiation of treatment and monitoring early events of adverse drug reactions. There were two functional DR-TB centres in Chhattisgarh, one each at the public sector medical college located in the districts of Raipur and Bilaspur, respectively, until early 2014. Expenditures for diagnosis (culture and drug-sensitivity tests) and treatment of MDR-TB (second-line anti-TB drugs) are, as per policy, provided free of charge to the patients registered for treatment under the public sector. Drugs to treat MDR-TB are toxic and expensive compared with those used in the treatment of basic TB. While a course of standard TB drugs costs approximately ₹765 (~US$ 13), MDR-TB drugs can cost ₹103 920 (~US$ 1732) based on the National Programme’s drugs procurement cost.
A policy decision was taken in early 2012 by the Chhattisgarh State Government to include packages under RSBY and MSBY in various national health programmes, where hospitalization is necessary. Leveraging this opportunity, the State TB Control Programme in Chhattisgarh facilitated RNTCP partnership with RSBY and MSBY through creation of innovative MDR-TB packages (see [Table 1] and [Table 2]) under the UHIS, integrating it in a list of other disease packages in Chhattisgarh by December 2012. These packages are applicable for MDR-TB patients, above and below the poverty line, who are diagnosed as having MDR-TB, by a RNTCP-certified or any other recognized laboratory. Beneficiaries are provided with RSBY and MSBY smart cards for using the integrated schemes, which are ICT enabled and also linked with the Core PDS for nutrition support. Operational guidance on the RSBY and MSBY MDR-TB packages was issued by the State TB Officer of Chhattisgarh to all concerned, in early 2013, to establish close linkages with the RNTCP.
Study period and data collection
This is a descriptive study in which initial data on the uptake of packages was collected from the RSBY server, accessible at the RSBY and MSBY State Nodal Agency of the Directorate of Health Services, Raipur, from January 2013 to April 2014 (for the Round IV period of the health insurance programme in the state). This information was shared electronically for the purpose of the study. A simple survey was conducted in public health facilities (medical colleges where DR-TB centres are located) and private health facilities, by the RSBY and MSBY State Nodal Agency in the districts of Raipur and Bilaspur, Chhattisgarh, to estimate the direct expenditure a patient with MDR-TB incurs in the public and private sector, from diagnosis to treatment completion. Estimates of indirect costs, such as daily wages lost and nutritional costs, were excluded, as the study was based on record review of claims data and a simple estimate of direct costs incurred. A structured questionnaire was used to ascertain the cost for laboratory investigations (including the cost for X-rays) and a hospital stay in these health facilities.
The two districts of Raipur and Bilaspur were selected purposively, because they have an urban population and both private-sector health facilities and a public-sector medical college with a functional DR-TB centre. From the selected districts, three well-functioning private health facilities, identified by the RSBY and MSBY State Nodal Agency, and a public-sector medical college with a functional DR-TB centre, were enrolled to enable estimation of the market cost per individual MDR-TB patient. A structured questionnaire was completed by a field representative of the RSBY and MSBY State Nodal Agency and mean costs on pre-treatment investigations, hospital stay and follow-up investigations were calculated for each patient with MDR-TB seeking services from either the private and public sector (see [Table 4]).
|Table 4: Estimated costs of laboratory investigation and hospital stay based on a simple market survey conducted in Raipur and Bilaspur districts of Chhattisgarh|
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Data variables, data entry and analysis
The predefined data variables on hospital code, hospital name, package code, package name and claim status were collected from the electronic server and then directly exported to Microsoft Excel for further analysis. Data were tabulated and the following were calculated: the proportion of uptake of insurance claims of the RSBY and MSBY MDR-TB package by patients with MDR-TB; the number of claims processed in the public and private sector for both MDR-TB and TB packages; and the amount of catastrophic expenditure estimated to be saved by the UHIS.
Since this study was a review of reports and did not involve patient interaction, individual patient consent was deemed unnecessary. The protocol was reviewed and permission to conduct the study was granted by the RSBY and MSBY State Nodal Agency, Directorate of Health Services, Government of Chhattisgarh.
| Results|| |
A total of 206 patients with MDR-TB were diagnosed from 1 January 2013 to 30 April 2014, from recognized laboratories (especially from the intermediate reference laboratory) in the state. Of these, 113 (55%; 7 from private and 106 from public health facilities); underwent one pre-treatment evaluation (see [Table 5]) before initiating treatment for DR-TB, as the MDR-TB package on pre-treatment evaluation could only be claimed for once by a patient with MDR-TB (see [Table 4] and [Table 5]); these patients benefited from the RSBY and MSBY MDR-TB insurance packages.
|Table 5: Status of uptake of insurance claims by TB patients in RSBY (1 January 2013 to 30 April 2014)|
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A total of 207 total health insurance claims under three different MDR-TB health insurance packages were processed in RSBY and MSBY empanelled private and public hospitals (see [Table 5]). Of these, 20 claims were from the private and 187 from the public hospitals (see [Table 5]). In the pre-existing RSBY and MSBY Respiratory Medical TB Package, 196 claims were processed from the private hospitals and 137 from the public hospitals (see [Table 5]).
Considering that a patient with MDR-TB spends, on average, ₹120 238 (~US$ 2000) in the private sector (without free diagnosis and drugs) and ₹3636 (US$ 61) in the public sector (with free diagnosis and drugs) from diagnosis to treatment completion (see [Table 6]), the total catastrophic expenditure estimated to be saved as a result of uptake of 207 health insurance claims by the MDR-TB patients (see [Table 7]) from this intervention during the study period was approximately ₹1 169 709 (~US$ 20 000).
|Table 6: Estimated expenditure an MDR-TB patient incurs in the private and public sectora from diagnosis to treatment completion|
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|Table 7: Total catastrophic expenditure estimated to be saved due to uptake of insurance claims of RSBY and MSBY MDR-TB packages|
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| Discussion|| |
For the first time in India, national health insurance was successfully linked with the national TB control programme through creation of special packages for patients with MDR-TB. This is the first study that describes collaboration between RSBY and the RNTCP, and early findings of implementation of the RSBY and MSBY MDR-TB packages shows that this innovative mechanism is working. The possible implications of RSBY linkage with the RNTCP on policy and practice are discussed next.
Firstly, synergy with RSBY and MSBY to cover MDR-TB broadens the scope of uptake of standardized services from the public and private sector, free of charge, reducing catastrophic expenditure (~US$ 20 000 was estimated to be saved through the RSBY and MSBY insurance mechanism), which was earlier untapped by the RNTCP. RSBY and MSBY makes the participating poor (below poverty line) and non-poor (above poverty line) household a potential client worth attracting, on account of the significant revenues that hospitals, in both the public and private sector, stand to earn through the scheme. The scheme has been designed as a business model for a social-sector scheme with incentives built for each stakeholder, namely, insurers, hospitals and government. Even public-sector hospitals have an incentive to treat beneficiaries under RSBY, as the money from the insurer will come directly to the concerned public hospital, where it can be used for their own development. This will lead to healthy competition between public and private hospitals, which, in turn, will improve the functioning of public-sector hospitals. The RSBY and MSBY MDR-TB packages could empower patients with DR-TB to avail cashless, paperless and portable transactions as per their choice, by increasing their access to any RSBY-and MSBY-empanelled hospitals providing quality care across Chhattisgarh, thereby encouraging them to adhere to treatment and achieve treatment success with better survival probabilities. These integrated health insurance schemes have triggered an increase in the number of providers involved, as many private hospitals have started treating MDR-TB cases under the health insurance schemes, with improvement in the quality of care. However, as indicated by the simple market survey in Raipur and Bilaspur districts of Chhattisgarh, the availability of Programmatic Management of Drug Resistant Tuberculosis (PMDT) services in the public sector is mostly free of charge (especially the component of MDR-TB drugs and diagnosis); this contrasts with the private sector in the state, where the cost is substantial. Therefore, without proper social-protection linkages such as the RSBY and MSBY MDR-TB health insurance packages, a greater number of patients may not be able to afford private care for MDR-TB. Coincidentally, this study also found that a total of 333 claims of the pre-existing Respiratory Medical TB insurance package, without RNTCP linkages, were processed for TB patients requiring inpatient care from RSBY- and MSBY-empanelled hospitals. This could be indicative of increasing demand for affordable treatment services by the patients, both below and above the poverty line, in these health facilities under health insurance cover, and requires further investigation.
Initial acceptance of these integrated schemes by the providers and the beneficiaries clearly shows this model is able to fulfil its objectives to provide social protection to poor (below poverty line) and non-poor (above poverty line) households from catastrophic expenditures related to MDR-TB treatment. RSBY is a government-sponsored scheme especially for the population of India living below the poverty line, and the majority of the financing, about 75%, is provided by the Government of India, while the rest is paid by the respective state government. However, in the case of MSBY, the Government of Chhattisgarh is financing 100% in implementation of its schemes for households both below and above the poverty line, with assurance of full financial support. RSBY and MSBY have provision for secondary care treatment up to US$ 500 (?30 000) in a year. The cost for each procedure has been fixed and a household can only avail only up to US$ 500, even if a single procedure absorbs the entire amount. However, it has been observed over the years by the RSBY and MSBY State Nodal Agency that the mean hospitalization cost per patient in Chhattisgarh is around US$ 133 (?8000) through RSBY, and so the integrated packages for MDR-TB patients can be well absorbed in the health coverage ceiling of US$ 500. In this integration model, MDR-TB drugs should be provided free of cost from the programme when a patient seeks treatment services from the RSBY- and MSBY-empanelled hospital in the private sector. An initial guidance document was issued by the State TB Officer of Chhattisgarh for linking MDR-TB treatment initiation by national government-approved TB drugs with RSBY and MSBY. There are 3 820 000 families enrolled under the scheme and each year 8% of these families utilize RSBY and MSBY services in Chhattisgarh. RSBY and MSBY cover most of the diseases that require hospitalization, including pre-authorization, apart from immunization, alcohol-induced disease and war-related injuries. A third-party evaluation of RSBY implementation in Chhattisgarh has indicated that 80% of people rated their satisfaction from the schemes as “good” (34%), “very good” (28%) or “excellent” (18%).
Secondly, hospitals empanelled under RSBY are ICT enabled and connected to the server at the district and state level, ensuring smooth data flow regarding service utilization; this can be an opportunity to improve TB notification in the private sector through the existing ICT platform in the RSBY health insurance scheme, by bridging it with NIKSHAY, the national online case-based notification and patient tracking system in India.
Thirdly, the claims were processed after the launch of the RSBY and MSBY MDR-TB packages in early 2013-2014, with minimum advocacy communication and social mobilization (ACSM) activities such as media publicity, sensitization meetings etc., carried out by the RSBY State Nodal Agency. Whenever a new, innovative and integrated scheme is introduced in the system, an awareness campaign is an important component for the success of the scheme. Therefore, proper planning, coordination, awareness (ACSM) activities and sensitization of the RNTCP and RSBY staff are essential to improve uptake of the claims and resolve any operational challenges towards its implementation in Chhattisgarh. The RSBY and MSBY MDR-TB insurance package model in Chhattisgarh can also be scaled up across the country through proper ACSM activities. There is a pertinent need for further systems to be built up jointly by RNTCP and RSBY, to operationalize successful implementation of these innovative and integrated schemes in the state with adequate awareness campaigns.
This study had certain limitations. Firstly, it was expected that each patient with MDR-TB would undergo pre-treatment evaluations once under hospitalization, before initiating the DR-TB treatment. However, it was found that, in the public sector, fewer claims (68) were processed for hospital stays than for pre-treatment evaluations (106), while in the private sector, more claims for hospital stays (13) than for pre-treatment evaluations (7) were processed. It is possible that a greater preference for pre-treatment evaluations for MDR-TB patients, followed by decentralized outpatient treatment and care (not limited to the DR-TB centres) has started in RSBY-and MSBY-empanelled hospitals in the public sector, in an attempt to optimize convenience for patients with MDR-TB. On the other hand, it is observed that, in the private sector, more emphasis is placed on inpatient care for patients with MDR-TB. MDR-TB patient admissions to hospital in the private sector resulting from adverse drug reactions also cannot be ruled out. These new patterns of seeking pre-treatment investigation for MDR-TB patients in public and private sector health establishments, emerging since the launch of MDR-TB insurance packages, need to be further explored. There is scope for separate research in this area to establish the relationship between treatment seeking and the new insurance packages, and implications for treatment outcomes of MDR-TB patients in the two years since introduction of the integrated MDR-TB packages in January 2013.
Secondly, the study’s estimation of the cost a patient with MDR-TB incurs for pre-treatment investigations, admissions, ancillary drugs, nutrition and travel support in India, if managed in the public sector (with free diagnostics and drugs from the programme) and separately for the private sector (without free diagnostics and drugs), is based on a simple survey conducted in public (medical colleges where DR-TB centres are located) and private health facilities by the RSBY and MSBY State Nodal Agency in the districts of Bilaspur and Raipur, Chhattisgarh. However, the cost of pre-treatment investigations, admissions, ancillary drugs, nutrition and travel incurred by the patient with MDR-TB may vary from state to state in the country; therefore, a nationally representative cost-analysis study to investigate catastrophic expenditure incurred by the MDR-TB patient, with or without HIV co-infection, and the social-protection strategy adopted by the states to mitigate this expenditure for impacting MDR-TB outcomes, could also be a topic for further research.
| Conclusion|| |
Initiation of decentralized treatment of DR-TB patients in RSBY and MSBY empanelled health facilities (both public and private) due to RSBY and MSBY MDR-TB packages, indicates that initiation of treatment for MDR-TB is not only limited to DR-TB centres in the medical colleges of the state. This is an innovative step towards making systems more efficient for the management of patients with MDR-TB, with the possibility of reducing the time between diagnosis of MDR-TB to initiation of treatment for MDR-TB. Coverage through RSBY insurance schemes is primarily based on hospitalization, to make use of the packaged services and not outpatient treatment. Considering that treatment for both drug-resistant and drug-sensitive TB is ambulatory and takes a long time to complete, outpatient care needs to be included in the mainstream health insurance. RNTCP collaboration with RSBY and MSBY can ensure financial protection to patients with TB, and, in order to address the social-protection component of the post-2015 End TB strategy,, mechanisms emphasizing collaboration with existing social health insurance schemes need attention in the national policy framework for TB control.
| Acknowledgments|| |
The authors acknowledge the assistance provided by the staff of the Rashtriya Swasthya Bima Yojna (RSBY) and Mukhyamantri Swasthya Bima Yojana (MSBY) State Nodal Agency, Directorate of Health Services, Government of Chhattisgarh. The State TB Officer of Chhattisgarh provided initial guidance to operationalize integration of RSBY and MSBY multidrug-resistant tuberculosis (MDR-TB) health insurance packages with the Revised National TB Control Programme. The cost estimate of first- and second-line anti-TB drugs per patient in India was communicated by Strategic Alliance Management Services, Central TB Division, Ministry of Health and Family Welfare, Government of India. A workshop was convened in Delhi, India, for the purpose of building capacity in writing scientific papers. The workshop was run by the World Health Organization Country Office for India, New Delhi, India.
Source of Support: Nil.
Conflict of Interest: None declared.
Contributorship: DK developed the concept, designed the experiment, analysed the data, wrote the paper, developed, edited and revised the final manuscripts; VK performed the analysis and market survey on costs of clinical investigations, reviewed and revised the paper; KS reviewed the paper; MD reviewed and revised the paper; PN reviewed and revised the paper; KK contributed materials; AM reviewed and analysed the data; SAN designed the experiment, analysed the data, edited the manuscript and reviewed the paper; MP designed the experiment, analysed the data, reviewed, edited and revised the final manuscript. All authors read and approved the final manuscript.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]
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