(1000 Questions) - (Answer Updated) Model Question By ATCHITAMIL IAS ACADEMY!!
The NGO becomes the insurer, as it is collecting funds (from the people and the government) and managing the funds. This may not be acceptable with the IRDA which does not recognise such stand alone models of health insurance. So other options should be considered e.g. simplest would be to call it a "Health Fund" rather than a health insurance programme.
The NGO should reimburse the providers on a monthly basis (if voucher system) or pay the capitation fees in three monthly advances. They should however monitor the scheme closely, especially monitor the extent of fraud. Social audits should be used for minimising this and the community representatives should be available in the claims committee. Random checks on claims should also be made, to verify that vouchers are not being misused by the insured community.
The NGO should also negotiate with the providers for empanlling them and providing the desired quality of care. It should of course create awareness among the population about the benefits of health insurance and the possibility of improving their access to health care.
Risk management
The main risk here is that of moral hazard and fraud. Every headache may land up at the doctor's clinic for treatment. The people should be informed about the price of abuse. If they use their vouchers for frivolous conditions, then when they really fall sick, there may not be any vouchers for their health care. This may reduce moral hazard. Also if people save vouchers, then it may be carried over for one year. This would be an incentive for patients not to abuse the system.
Fraud is a potential problem as anybody can borrow their neighbour's voucher and seek care. Of course, one can introduce some identification mechanism e.g. a ration card, or a voter's id card, or a BPL card etc. But as stated earlier, social audit is more effective. Responsible members of the community / NGO field staff should verify random claims.
Monitoring
The main indicators to monitor are the coverage rates and the utilisation rates. This will give an idea about the inflow and outflow and will allow the NGO to plan for the next financial year.
Conclusions
This programme should be a pilot to test whether insuring OP services is feasible in poor rural areas. The programme should be monitored closely to understand what are the other measures that need to be introduced to make it run successfully.
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