The SSK scheme: a first step towards Universal Health Coverage
The pilot introduction of social health insurance for Below Poverty Line (BPL) households in Tangail District, which German Development Cooperation supports through KfW, is an innovative example of outcome-based financing. Operated by a private insurance company under Government contract, the scheme pays for services delivered, using predefined Diagnosis-Related Groups (DRGs).
Unusual visitors in Bolla village
Surrounded by a network of deep ponds, their emerald-green slopes separated by perilously high and narrow pathways, today the sleepy village of Bolla Union, with its colourful ‘gingerbread’ houses and age-old trees, is astir. Visitors, equipped with an electronic tablet, are going house to house and registering the poorest families. What is going on?
Now it is the turn of Bolla’s traditional birth attendant. ‘Please sit, so we can take your photograph; we also need your fingerprint and those of your other household members. This information will be available through your Health Card, so that when you present it at the local hospital you can be admitted as an in-patient for free.’
Bangladesh is committed to achieving Universal Health Coverage (UHC) by 2032. At present, however, although public primary health-care services are officially free, lack of essential drugs and other necessary resources has led to a situation where out-of-pocket payments represent nearly two thirds of total health expenditures. This burden falls most heavily on the poor, who make up nearly a third of the population, and catastrophic health costs risk precipitating others below the poverty line.
To rise to this challenge, the Health Economics Unit (HEU) of the Ministry of Health and Family Welfare, with support from Germany through KfW Development Bank, is piloting Bangladesh’s social health protection scheme Shasthyo Surokhsha Karmasuchi (SSK) in three sub-districts of Tangail District with a total population of over 1.3 million. This pilot is overseen by the HEU’s SSK Cell and technical assistance is provided by Oxford Policy Management and management4health.
Ultimately, SSK is planned to englobe all of Bangladesh’s citizens, but the initial – and urgent – focus is on the most vulnerable: households living below the poverty line. These have been identified through a census carried out at grassroots level by local government health workers. The four-year pilot phase aims to include around 100,000 poor households – the entire BPL population of Kalihati, Ghatail and Modhupur sub-districts.
A card for accessing free health care
The SSK card is the key that provides poor families cost-free access to a doctor, and to in-patient care for a standard list of diseases at sub-district hospital. If referred to the District Hospital, the cardholder is transported and hospitalised for free. This card gives health providers access to the household’s file in the SSK database, to check the patient’s eligibility for coverage, and keeping track of their medical records. Medical costs up to €500 per household per year are covered.
The point of entry into the system are the three sub-district hospitals, where (as in the District Hospital) an SSK Service Booth, open around the clock, has been installed next to the Emergency Ward. At any hour, medical assistants are there to read the patient’s card in the SSK computer and accompany him or her to the nearby specially assigned SSK doctor.
Quality improvements in sub-district hospitals
As part of setting up the SSK system, the Government of Bangladesh has invested in improving quality of care in the three pilot hospitals. Major renovations, new equipment (including telemedicine facilities) and supplies such as reagents to ensure uninterrupted functioning of diagnostic equipment have been funded through the country’s Health Basket, to which German Development Cooperation contributed an additional €8 million. In the pilot hospitals, the number of doctors (including specialists), has been greatly increased, though still falling short of official norms. Hygiene and security have been enhanced by auxiliary personnel contracted directly by the hospital and paid from revenues generated through the SSK scheme.
A major problem remains the insufficiency of drugs in public hospitals. To ensure that hospitalised SSK cardholders get the medicines they need, the three sub-district hospitals have contracted a local private pharmacy to set up a special pharmacy for SSK patients within the hospitals.
Encouraging cardholders to use their cards
With improved hospital quality, and SSK registration of BPL households progressing rapidly, it was important that cardholders actually use their cards when ill. A multi-channel communication campaign was developed, reflecting the need expressed by target group members to see a doctor and get free treatment, and providing clear information on the card’s benefits and how to use it. The messages are presented via flyers, posters and billboards, as well as a 4-minute video drama on a poor household confronted by sudden illness.
Outcome-Based Financing through a private Scheme Operator and use of DRGs
Through a competitive bidding process, the Ministry’s HEU contracted a local, highly experienced private insurance company to run the daily operations of SSK in the field, including the SSK Booths in the hospitals. This private Scheme Operator takes care of member registration, verification of beneficiaries’ eligibility and appropriateness of services, as well as the management of claims and reimbursements to the four hospitals that provide services, based on the agreed list of diagnoses (currently 78) that are covered by SSK.
Rather than invoicing SSK for each act with itemised bills, the hospitals are paid by the Government through the Scheme Operator based on a simplified DRG system, whereby lump sum fees are paid for predefined service packages. The lump sums have been calculated by SSK Cell at an amount enabling the hospital to maintain the same level of service provision plus a surplus that can be invested in improved quality. These reimbursements play a vital role in increasing autonomy and managerial flexibility of public hospitals, almost solely dependent on a once-yearly budget allocation from the Government.
Local public representatives are strongly implicated in management of SSK. Each sub-district has a Health Management Committee which meets once a month under the leadership of the Sub-District Chairperson to discuss the progress, problems and potentials of SSK, and also decide how the SSK reimbursements will be used.
The Ministry’s role – through SSK Cell – is to steer and supervise the interaction between the private Scheme Operator and the health providers, reflecting the principle of a purchaser / provider split fundamental to Outcome-Based Financing. This is exemplified in the insurance concept, where verified performances – proof that patients have been treated – are paid for. Dr Michael Niechzial of management4health, Team Leader of HEU’s technical assistance team, asserts, ‘You want Results-Based Financing? We have it: The SSK Social Health Insurance is based on RBF!’
ICT plays an essential role
Implementing so complex a system would have been unthinkable before the era of modern Information and Communication Technology (ICT). SSK has introduced an electronic Insurance Data Management and Information System (DMIS) to increase the efficiency and transparency of all aspects of scheme management (enrolment, case management, claims processing and accounting, controlling and reporting, etc.). Household registration picked up enormously when a manual process, handing out paper slips to those registered, was replaced by use of electronic tablets.
This insurance management software has similarities with India’s RSBY system, and was developed by the same company. It was agreed with the developer that in Bangladesh it would be a license-free software based on an open-source database platform and operating system in order to facilitate roll-out and assure sustainable operation of the scheme.
The SSK software is closely linked to the Ministry’s Health Management Information System, where it is hosted, and thus integrated into Bangladesh’s overall National Data Warehouse. Since the SSK software stores electronic records of all members and claims data from hospitals, the data warehouse can provide a variety of reports based on this data. The SSK software has automatic routines for claims verification and for monitoring of the hospitals’ efficiency, of disease patterns, and of possible fraudulent activities.
Dr Niechzial reports, ‘Thanks to the Data Management and Information software package, we can now monitor what is happening with the insured population: their health care seeking behaviour, the admission rate, key diagnoses. I think in that regard we did everything right!’
SSK is a work in progress
The pilot programme was launched in March 2016 in Kalihati sub-district, and implementation was closely monitored in view of improving the approach before introducing it elsewhere. During this time, the number of diagnoses covered was raised from 50 to 78, the Scheme Operator’s mandate and staff were increased to ensure stronger quality control, and electronic registration was introduced with an immense gain in efficiency. After one year, 80% of Kalihati’s 33.000 BPL households had received their Health Cards, and by September 2017 Kalihati was on its way to becoming a ‘mature system’, when SSK was launched in the two neighbouring sub-districts of Ghatail and Modhupur.
The quality improvements in the supported hospitals had led to a remarkable increase in use – but not by BPL households. For them the cost of diagnostic tests and drugs in the Out-Patient Department remained a daunting financial barrier. This realisation led SSK management to reflect on a further adaptation of the benefits package: extending Out-Patient coverage for selected Non-Communicable Diseases such as diabetes and high blood pressure. This measure is expected to increase attractiveness of the SSK card and reduce the disease burden while keeping a lid on health expenditures, since these diseases are increasingly prevalent, but treating them before they become severe is relatively inexpensive.
SSK membership is calculated at about €10 per household per year. This ‘insurance premium’, once the system is formally launched, will be paid on behalf of the BPL households by the Government.
With a total budget of €1,000,000 over three years, the German-funded technical assistance managed to register approximately 360,000 individuals and to establish all the components of an insurance scheme that can now be rolled out to a steadily growing membership. In a longer-term perspective, SSK is to become a national health insurance scheme with mandatory membership for all citizens. Adding Above Poverty Line (APL) households will introduce the principles of solidarity and risk pooling – to make SSK a ‘real’ insurance system – and will inject non-governmental funds to enable long-term financial viability.
The benefit package is planned to be extended to include private health providers, popularly considered to provide better services than the public sector. This will further enhance attractiveness of SSK. A necessary complement will be introducing a process of formal accreditation to maintain quality of both private and public providers of SSK-reimbursed services. The insurance scheme can play a role in quality control and standardisation by use of DRGs and by only paying health facilities that are accredited. Thus introduction of national health insurance can become an important element of systems reform.
While the German-financed consultancy will not be accompanying SSK to its full deployment, KfW’s Technical Advisor, Dr Matthias Nachtnebel, expresses satisfaction that SSK’s implementation will be continued with funding from both domestic and external sources: ‘SSK has helped pave Bangladesh’s way towards UHC, and it has done so with a focus on equity. The management tools, standard procedures and software that were developed with German support will facilitate SSK’s further roll-out by Bangladesh’s government.’
Key lessons for other social health insurance schemes
- Consider health-care seeking behaviour and adapt benefit packages to services that are of (perceived) priority to the population (frequent out-patient rather than rare in-patient cases).
- Assure service quality (staff, infrastructure and equipment, drugs).
- Consider performance-based staff remuneration and including private sector in service delivery.
- Assure continuous M&E of service provision and utilisation to continuously finetune all elements of the scheme (benefit package, modes of access and service delivery).
Dr Mary White-Kaba
Dr Michael Niechzial