Health scheme

HEALTH SCHEME

BYAMBILY ULAHANNAN

FINAL YEAR MSC NURSINGP.D HINDUJA COLLEGE OF NURSING

GENERAL OBJECTIVESAt the end of the session the student

gain knowledge about health schemes of the country and apply that in the field of community health nursing

SPECIFIC OBJECTIVESAt the end of the session the group will be

able to • Define the health scheme in India• List down the need of health insurance• Explain the purpose of heal insurance• Discuss the type of health schemes in India• Explain the role of nurse in health scheme.

DEFINITION Health insurance programme, people

who have the risk of a certain event contribute a small amount (premium) towards a health insurance fund. This fund is then used to treat patients who experience that particular event (e.g. hospitalization

OBJECTIVES Health insurance programme have

two main objectives:• To increase the access to health care• To protect the employees from high

medical expenses at the time of illness.

HEALTH SCHEME IN INDIAIT IS MAINLY CLASSIED INTO FOUR• Mandatory Health Insurance schemes The two mandatory government run schemes

includes:Central Government Health Schemes(CGHS)Employee’s state insurance scheme(ESIS• Employer based scheme The railways ,defense and security forces provides

medical benefits to the employeesVoluntary Health Insurance Schemes Or Private

For Profit Scheme

MANDATORY SCHEME

EMPLOYEES STATE INSURANCE SCHEME

• Started in the year 1948• programme provides health care to

industrial labors and their families • money is contributed by the

management as well as the employees.

• It extends the whole India

BENEFICIARIES• Non –power using factories employing ten or

more persons.• Power using factories employing ten or more

persons• Road transport establishments• Cinemas and theaters• Hotels and restaurants• shops

BENEFITMEDICAL

SICKNESS

MATERNAL

DIASBLEMENT

dependent

FUNERAL

REHABILITAION

CONTRIBUTION• Employer - 4.75 percent of the total wages• Employee - 1.75 percent of his /her wage• Sate government - 1/8 th of the total

expenditure of medical care.• ESI co operation - 7/8 th of the total

expenditure of medical care• As far the central government is concerned

it supports 2/3 of the administrative expenditure.

LIMITAIONS

• Less than half the enrollees use the ESIS facilities because of the low quality of care

• Many of the staff are not aware of the benefits.

• The employers also do not disseminate the information to their staff.

• There is duality of control, with both the ESIC and the State governments trying to establish superiority

• Poor penetration in rural areas

• Act does not include employees of Indian navy, military or air force; or whose wages exceed Rs. 15000 or as prescribed by the Central Government

• To avail of the sickness benefit, the employee has to have worked for 78 days prior to the sickness. Similarly, to avail of the maternity benefit, the woman has to have worked for 70 days prior to the sickness.

CENTRAL GOVERNMENT HEALTH SCHEME

INTRODUCTION• For the central government

employers • It was introduced in Delhi in 1954AIM• to provide comprehensive health

care to the employees

OBJECTIVES• To give extensive medical facilities

too central government employees and their family members

• To save the government from heavy expenses on medical refund.

BENIFICERIES• Central government employees and their

family members• Members of parliament• Judge of supreme court and high court• Freedom fighters• Pensioners of central government semi

government organizations• Journalists• Governors and ex- Vice presidents

FACILITIES• Outdoor treatment facilities in all medical systems• Emergency services in allopathy system• Free medication• Facilities for laboratory tests and radiological tests• Treatment facilities for serious patients at their

home• Specialist consultation facilities• Treatment facilities in the government or

government recognized private institutes.• Facilities for 90 percent advanced payment, in

case of need.

PROBLEMS

EQUITYDEMAND

SIDE MORAL HAZARD

POOR QUALITY

CARE

HIGH OUT OF POCKET

EXPENDITURE

EMPLOYEE BASED SCHEME

DEFENSE SCHEME

RAILWAY SCHEME

PRIVATE AGENCIES

MEDICLAIM THIRD PARTY ADMINISTRATOR

INSURANCE REGULATORY

DEVELOPMENT AUTHORITY

Role of nurse

EDUCATOR COLLABORATER

ADVOCATE CASE FINDER

COUNSELOR

THANK YOU