Introduction to Swasthya Sathi Scheme

Government  of  West  Bengal  has  taken  the  historic  decision  of  providing  free  treatment  to  all, including medicines, implants and diagnostic in all public hospitals since 2015. Though more than 80% of the population is availing treatments in public hospitals but still there is high out-of-pocket expenditure with respect to secondary and tertiary care in the private hospitals. Government of West Bengal is taking every effort to improve health conditions and thereby reducing vulnerability of population to poverty traps by introducing Fair Price Medicine Shops, Fair Price Diagnostic Centre, Critical Care Unit facilities within 50 KM radius, establishment of Super Specialty Hospitals in the semi urban and rural areas, formation of Clinical Establishment Regulatory Commission, which are few such initiatives. Still State Government is in active consideration to provide coverage to protect eligible groups from financially debilitating effect of illness and adverse health conditions. The Service of this unique Group Health Swasthya Sathi Scheme was launched by Hon’ble Chief Minister of West Bengal on 30th December 2016.

Government employees and pensioners in the State of West Bengal are covered under West Bengal Health Scheme, 2008. Below Poverty Line Population and workers under National Rural Employment Guarantee Act are covered under the Rashtriya Swasthya Bima Yojana Scheme. Police personnel of the State of West Bengal do have their health insurance scheme. Media personnel in the State of West Bengal are provided with Government sponsored Health Insurance Scheme. Labour Department has introduced one comprehensive insurance policy including health for the labourers from unorganized sectors.

State Government felt it a necessity to bring the population living in between the groups under a group health scheme and thus emerged the unique scheme of the State of West Bengal called “Swasthya Sathi”.  Govt.  of  West  Bengal  has  decided  to  initially  cover  the  low  paid  contractual  workers, volunteers associated with various schemes/projects/ programmes administered by various State Government Departments.

Very Objective of the scheme is to gradually provide health care coverage for larger section of the society in the State with the aim to provide 100% health protection for every resident of the state.

The scheme is presently operational in all districts of the state and around 36.70 Lakh families have already been provided with 64 KB smart card, which constitute 91.15% of the targeted population of First Phase & Second Phase of enrolment. The distribution of Smart card going on in the District for the left out beneficiaries of First Phase and newly approved categories of members of Three Tier Panchayats, Other contractual staff of Panchayat & Rural development department and Part time lecturers of Govt aided colleges and Universities. It is expected that around 10 lakh new families will be added by October 2017. Issuance of Swasthya Sathi smart card to beneficiaries of second phase will be completed by November 2017.

A third phase of data collection & entry has been initiated for extension of coverage of “Swasthya Sathi” Scheme approved by the Finance Department, West Bengal for inclusion in the Swasthya Sathi Scheme (3rd phase). Memo No. 5594-F (P) dated: 6th September, 2017. Distribution of Swasthya Sathi smart card to those beneficiaries will be completed by December 2017.

Organizational Structure

Performance Improvement System

• Smart Card based transaction in hospitals & ZERO charges from beneficiaries
• Complete IT based platform, real time,  online transaction & monitoring system
• Online real time KPI dashboards for checking fraudulent activities. 100% preauthorization based system, all relevant documents regarding patient is required to be uploaded to state server for pre-approval of the treatment.
• Smart Card  is  activated  only  through  biometric  conformation  from  Beneficiary/  family member.
• For critical illness and big ticket expense, an Assurance mode of transaction is available up to a limit.
• Online portal for grievance redressal for Hospitals
• Android based mobile app for information on hospitals, facilities available, package charges, location of hospitals etc.
• 24X7 Call centre support with feedback option.
• Constant Monitoring and feedback from the Stakeholders through review meetings are part of the Scheme to make the system more robust and user friendly.

Unique features:

In  the Swasthya  Sathi  Scheme, for every medical  case the  hospital  authority has  to  provide previous medical history (if available) of the case/Patient as well as present status of ailment before any surgical or specific medical procedure undertaken. On examining the same, pre-authorization for treatment is allowed with TAT of 24 hrs.

The medical packages include the cost and specifications of the implants separately to ensure the quality.

Online e-Health records of the patient are captured and may be accessible for future medical reference using the login credentials.

Unique features of the Scheme are:

1. The scheme has basic health coverage for secondary & tertiary care up to 1.5 lakhs per annum per family through Insurance mode &up to 5 lakhs through Assurance mode for certain critical diseases like, cancer, Neuro-surgery, orthopedic and cardio- vascular diseases etc.
2. Parents of both the spouses are covered
3. All new-born babies are also covered within the scheme.
4. All pre-existing diseases will be covered from day one.
5. This service is paperless, cashless, smart card based, entirely based on IT platform
6. Each beneficiary will  be  entitled  to  get  cashless  treatment  including      200  as transport allowance on discharge from the Hospitals.
7. The empanneled hospitals are graded as Grade-A, Grade-B & Grade-C, according to the facilities available through an online Hospital empannelment module.
8. All patient admissions are by 100% pre-authorization, online, with a TAT of 24 hours else penalty payment @1.5% per 15 days delay.
9. If the claim ratio is less than 80%, premium amount which is less than 80% has to be refunded to the state.
10. More than 1900 Packages are available under the scheme
11. The Claim Reimbursement by Insurance Company has a TAT of 30 Days.
12. The  entire  system  is  based  on  IT,  developed  in-house  and  from  registration  to discharge all documents is uploaded online.
13. All data & transactions are done through a Centralized Server, owned and managed by State Nodal Agency, Swasthya Sathi, and Govt. of West Bengal.
14. Android based bilingual mobile app for Swasthya Sathi for checking card balance, tracking nearest empaneled hospital, searching doctor name, package, grievance redressal, etc. Toll Free Call Centre support on 1800 – 345 – 5384
15. Real   time   uploading   of   e-health   record   i.e.   Investigation   records,   Doctors Prescription, Inpatient slip, Discharge slip etc. are found in the web portal (https://swasthyasathi.gov.in)  is  administered  through  paperless  hassle  free  cloud based IT platform.
16. System generated SMS alerts in the registered mobile number of beneficiary for better transparency.
17. Post enrolment data of Beneficiary are being verified before admission.
18. Outbound call to discharged patient to analyse patient satisfaction level.