Monday, August 24, 2020
Answers for Burundi Civil War expositions Up until this point, the 10-year common war against the Tutsi and Hutu in Burundi has been inescapable. Each arrangement that attempted to produce results on the issue in Burundi has fizzled. Africa is consistent losing center and starting to take a gander at Burundi as an act of futility due to the certainty to make a ceasefire. In this way, there are still some potential arrangements that can bring harmony or possibly balance out Burundi for a long time. One answer for potentially carry harmony to Burundi is to shape arrangements. So as to figure an arrangement, the strategy producer should comprehend the idea of the contention. Making significant arrangements will help bolster Burundi with the expectation that it might help save business as usual and look after strength. In spite of the fact that Tutsis just make up 15 percent of the number of inhabitants in Burundi, they overwhelm all political and monetary parts of the nation. They likewise run the military. So one proposition to perhaps carry harmony to the on going war will be a force sharing understanding. A force sharing understanding would incorporate the military and make a multiethnic parliament with equivalent portrayal of every ethnic gathering. The proposition additionally calls for capacity to be given over to a justly chose government after a transitional period. Truce Agreements can likewise become an integral factor with the Burundi Civil War. With Cease Fire Agreement, neither one of the groups can start shooting at one another in any way, shape or form. In the event that in actuality, the Tutsi and Hutu can concentrate more on harmony converses with make a goals, understandings, and approaches. The last answer for help settle Burundi is implementing harmony by military commitment from predominant nations. This would need to be the last arrangement since this arrangement would happen if neither one of the groups went to a ceasefire. Through military commitment, the prevailing country would most likely need to isolate the nation between the two countries, make an administration, control the economy, and secure the fringes. ... <!
Saturday, August 22, 2020
Maori Culture expositions In ongoing decades, Maori individuals have made some amazing progress toward recovering the status and land that used to be theirs when they originally settled New Zealand, a few centuries before the convergence of Europeans. Today, the Maori individuals contain around 15 percent of the number of inhabitants in Aotearoa, and the country is in numerous regards bi-social. In the customary Maori social structure, unmistakably characterized jobs for guys and females exist and male-commanded structure is accentuated. Status was constantly granted to a man and qualities of masculinity were compensated. The division of work was additionally gendered. Men did the angling and chasing while ladies were answerable for the food preparing and cooking (Salmond, 2004). In any case, todays Maori ladies start to expect dynamic jobs in Aotearoa. Mana Wahine, deciphered as intensity of ladies, is about the intensity of Maori ladies to oppose challenge change or change spaces inside arrangement of maste ry (Class notes, 2004). The status of ladies, Mana Wahine, is significant to otherworldly, physical, passionate and social prosperity for whanau, hapu, iwi and for Maori society in any specific situation. These days Mana Wahine assumes a critical job being developed of New Zealands ladies. In this exposition, I will examine the gigantic contrasts between Maori ladies and Pakeha ladies (non-Maori ladies) in various divisions, for example, training, decolonization/indigenization, effect of Treaty of Waitangi and work. Those distinctions are progressively standing out of New Zealands society and sexual orientation issues are paid attention to ,for advancement of Maori ladies is significant for the entire improvement of New Zealand. Whats more, the act of advancement considers these distinctions. Successful improvement methodology underpins Maori monetary and social advancement including advancement of Maori ladies. Likewise, Maori ladies need to improve their ability constantly for the mselves as well as for Maori recovery an... <!
Saturday, July 18, 2020
Should I Perform Primary or Secondary Market Research © Shutterstock.com | Rawpixel.comAfter exploring in details the topics of primary and secondary market research techniques, this article focuses on the comparison of both types of market research. We will first gain 1) an insight into primary and secondary market research, and explore then the benefits and disadvantages of both types of research when choosing to perform 2) primary or secondary market research.AN INSIGHT INTO PRIMARY AND SECONDARY MARKET RESEARCHPrimary ResearchPrimary market research is one of the two major market research methods used by most businesses across the world. Primary research is the research that a business does on its own, without the help of any previously collected data or information. The data collected in primary research is being collected for the first time and is specific to the businessâs purpose or objective. This is why the information gathered can be referred to as âraw dataâ. Primary market research can be done through many methods of which some include focus groups, face to face interviews, telephone interviews, surveys, questionnaires and observational techniques, etc.One of the main benefits of conducting this kind of research is that it helps to gather only the data needed and no extra information. This can be time taking and cost bearing but avoids the need to cut back on several pieces of useless information. Primary market research is of two major types: quantitative and qualitative. Quantitative research focusses more on hard facts, stats and figures whereas qualitative research takes into account the feedback, opinions and emotions of the consumers.Examples of primary researchExit Surveys Exit surveys are those kinds of surveys which customers are requested to answer before leaving the store or the website and help to gather views on products, services, etc.On-site fieldwork This kind of research is related to gathering information about a particular location for the business, its access to consumers , its popularity, and other such factors. Based on the results, a business decides which location will serve best for its store or functioning.Interviews Face-to-face interviews or telephone interviews help to gather information about the customerâs satisfaction levels, preferences, dislikes, and expectations.Focus groups Groups of 8-20 people are brought together, and a researcher is asked to conduct group discussions to fathom opinions regarding products and services. In such a method, direct feedback from core customers can be collected efficiently.Secondary researchSecondary market research is a kind of a market research method that involves gathering already researched and collected information. This technique tries to search for and compile information that is already existing and can either be for free or for certain cost. This method of research does not include finding any original or unique data and relies on information obtained through the internet, libraries, govern ment sources, trade associations, existing business documents, competitorâs data, etc.While it may be very time-saving and cost saving to find information through secondary research, the amount of data gathered may not match the businessâs requirements or may not be specific to its needs. Secondary research is however still preferred and widely used across industries and businesses. This method is also termed as âdesk researchâ since it can easily be done from behind a desk, and one doesnât need to step out for it. Most of the times, secondary research is for free and hence very popular.Secondary market research can be used to gain an early understanding of the industry or the market. But proper interpretation is needed to understand and evaluate the data collected.Examples of secondary researchData on internet One of the most preferred and popular sources for collecting secondary data is the internet. The web provides a lot of information which can be used by businesses to meet their research requirements. However, only credible sources and trusted websites must be referred to and used.Government data One can also make use of data recorded and filed by government organizations for their secondary market research. Some data that can be availed through this method includes economic factors, industry trends, company rankings, etc.Data on customer databases and demographics A lot of data is available on customer databases such as stock lists, etc. and this information can prove very valuable for businesses that need to study customer trends, behavior, names, addresses, etc.Information through libraries, etc. Libraries can be a great source for a lot of business related information, marketing tactics, promotional methods, etc.PRIMARY OR SECONDARY MARKET RESEARCH?In order to compare which type of market research would fit your business purposes better, we listed the benefits and disadvantages of Primary and Secondary market research below.Benefits of PRIMARY Market ResearchSpecific data can be found: One of the most important benefits of primary market research is that it can help find information that is customized according to the needs of the business and is highly specific in nature. The research helps to investigate issues that the business may need to know the most about and is flexible enough to leave out unwanted or useless information. It helps to gauge customer behavior, the consumer likes/dislikes, their expectations and market trends in a specific way. Methods like focus groups, surveys, and interviews, etc. help to gain knowledge that can be directly used for product development, etc.Customized to personal needs: Unlike secondary market research, the approaches used in primary market research methods can be tailored according to the personal requirements and needs of the business. One has total control over the manner of conducting the research and finding solutions. For example, if a business needs to find out cust omer behavior in a particular age group, it can do so by conducting surveys for that particular age group.Targeted issues can be addressed: Only those issues which the business is most interested in addressing can be touched through the method of primary market research. No extra information needs to be collected or goes to waste through this method. The research work is streamlined in such a way that its scope is limited to the businessâs interest. The efforts can thus be concentrated on specific matters and not a whole array of other areas. This is another very important benefit of using the method of primary market research as a part of a businessâs research efforts.Ownership of information: Another important advantage of primary market research is that by using this method of gathering information, a business can claim to own exclusive rights over collected data. This means that no one else but that business can use the information, and it may choose to offer it or not offer it to anyone else. The proprietary of information or ownership of information can bring about further benefits for the business.Better data examination: When it comes to primary market research, the data collected or information gathered can be better interpreted or evaluated by the business. The data can be examined based on the needs, and this doesnât have to depend upon the interpretation of the secondary data, which is complex and time taking. This means that in primary research, the time taken to evaluate data is less, and the process is more efficient.Efficient spending: In the case of primary market research, a business spends only on what is required and doesnât end up wasting money on data that may be useless or irrelevant. This means that a business can spend smartly and efficiently when it chooses to conduct primary market research. This helps to remain within budget and save on the overall costs.Disadvantages of PRIMARY Market ResearchExpensive to conduct: One of th e main disadvantages of opting for primary market research is that it can be very expensive to conduct. One may be required to spend or invest huge amounts of money to conduct interviews, surveys, organize focus groups and experiments and trials. Not all businesses can afford to opt for these methods, especially startups or small scale organizations. They may rather opt for secondary methods such as researching for free on the internet, etc.Time taking: Another negative associated with the process of primary market research is that it can be very time-consuming. Conducting interviews, market surveys, and experiments, etc. may take a long time. Moreover, evaluating the results and applying the obtained results on product development, etc. may take further time. Those businesses that do not have the required time may rather opt for less time taking alternatives like using secondary sources, etc.Feedbacks may not always be accurate: The feedbacks obtained from audiences and respondents may not always be honest and accurate. Not all respondents may be totally true or honest in giving their opinions and feedback. Some may not state what they feel accurate and this could mean evaluation of incomplete or wrong information. Thus, the entire process of primary market research may topple over or lead to slightly incorrect findings.Several sources needed: In order to come up with results or final reports, the help or assistance of many different sources may be needed. One may need to rely on several different methods including focus groups, face to face interviews, online surveys, physical surveys and observational tactics, etc. This may be even more time-consuming and expensive. This thus proves as another negatively related to primary market research.Benefits of SECONDARY Market ResearchEasy availability of information: One of the main advantages or benefits of secondary market research is that all the information gathered through it is very easily available and access ible. There are many sources from which information can be taken, and this makes it easy for researchers to gather relevant information. Unlike primary research, in this method, one tends to collect huge amounts of information in lesser amount of time.Less expensive: As compared to primary market research, secondary market research is cheaper to conduct and hence helps saves a lot of money. It allows businesses to remain within their budget limits and requires spending of the petty amount of money. In fact, most of the information can be found for free through secondary data sources like the web, public directories, governmental organizations, and libraries. This very benefit makes it a popular choice among small or new businesses and organizations.Lots of available data: Besides the easy and cheap availability of information, secondary market research also offers the benefit of availability to lots of data. There is a gamut of data available for each business, company and industry and several objectives can be fulfilled by making use of such information. The abundance of secondary data sources is responsible for this in addition to the fact that most information these days is stored on web search platforms like Google, Yahoo or Bing, etc.May highlight truths about conducting primary research: Most of the times, the people who contribute data to secondary market research may point out to the original sources, the time it took to collect the information, the difficulties and challenges faced while gathering data and other information relevant to it. This may help secondary researchers to know whether or not it was practical to conduct primary research in the first place. This very fact makes secondary market research a beneficial process. It highlights the truths about primary research.Answers research questions: Secondary data research or market research is a method that helps to bring together or align the concentration of widespread primary research. When co nducting this form of research work, businesses or researchers often realize that the information they were looking for is actually present for free and this may reduce the need for conducting primary or original research work from scratch.Lots of free information available: Often, businesses can conduct secondary market research without spending even a single penny. This is because of the availability of high amounts of free data. For some organizations, the entire research can be conducted using this free information, and this would mean zero expenses on market research.Quicker to conduct: Since most of the data is available easily and can be accessed without many efforts, the process of secondary market research is much easier and convenient to conduct as compared to primary market research. This type of research can be done within days or weeks, depending upon the objectives of the business or the scale of information needed.Disadvantages of SECONDARY Market ResearchDifficult to cut back on useful information/not specific: One of the main drawbacks of secondary market research is the difficulty in selecting some pieces of useful information from the sea of data collected. Since lots of data is available but specifically needed data is less, businesses may have to spend a lot of time and energy in picking out information that is relevant to it. In fact, they may sometimes realize that they havenât found what they were exactly looking for due to variations in customer demographics, location, and other factors.Lots of non-credible sources create difficulty/lack of quality research: Of course, there is a lot of secondary data available out there, but not all is offered through credible or trusted sources. Most of the data on the web cannot be trusted, and the same holds true for the information offered by directories, trade associations, etc. Thus secondary market research may not always be quality research as sometimes it is difficult to know which source i s credible and which is not.Incomplete information also available: Besides the lack of credible sources and quality data, most of the information available through secondary sources may be incomplete or lacking on some main points or statistics. As they say, incomplete information can be dangerous; using incomplete data results can also prove dangerous as far as market research goes. Especially when it comes to using competitor data or information on the web, several links can be broken, and the true picture may not be presented.May not be updated: Not all secondary data sources available offer the latest reports, data, and statistics. Some of the data may be outdated; other may just not be valid according to the current situations like economic climate, market trends, user demographics and other factors. This is a major drawback of using secondary sources for market research. Old and outdated data may lead to incorrect results or findings, and this very fact interferes with product development, service enhancement, and other business processes.CONCLUSIONWhen it comes to choosing primary or secondary market research, no one type of research comes out as a winner. Both the research methods have their positives and negatives, and the decision to choose one depends upon the individual business needs and requirements. Where on one hand, secondary market research presents data which you may never be able to uncover yourself, primary market research can help fill the gaps which secondary research wasnât able to answer. Neither of the research methods alone could help a business reach its objectives, and the wise thing to do is to pick smartly both options, in the right proportions.Relying on primary market research alone can lead to missed opportunities, incomplete information, and limited data, using secondary data alone may leave you with vague answers to specific questions. Both research works hold their importance and present beautiful opportunities for busine sses when combined well together. A successful business is one that has learned to utilize these processes together and in the right amounts. Thus, it wonât be wrong to say that no method is better than the other, and only the combination of both can give a well-rounded view of the market or the industry.
Thursday, May 21, 2020
Mummy Case of Paankhenamun Works Cited Not Included The work I chose to analyze was from a wall fragment from the tomb of Ameneemhet and wife Hemet called Mummy Case of Paankhenamun, found in the Art Institute of Chicago. The case of the Mummy Paankhenamun is one of the most exquisite pieces of art produced by the Egyptian people during the time before Christ. This coffin belonged to a man named Paankhenamun, which translates to Ã¢â¬Å"He Lives for AmunÃ¢â¬ (Hornblower Spawforth 74). Paankhenamun was the doorkeeper of the temple of the god Amun, a position he inherited from his father. Interestingly, X-rays reveal that the mummy case of Paankhenamun does in fact contain a mummy inside dating back to the years of c. 945 Ã¢â¬â 715 B.C.Ã¢â¬ ¦show more contentÃ¢â¬ ¦Nonetheless, during the 12th Dynasty, there was a temple built for AmunÃ¢â¬â¢s worship and toward the end of the 18th Dynasty, AmunÃ¢â¬â¢s status increased even more and he became known as Ã¢â¬Å"Ã¢â¬ ¦the great royal deity who was Ã¢â¬Å"Father of the GodsÃ¢â¬ and ruler of Egypt and the people of its empire (Rosalie 104). The Mummy Case of Paankhenamun was composed of a substance known as cartonnage, which was usually made out of linen or papyrus strips bound together with a sticky substance in order to form a flexible shell. After mummification, the wrapped body was placed in the coffin-case through the back, which was then laced up and a footboard was added for support. Only then the case was ready to be painted. Such cartonnage cases as the case of Paankhenamun were normally placed inside one or more layered wooden coffins and were also decorated. The innermost coffin was always in the shape of the mummy and due to its utmost importance, it was the case with the richest decorations. The amazing detail is still a wonder to many historians and anthropologists (Stockstad 120-3). Similarly to other Egyptian funerary rituals, the case of Paankhenamun was also buried inside of a Ã¢â¬Å"sarcophagusÃ¢â¬ case, a huge stone case for the coffin, and then inside of a decorated tomb, which most likely contained his most valuable personal belongings and religious symbols. The decorations often consisted of imagesShow MoreRelatedEgyptian Religion and Immortality Essay1395 Words Ã |Ã 6 Pagesmost noticing aspect of Egyptian religion is its obsession with immortality and the belief of life after death. This sculpture can show you this on how mummification gave upbringing to complex arts in ancient Egypt. The sculpture is the Mummy Case of Paankhenamun. The artwork is currently viewed at The Art Institute of Chicago. The sculpture was from the third period, Dynasty 22, in ancient Egypt. However, the sculpture has many features to it that makes it so unique in ancient Egypt from any other
Wednesday, May 6, 2020
A Thesis Presented to the Faculty Of Tourism and Hospitality Management Department National College of Science and Technology In Partial Fulfillment Of the Requirement for the Degree Bachelor of Science in Hotel and Restaurant Management Mr. Christer John R. Manalo Ms. Jemimah V. Camitan Ms. Krystal Jane M. Fello Mr. Clarenz Marr Javier Ms. Emerlene P. Milan APPROVAL SHEET This Thesis study entitled Ã¢â¬Å"STUDYING DIFFERENT FACTORS AFFECTING ACADEMIC PERFORMANCE OF THIRD YEAR BACHELOR OF SCIENCE IN HOTEL AND RESTAURANT MANAGEMENT STUDENTS OF NATIONAL COLLEGE OF SCIENCE AND TECHNOLOGY DUE TO SELECTED ACTIVITIESÃ¢â¬ prepared and submitted by Mr. Christer John R. Manalo, Ms. Jemimah V. Camitan, Ms. Krystal Jane M. Fello, Mr. Clarenz Marr R.Ã¢â¬ ¦show more contentÃ¢â¬ ¦HA: There is a significance difference between Ã¢â¬Å"STUDYING DIFFERENT FACTORS AFFECTING ACADEMIC PERFORMANCE OF THIRD YEAR BACHELOR OF SCIENCE IN HOTEL AND RESTAURANT MANAGEMENT STUDENTS OF NATIONAL COLLEGE OF SCIENCE AND TECHNOLOGY DUE TO SELECTED ACTIVITIESÃ¢â¬ in terms of their gender and age. The students choose the activity based on their personal and/or academic interests. In general, students who participate in extracurricular activities have higher grades point average than students who donÃ¢â¬â¢t. SIGNIFICANCE OF THE STUDY For the instructors, this study may help them to identify the strong and weaknesses of the extracurricular activities that they perceived. The instructors may also help by this study to know the insights of the students about the extracurricular activities that they perceived. In this way, the instructors will easily identify the things that the student wants in an extracurricular activity so the instructors can find out ways to attract the students to join extracurricular activities without any hesitation. For the students, this study may help the students to know what extracurricular activity is perfect for them to join and they will know the importance of joining extracurricular activities.Show MoreRelatedThesis Name6268 Words Ã |Ã 26 PagesA Thesis Presented to the Faculty Of Tourism and Hospitality Management Department National College of Science and Technology In Partial Fulfillment Of the Requirement for the Degree Bachelor of Science in Hotel and Restaurant Management Mr. Christer John R. Manalo Ms. Jemimah V. Camitan Ms. Krystal Jane M. Fello Mr. Clarenz Marr Javier Ms. Emerlene P. Milan APPROVAL SHEET This Thesis study entitled Ã¢â¬Å"STUDYING DIFFERENT FACTORS AFFECTING ACADEMIC PERFORMANCE OF THIRD YEAR BACHELORRead MoreAnalysis Of The Novel The Girl Who Was Saturday Night 1137 Words Ã |Ã 5 PagesSTUDENT NAME: Ramnik Cheema ENG3U0 - F CANADIAN NOVEL ISU PART A: KEYS TO THEME AND DRAFT THESIS STATEMENTS For the following Ã¢â¬Å"Keys to Theme Template,Ã¢â¬ record a quotation and explanation of how the statement fulfils the characteristic of each section of the template. Title of the Novel: The Girl Who Was Saturday Night Author: Heather OÃ¢â¬â¢Neill CharacterÃ¢â¬â¢s Name: Nouschka Trembley Theme: Isolation 1. 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In Called to Care, the authors state Ã¢â¬Å" Whenever a society ceased to recognize the image of God in human beings, whether the name of science, political, ideology, religion, or simply greed serious moral decay followedÃ¢â¬ (Shelly Miller, 2006, p. 77). The truth is God is good in all things. References Shelly, J. A., Miller, A. B. (2006). Called to Care (Second ed.). RetrievedRead MoreA1 Introduction to High School Academics UA1821 Words Ã |Ã 8 Pagesquestions, synthesize the information that you have gathered and develop an overall thesis that examines a specific aspect of the text. Forming Your Response Synthesize and evaluate your thoughts and response. Researching and preparing for a discussion helps to ensure the effectiveness and efficiency of a group discussion. To start forming your response, use your notes from the initial task. Then, generate and capture a thesis statement of sorts that summarizes your view of the work based on your answersRead MoreLife of Pi: the Correlation Between Science and Religion Essay1582 Words Ã |Ã 7 Pages(Martle, 84).This quote seems to blend the dichotomy so well that the audience isnÃ¢â¬â¢t clearly able to distinguish between the two Mr. Kumars. Through close reading, Mr. Kumar the biologist teacher states Ã¢â¬Å"Equus burchelli bohemiÃ¢â¬ which is the scientific name to the GrantÃ¢â¬â¢s Zebra, through which Mr. Kumar separates the Zebra being viewed from other Zebras. Dissimilarly, Mr. Kumar the Sufi states Ã¢â¬Å"Allahu akbarÃ¢â¬ , which means Ã¢â¬Å"God is the GreatestÃ¢â¬ , through which Mr. Kumar recognizes God and the zebra as a partRead MoreCreating Opportunities For Students Proficiency Directing Their Own Learning And Have Done So Within My Classroom Environment Essay1865 Words Ã |Ã 8 Pagescollaboration with the classroom rules, two charts were created that demonstrated the application of gamification within the classroom in order to improve the student s participation. The first chart was referred to as the Ã¢â¬Å"smilesÃ¢â¬ chart. StudentÃ¢â¬â¢s had their names down the side of the chart and were awarded Ã¢â¬Å"smilesÃ¢â¬ for participation, positive behavior and achieving personal goals. The Group Chase chart looked similar to a board game, and was used in correlation with a seating plan, groups were allocated a colourRead MoreLe Management Interculturel de Sylvie Chevrier1999 Words Ã |Ã 8 Pagesbibliography (from page 123 to 126) and finally a table of contents at the end of the book (page 127). The book is written in French and can be found in the collection Ã «Que sais-je?Ã » at the Presses Universitaires de France editions (known also as Puf). Thesis The goal of the author is to delineate the field of intercultural management and to clarify its content for the reader. Strategies 1. Construction * Introduction The introduction of the book is longer than the conclusion. IndeedRead MoreWhy Are We Named?1356 Words Ã |Ã 6 Pagesword fit precisely for them? This will be a paper on the study of names, specifically mine- Emma Lee Ketelsen. The study of personal names is anthroponomastics, while the study of proper names in general is onomastics, according to Wikipedia. Source I was named after my fatherÃ¢â¬â¢s confirmation instructor, Emma Langholt. According to Dad, it was because my parents liked the name and it was a pleasant coincidence that that was her name. My father went through six years of catechetical instruction with
string(170) " by the Ministry of Health and Family Welfare, Central Ministries and local bodies, while private expenditure includes health expenditure by NGOs, \? rms and households\." Institute for Financial Management and Research Centre for Insurance and Risk Management Delivering Micro Health Insurance Through the National Rural Health Mission A Strategy Paper Rupalee Ruchismita, Imtiaz Ahmed and Suyash Rai August 2007 Rupalee Ruchismita (rupalee. ruchismita@ifmr. ac. We will write a custom essay sample on Health Financing in India or any similar topic only for you Order Now in) and Imtiaz Ahmed (imtiaz@ifmr. ac. in) are with the Centre for Insurance and Risk Management at IFMR, Chennai (http://ifmr. ac. in/cirm). Suyash Rai is with the ICICI Centre for Child Health and Nutrition, Pune. The views expressed in this note are entirely those of the authors and do not in any way re? ct the views of the Institutions with which they are associated. . Ruchismita, Ahmed, Rai: Delivering Micro Health Insurance through the National Rural Health Mission Contents 1 Introduction 2 Health Financing in India 3 Key issues in Health Financing 4 Exploring Risk Transfer and Pooling Strategies 5 Proposal for a National Apex Body 6 Conclusion 7 Annexures 7. 1 ANNEXURE I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7. 2 ANNEXURE II . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7. 3 Objectives, Activities, and Services . . . . . . . . . . . . . . . . . . . . . . . 1 1 3 4 8 13 14 14 19 22 0 Ruchismita, Ahmed, Rai: Delive ring Micro Health Insurance through the National Rural Health Mission 1 Introduction The Indian health scenario is fairly complex and challenging with successful reductions in fertility and mortality offset by a signi? cant and growing communicable as well noncommunicable disease burden1 , persistently high levels of child undernutrition2 , increasing polarisation in the health status of the rich and the poor3 and inadequate primary health care coexisting with burgeoning medical tourism! This situation is further complicated by the presence and practice of multiple systems of medicine and medical practitioners (several of whom are not formally certi? ed and recognised) and very limited regulation. In such a context, this paper highlights the challenges in ? nancing health in India and examines the role of health insurance in addressing these. It proposes an operational framework for developing sustainable health insurance models under the National Rural Health Mission, responding to the contextual needs of different states. 2 Health Financing in India The total spending on the health sector in India is not low. According to the National Health Accounts 2001-02, the total health expenditure in India for the year was Rs. 1,057,341 million, which accounted for 4. 6 percent of the Gross Domestic Product (GDP). The concern lies in the fact that households are the major ? nancing sources, accounting for 72 percent of the total health expenditure incurred in India. State Governments contribute 12. 6 percent of the total health expenditure, Central Government 6. 4 percent and the public and private ? rms 5. 3 percent. External support from bilateral and multilateral agencies accounts for 2. percent of health expenditure in India, a majority coming in as grant to the Central Government. So, only about 20% of the overall funding comes from India accounts for only 16. 5% of the global population, it contributes to approximately a ? fth of the worldÃ¢â¬â¢s share of diseases: a third of the diarrheal diseases, tuberculosis, respiratory and other infections, parasitic infestations and perinatal conditi ons; a quarter of maternal conditions; a ? fth of nutritional de? ciencies, diabetes, cardiovascular diseases, and the second largest number of HIV/AIDS cases in the world. Report of the National Commission on Macreconomics and Health. 2005. New Delhi: Ministry of Health and family Welfare. ) 2 National Family Health Survey III, 2005-06. Mumbai: International Institute of Population Sciences. 3 The poorest 20 percent of Indians have more than twice the rates of mortality, malnutrition, and fertility of the richest 20 percent. (Peters DH et al. Better Health Systems for IndiaÃ¢â¬â¢s Poor. 2002. New Delhi: World Bank. 1 Although 1 Ruchismita, Ahmed, Rai: Delivering Micro Health Insurance through the National Rural Health Mission he government, which is one of the lowest in the world. This is a signi? cant problem in a country where the government has mandated itself to provide comprehensive quality health care to all. The problem of household expenditure for health care is compounde d by the fact that 98 percent of this is Ã¢â¬Å"out-of-pocketÃ¢â¬ , which is fundamentally regressive and burdens the poor more. Also, the absence of proper pooling and collective purchasing mechanisms for the householdsÃ¢â¬â¢ money further worsens the situation because of the resulting inef? ciencies. Most of the household expenditure on health goes to the fee-levying and largely unregulated private providers. The share of household consumption expenditure devoted to health care has also been increasing over time, especially in rural areas where it now accounts for nearly 7 per cent of the household budget4 . This situation is not surprising since public and private expenditure on health are closely linked. Given that government spending on health stands at less than 1 per cent of the GDP, which is very low by international standards, the need for private out-ofpocket expenditure increases. Seventy percent of the total ? nancial resources ? ow to health care providers in the for pro? t private sector. Only 23 percent are spent on public providers. In an environment of minimal regulation, this provides signi? cant opportunity for the exploitation of health care seekers. In addition, there are signi? cant inter-state differences in health ? nancing. Among the major states, Himachal Pradesh ranks highest in terms of per capita public spending on health (Rs. 493 per year) and also has the highest public expenditure as percentage of total expenditure (37. 8%). On both these parameters, Uttar Pradesh is the lowest ranking state, with a per capita public spending on health of Rs. 84 per year, and only 7. 5% of the total health expenditure is public expenditure. All India per capita expenditure on health is Rs. 997 (207 from public and 790 from private)5 . There are also indications of declining state government spending in crucial areas. Overall health spending declined over the decade 1993-94 to 2002-03 in 3 states, and declined between 1998-99 and 2002-03 in 6 4 Government Health Expenditure in India: A Benchmark Study. 2006. New Delhi: Economic Research Foundation. All India public expenditure including expenditure by the Ministry of Health and Family Welfare, Central Ministries and local bodies, while private expenditure includes health expenditure by NGOs, ? rms and households. You read "Health Financing in India" in category "Essay examples" 2 Ruchismita, Ahmed, Rai: Delivering Micro Health Insurance through the National Rural Health M ission states6 . There are also sharp and generally growing rural-urban disparities in spending in most states. 3 Key issues in Health Financing Drawing from the above analysis and other related literature, the following emerge as the key issues in reforming health ? ancing in India. Increasing government spending on public and more speci? cally, primary health care As discussed earlier, the government spending on public health in India, constituting about 4% of its total expenditure and less than 1% of the GDP, is very low. In per capita terms, the government spends only USD 4 annually on public health. According to the World Health Report (2000), only twelve other countries spend less than India on public health, most of them in Africa. For most other nations, government spending on health is more than 10 percent of the total government expenditure. The Commission on Macroeconomics and Health has estimated that public spending in low income countries should be within the range of $30-$45 per capita to ensure achievement of public health goals. In India, most of the government spending is on medical colleges, into tertiary centres, and very little trickles down to the primary and secondary levels. There is therefore a strong case for increasing government spending across the board, with a much higher focus on primary care services. This will reduce the need for spending by the poor and also improve the overall health status. The options for increasing public ? ancing of health include reallocation of the government budget (possibly by re-routing other direct and indirect subsidies) and earmarked taxes (such as the taxes levied for ? nancing the Sarva Shiksha Abhiyan). Addressing the supply and demand-side factors that prevent the poor from bene? ting from the health sector In general the poor bene? t much less from the health sec tor than the rich do largely because of their inability to seek timely and adequate health care. The poorest quintile of Indians are 2. 6 times more likely than the richest to forgo medical treatment when ill7 . Government Health Expenditure in India: A Benchmark Study. 2006. New Delhi: Economic Research Foundation. 7 Peters, D. et al. Better Health Systems for IndiaSs Poor: Findings, Analysis, and Options. 2002. Washington 3 Ruchismita, Ahmed, Rai: Delivering Micro Health Insurance through the National Rural Health Mission However, whatever care they do access, the poor are found to rely signi? cantly on the public system for preventive and inpatient care including 93 percent of immunizations, 74 percent of antenatal care, 66 percent of inpatient bed days, and 63 percent of delivery related inpatient bed days. Improvements in the public system through increased and more effective spending would therefore bene? t the poor signi? cantly. Increasing the effectiveness of public health spending would require attention to supply side factors such as facility location, availability of staff, medicines, equipment and quality of care as well as demand-side factors such as indirect costs (travel, wage loss), non formal charges, awareness levels, perception of quality and uncertainty about payment. Mitigating risks due to out-of-pocket expenditure, particularly catastrophic expenditure for the oor At least 24 per cent of all Indians fall below the poverty line because they are hospitalised8 . It is estimated that out-of-pocket spending on hospital care might have raised the proportion of the population in poverty by 2 per cent. Risk-pooling and collective purchasing mechanisms could increase the ef? ciency and equity with which the householdsÃ¢â¬â¢ money is collected, managed and used, so that the householdsÃ¢â¬â¢ burden is reduced. 4 Exploring Risk Transfer and Pooling Strategies Exploring Risk Transfer and Pooling Strategies in the context of the NRHM In attempting to understand the potential of risk pooling or risk transfer mechanisms such as insurance (which immediately addresses the cost which a household spends on hospitalization) in achieving public health goals within the overall NRHM mandate, the following issues become relevant: 1. The potential value addition that insurance could provide 2. The various models of health insurance for the poor 3. Implementation of the insurance programme in the context of the NRHM D. C. : The World Bank. 8 Ibid 4 Ruchismita, Ahmed, Rai: Delivering Micro Health Insurance through the National Rural Health Mission 1. Health Insurance leads to: Ã¢â¬ ¢ Risk pooling for in patient care (hospitalization): As discussed, one of the major causes of poor households slipping into the poverty cycle is out of pocket expenditure incurred for hospitalization. In such a scenario, insurance, which allows for risk pooling, helps in making available additional source of ? nancing for the household thereby reducing overall vulnerability and smoothening expenditure shocks for larger unpredictable catastrophic health events. Increased utilisation of health services: It is expected that the introduction of health insurance will lead to greater utilisation of health care services. Across the world it has been found that the overall use of curative services for adults and children was up to ? ve times higher for members of health insurance programmes than non-members9,10 . Ã¢â¬ ¢ Standardization and cost effective q uality health care: Insurance as a mechanism attempts to standardize protocols, procedures and bring down cost through rate negotiations. This ensures the availability of cheaper healthcare, controlling fraud and possibility of rent seeking behaviour which is high in the case of the poor who have comparatively lesser knowledge about their health status or possible treatment required. Further due to Health Insurance, the out of pocket expenditures per episode of illness are signi? cantly lower for members as compared with those for non-members11 . Under the NRHM it is hoped that a national level expert committee will play a pivotal role in standardizing treatment protocol and rates. Presently such an activity has been undertaken by World Health Organisation (WHO), India-Of? e, in collaboration with Armed Forces Medical College (AFMC). Ã¢â¬ ¢ Cover for access barriers (loss of wage, transportation cost) and new and emerging diseases: It has been seen that since most of the micro insurance models evolved from community institutions and NGOs, they packaged critical P. , and F. Diop. Synopsis of Results on the Community Ã¢ â¬â Based Health Insurance (CBHI) on Financial Accessibility to Healthcare in Rwanda. HNP Discussion Paper. 2001. Washington, D. C: World Bank. 10 Preker, A. S, Carrin, G. SHealth Financing for Poor People Ã¢â¬â Resource Mobilisation and Risk Sharing. T 2004. ? ? Washington D. C. : World Bank. 11 Preker, A. S and G Carrin. Health Financing for Poor People Ã¢â¬â Resource Mobilisation and Risk Sharing. 2004. Washington D. C. : World Bank. 9 Schneider 5 Ruchismita, Ahmed, Rai: Delivering Micro Health Insurance through the National Rural Health Mission access barriers as part of their insurance cover. Also, insurance as a concept works on the principle of risk pooling and cross subsidization for low frequency events. The cost of healthcare for life style diseases like diabetes or critical illnesses and HIV/AIDS, is very high. Community Insurance models delivered at a large aggregation can cover for these rare events and ensure that the poor do not fall back into poverty in the process for paying for this high cost event. This has been tried in some schemes like the Arogya Raksha Yojna (ARY)12 . Ã¢â¬ ¢ Development of stronger referral linkages: Insurance as a mechanism to be sustainable requires developing strong upward as well as downward referral mechanisms. Strong referrals ensure non escalation of cases, thus ensuring Ã¢â¬Ëright care at the right timeÃ¢â¬â¢, reducing possibilities of collusion and fraud. Ã¢â¬ ¢ Ef? ciency in the health system in terms of: Ã¢â¬â Allocative ef? iency in addressing the most risky event a household faces i. e. hospitalisation and by diverting the surplus premium to strengthen the health infrastructure and incentivise manpower. Ã¢â¬â Value for money: Presently the expenditure on health by the poor includes leakages such as transport costs, spurious drugs, unlice nsed medical practitioners who offer health care of sub optimal quality. 2. Various Models of Health Insurance for the Poor Models of micro health insurance may be categorized into the following: Ã¢â¬ ¢ Social Health insurance: Such insurance models are found in about 8 countries across the world. The overall model works with a differential premium payment mechanism where the economically secure pays a relatively higher premium than what their risk pro? le dictates and the poor pay a comparatively lower premium commensurate with their income. This leads to cross subsidization across the rich and poor category. In India it is mostly seen in the formal sector in the form of ESIS and the CGHS scheme. 12 With Narayana Hrudayalaya, Biocon and ICICI Lombard in Anekal Taluka of Bangalore district of Karnataka. 6 Ruchismita, Ahmed, Rai: Delivering Micro Health Insurance through the National Rural Health Mission Community Based Health Insurance (CBHI): There are three basic designs of CBHI, depending on who the insurer is. In Type I (or HMO design), the hospital plays the dual role of providing health care and running the insurance programme. In Type II (or Insurer design), the voluntary organisation is the insurer, while purchasing care from independent providers and ? nally in Type I II (or Intermediate design), the voluntary organisation (NGO/CBO) plays the role of an agent, purchasing care from providers and insurance from insurance companies. This seems to be a popular design, especially among the recent CBHIs13 . The merit14 of the last model is the aggregating role and the context speci? city that the NGO/CBO assumes. Since the NGO has systematically addressed information asymmetry, and also shares the communityÃ¢â¬â¢s trust, these initiatives show better results (as seen in case of Dhramasthala insurance programme). In the case of a national roll out this can be the best model as it will capture the diverse nature of health requirements in the different NRHM states. The provider model or insurer model may not work out as customisation to local condition becomes the main crux of success or failure of the scheme. Further an NGO along with an insurer will be in a better position to retain the large risk of the community as compared to an individual entity like a provider or an NGO alone. It is crucial to ? nd NGOs that have a long term stake and therefore would act as Ã¢â¬Ëconscientious playersÃ¢â¬â¢ who will ensure that the insurance programme, generates long term positive impact on the health system of the speci? c geography. 3. Some suggestions for the proposed Health Insurance Programme As discussed earlier, the health system in India is characterised by grave inequities leading to a political economy that makes health care access income and classdependent. This creates the need to explore various types of innovations and changes that could improve this unacceptable situation. Insurance is potentially one such et al. Community-based Health Insurance in India: An Overview. July 10, 2004. Economic and Political Weekly. New Delhi. 14 The Yeshaswani insurance programme (the large health insurance programme in the country) follows this model through the various cooperatives facilitated by the department of cooperatives. Other example is the Dharamasthala insurance programme where the NGO (Dharmastahala trust) is the aggregator and has about 1 million insured under its scheme. 3 Devadasan 7 Ruchismita, Ahmed, Rai: Delivering Micro Health Insurance through the National Rural Health Mission innovation. However, for health insurance to effectively improve the ef? ciency of health spending and ultimately improve health status, it would need to be conceptualised as a part of a larger effort to improve the accessibility and quality of health care s ervices, especially for the poor. In the Indian context, any health insurance programme will have to take into account the plural nature of the health system, especially the presence of a large fee-levying, unregulated and ill understood private sector. It will have to explore synergies and integration with the widespread public health system and its current ? nancing mechanisms. Questions such as who should pay the premiums for the poor and how should incentives be aligned will have to be carefully thought through to ensure the management of problems such as adverse selection, inadequate monitoring and moral hazard, exacerbated because of extreme information asymmetries inherent in health services and goods. Internationally and within India, there is a signi? ant body of literature regarding the impact of different health insurance programmes on the health system. For the Indian context, it would be important to learn from these various experiences, develop a theory about the mechanisms through which insurance can contribute to public health goals, run pilots in different contexts within India to understand feasibility and impact, and determine the ? nal programme based on these learnings. 5 Proposal for a National Apex Body Proposal for a National Apex Body Working as a Coordinating Centre for Micro Health Insurance: It is proposed that a National Apex Body, ideally placed within the Insurance Regulatory and Development Authority (IRDA), be established to monitor and coordinate the implementation of the micro health insurance operations in the country (see ANNEXURE 2). The Apex body should have capacity in the areas of public health and insurance, host national and state-level dialogues on the idea of insurance in the context of health systems, implement pilots in speci? geographies and take forward the learning, and ensure knowledge sharing so that progressively larger regions can be covered under the micro 8 Ruchismita, Ahmed, Rai: Delivering Micro Health Insurance through the National Rural Health Mission insurance scheme. ANNEXURE 2 provides details of potential roles this apex body (tentatively named Micro-insurance Coordinating Centre) could play in taking forward the agenda of usefully employing the strategy of insurance to get closer to the public health goals of the country, focusing on the vulnerable. It is envisaged that this body should play a knowledge-building, technical advisory, policy advisory, facilitative coordination role with a long-term aim of achieving universal health insurance coverage by an optimal combination of social and micro health insurance mechanisms, in a manner that it integrates seamlessly with the overall health system. The proposed apex body should host a process that Ã¢â¬ËarrivesÃ¢â¬â¢ at a framework of implementing health insurance under NRHM. Based on our understanding, the following emerge as important aspects of any national level health insurance programme developed under the NRHM. The health insurance model under the NRHM should explore the Partner-Agent approach which includes both the insurance partner (risk partner) and the agent (NGO). Based on experiences from the pilots, the insurance cover could be a compulsory, cash less health insurance product with a family ? oater with minimum initial deductibles. Depending on the availability and quality of providers, the insured should have the choice to access the nearest (private or public) health care facility and should be allowed to choose between any provider within a given geographical parameter. The client could be issued a biometric ID card which is updated with diagnostic information and refers her/ him to the desired care provider to control overcrowding at the tertiary facility. 1. Product Cover: To begin with, the product should cover basic hospitalisation at the secondary care level (either at the cluster of village, block or district level). It should include the cost of: Ã¢â¬ ¢ Hospitalisation Ã¢â¬ ¢ Diagnostic services Ã¢â¬ ¢ Medicine and consumables Ã¢â¬ ¢ Consultation and nursing charges Ã¢â¬ ¢ Operative charges 9 Ruchismita, Ahmed, Rai: Delivering Micro Health Insurance through the National Rural Health Mission The product should also try to cover for access barriers like transportation cost (with a initial deductible to control frauds and limited to only the cheapest mode of transport available, customized according to the district), loss of wage (in case of the male or female member of the household as de? ned by the state according to the minimum wage guaranteed by the state government. This could be done in tandem with the National Rural Employment Guarantee Scheme (NREGS). In geographies where investment in directed preventive and promotive services can bring down the need for seeking in-patient care, directed primary care primary level care can be provided by the insurance programme. For example, Directed preventive promotive community health education could lead to reduction in the frequency of inpatient care due to vector borne diseases in several geographies15 . Thus based on the speci? location package of additional community health intervention will be developed, which can be paid from the insurance model The insurance programme can work with District Health Societies to offer rehabilitative care and ? nancial help to patients who have recovered but are disabled due to diseases like leprosy or polio. It can also help the People Living with HIV/AIDS (PLHIV) by providing additional services like providing nutritional supplement and other additional services wh ich will supplement the current care being provided by the national programme for control of HIV/AIDS. 2. Health providers: Both private and public facilities at the secondary care level could be empanelled as providers. Private care hospitals could include nursing homes or 20 bedded medical facilities as seen in the Missionary hospitals as well as entrepreneur led inpatient care. For the government hospitals such as the district hospital, the difference in rates could be used for improving infrastructure and incentivising staff. 3. Building information systems: There is a need for a reliable transparent MIS sys15 For Insurance covering hospitalization due to events that can be impacted by Sspeci? S preventive promo? tive health education, it makes economic sense to proactively invest in Community Health Education, which will reduce the probability of hospitalization due to the event. Vector borne diseases show a high degree of sensitivity to such Community Health Education programmes. 10 Ruchismita, Ahmed, Rai: Delivering Micro Health Insurance through the National Rural Health Mission tem to improve the overall ef? ciency of the system. This would reduce paper work, streamline referral linkages and aggregate data helpful for product customization. The community health insurance model could generate a much needed Electronic Health Records (EHR) system. This would imply that as per commonly agreed terms all health related information of an individual (parameters like diagnostic test results (blood pressure, body temperature, pulse rate, ECG), diseases to which he/she is prone; past illnesses etc) is stored onto a system or a database. This database can be accessed by all ensuring anonymity and therefore all insurers, health workers and policy makers can access and interpret the health data to be able to conduct community risk assessment. This will encourage insurers to compete for risk pricing of the community in the said geography and lead to cheaper insurance premiums. The focus of the EHR system would be to ensure Ã¢â¬â Universality, Consistency, Open Standards, Non-Proprietary, and Acceptability. To institutionalize a reliable EHR system it should be made compulsory that any treatment/diagnosis/medical intervention be updated into the individualÃ¢â¬â¢s EHR, such that the EHR is the most authentic source of health information about an individual. The other challenge that needs to be addressed for development of better health insurance products as well as better health care delivery is the challenge of targeting and uniquely identifying the individual. Such identi? cation could be achieved through a biometric identi? cation smart card. The smart card can be used to not only help in identi? cation, but also for storing of? ine health information With an EHR and smart card system, the insured can freely access b oth the public and private health care facilities available in the geography. This helps the insured as well as the medical practitioners and improves diagnosis and response time. The Smart Card can also be used to store health insurance related information of the client. The health provider can thus check the eligibility of the individual in terms of insurance before delivering treatment. The same card can also be used as a payment instrument to capture the payments that need to be made to the health providers. The card can be used to pass 11 Ruchismita, Ahmed, Rai: Delivering Micro Health Insurance through the National Rural Health Mission n incentives to clients as well as the hospital to keep using the card. The biometric card will have terminals (which can upload data of? ine) in the various network hospitals to upgrade data whenever the insured avail care. 4. Formative Research: a Community Needs Assessment (CNA) will need to be done to list down the health needs and the willingness to pay, a mapping of the healthcare facilities in the geography, an unde rstanding about the type of premium and payout that the community are expecting from the insurance scheme and the broad range of social protection measures that they want the insurance to take up. Based on the information provided above the product and the EHR can be developed. Initially, it is advisable to undertake health insurance pilots in different contexts to develop and ? nalise the health insurance programme. 5. Implementation and monitoring: The proposed National Apex body, should monitor and coordinate the implementation of the micro health insurance operations in the country (see Annexure- 2). The following ideas can potentially strengthen the monitoring and implementation of the programme: Ã¢â¬ ¢ The District Health Accounting System and the proposed ombudsman (to be created under NRHM to monitor the District Health Fund Management) will work closely with the NGO and the insurer to ensure the smooth running and monitoring of the programme. Ã¢â¬ ¢ At the backend, the insurance programme with the EHR system will develop a rich data source and act as a Fraud control mechanism. This data will help in identifying disease patterns for the community and could be a critical tool for the NRHM team to de? e ? nancial allocations, target services and make evidence based policy recommendations. (While developing this EHR we should ensure that we are following international standards to be able to be coded properly and stored in a card). In the long run, this apex body should aim at achieving universal health insurance coverage by combination of social and community based health ins urance mechanisms. There is a case for building facilitative institutional arrangements of the Ã¢â¬ËrightÃ¢â¬â¢ stakehold12 Ruchismita, Ahmed, Rai: Delivering Micro Health Insurance through the National Rural Health Mission rs who will pursue this goal. The learning from the challenges and processes involved in implementing Universal Health Insurance Scheme (UHIS) will be very valuable. 6 Conclusion Promoting health and confronting disease requires action across a range of challenges in the health system. These include improvements in the policy making and stewardship role of the government; better access to human resources, drugs, medical equipment, and consumables; and a greater engagement of both public and private provider of services. Insurance has a limited but important role to play in solving some of the health ? nancing challenges. Innovative pilots of partner agent model led micro health insurance could giver useful insights for designing a national level programme, led by an apex body. Such a programme could systematically impact the health system in the country. 13 Ruchismita, Ahmed, Rai: Delivering Micro Health Insurance through the National Rural Health Mission 7 Annexures 7. 1 ANNEXURE I Beyond the pilot, the initial cover will be modi? ed to cover primary and tertiary tier of the health systems in the country. . Primary level: The Insurance will cover: Ã¢â¬ ¢ Diagnostic charges incurred on low and high end diagnostic16 Ã¢â¬ ¢ Medications including expensive medication (like life saving drugs, higher antibiotics etc), injectibles and other consumables not usually available in the primary health centre Ã¢â¬ ¢ Based on the recommendation given in the NRHM document, practitioners of AYUSH and other speci alties can be roped in to act as the Primary Physician Ã¢â¬ ¢ Based on the scale and/or the insurance experience in 1st year, further social security bene? s can be added as follows: Ã¢â¬ ¢ Reimbursement of transportation charges, wage loss, ? nancial compensation for attendant, compensation for disability and subsequent rehabilitation. 2. Impacting infrastructure and Manpower: Ã¢â¬ ¢ Depending on the claims experience and the volume, some monies can be utilized to purchase new or replace old goods/equipment at the Primary Health Centre (PHC) and such activity monitored by District Health Mission through district health accounting system and the proposed ombudsman under NRHM. Besides there is a need for 5-10 bedded hospitals to come up at the taluka or clusters of village level in severely resource constrained area for which emerging entrepreneurs like the Vatsalaya hospitals who have already set up such hospitals elsewhere in the country (especially in Karnataka in this case). L ocal doctors looking at running hospitals can set up such hospital and run it on a franchise model. in this realm may lead to cost effective and customised diagnostic solution. in this regard ICICI Knowledge Park is involved in coming out with such customised solution for the rural poor 16 Innovation 14 Ruchismita, Ahmed, Rai: Delivering Micro Health Insurance through the National Rural Health Mission Ã¢â¬ ¢ There is also a need for high end diagnostic chain to come in to the rural space with similar franchise model of commercial diagnostic companies17 . Standardization of all the services will be done by a committee of experts in each state. These services will include outpatient, in-patient, laboratory and surgical interventions. Ã¢â¬ ¢ Manpower: The ANMs/CHWs/ASHA/MPWs can be incentivised to provide their services more ef? ciently and quickly from such fund given to the Panchayat either from the government or from the insurance fund. It is assumed that with the introduction of ICT component (EHR and biometric cards) like smart card, the 40% of time wasted by ANM on documentation will be saved18 . Ã¢â¬â To incentivise the doctors to work in the PHC: Ã¢â¬â Posting of quali? ed graduate doctors in PHCs can be made mandatory and also made necessary pre-requisite for eligibility to sit for Post Graduate Medical Entrance Examination. Ã¢â¬â Top 10 or 20 high performing PHC doctors in the entire state might be allowed to join specialty of their choice in P. G courses directly or some higher percentage of quotas may be assigned to them which will facilitate them to get admission. Transparency and accountability in the whole service delivery can be brought about by making the health manpower within the PHCs and other levels accountable to the PRIs and the Village Health Committee through a rigorous and scienti? c accountability system19 . Ã¢â¬ ¢ Additional Services: De? ned amounts of fund can be made available to the local Panchayat or a certain percentage of premium collected be allowed to remain with them and be spent for these purposes according to their discretion 17 This entity can set up satellite diagnostic centre at the taluka or district level. They can have sample collection unit which collects the pathological samples from the villages and brings it to the satellite centre where it is examined. The report is either passed on to the patient the next day when the sampling collection team goes to the villages or can be sent directly to the referred doctor under the health insurance scheme. 18 This will give her more time to cover more villages, services and bring about ef? ciency in the overall healthcare delivery. It will also reduce paper work and make information easily accessible at each level. 9 Smart card technology will be used to increase transparency and accountability of the health staff bringing about good people governance. In this the gram Panchayat and the Village Health Committee will completely evaluate the work of ANM and other staffs (including the doctor). Their performance will be graded in a scale devised in consultation with the representatives of the PRIs and the District Health Mission and accordingly incentive/disincentive can be given based on the score. This information can be made available online for access to the general public. 5 Ruchismita, Ahmed, Rai: Delivering Micro Health Insurance through the National Rural Health Mission and mutual decision (It can also cover other expenses like loss of wage and destitute supports). Ã¢â¬ ¢ Health Database management system: ICT component in the form of smart card technology (in the form of a biometric card) be introduced which will ensure the capturing of health and insurance data of the population and minimize fraud. Ã¢â¬ ¢ It requires a decoder cum uploading device which will be portable and hand held. This can be used by ANM/Health staff/PRI/Hospitals to upload or read information starting from the primary to tertiary level Ã¢â¬ ¢ Will be able to transmit images and radiographic reports (X-ray and ultrasound, CT scan) apart from other routine test results. This can be done of? ine (Because in villages, the power supply is erratic or absent and the internet connectivity is lacking) and can be the precursor of telemedicine20 . 3. Tertiary level: It will cover all high cost, sophisticated care which may not be available at the secondary level. The diseases that can be covered are as follows: Ã¢â¬ ¢ Cancer Ã¢â¬ ¢ Myocardial infarction Ã¢â¬ ¢ Major organ transplant Ã¢â¬ ¢ Paralysis Ã¢â¬ ¢ Multiple sclerosis Ã¢â¬ ¢ Bypass surgery Ã¢â¬ ¢ Kidney failure Ã¢â¬ ¢ Stroke Ã¢â¬ ¢ Heart valve replacement 20 With internet connectivity through satellite (which are now provided free of cost by ISRO to interested NGOs and CBOs) which will mean that the patient will not have to travel to district level or tertiary level care and can walk in to such tele-consulting centre within the village where his diagnostic reports are accessed by punching in the unique I. D number of the patient on the smart card. The specialist sitting at the district level can then assess the prognosis of the case and decide whether the patient needs to travel or else advices the local doctor on what is the line of treatment for the patient which then can be carried out locally. This will save a lot of money (on traveling and loss of wages), time and resources which the patient would have spent otherwise. 16 Ruchismita, Ahmed, Rai: Delivering Micro Health Insurance through the National Rural Health Mission 4. Impacting infrastructure, Manpower and Services: Ã¢â¬ ¢ It is envisaged that the government medical college hospitals, other government health institutions, central or regional health institution operating in the state can act as the tertiary care provider. Ã¢â¬ ¢ Insurance can start paying for upgrading these infrastructures and incentivising the medical work force in a similar way as was explained under primary level care. Besides private healthcare who will start the franchise model or other wise interested (and agreeable to the negotiated rate for the insured) will act as the tertiary care providers21 . The government should play a central and leading role in developing a strong referral linkage in the state. Ã¢â¬ ¢ As most high level tertiary care hospital are charitable trust hospital and get substantial subsidies and exemption from the government in return for providing subsidized services for the poor (but in reality a very few actually provide such services) it should be made mandatory and compulsory for these hospitals to treat the insured poor. 5. Health Database Management: Ã¢â¬ ¢ There will be a Central Data Warehouse which will develop from the EHR integrate all the information collected from the primary level upwards, making it accessible to each level and hence acting as a central store house of information. Ã¢â¬ ¢ Additionally it will have personnel(s) who will analyse such data. Such analysis will be invaluable for monitoring, evaluation and mid-course correction. This will help in achieving the following: Ã¢â¬â Help revise insurance premium Ã¢â¬â Incentivise and monitor providers 21 The bene? will be two fold Ã¢â¬â it will provide quality care to the poor (through a TPA and the District Health Mission and Rogi Kalyan Samiti which will empanel hospital) which will ensure compliance to a particular standard of care) and will also help reduce crowding in the government hospital. At the tertiary level, a working arrangement should be made with national level government hospital (like AIIMS,CMC etc), regional ins titutes, post graduate medical institutes (JIPMER) and large private/corporate hospital (Apollo, Wockhardt, Fortis etc) so that patient requiring advanced critical care can be referred to them. 7 Ruchismita, Ahmed, Rai: Delivering Micro Health Insurance through the National Rural Health Mission Ã¢â¬â Control fraud The developing of referral linkages is very much possible with insurance playing a central role and ICT in the form of smart card technology will ensure equity, ef? ciency and quality in healthcare delivery at each level. The coupling of the whole machinery with tele-medicine will bring about synergy and help the poor in terms of saving money on traveling and also loss of wages. It has to be always borne in mind by all the stakeholders that all component of health care i. . preventive, promotive, curative and rehabilitative care as emphasized under National Rural Health Mission as well as the coming of all stakeholders to work together will ensure harmonious and ef? cie nt delivery of quality healthcare with insurance playing a vital role. None of the components or stakeholders can be undermined as each will ensure that we will be able to see demonstrable impact in the health indicators of the community in days to come. 18 Ruchismita, Ahmed, Rai: Delivering Micro Health Insurance through the National Rural Health Mission 7. 2 ANNEXURE II Setting up of a national coordinating and development entity: One of the key issues recognised by many is that increased coordination as well as sharing of knowledge and resources among the various actors in the sector would greatly stimulate success of NRHM as well as micro insurance development. This is especially true of health micro insurance for which few (if any) truly successful and sustainable programs have been observed to date. Hence it is felt that there has to be an apex body in the form of a coordinating centre which will initiate, regulate and monitor these activities. Following is a matrix which delineates the various stakeholder who will be represented in such a supra structure. 19 Ruchismita, Ahmed, Rai: Delivering Micro Health Insurance through the National Rural Health Mission Stakeholders Stakeholder Needs Coordinating CentreÃ¢â¬â¢s Criteria for Success 1. Bene? ciaries * Simpli? ed claims procedures with minimal bureaucracy * Solutions that result in fast claims payment 1. 1 BPL families * Timely payments of * Service satisfaction from bene? ciaries * Solutions leading to affordable insurance products with quality servicing promised bene? s * Systematic increase in product coverage to ensure reduction of access barriers * Access to health services and health risk protection services 2 Microinsurers, Insurers, reinsurers * Access to technical assistance, actuarial studies, EHR records and the Centralized Data Warehouse reports, exposure to international innovations * Long term sustainability of microinsurance programs servicing the poor * E ffective, broad-based microinsurance delivery channels * Microinsurance pro? ts commensurate to investment risk * Competent pool of microhealth experts insurance technical Service packages developed and patronized * Service satisfaction from micro-insurers * Insurers aggressively competing to offer superior products and services to MICC client governments * Investment and ? nancial support from insurers 20 Ruchismita, Ahmed, Rai: Delivering Micro Health Insurance through the National Rural Health Mission Stakeholders Stakeholder Needs Coordinating CentreÃ¢â¬â¢s Criteria for Success 3 NGOs, MFIs, trade unions, employer grassroots organizations, organizations, * Strong partnerships with hospitals, diagnostic players, NRHM team, AYUSH, ASHA workers and insurers Satisfaction with the coordinating agencyÃ¢â¬â¢s ability represents all stakeholdersÃ¢â¬â¢ interest and re? ected by strong involvement and support and investment through time in the centres work corporate sector, co-opera tive sector, etc. * Successful delivery of risk protection services to their memberships and clientele 4 Insurance Regulatory Development Authority * Robust, vibrant health microinsurance industry * Insurance regulations followed * Robust and vibrant network of micro-insurer clientele * Mandate and support from the IRDA * Achievements towards supportive and enabling policy 5 Health Providers * Timely payment from insurers * Reliable stream of BPL clients utilizing their services * Reasonable pro? tability * Positive ratings from health providers * Service satisfaction of BPL clients * Minimal problems with * Fast claims turnaround Solutions that result in: fraud and overcharging, etc. 6 TPAs Innovative and effective collection, distribution, and servicing channel 21 Sharing best practices Ruchismita, Ahmed, Rai: Delivering Micro Health Insurance through the National Rural Health Mission Stakeholders Stakeholder Needs Coordinating CentreÃ¢â¬â¢s Criteria for Success 7 State Governments * BPL population covered Support and mandates from governments * Ef? cient utilisation of resources and resources leveraged through a resource center * Moving closer to the goals stated under NRHM 8 Government of India * Access to comprehensive and quality health care for all * Improvement in national statistics on accessibility of health care services 8. 1 Ministry of Health and Family Welfare 8. Department of Insurance, Ministry of Finance * In synergy with existing programmes and structures * Proper utilization of departmental funds * National statistics on health insurance penetration * Increase in the number of legalized community health insurance programmes * Moving towards universal coverage * Regularising illegal community health insurance programmes Other major stakeholders that will have to be consulted are the likes of Indian Medical Association (IMA), Institute of Public H ealth (IPH), Federation of Obstetric and Gynecological Societies of India (FOGSI) and Institute of Health Management Research (IHMR). . 3 Objectives, Activities, and Services The stakeholders and clients of the Microinsurance Coordinating Centre envision a network of professionally-managed micro-insurers and accredited service providers offering 22 Ruchismita, Ahmed, Rai: Delivering Micro Health Insurance through the National Rural Health Mission affordable, comprehensive, quality risk protection to the majority of poor people in India. Similarly, the Mission Statement may read as follows: The Microinsurance Coordinating Centre aspires to facilitate delivery of innovative health ? ancing and health insurance solutions in the country and improve the health indicators. It also aims to improve the capacity of insurance providers to provide risk protection services on a sustainable basis. The Centre is committed to building a vibrant health ? nancing and risk pooling sector through coll ective advocacy and through concentration, leveraging, and focusing on resources and knowledge towards developing innovative technologies. More speci? cally, activities and services of the MCC may include the following: Ã¢â¬ ¢ To diagnose the feasibility and requirements of proposed micro-insurance projects in speci? districts of the identi? ed NRHM states; Ã¢â¬ ¢ To develop and offer comprehensive, feasible, customized technical solutions complete with onsite guidance and implementation assistance; Ã¢â¬ ¢ To facilitate strengthening the technical and cost effective management capacities of the NRHM team at the district level; Ã¢â¬ ¢ To analyze and document the leading and best practices in the health microinsurance industry; Ã¢â¬ ¢ To provide a forum for regular exchange and dissemination of ideas, innovations, lessons learned, achievements, and international best ractices; Ã¢â¬ ¢ To develop and support EHR central data warehousing and tools; Ã¢â¬ ¢ To develop health microin surance performance standards and prudential indicators, and the supporting technologies and tools that will enable micro-insurers to meet these standards; Ã¢â¬ ¢ To provide a rating service of NRHM districts with micro health insurance pilots micro-insurers with respect to the standards and indicators; 23 Ruchismita, Ahmed, Rai: Delivering Micro Health Insurance through the National Rural Health Mission To facilitate and strengthen collaboration and partnerships among the various microinsurance providers and Health Ecosystem partners Ã¢â¬ ¢ To establish linkages between insurers and resource institutions such as funding agencies, ? nancial institutions, and research institutions; Ã¢â¬ ¢ To accredit a network of providers delivering affordable, quality health care through use of clinical protocols and negotiated tariff schedules; Ã¢â¬ ¢ To provide and manage a data repository and also a national helpline for query redressal. To conduct industry experience studies and share resul ts for use in pricing and management purposes; Ã¢â¬ ¢ To represent the health microinsurance sector to the Government of India and lobby for favorable and enabling policy; Ã¢â¬ ¢ To identify and facilitate networking and business opportunities among the various stakeholders; and Ã¢â¬ ¢ To elevate the insurance consciousness through awareness campaigns and education. Some of the activities such as product design are already being carried out by insurance companies. However, since microinsurance differs greatly from commercial insurance it requires unique design, marketing, and distribution strategies and skills. The MICC, with its personnel focused and specializing in micro insurance and health (health economists), with access to current data, and with concentration of knowledge about the industry would be positioned to facilitate superior solutions in these areas. 24 How to cite Health Financing in India, Essay examples
Sunday, April 26, 2020
One Flew Over The Cuckoo's Nest A hero is considered to be any man noted for feats of courage or nobility of purpose; especially, one who has risked or sacrificed his life. This describes one of the main characters in the highly acclaimed novel, One Flew Over the Cuckoo's Nest, by Ken Kesey. Randle McMurphy is the hero of this novel because he stood firmly against oppressive powers, showing courage and ultimately paying with his life. There were no heroes on the psychiatric ward before McMurphy's arrival. Nurse Ratched wielded supreme power. No single patient had the ability to stand against the injustices to which they were subjected. McMurphy united these patients. He gave them collective courage and a sense that they could resist their persecutor. For example, Harding states, "No one's ever dared to come out and say it before, but there's not a man among us that doesn't think it. That doesn't feel just as you do about her and the whole business-feel it somewhere down deep in his scared little soul." Not only did McMurphy unite his friends, the patients; but he understood the enemy, the staff. He recognized the ultimate authority and oppressive power of those in charge of the psychiatric ward. He also knew that to resist them would put himself at great personnel risk. McMurphy, however, took the risk and defended his fellow patients. For example, McMurphy says to the black boy who is harassing George, "I said that's enough buddy." McMurphy knew this confrontation would have harsh consequences, but he took the chance. In fact McMurphy took one too many chances. This hero's end comes when he lashes out at nurse Ratched, blaming her for the death of Billy Bibbit. McMurphy demonstrated his feeling for Billy by his emotional reaction to his death, "First Charles Cheswick and now William Bibbit! I hope you're finally satisfied. Playing with human lives-gambling with human lives-as if you thought yourself to be God!" This outburst results in McMurphy having a lobotomy and later dying. In conclusion, Randle McMurphy lost his life courageously defending the other patients. McMurphy had several chances to save himself, but chose instead to stay and help his fellow patients. McMurphy is a true hero and his acts of bravery and selfless behavior prove this.