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Preface
these abuses, schemes require control systems in three domains: constant vigilance over claims data, reviews of preauthorization requests, and physical verification of beneficiaries undergoing treatment. They also need grievance and feedback systems for patients and providers. Some schemes have implemented sound vigilance measures along these lines with varying degrees of sophistication. Others appear to be in reaction mode, responding to press reports or random beneficiary complaints. Few schemes systematically or proactively implement fraud-detection measures. Nevertheless, when detected, there is a noticeable tendency to deal with unethical practices or unwarranted treatment. Many schemes have disempaneled hospitals as a disciplinary action after investigation confirmed such complaints. For example, as of September 2010, RSBY, AP, and Yeshasvini had disempaneled 54, 67, and 58 hospitals, respectively. Whether these actions have decreased the incidence of such practices is unknown, but enforcement of rules and policies is a good sign. What are the GSHIS linkages to the public delivery system? Most GSHISs are marginally linked to the public delivery system, and most networked hospitals are private. Particularly for the tertiary-focused state GSHISs, one of the main reasons to initiate these schemes was the limited capacity in the public sector to provide tertiary care. The actual share of private hospitals in service utilization may be larger than implied by the quantum of networked hospitals since most beneficiaries choose private facilities when seeking care. For example, in the AP, TN, and KA schemes, most network facilities are private hospitals, which, ranked by number of admissions, are also predominant among the top 20 facilities. However, a few public medical colleges and public autonomous hospitals were also included among the top 20 hospitals for Vajpayee Arogyashri, Yeshasvini, and Rajiv Aarogyasri. Nevertheless, barring these few large, tertiary public institutions, many other public hospitals empaneled by the schemes, especially district and subdistrict hospitals, saw little or none of the insurance traffic. This is particularly the case for the tertiary-focused schemes. The exceptions to this observation include public hospital utilization in Kerala (under RSBY) and the linkages for referral from public facilities in AP. Under current governance and institutional arrangements, most public hospitals are in no position to compete with private facilities. Few have the autonomy or flexibility to manage their own affairs. They are entirely dependent on the hierarchical control of state health authorities for nearly all budgetary and input decisions.