Healthcare Monitoring & Delivery Architecture

  • 3 mins read
  • 31st Mar,2021

Globally, nations are striving hard to inch closer to the United Nations Sustainable Development Goal (SDG) of ‘Universal Health Coverage (UHC)’ for all by 2030. UHC is expansive in scope- it means that people should have access to health services they need, when and where they need them without financial hardship. Under UHG, nations have the mandate to provide the full range of essential health services, from health promotion to prevention, treatment, rehabilitation, and palliative care.

In the current scenario, about half of the world’s population does not receive the health services they need. Of the total worldwide population of 7.9 billion (as on March 2021), over 930 million people spend at least 10 per cent of their income on healthcare. Also, some 100 million people are pushed into abject poverty each year due to mounting out of pocket spending on health costs. In India, the scenario is unsettling as on an average, each person spends $109 per year from his own pocket to access health services. Hence, the critical target here is not UHC alone but a health coverage with financial risk protection. And, this builds the case for an efficient delivery of health insurance solutions especially in India where 60 per cent of the insurance market is government led.


Why Developing Nations Are Struggling?

Many developing nations across Asia and Africa bump into hurdles while implementing healthcare programs, making it tough to attain the SDG of universal health coverage. For them, it is like combating many-layered challenges- delivering healthcare systems to the remotest hinterland, stemming the rising incidence of non-communicable diseases with exorbitant treatment costs, a growing uninsured population, political or economic instability, increasing budget deficits and increasing pressure to reduce healthcare costs. Unless there is an automated system for healthcare scheme monitoring and evaluation, the ambitious goal of UHC would remain elusive for these nations.


How CSM Transformed Healthcare Delivery With Himcare

Ever since the Department of Health & Family Welfare, Himachal Pradesh partnered CSM Technologies, the parameters in healthcare delivery have changed drastically. During 2019 and 2020, the end-to-end automated solution received 584,448 applications, issued 534,579 health cards, empanelled 305 hospitals, settled 108,546 claims and paid Rs 86.35 crore to hospitals for settled claims. But before this seamless system was rolled out, the department confronted many a hurdle. There was no centralized system which made it difficult to authenticate the beneficiaries and verify their credentials. That apart, the practice of multiple back and forth performed manually for empanelment of hospitals and verification of beneficiary’s credentials had turned irksome. The whole process devoured time, lacked transparency and raised risks of frauds and duplication of records.

Himcare Scheme Monitoring System brought in a wave of transition with an automated ICT platform wherein layers of data pertaining to beneficiaries, hospitals, medical records, treatment packages and claims are authenticated and validated through data mining and warehousing.  

Both government and private hospitals can be empanelled under the scheme. The automated system generates health card and offers a DigiLocker for saving it. Settlement of claims is governed by a four-stage verification process. Moreover, the system provides for a Grievance Management System and offers an ‘Audit and Support Service’ where empanelled hospitals are audited by the Third Party Administrator (TPA) to appraise their services.


Benefits of Our Healthcare Monitoring Scheme

  • Beneficiary Registration: Authentication of beneficiaries, Generation of Unique ID, Evaluating Eligibility as per Scheme and Digitization of Medical Records
  • Hospital Registration: Infrastructure Mapping of hospitals, Empanelment of hospitals as per infrastructure readiness & healthcare demand in catchment area
  • Treatment Packages: Creation of custom treatment packages based on diagnosis of patient medical records
  • Claim Processing: Online applications for claims, automated workflows for sanction, online disbursement
  • Grievance Management: Ticketing and auto escalation of grievances raised by citizens
  • Decision Support System: Advanced analytics and reports on performance of hospitals & insurance providers, fund deployment & utilization under scheme at all levels.

Automated schemes like Himcare are kindling hope for a vast swathe of population with no access to quality healthcare services. They also strengthen the governments’ resolve to connect and deliver health benefits to people at the bottom of the pyramid.

Jayajit Dash

Research Analyst - Public Policy

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