CII White Paper_Accesscibility

8/6/2019 CII White Paper_Accesscibility

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1

Company Name CONFIDENTIAL


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Policy Paper

for

Enhancing

Healthcare Accessibility

through

Financing


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Enhancing Healthcare Accessibility through Financing

Contents

A. Executive Summary 1

B. Preamble/Objectives 1

C. Environmental Analysis 2

D. Issues in Healthcare Financing 12

E. Medical Requirements of the Population 13

F. Newer Health Financing Options 15

G. Recommendations 19

H. Conclusion 21


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Acknowledgements

The white paper on Enhancing Healthcare Accessibility through Financing has been prepared under thepurview of CII Healthcare Sub-Committee on Accessibility. Valuable contributions from the followingmembers of the Sub-Committee have been the guiding force behind this white paper:

1. Mr N Rangachary, Advisor to Government of Andhra Pradesh and Chairman of the CII

Healthcare Sub-committee on Accessibility

2. Dr Ajit K Nagpal, Chairman - Executive Council, Batra Hospital & Medical Research Centre

3. Mr Nimish Parekh, Founder & President, Cecilia Healthcare Services Pvt. Ltd.

4. Dr T Jagannathan, Chief Administrative Officer, Sir Ganga Ram Hospital

5. Ms Rajni Sekhri Sibal, Director - Health Insurance, Max Healthcare Institute Ltd

6. Ms Ujjaini Dasgupta, Head Health Insurance, Bajaj Allianz General Ins. Co. Ltd.

7. Mr Chandrashekhar, Chief Marketing Officer, Apollo DKV Insurance Co. Ltd

8. Dr Ashoke Bhattacharjya, Executive Director - Health Outcomes & Policy, Johnson & Johnson

Ltd


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Abbreviations

CGHS Central Government Health Scheme

CHI Community Health Insurance

ESIS Employee State Insurance Scheme

GDP Gross Domestic Product

GIC Government of IndiaGOI Government of India

HAS Health Savings Account

HMO Health Management Organisation

IRDA Insurance Regulatory and Development Authority

MSA Medical Savings Account

NBFC Non- Banking Financial Company

NGO Non-Government Organisation

NSSO National Sample Survey Organisation

PPF Public Provident Fund

PPO Preffered Provider Organization

RSBY Rashtriya Swasth Bima Yojna

TPA Third party Administrator

UHI Universal Health Scheme

US United States


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Enhancing Healthcare Accessibility Financing

A. Executive Summary

Accessibility to Healthcare pertains to the populations ability to reach, obtain or afford entranceto the healthcare services. India being the second most populous country with a pronounced

fragmentation in its social, economic and demographic structure, accessibility to healthcare to

the population has become a matter of concern. The growth of the healthcare sector per se has

been rather slow to address the need of the society.

The purpose of this document is to discuss the various options available in the binging of health

care within common reach to and suggest that health care, if properly financed, can be a major

impetus for improving accessibility among all the sections of the society. A multiprongedapproach by the government in partnerships with banks, micro finance institutions, Non-Banking

Financial Companies (NBFCs) and Third Party Payers is required. Participation across all the

services, modes and participants at all the levels of care designed to promote health from

preventive to trauma care, whether directed to individuals or to groups is equally vital.

The growth in the health insurance area has been slow and it is thought that insurance being

only one of the modes of accessibility, various other possible options that could meet the

unique needs of the different segments should be seriously considered. Measures such ashealth savings account, government grants, risk pooling insurance, capitation and other

provider risk sharing, borrowing and self financing have been discussed in the main study. For

a country where more than 25% of the population lives below the poverty line it becomes

necessary to find out of the box solutions and not stick to traditional measures which prima

facie have proved ineffective.

A single system / limited approach to health financing may not work in a country of 1.2 billion

with such diverse needs.

The country needs viable alternatives to the existing pattern of accessibility to healthcare

including possibly a medical investment account to be operated as a running account over a

period of time enhanced by conditions and depleted by accessibility This document gives a

preview to the approach which suggests how future policy needs to be formulated in order to

encapsulate the role of each stake holder.

B. Preamble/ Objectives

The CII Healthcare Subcommittee on Healthcare Accessibility has been constituted under the

chairmanship of Mr. N. Rangachary, for understanding the issues related to health manpower

and to crystallize governments plans of action


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C. Environmental Analysis

Today India spends around 4.8% of its GDP on healthcare. Around 78% of healthcare spent

in India is done from private funding. The voluntary (private) insurance cover is still limited to

only 1.4% of the total population of India. The Government (central and state) spends is

around 1.2% of GDP on health care. The focus of Government is today on primary

healthcare and healthcare awareness programmes.

India is still among the few of the least spending countries on healthcare. It lags behind most of the

developing countries in this aspect - except for certain emerging economy nations like Pakistan,

Bangladesh Afghanistan etc as can be seen from the exhibit above. Comparable countries like

China, Brazil and Mexico along with the developed world have a much better coverage of public

spending on healthcare as a percentage of GDP. United States approximately has three times the


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Coverage of health care in India is limited to a small fraction of the population. The private fundingstill plays quite a vital role in filling the financing gaps, through out-of-pocket spending, insurance,

employee benefit schemes etc.

Sources of Health Financing in India

Health financing is by a number of sources as depicted below.

1.2%

2.0%

3.4%

2.9%

3.2%

6.4%

6.8%

3.6%

3.6%

4.2%

3.3%

5.2%

3.1%

8.4%

0.0% 2.0% 4.0% 6.0% 8.0% 10.0% 12.0% 14.0% 16.0%

India

China

Brazil

Mexico

South Africa

Australia

United States

Public Health Expenditure (% of GDP) Private Health Expenditure (% of GDP)

Health Insurance Insurance-social andi b d h

Employers BenefitSchemes, the not-for-profit

sector (NGO andCharitable hospitals)organizing and financinghealthcare;

Households:out-of-pocket

Local, State and CentralGovernments, in addition to

numerous autonomouspublic sector bodies;

PublicFinancing

PrivateFinancing:

Risk PoolingOthers


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1. Public Financing of Healthcare in India

Health is primarily a state responsibility in India. State governments mostly take care of healthcare

delivery and central government works more on the preventive and on national disease control

programs.

State Government Healthcare Spending Distribution

Health care functions % Distribution

Services of curative care 47.6

Rehabilitative or long term nursing care 0.2

Ancillary services & therapeutic appliances 1.9

Reproductive and child health services 12.2

Drugs control 0.3

Nutritional program of State Dept of Health 0.1

Control of Communicable diseases 6.2

Control of non-communicable diseases 0.4

Public health or RCH education/training 0.5

Other public health related activities 1.3

Health administration 8.4

Capital expenditure 4.7

Medical education and training of health personnel 8.7

Research and development 0.2

Food adulteration 0.2

3528, 39%

5455, 61%

Government Expenditure on Healthcare in India (US$ Million)

Central Government

State Government


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2. Private Healthcare Financing in India

Private Financing constitutes of: (1) Public and Private Employer financing, (2) Out of Pocket

spending, (3) Non-Government Organizations etc.

As discussed earlier, this constitutes around 78% of total healthcare financing in India. Around 5% of

financing is done by private and public employers. Others such as not-for-profit organization, non-

government organization etc constitute 2.4% of total healthcare spend. Around 69% of total

financing in India is purely out of pocket.

Employee Benefit is another way of private financing happening in India, which is still in a very

limited scale in India, primarily due to the reasons:-

Most people work in the vast unorganized sectors in India and in these sectors the

companies dont give any health benefit to employees

The original schemes presently run do not cover self-employed personnel, professionals,e tc.

This sector, because of the tremendous growth of the service sector in the recent times

constitutes on major chunk of employed population still not governed by any health

protection measures as part of employer-employee relationships.

The daily wage workers are given very little or no benefits by employers and a large

proportion of employee fall under these category.

There is no mandatory regulation or legislation by government for enforcement of medical

benefits for employee.

Recent statistics shows a major fraction of the private healthcare funding in India is financed out ofpocket. The rising costs are and will pose major challenges to its sustainability in the times to come,as major hospitalization especially during emergencies often mean a huge financial burden onindividuals.

7.2%

14.4%2.2%

68.8%

2.0%3.0% 1.4%

2.4%

Sources of Finance in Health Sector in

India

Central Government State Government

33%

26%

19%

18%4%

Composition of World health

expenditures

General Social Insurance Private Insurance


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3. Risk Pooling - Health Insurance

With rising health care costs, risk pooling by health insurance is one of the significant modes of

optimizing efficiency of health care financing and delivery. Health Insurance is still in its infancy, with

a current meager coverage of approximately 2% in India.

Evolution of Health Insurance in India

1850

Triton Insurance Company Ltd., the first general insurance company established in Calcutta by the British-Advent of General insurance business in India

1907

The Indian Mercantile Insurance Ltd. set up, the first company to transact all c lasses of general insurance

business.

1938Insurance Act,1938 for effective control over the activit ies of insurers

1957

General Insurance Council, a wing of the Insurance Association of India, formed & framed a code of conduct forensuring fair conduct and sound business practices.

1968

The Insurance Act amended to regulate investments and set minimum solvency margins and the Tariff Advisory

Committee set up.

1971General Insurance Corporation(GIC) incorporated as a company and commence its business on 1st Jan,1973

1972-

73

The General Insurance Business (Nationalization) Act, 1972 nationalized general insurance business with effectfrom 1st January 1973. 107 insurers grouped into four companies viz. the National Insurance Company Ltd., the

New India Assurance Company Ltd., the Oriental Insurance Company Ltd. and the United India InsuranceCompany Ltd.

1986Introduction of first mediclaim Insurance Scheme by GIC

1993

Malhotra Committee Set up to propose recommendations for reforms to complement the reforms initiated in

the financial sector

1994

Malhotra Committee recommended that Govt stake in insurance companies to be brought down

Pvt companies be permitted to enter the insurance industry

Foreign companies be allowed to enter by f loating Indian companies in a joint venture

1999-

2000

Insurance Regulatory and Development Authority (IRDA) constituted as an autonomous body on

recommendations of Malhotra Committee and incorporated as a statutory body in April, 2000


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Functioning of Health Insurance in India, the flow of finances and services has been depicted the

exhibit below.

The coverage of health insurance has been gaining ground in India since its evolution d but the

growth trajectory in terms of population covered has been quite gradual. 17 out of 1000 hospitalisedcases are reimbursed as of now. This can be further bifurcated as 7 in rural and 39 in urban per

1000 cases, as per NSSO 60th Round Morbidity, Health Care and Condition of the Aged (Report

507, 2006).

0

5

10

15

20

25

30

0

100200

300

400500

600700

800

900

1000

Health Insurance

0.10% 0.17%0.20%

0.30%0.46%

0.80%1%

1.55%

2.20%

0.00%

0.50%

1.00%

1.50%

2.00%

2.50%

Percentage of Population Covered


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Types of Health Insurance in India

I.

Voluntary health insurance is provided by all insurance companies in India - both public and

private companies. Buyers pay premium to an insurance company that pools people with

similar risks and insures them for health expenses. The premium is set at a level, which

provides a profit to third party and provider institutions and they are based on an assessment

of the risk status of the consumer and the level of benefits provided.

Voluntary health insurance schemes or for-profit schemes

Since last few years the health insurance market in India has been growing somewhat

rapidly. Not only the premiums collected by the insurance companies have been growing but

also the coverage of population has increased but not to those levels that promises

universal coverage.

The premiums of health portfolio has increased by 55% (year on year) in 2006-07. The

reasons for this growth have been increased awareness and knowledge amongst the

consumers. With more stand alone health insurance coming up the focus on healthinsurance is increasing. So it is expected that the industry will bring more innovative health

insurance products which will push further the coverage of health risks. .

II.

o Employee State Insurance Scheme or ESIS

Mandatory Social Health Insurance Schemes or government run schemes

o Central Government Health Scheme or CGHS

o Universal Health Insurance (UHI) scheme

Employee State

Insurance Scheme

The Employee State Insurance Scheme (ESIS) is a social insurance

scheme which provides protection to employees against loss of

wages due to inability to work due to sickness, maternity, disability

and death due to employment injury. It offers cash benefits,

preventive care and health education. Medical care is also provided

to employees and their family members without fee for service.

The monthly wage limit for enrolment in the ESIS is under

Rs.10,000, with a prepayment contribution in the form of a payroll

tax of 1.75% by employees, 4.75% of employees' wages to be paid

by the employers, and 12.5% of the total expenses are borne by the


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state governments, with total expenditure of Rs. 1,27,896 Lakhs.

Central Government

Health Scheme

This scheme entitles Central Government employees medical

facilities for which comprehensive provisions are contained in

Central Services (Medical Attendance) Rules 1944. Presently, it

covers employees in 30 cities including almost all state capitals,

with more than 4,32,000 beneficiaries.

Benefits offered include all outpatient care preventive and

promotive care in dispensaries. Inpatient facilities in governmenthospitals and approved private hospitals are also covered.

This scheme is mainly funded through Central Government funds,

and a very small premium is collected from employees.

Insurance offered by

NGOs / communitybased health

insurance

There are 20 documented Community Health Insurance (CHI)

schemes in India. The members prepay a set amount each year forspecified services. The premiums are usually flat rate (not income-

related) and therefore not progressive. The purpose of these funds

is improving access to services rather than making profit. Quite

often there is a problem with adverse selection because of a large

number of high-risk members as premiums are not based on

assessment of individual risk status. Typically targeted at poorer

populations living in communities, in which they are involved in

defining contribution level and collecting mechanisms, defining the

content of the benefit package, and/or allocating the schemes,

financial resources. These are generally run by trust hospitals or

nongovernmental organizations (NGOs).

The schemes that are normally on offer are group insurance

schemes and not much of an encouragement is found to cover

individuals for obvious reasons.


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Coverage under Various Insurance Schemes

Critical Issues in Health Insurance

There are many crucial issues associated with health insurance both from the supplier or insurers

side as well as from the demand or the insured individuals side. The consequences faced and the

possible corrective measures have been discussed in detail below:

Issues Consequences Corrective Measures

Supply side (Risk posed by Insurers)

Supplier induced demand Increased demand by patients.

Raises costs of care

User provider payment like

capitation, pre-payment, case

payment etc

Risk Selection (Skimming) No insurance for sick, poor and

elderly

Open enrolment, Community

rating, Risk adjusted premiums

for individuals

17.6

4.4

35.5

30.0

0.7

Lives Covered (Millions)

Voluntary health insurance CGHS (Centre Government Health Scheme)

ESIS (Employee State Insurance Scheme) Community Based Insurance

Micro Insurance


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Demand side (Risk posed by

the insured)

Moral Hazard

Over-use of services by patients Deductible, Co-insurance, Co-

payments, Gatekeepers

Adverse SelectionLittle risk pooling.

Insurance market to be

adversely affected

Tax subsidy, Group Coverage

Under-utilization of healthcareservices

Under use of health services

due to lumpy costs, mainly by

the poor and also for preventive

care

Education and awareness, Free

or subsidized care, networking

with hospital through TPAs to

facilitate cashless hospitalization


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D. Issues in Healthcare Financing

Certain crucial concerns associated with healthcare financing affect the accessibility to

healthcare in India. The issues that need to be addressed are enumerated below:

a) Health Insurance coverage

Health Insurance has been able to cover less than 2% of population in India as of now. A

better coverage can play an important role in addressing the societal burden of financial

catastrophe that many Indians face when facing health problems.

b) Private Financing primarily out-of-pocket spending

More than 78% of the population still meets the healthcare costs from their own resources -

94% of this being out-of-pocket.

c) People spending a lot even while accessing services from public providers

Studies reveal that people especially the vulnerable individuals end up spending more thanthe required fee-for-service, even while accessing services from public providers, which

might be primarily due to improper mobilization of the available limited resources.

d) Low awareness

Low awareness level about health financing mechanisms such as insurance, financing

options, available products, role of TPAs, associated organizations etc contribute to a

considerable extent to the problem of inadequate coverage. Even in terms of existingschemes in the organized sector, there is the phenomenon of information inadequate

information amongst the vast majority of the population. Community financing schemes

usually require training and education of all those involved.

e) Lower Outreach

Outreach of financing options as well as their modes has not been very significant, taking

into account the vast differentiated population across the geography of the country.

f) Insurance Malpractices

Malpratice in insurance pertains to unfair trade practices, faulty claims, overcharged bills etc.

g) No other financing option


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E. Medical Requirements of the Population

Health care embraces all the goods and services designed to promote health, including preventive,curative and palliative interventions, whether directed to individuals or to populations. The various

services and their modes are described in detail below.

1. Tertiary care, Critical care, trauma care

This level offers super-specialist care, provided by regional or central level institutions. This

is largely covered by most insurance products with certain selective clauses.

Tertiary care is provided by many large Government and Charitable Hospitals spread across

the country. Though these hospitals mostly provide services at highly subsidized rates, but

the cost of medicines and consumables is mostly borne by the patient, which is often very

high and unaffordable by many.

2. Secondary Care, Maternity, Geriatric Care, Pre and Post Natal care

Tertiary care, Criticalcare, trauma care

SecondaryCare, Maternity, Geriatric

Care, Pre andPost Natal care

Primary care, Pharmacy, Diagnostics, MedicalTransport

Nutrition, Safety Sanitation, Hygine


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Most of the deliveries in India take place in houses by untrained people (Dai) rather than in

hospitals or by trained medical personal. One of the reasons for that is affordability and

accessibility of medical services. The current public infrastructure is unable to reach

everywhere and cater everyone with its limited infrastructure and at the same place private

healthcare facilities cannot be afforded by all.

3. Primary care, Pharmacy, Diagnostics, Medical Transport

These are the first levels of contact between individual and the health system where

essential healthcare is provided. A majority of prevailing health complaints and problemscan be satisfactorily dealt with at this level. This level of care is closest to the people and

basically represents outpatient clinical care by general physicians. In the Indian context, this

care is provided by the primary health centers and their sub-centers, in the government

sector and by general physicians and clinics in the private sector.

In todays insurance regime, the out patient services are not covered largely and so primary

care is mostly out of pocket except for certain employees whose employers cover the cost as

reimbursement, though this is still considered as part of the employees overall remuneration.

Mostly the cost of medicines is paid by the patient from pocket. This gives rise to the practice

of self purchase without prescription and is expected to change if medicines get covered by

insurance or some other mechanism. The patients then buy them only with prescription, to

get the reimbursement / availing coverage.

As in primary care and pharmacy coverage, the diagnostics segment also does not getcovered by any insurance mechanism except being taken care of by some employers

providing for reimbursement.

4. Nutrition, Safety, Sanitation, Hygiene

The Indian government has focused increasingly on improving the nutrition safety and

sanitation standards for the majority of the population.


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F. Newer Health Financing Options

Appropriate and sustainable financing mechanism with a multi-pronged approach to alternative

options in financing are required, as insurance coverage alone is not always sufficient to ensure

healthcare accessibility, in a country like India with varying geographical, demographical,

infrastructural and epidemiological patterns. Different possible financing options that can be

feasibly used in India are:

1. Health Savings Account

2. Risk pooling - Insurance

3. Capitation and other provider risk sharing4. Borrowing

5. Government grants

1. Health Savings Account

Around 78% people pay their medical bills from out of their own pockets in a way comes from

either savings or borrowers. A way to get people to invest in their health by a mandatory Health

Savings Account for Employees might be helpful.

The Mechanism of HSA

HAS accounts should be similar to the PPF (Public Provident Fund) accounts. The salary of an

provident fund employee will have a deduction similar to deduction an amount equal to the

employees contribution should be contributed by the employer.

The accounts and the contributions are to be handled by a trust or a central organization which

also shall take care of the application part of the process.

The deposits to Health Savings Account would be totally tax free. The depositor will be able to

use the money in the account for certain stated needs - medical needs of persons covered (self

and members of the family).

The deductions from the salary can be put at anywhere between 5-10% of their basic salary and

an equal contribution will come from the employer.

In case of the self employed and professionals, the contributions will be paid by them individuallyto the account such contributions will be.

Funds deposited in the HSA by individuals or employees shall be completely free of any tax and

a higher interest should be given on it.

U f HSA F d


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Whether medical savings accounts would be mandatory and universal (Singapore) or

private and voluntary (US).

Whether universal MSAs would be funded by payroll contributions (Singapore) orthrough general tax revenue allocated by the government to individual accounts (and if

so, how the allocations would be made).

What restrictions there would be on eligible expenses and whether/how to use

deductibles and co-payments to ensure fiscal solvency and to further restrain demand

(as in Singapore).

Whether MSA funds would be managed centrally (as in Singapore) or by private fund

managers.

Funding Vehicles

The Funding Vehicles for this could be

1. Banks

2. Post offices

3. Public Provident Fund Organisation

2. Risk Pooling Insurance & Capitation

Funding of healthcare by risk pooling is done through Health Insurance and Capitation.

Health Insurance

Both Public and Private Companies provide Voluntary Health Insurance. Buyers pay premium to

an insurance company that pools people with similar risks and insures them for health expenses.Premium is set at a level, which provides a profit to third party and provider institutions and is

based on an assessment of the risk status of the consumer and the level of benefits provided.

Capitation and other provider risk sharing

Capitation is defined a fixed sum per person paid in advance of the coverage period to a

healthcare entity in consideration of its providing, or arranging to provide, contracted healthcare

services to the eligible person for the specified period.

For example, a hospital may receive a capitation premium per month for every member of a

particular health plan. In return for this capitation (or per capita rate), the hospital agrees to

provide hospital services to all members of that health plan, regardless of what the actual cost of

these services ends up being.


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structure, the Prefered Provider Organisation insurance company assumes and retains all

insurance risk. The healthcare providers are paid on a fee-for service basis, typically pre-

negotiated at a discount off of normal charges, The providers bear little risk except for the fact

that they have agreed to receive lower rates in the hopes that their volume of business will

increase.

In a staff model Health Maintenance Organisation (HMO), the healthcare providers assume no

insurance risk. Under this model, healthcare providers are employees (staff) of the HMO. The

HMO collects a fixed premium per member in return for a promise to provide healthcare services

to those members. The HMO assumes and retains all insurance risk.

Funding Vehicles

The Funding Vehicles for this could be Health Management Organisations etc.

3. Borrowing

In India, many people who cannot afford the ever-increasing costs of extended hospitalisation,medical tests, surgeries etc. borrow money from friends and relatives, as this seems to be the

only way to ensure that the care for themselves or their families is not compromised at the time

of need.

According to NSSO 60th Round survey, 308 individuals in every 1000 hospitalized, funds their

hospitalization through borrowing. An estimated 3.3% of the population is estimated to be getting

pushed below poverty line on account of medical treatment. The interest rates in India are so

high that most people cannot take loan for their illness and repay it.

We need to have a system of Health Benefit Loans at much lower interest rates than personal

loans. There could be various tax benefits attached the loan.

Funding Vehicles:

1. Banks

2. Post offices

4. Government grants and Subsidies

With more than 25 % of the population living under poverty line the government has to intervene


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Utilization of these funds:

i. In creating healthcare infrastructure (Government Hospitals)

ii. Funding for in hospital cure and care of the Below poverty line hospitals.

Few Government initiatives are already available and in place to pool the risks of these

population, of which few important ones are enumerated below:

Rashtriya Swasthaya Bima Yojna is a Central Government scheme, a health insurance for the

Below Poverty Line (BPL) families in the unorganized sector. It was formally launched onOctober 1, 2007. The objective of RSBY is to provide the insurance cover to below poverty line

(BPL) households from major health shocks that involve hospitalization.

Rashtriya Swasthaya Bima Yojna (RSBY)

The majority of the financing, about 75 per cent, is provided by the Government of India (GOI),

while the remainder is paid by the state government. State governments engage in a competitive

bidding process and select a public or private insurance company licensed to provide health

insurance by the Insurance Regulatory Development Authority (IRDA).

National Rural Health insurance programme is also specifically aimed for the BPL families.

National Rural Health Mission

Aarogyasri is a Community Health Insurance scheme implemented in Andhra Pradesh. The

scheme provides financial protection to families living below poverty line up to Rs. 2 lakhs in a

year for the treatment of serious ailments requiring hospitalization and surgery.

Aarogyasri

Healthcare Needs and Sources of Fund

Tertiary

care, Critical

care, trauma care

Secondary

Care, Maternity,

Geriatric Care, PreandPost Natal care

P i Ph

Savings, Borrowings, Insurance

Savings, Borrowing, Insurance

Fundin Sources


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image of health insurance. Thereby they need to be educated on how to choose the

right product/service, importance of age factor and the understanding of exclusions

and claims process.

b. Communication needs to focus also on providing clarity of products / services,

grievance re-dressal system.

c. Public awareness campaigns needs to be undertaken by government and non-

government organizations through print and electronic media.


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H. Conclusion

India is a large country with huge population and immense diversity. It makes it very difficult to cover

everyone under one scheme. One scheme like health insurance may not be the best way to cover

this huge population.

A Multi- Channel Healthcare Funding Model

I di d l i h l H l h f di h i d b i l d i I di A i f


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CII White Paper_Accesscibility