Study of Rashtriya Swasthya Bima Yojana Health Insurance in India Study conducted in Gujarat, India
WHO Reference no.
2011/126289-0
Project title
Study of Rashtriya Swasthya Bima Yojana (RSBY) Health Insurance in India Alliance for Health Policy and Systems Research (AHPSR),
Donor World Health Organisation (WHO) Dissemination level
1
Public
Study of Rashtriya Swasthya Bima Yojana Health insurance scheme in India
Abstract
The study assesses the impact of Rashtriya Swasthya Bima Yojana (RSBY) in Gujarat, India. RSBY is a national health insurance scheme launched by the Government of India in 2008, to enhance access to quality hospital care by families living below the poverty line (BPL). The impact of RSBY was measured with respect to its enrolment rates, effect on access to hospital care, and financial protection offered to BPL families. This study also attempts to understand the factors influencing these outcomes by describing issues related to performance, governance, and monitoring of the scheme via stakeholder analysis. This cross-sectional study was conducted in Patan District in Gujarat using both qualitative and quantitative methods. A household survey was conducted for 3,120 BPL households (17,420 members). A high enrolment rate of 94% among BPL households was noted; however, only 67% of the enrolled population was included in the card and the remaining were excluded for various reasons. The insured had a significantly high hospitalisation rate of 39/1000 compared to the non-insured population (16/1000) showing an improvement in access to hospital services. However, 85% of the insured patients despite using the scheme incurred varying degrees of out-of-pocket expenditure with a median US$125 (57, 269). Other insured and non-insured patients who did not use the scheme also incurred similar high expenditure with a median US$125 (49,313) and US$143 (54,483) respectively. To understand the context of RSBY in Gujarat and the study findings, a stakeholder analysis was conducted among stakeholders from government officials to service providers. This has identified key issues like inadequate, ineffective awareness campaigns, power inequity between stakeholders and poor governance of the scheme.
Keywords
Health insurance, BPL, RSBY, Rashtriya Swasthya Bima Yojana
Suggested
Seshadri T1, Trivedi M2 , Saxena D2, Nair R2, Soors W3, Criel B3, Devadasan N1
citation
1
Copyright
All rights reserved. No part of this material may be reproduced or transmitted in any
Institute of Public Health, Bangalore, India Indian Institute of Public Health, Gandhinagar, India 3 Institute of Tropical Medicine, Antwerp, Belgium 2
form or by any means, including photocopying and recording, without the written permission of the copyright holder, application for which should be addressed to the World Health Organisation India. Such written permission must also be obtained before any part of this material is stored in a retrieval system of any nature.
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Study of Rashtriya Swasthya Bima Yojana Health insurance scheme in India
Table of contents List of figures ............................................................................................................................... 5 List of tables ................................................................................................................................ 5 Chapter I: Background .................................................................................................................. 7 1.1 Health financing in India ............................................................................................................... 7 1.2 Rashtriya Swasthya Bima Yojana (National Health Insurance Scheme) ....................................... 8 1.3 Gujarat State, Patan District and RSBY ....................................................................................... 10 1.4 RSBY in Gujarat and Patan .......................................................................................................... 13 Chapter 2: The study .................................................................................................................. 14 2.1.
Background ........................................................................................................................... 14
2.2.
Study objectives .................................................................................................................... 14
2.3.
Methods, design and tools.................................................................................................... 14
2.3.1.
Design............................................................................................................................ 14
2.3.2.
Selection of district for study ........................................................................................ 15
2.3.3.
Household survey.......................................................................................................... 15
2.3.4.
Focus group discussions .................................................................................................... 15
2.3.5.
In-depth interviews ........................................................................................................... 16
2.3.6.
Study tools .................................................................................................................... 16
2.4.
Monitoring and quality control ............................................................................................. 16
2.5.
Data management ................................................................................................................ 17
2.6.
Ethics ..................................................................................................................................... 17
2.7.
Limitations of the study and implications ............................................................................. 17
2.8.
Dissemination of findings...................................................................................................... 18
Chapter 3: Results ...................................................................................................................... 19 3.1.
Household survey.................................................................................................................. 19
3.1.1.
Study population profile ............................................................................................... 19
3.1.2.
RSBY related details ...................................................................................................... 22
3.1.3.
Hospitalisation related details ...................................................................................... 25
3.1.4.
Utilisation of RSBY card/benefits .................................................................................. 26
3.2.
Qualitative methods ............................................................................................................. 31
3.2.1
Awareness about RSBY and card ...................................................................................... 31
3.2.2
Enrolment ......................................................................................................................... 33
Procedure ...................................................................................................................................... 33 Reasons for not enrolling .............................................................................................................. 33
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Study of Rashtriya Swasthya Bima Yojana Health insurance scheme in India
3.2.3
Utilisation of scheme/card ................................................................................................ 34
Interaction with service providers ................................................................................................ 34 Issues with the card ...................................................................................................................... 35 Out of pocket expenditure ............................................................................................................ 36 Services provided under RSBY ...................................................................................................... 36 3.2.4
Claims in RSBY ................................................................................................................... 37
3.2.5
Grievance redressal mechanism ....................................................................................... 39
3.2.6
Governance ....................................................................................................................... 41
Chapter 4: Conclusions ............................................................................................................... 44 I.
Population: who is covered and extent of coverage? .............................................................. 44
II.
Services: which services are covered? ...................................................................................... 45
III.
Direct costs: what proportion of the costs are covered? ..................................................... 46
IV.
Other significant cross-cutting issues: .................................................................................. 46
Competing interests ................................................................................................................... 47 Authors’ contributions ............................................................................................................... 47 Acknowledgements.................................................................................................................... 47 References................................................................................................................................. 47 Annexes..................................................................................................................................... 47
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Study of Rashtriya Swasthya Bima Yojana Health insurance scheme in India
List of figures Figure 1.Distribution of total health expenditure in India 2004-051 ...................................................... 7 Figure 2. Diagrammatic representation of the RSBY scheme ................................................................. 9 Figure 3. Gujarat State profile5,6 *Patan district has been marked ...................................................... 11 Figure 4. Map showing Patan District ................................................................................................... 12 Figure 5. Age-sex pyramid of study population (n=17,416*)................................................................ 20 Figure 6. Education attained - total and gender-wise (n=15,677) ........................................................ 20 Figure 7. Reason for availing loan (n=1,705) ........................................................................................ 22 Figure 8. Summary of households’ RSBY status** ................................................................................ 23 Figure 9. Insured status of RSBY cardholders** ................................................................................... 24 Figure 10. Age comparison of insured and not insured members (n=15,786) ..................................... 25 Figure 11. RSBY status of hospitalisations** ........................................................................................ 26 Figure 12. Utilisation of RSBY card/scheme .......................................................................................... 27 Figure 13. Type of treatment compared with RSBY status ................................................................... 29 Figure 14. RSBY enrolment rates for Gujarat State from 2008-12 ....................................................... 31 Figure 15. Grievance redressal mechanism in Gujarat ......................................................................... 40
List of tables Table 1. History of RSBY in Gujarat since 2008 ..................................................................................... 13 Table 2. Details of sampling households............................................................................................... 15 Table 3. Baseline characteristics of study population in comparison with Patan ................................ 19 Table 4. Common assets found in households ..................................................................................... 21 Table 5. Means of livelihood of household........................................................................................... 21 Table 6. Reasons stated for not enrolling in RSBY (n=197) .................................................................. 22 Table 7. Baseline characteristics of enrolled and not enrolled households (n=3117)*........................ 23 Table 8. Baseline characteristics of insured and not insured within cardholder households .............. 24 Table 9. Reasons stated for not insuring members within the household (n=4,766) .......................... 25 Table 10. Inpatient admission rate of the three groups ....................................................................... 26 Table 11. Profile of the hospitalised ..................................................................................................... 26 Table 12. Reasons given by insured members for not using the card (n=191) .................................... 27 Table 13. Utilisation rate of RSBY ......................................................................................................... 28 Table 14. Details of hospitalisation across groups ................................................................................ 28 Table 15.Hospital related out-of-pocket (OOP) expenditure of different groups ................................ 30 Table 16. OOP expenditure for hysterectomy, cataract surgery and pregnancy delivery ................... 30 Table 17. Action against suspended HOSPITALS IN Gujarat (till April 2011) ........................................ 41
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Study of Rashtriya Swasthya Bima Yojana Health insurance scheme in India
LIST OF ABBREVIATIONS AHPSR
Alliance for Health Policy and Systems Research
ANM
Auxiliary Nurse Midwife
ASHA
Accredited Social Health Activist
BPL
Below poverty line
CDHO
Chief District Health Officer
CHC
Community Health Centre
FGD
Focus group discussion
GDP
Gross Domestic Product
HH
Household
HHS
Household survey
IDI
In-depth interview
IPH
Institute of Public Health, Bangalore, Karnataka, India
IIPHG
Indian Institute of Public Health, Gandhinagar, Gujarat, India
ITM
Institute of Tropical Medicine, Antwerp, Belgium
MNREGS
Mahatma Gandhi National Rural Employment Guarantee Scheme
NGO
Non-governmental organisation
NRHM
National Rural Health Mission
OOP
Out-of-pocket
PHC
Primary Health Centre
RSBY
Rashtriya Swasthya Bima Yojana
SC
Sub-centres
TPA
Third party administrator
WHO
World Health Organisation
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Study of Rashtriya Swasthya Bima Yojana Health insurance scheme in India
Chapter I: Background
1.1 Health financing in India In India, the Central, State and local governments together contribute only 20% of the total health expenditure while 71% of the total is contributed by individual households through out-of-pocket (OOP) expenditure at the time of illness. This high level of OOP expenditure by individual households is one of the highest amongst low and middle income countries, thus ranking India low in terms of financial protection. Figure 1.Distribution of total health expenditure in India 2004-051 External flow 2%
Public expenditure 20%
Private expenditure 78%
In India, the government acts as both a financer as well as a provider of health care. Households are expected to seek care in the grossly underfunded network of public health services. The government spends only US$ 5 per person per year on health care. Not surprisingly, the patients shift from these dysfunctional public health services to private health services for their care. Studies show that about 72% of outpatient care and about 40-60% of inpatient care is sought from the private health sector (2). This has obvious implications for the patient community. Between 1995-2004, serial NSSO morbidity and health care utilisation surveys show that the absolute expenditure per outpatient and inpatient visit has increased in both urban and rural areas.(1) About 6% of patients who require hospitalisation do not seek health care because they cannot afford it (3). Among those who seek hospital care, about 2540% of patients have to borrow or sell their assets to meet their medical expenses. Van Doorslaer estimates that about 2 – 3% of Indians are impoverished every year because of health care expenditure (4). Some authors have called this ‘iatrogenic poverty’ (5). All these figures are aggregate, the picture is worse if one disaggregates along the divides of urban/rural; male/female; upper/lower quintile; upper/lower caste, etc. A recent study done using the unit level data from NSSO 2004 survey data has estimated that around 63.22 million individuals or 11.88 million households were pushed below the
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Study of Rashtriya Swasthya Bima Yojana Health insurance scheme in India
poverty line (BPL) due to healthcare expenditure in 20041. The Indian health system is thus characterised by large inequities between communities and within them. Thus, in order to achieve an equitable health system and move towards universal health coverage in India, there is an urgent need to reduce the OOP expenditure on health services. The government has recognised this problem and has introduced various measures to solve it. One step was to increase the budgetary allocations for health care. The National Rural Health Mission (NRHM) promises to increase the government spending on health care from the current 0.9% of GDP to 3% of GDP (6) though currently its stands at 1.1% GDP. States also are in the process of adopting new financing mechanisms. In recent years, both Central and States governments have introduced various demand side financing mechanisms to provide financial protection to vulnerable sections of the community. Health insurance schemes like the Universal Health Insurance Scheme launched by the Ministry of Finance in 2003, the Sanjeevani Scheme launched by the Punjab Government in 2005 and the Chief Minister’s health insurance scheme launched by the Assam Government in 2004 are some examples (7). However some of them have been discontinued because of poor design features.
1.2 Rashtriya Swasthya Bima Yojana (National Health Insurance Scheme) The Ministry of Labour and Employment launched the Rashtriya Swasthya Bima Yojana (RSBY) for the poor (BPL) families of India. This National Health Insurance Scheme was launched in April 2008 and as of April 2012; the scheme is being functioning in twenty five of the twenty eight states. Around 28.6 million households have been enrolled across the country and around 3.4 million people have benefitted so far. Today more than 10,000 hospitals have been empanelled in the scheme and thirteen Insurance Companies (both public and private sector) implement the scheme.2 Design: This scheme is strongly subsidised with public funds coming from both Central and State governments (75% of the premium is paid by the Central government and 25% by the State government). A nominal yearly adherence fee of 30 Rs (approx. US$ 0.5)) per family of five is paid by the BPL household itself. A summary of the design of RSBY is provided in the figure below.
1
Berman P, Ahuja R, Bhandari L. The impoverishing effect of healthcare payments in India: new methodology and findings. EPW: Vol XLV no 16; Apr 17 2010. 2 Nishant presentation
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Study of Rashtriya Swasthya Bima Yojana Health insurance scheme in India
Figure 2. Diagrammatic representation of the RSBY scheme3 Central Centralgovernment government Premium – 75% Insurance Insurancecompany company Premium – 25%
Re gi st ra tio n
fe e
–
Rs
30
State Stategovernment government
Hospitalisation expenses Select day care procedures Max – 30,000 – family floater Transportation costs Max 100 per trip and totally 1000 Pre-hospitalisation (1 day) & Posthospitalisation (5 days) expenses Minimum exclusions
BPL BPLfamilies families
CARE
s im Cla nt & eme ) rs bu t card m i Re smar (
Public Publicand andPrivate Private Providers Providers
Actors and their role in the scheme: •
Beneficiaries: Initially the scheme targeted BPL population alone. Now it has started expanding its coverage to include other occupational groups. Beneficiaries of the MNREGS 4 scheme, domestic workers, auto-rickshaw drivers, etc. Beneficiaries are expected to enrol in the scheme by paying Rs.30 (approx. US$ 0.5) per family (for five members) for a year, receive a smart card, and then use the benefits when hospitalized in empanelled hospitals.
•
Non-governmental organisations (NGO): NGOs are expected to create awareness among the community esp. the eligible groups about RSBY and mobilize them for enrolment.
•
Insurance Companies (both private and public sector companies): The companies compete with each other for covering the eligible families in each State. The company with the lowest bid gets the contract for implementing the scheme in that specific State. Once selected, the company has to appoint smart card agencies, work closely with the State government’s Nodal Agency to identify the eligible households, empanel hospitals and contract NGOs to create awareness in the community.
•
Third Party administrators (TPA): These are private agencies that help the Insurance Company in implementing the scheme in the field level.
•
Smart Card Providers. They provide the technology for this scheme.
3
Source: N. Devadasan et al. Rashtriya Swasthya Bima Yojana: an overview. IRDA journal (2008)
4
MNREGS expand
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Study of Rashtriya Swasthya Bima Yojana Health insurance scheme in India
•
Empanelled hospitals (both public and private): Once empanelled by the Insurance Company, they provide the necessary services to the RSBY beneficiaries. Their services are reimbursed by the Insurance Company via TPAs or directly.
•
State government Nodal Agency (SNA): It is an independent body formed by the Government which acts as the focal point for governing the programme. In most States, it is led by the Department of Labour while in some it is the Department of Health & Family Welfare. It initiates the process of introducing the scheme in the State, negotiates with the insurance company and monitors the enrolment and the utilization. The State contributes 25% of the premium through this agency.
•
Central government. The Ministry of Labour and Employment launched the scheme and its main responsibility is to develop technical and administrative guidelines and market the scheme to the State governments. The Central government contributes 75% of the premium to the Insurance Company through the Ministry.
The RSBY, along with the NRHM, is a flagship programme of the Central government to increase the breadth, depth and height of coverage so that ultimately universal health coverage is achieved (8). By systematically focussing on the poor, it attempts to cover all BPL families within a period of five years by increasing the breadth of coverage. At the same time, by covering over thousand hospitalisation packages, RSBY aims to protect the poor from major health shocks and hence the depth of coverage is expanded systematically. Finally by introducing a cashless mechanism through a “smart card”, the height of coverage is also enhanced as the poor will not have to pay out of their pocket at the time of hospitalisation. The RSBY is an excellent attempt of the Government of India at moving towards universal health coverage by providing social protection in health for the vulnerable and poor 300 million in India. Hence, RSBY was chosen for studying in this project. This also provided an excellent opportunity to provide feedback to policy makers and managers of this scheme, to help strengthen it and help the poor benefit from the government largesse. The scale of RSBY, its clear social purpose, as well as its innovative design - the existence of important public subsidies, the possibility to empanel public and private hospitals, the option to involve public as well as private insurers, the use of high level information technology, etc. - make the scheme a tremendous learning opportunity for social policymakers in India and all over the world. The potential contribution to enrich the existing body of knowledge in the field of strategies to achieve universal coverage is considerable.
1.3 Gujarat State, Patan District and RSBY
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Study of Rashtriya Swasthya Bima Yojana Health insurance scheme in India
The State: Gujarat, also known as the Land of the
Figure 3. Gujarat State profile5,6 *Patan district has been marked
Legends, is situated in west India, and stands bordered by Pakistan and Rajasthan in the north, Madhya Pradesh in the east, and Maharashtra and the Union territories of Diu, Daman, Dadra and Nagar Haveli in the south. The Arabian Sea borders the state both to the west and the south west.56 The State is divided in to 26 districts and has a strong cultural identity. According to Census 2001, 7% of population belong to Scheduled Caste (SC)7 while 15% belongs to Scheduled Tribes (ST). The sex ratio is 918 females per 1000 males (Census 2011) which is low when compared to 933 for the country but the urban sex ratio is only 880 an outcome of the strong patriarchal beliefs in the State.
Area: 196,024 sq. km
Coming to a few important health indicators, the Infant
Population: 60,383,628 (Census 2011)
Mortality Rate is 31 per thousand live births (2010) and
Capital: Gandhinagar
Maternal Mortality Ratio is 160 per one hundred
No. of districts: 26
thousand live births (SRS 2004 - 06) which are lower
Principal language: Gujarati
than the national averages.
Literacy rate: 79.31% (Census 2011)
The District: Patan District is situated at north of
Ecosystem: Ranges from deserts,
Gujarat. Created in 1998, it has a total population of
scrublands, grasslands, and deciduous
1,342,746 (Census 2011). It is bound by Banaskantha
forests, wetlands to mangroves, coral
District in the north and north-west, Kutch District in
reefs, estuaries, and gulfs.
West, Desert of Kutch and Surendranagar in the south and south-east, with Mehsana District in the east. Administratively, it has been distributed across 7 sub-divisions called Taluks namely, Patan, Santalpur, Radhanpur, Siddhpur, Harij, Sami and Chanasma. Key demographic indicators have been listed in the table below in comparison to the State. Table 1. Demographic profile of Patan District Indicators (2011 Census)
Patan
Gujarat
Total population
13,42,746
6,03,83,628
Sex ratio
935/1000
918/1000
5
Source: Map of India showing Patan district in Gujarat State. Wikimedia commons. Created by User:Haros. 2 Nov 2008 6 Government of Gujarat. Gujarat fact file – Official State website. 2009. Available at URL: www.gujaratindia.com/about-gujarat/fact-file.htm 7 What is SC and ST
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Study of Rashtriya Swasthya Bima Yojana Health insurance scheme in India
Female literacy
62 %
70%
Rural proportion
78.7%
57.4%
BPL Households (HH)- RSBY 2011-12
1,18, 473
36,39,364
44,215
11,87,729
Proportion BPL population (DLHS3)
31.1%
31.9%
SC (2001)
9.9%
7.1%
ST (2001)
1.1%
14.8%
Median household (HH) size
5
5
- 2002 RDPR
The State Human Development Report 2005 revealed important information about the district. Patan is in the northern arid region in Gujarat and badly environmentally depleted resulting in poor growth and human development. It has a large population of socially and economically backward castes, a strong patriarchal society and ranks 20 (out of 25) in terms of Human Development Measures and Human Development Index. It ranks 22 (out of 25) for Gender Equality Index (GEI) and ranks 23 in health specific GEI i.e. the third worst in the State. Figure 4. Map showing Patan District
Source: Wikimedia commons/user: Miljoshi
Health related: Patan has one District hospital in Patan (currently being upgraded into a Medical College) and a sub-District hospital in Siddhpur. It has 11 CHCs (2 FRU), 32 PHCs (3 24x7), and 210 sub centres. Patan also has well established private sector hospitals and clinics. A private gynaecologist from Patan holds a place in the Limca book of records (2003) for conducting the largest number of hysterectomies (66) in 22 hours!
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Study of Rashtriya Swasthya Bima Yojana Health insurance scheme in India
1.4 RSBY in Gujarat and Patan RSBY was launched in Gujarat State in 2008-09 in five districts as namely, Bharuch, Dahod, Jamnagar, Kutch and Patan. Since then in a phase wise manner, the scheme was extended to the remaining districts. By 2010-11, all 26 districts were covered while this year in 2011-12, it has been extended to urban population as well. There are three Insurance Companies involved in RSBY in Gujarat namely, Oriental Insurance, Cholamandalam MS General Insurance and ICICI Lombard General Insurance Companies. Today there are over 1500 empanelled hospitals across the State, with 1134 in private and 432 in public sector. Table 2. History of RSBY in Gujarat since 2008 Policy Year No. of Beneficiaries year districts (BPL) 1 2008-09 5 Rural
Total no. of households 566,000
No. of enrolled households 314,000
Enrolment rate 55.5%
2
2009-10
10
Rural
566,000
342,000
60.4%
3
2010-11
26
Rural
2,969,000
1,910,000
64.3%
4
2011-12
26
Rural & urban
3,884,000
1,971,000
50.7%
Gujarat is considered to be one of the best performing States in India for implementation of RSBY. It is one of the pioneer States to develop a grievance redressal and fraud management system (explained later). Despite this, the current enrolment rate is only 50.2% in its fourth year of implementation. Recently the Ministry of Labour and Employment launched an outpatient experiment in partnership with Micro Insurance Innovation Facility, International Labour Organisation, Geneva and other external partners. This outpatient initiative was launched in two districts in India namely Puri in Orissa and Mehsana in Gujarat. This is an attempt of RSBY to tackle the main cause of OOP expenditure – expenditure on outpatient services. Patan was one of the first districts in Gujarat where RSBY was launched. In its fourth year today, the enrolment rate is only 45.3% with 64 private and 17 public hospitals empanelled. There is no separate TPA or Smart Card Provider as the Insurance Company also fulfils both these functions. In its previous year, the admission rate was high at 3.5% in 2010 and claims ratio was high at 144%.
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Study of Rashtriya Swasthya Bima Yojana Health insurance scheme in India
Chapter 2: The study
Background
2.1.
The Institute of Public Health, (IPH) Bangalore, India conducted this study in partnership with Institute of Tropical Medicine, (ITM) Antwerp and Indian Institute of Public Health Gandhinagar (IIPHG), India. Study duration: February 2011- June 2012 Donor: Alliance for Health Policy and Systems Research (AHPSR), World Health Organisation (WHO)
Study objectives
2.2.
1. To study the impact of RSBY in Patan District of Gujarat State in terms of enrolment rates, access to quality hospital care and financial protection. The specific objectives are: a. To study the enrolment rate in Patan District, disaggregated by some determinants like economic status, caste, religion, household size, location, etc.; b.
To study the admission rates in Patan District, disaggregated by insurance status and other relevant determinants;
c. To study the extent of OOP payments, catastrophic health expenditure and impoverishment in Patan District, disaggregated by insurance status and other relevant determinants; and d. To study the patient’s perception on quality of hospital care received, disaggregated by insurance status and other relevant determinants. 2. To list and understand the issues with governance, enrolment, utilisation and monitoring of the scheme. The specific objectives are: a. To identify the stakeholders involved with governance of the scheme and document their understanding about the RSBY in Patan District; b. To understand reasons for non-enrolment among the eligible families; c. To understand reasons for the low utilisation of hospital services by insured members; and d. To identify the key indicators monitored by the State and District nodal agencies, thereby giving an insight into the focus of the governing body.
2.3.
Methods, design and tools
2.3.1. Design The study involved both quantitative and qualitative methods of data collection and analysis. It is observational and retrospective in nature. Since there were two dimensions that were being studied, two distinct methodologies were used for each.
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Study of Rashtriya Swasthya Bima Yojana Health insurance scheme in India
•
To measure enrolment status, utilisation and out-of-pocket expenditure, a household survey was conducted.
•
To explore and understand how and why the findings occurred, qualitative methods were used.
2.3.2. Selection of district for study By September 2010, there were 9 districts in Gujarat where RSBY had been implemented. Patan was one of four districts that had completed two years of implementation of RSBY. Kutch and Patan districts had enrolment rates of around 53%; but Patan District had a higher inpatient admission rate. In addition within Gujarat, Patan District had an average Human Development Index (HDI) and hence, was more representative of the State. Hence, Patan District was selected with a higher chance of getting households that were enrolled and that had utilised the scheme, thus enhancing the power of study and validity of results. 2.3.3. Household survey A cross-sectional household survey was conducted among 3,120 households in Patan District between June–August 2011. Households were selected from the list of RSBY eligible BPL households for the year 2010-2011. This list was availed from the State Nodal Office, RSBY Gujarat. Sample size estimation: Considering an admission rate of 3.5% for the insured and 2.5% for the uninsured households, a sample size of 2000 households was estimated with 80% power and 95% confidence interval. Expecting a 50% enrolment rate, a total number of 3000 households was reached for the survey. Table 3. Details of sampling households Total no. of villages No. of villages selected Total no. of households
Taluk Patan
135
20
810
Siddhpur
55
8
330
Santalpur
73
11
438
Radhanpur
56
8
336
Harij
39
6
234
Sami
100
15
600
59
9
354
517
78
3120
Chanasma Total
Administratively, Patan District is divided into seven sub-divisions called Taluks in Gujarat. A multistage sampling technique was used for sampling. The households were first stratified into seven taluks proportionately based on the population size. Next within each taluk, fifteen percent of the villages were selected. With a total of 517 revenue villages, data was collected from randomly selected sample
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Study of Rashtriya Swasthya Bima Yojana Health insurance scheme in India
of 78 villages/clusters. Finally in each village, around 40 households were selected randomly from the BPL list provided. If 40 households were not found in the selected village, then the adjacent village was included in the cluster. Further details can be found in Table 1 2.3.4. Focus group discussions Focus group discussions (FGD) were conducted among RSBY eligible BPL population among the sampled villages. Separate FGD were conducted for RSBY enrolled and RSBY not enrolled BPL people. Two FGDs (one each for enrolled and not enrolled) were conducted in was taluk. Villages in each taluk that reported highest and lowest enrolment rates in the survey were selected for these discussions. FGDs were conducted in all seven taluks in Patan District. A total of 14 FGDs were conducted with an average 12 participants (7 male: 5 female). The main objectives of the FGDs were to gain insight into the findings of the quantitative survey particularly regarding enrolment and utilisation, and also the grievance redressal mechanism in the community. 2.3.5. In-depth interviews In-depth interviews (IDI) were conducted for stakeholders of RSBY apart from the community. The stakeholders interviewed have been mentioned below: a. Service providers i.e. doctors from both public and private sector in Patan – 6 interviews b. Officers responsible for implementing RSBY from both Patan District and the State Nodal Agency – 4 interviews c. Officials responsible for administrating government hospitals – 2 interviews Patan has one agency that operates as Insurance Company, Third party administrator (TPA), and Smart card provider. Despite several rounds of requests, the research team were not able to interview any representative from this agency. 2.3.6. Study tools The tools used for the different methods have been enclosed in Annexure. a. A structured standardised questionnaire for the household survey b. Topic guides/checklists for FGDs – separate for enrolled beneficiaries and not enrolled BPL c. Topic guides/checklists for interviews – separate formats were created for each stakeholder
2.4.
Monitoring and quality control
A team of ten research associates were recruited and trained at IIPHG for conducting the survey. Data collection was cross-checked by two supervisors who validated 10% of the filled questionnaires in the field itself. A team member from the research team monitored the field survey. The questionnaires
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Study of Rashtriya Swasthya Bima Yojana Health insurance scheme in India
were pre-tested in two villages prior to the survey and to ensure standardisation in administering and supervising the survey.
2.5.
Data management
For quantitative data, a data entry programme was developed using front screen data entry software – Epi info. A Unique ID code was allotted for each household questionnaire during the data entry to help check the quality and duplications. Data was thoroughly cleaned with the help of STATA software and then shared with IPH team. Analysis was done using Epi info and STATA software keeping three dimensions in mind namely, different in enrolment, utilisation of scheme and out-ofpocket expenditure. For qualitative data, each of the FGD and IDI was recorded and transcribed verbatim first in the vernacular language by the interviewers themselves and then translated to English. The audio recordings (as Audio Cassettes) and the transcriptions (in hard and soft copies) were preserved. Once transcribed, these were cross-checked with written notes taken to ensure that no context is missing. Independent coding of the responses using Atlas TI software was undertaken by trained researchers. Coding and analysis was done by both IPH and IIPHG researchers, and was based on main, subresearch questions and the themes that emerged from the interviews.
2.6.
Ethics
The study received ethical clearance from the WHO Ethical review board once in 2010 and then again in 2011 for continuation of the study. It also received ethical clearance at the Institutional Ethical Committee at IPH and at IIPHG. Before conducting the study in the State, permission was obtained from the State Department of Health and Family Welfare. Witnessed written consent and Participant information leaflets were issued for every household; privacy and confidentiality was maintained throughout the study. All information regarding the identity of informants and households were removed from the data and unique id provided helped mask their identity during data analysis and reporting. However some issues were faced during data collection. In a proportion of households, members refused to put their thumbprints on the consent sheet (a procedure for illiterate respondents). They were willing to cooperate but not to give written consent. The reason for this was the scepticism that some in this vulnerable group had based on past bad experience. They provided verbal consent and cooperated with the investigators. In such cases, verbal consent was taken and this was noted with witness signatures.
2.7.
Limitations of the study and implications
There were some steps that did not go as planned and influenced the findings of the study. They have been mentioned in detail below:
17
Study of Rashtriya Swasthya Bima Yojana Health insurance scheme in India
a. Identification of eligible BPL households for the survey: As mentioned earlier, 40 households were randomly selected from the BPL list provided by the State nodal agency, RSBY Gujarat. However the quality of the list was found to be questionable in the field as a significant number of the households mentioned on the list were not found in the field. Hence once a household was identified then the data collection team would with their help identify nearby households who were enrolled in RSBY. Thus the households were identified using the list and the snowball technique. This implies that the study was more likely to include households that were enrolled in RSBY. Hence, the enrolment rate is high and there is inadequate information about those who were not enrolled, limiting the findings of this study to the experience of RSBY mainly among those already in the scheme. b. Interview with Insurance company/Smart card provider/Third party administrator: As mentioned earlier, in Patan District the Insurance Company also was the smart card provider and the third party administrator. Despite repeated requests and permission from the State, the agency did not cooperate with the research team. Hence, the findings of this study lack the perspective of this key stakeholder.
2.8.
Dissemination of findings
A dissemination workshop was held at Ahmedabad, Gujarat to share the preliminary findings with stakeholders of RSBY in Gujarat and other States. The main purpose of this workshop was to explore the stakeholders’ perceptions of the findings and the reasons behind them. There is a plan to publish two articles in open access, peer reviewed journals so that the information and knowledge garnered from this study can be disseminated to a larger pool of academics, activists and policy makers. Copies of the articles will also be posted to each of the State nodal agency for RSBY, so that they can also glean the relevant knowledge from this study.
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Study of Rashtriya Swasthya Bima Yojana Health insurance scheme in India
Chapter 3: Results 3.1.
Household survey 3.1.1.
Study population profile
A total of 3,120 households were surveyed comprising of 17,420 members. These households as explained above were selected across 78 panchayats across the 7 taluks. The average household size was 5.6 and the median was 5. Hence, it was seen that 49% households had more than 5 members in their household; the largest household size being 17 members. Only 3% were single member households. There were 8457 (49%) females and 8963 (52%) males. The baseline characteristics have been summarised in the table below and compared with those of Patan as a whole. Table 4. Baseline characteristics of study population in comparison with Patan Profile
Study population
Patan District (Census) BPL (2002)
No. of households
3120 (15%)
Population size
Total (2011)
1,18,473*
17,420
13,42,746
7
7
No. of villages covered
78 (15%)
523**
Sex ratio (Female/Male)
943/1000
935/1000
Median household size
5 (average-5.6)
5
Child proportion (0-6) years
11%
13.4%
OBC
71%
75%
SC
17%
14%
10% (2001)
ST
1%
3%
1% (2001)
Hindu
98%
89% (2001)
Muslim
1.8%
10% (2001)
No. of taluks covered
Social group category
Religion
*RSBY website ** Patan District panchayat website
Age group: The study population was largely a young population with 41% being less than 18 years and another 41% being between the ages of 18-40 years.
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Study of Rashtriya Swasthya Bima Yojana Health insurance scheme in India
Figure 5. Age-sex pyramid of study population (n=17,416*)
>90
Age group (in years)
80-89 70-79
Male
60-69
Female
50-59 40-49 30-39 20-29 10_19 <9 3,000
2,000
1,000
0
1,000
No. of persons (thousands)
2,000
3,000
*Age not known for 4 members
Education: Only 4% of the population had studied beyond 10th standard (grade) while 37% had never attended school. The difference between genders is apparent when the education level is looked at across them. 51% women had never attended school when compared to 24% of men; the difference being statistically significant (z=35.88, p<0.0002). Similarly, 7% men had studied beyond 10th standard when compared to only 2% of women (z=18.86, p<0.0002). Figure 6. Education attained - total and gender-wise (n=15,677) 100% 90% 80% 70% 60%
Higher secondary & above
50%
Class 6 - 10
40%
Class 1 - 5
30%
Never attended school
20% 10% 0% Female
20
Male
Total
*1769 not applicable
Study of Rashtriya Swasthya Bima Yojana Health insurance scheme in India
Marital status: 80% of the adults are married while 8% widowed. 15% of households were headed by women. Of these 91% (425) were widowed. ECONOMIC DETAILS Housing details: 96% households own their houses, and 46% houses are pucca. Only 10% households have their own latrine while 88% practise open defecation. Other asset ownership: 35% respondents own land esp. wet land averaging 2.7 acres. Table 5. Common assets found in households Asset
Count Percent
Electric Fan
2042
65%
Telephone / Mobile
1631
52%
Livestock
1375
44%
Colour TV
566
18%
Gold or silver ornaments
308
10%
Occupation (n=11,233 between 14-60 years): 50% of women are housewives and 42% selfemployed, while 83% of men are self-employed. Only 2% have a salaried job in public or private sector. Means of livelihood (n=3101): 71% of the families depend on casual labour for subsistence. 7% households have a member that migrates Table 6. Means of livelihood of household* Means of livelihood Casual labour, landless labour
No. of households
Percent
2205
71%
Subsistence cultivation
584
19%
Artisan, vendors, etc.
230
7%
Salary, service sector
45
1%
Others, business man, etc.
37
1%
3101
100%
Total *19 not available
Food security: 53% households stated that they have 2 full meals a day with occasional shortage most of the year. 45% households had sufficient food for most of the year.
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Study of Rashtriya Swasthya Bima Yojana Health insurance scheme in India
Indebtedness: 55% (1,705) households have taken some form of loan. Around 16% are in debt due to illness. Median loan amount is Rs.40,000 (20000, 60000) i.e. US$716 (358,1074)8 with a maximum of Rs.900,000 i.e. US$16,112. Figure 7. Reason for availing loan (n=1,705) Not available 2 <1%
Daily consumption 27%
Social reason 37%
Production 16% Illness 20% 3.1.2. RSBY related details Enrolment status: 94% households stated that they had been enrolled in RSBY for the year. These 2,920 households comprised of 16,368 members or 94% of the study population. The remaining 6% were not enrolled despite their name being on the BPL list. The reasons given for this by them have been listed below: Table 7. Reasons stated for not enrolling in RSBY (n=197) Reason given
No. of households
Not present at the time of enrolment
Percent
117
59%
Did not know about the camp
62
32%
Could not renew the card
18
9%
Did not know about the scheme
12
6%
Did not know that all members need to be present for enrolment
3
2%
We do not want insurance
3
2%
Refused by the enrolment team
3
2%
We had to miss our work to enrol so we did not go
2
1%
Name was in BPL list but not in computer
1
1%
Name not in BPL list
1
1%
There was a long queue and we had no time to wait for enrolment
1
1%
Reached late for registration
1
1%
8
Currency exchange rates on 13.06.12. Available at URL: http://www.xe.com/ucc/
22
Study of Rashtriya Swasthya Bima Yojana Health insurance scheme in India
The characteristics of the enrolled households have been compared with the not enrolled households in the table below. Table 8. Baseline characteristics of enrolled and not enrolled households (n=3117)* Characteristics Enrolled Not enrolled n=2,920 Gender
Sex ratio
947/1000
891/1000
98%
98%
2%
2%
OBC
78%
87%
SC
18%
10%
ST
1%
1%
5 and less
51%
55%
More than 5
49%
45%
Casual/landless labour
71%
65%
Hindu
Religion
Muslim
Social categories
Household size Means of livelihood
n=197
*3 households not known
Cardholding status: 97% of enrolled households received the RSBY card. These 2817 households comprised of 15,792 members or 91% of original study population. •
10% (285) cardholders did not receive their card at the enrolment camp despite this being standard operating practise in RSBY while the remaining 89% cardholders received their cards at the camp. 14% received cards in the same month while 58% one month later. The remaining 28% received their cards between 3-4 months following enrolment.
•
Among all who received cards, 97% paid Rs.30 at the camp as co-payment for the card.
The RSBY status of households has been summarised in Figure 5 below. Figure 8. Summary of households’ RSBY status** 3120 households surveyed across 80 villages (17,420 members) 197* not enrolled
94% (2920) households enrolled (16,638 members) 103 no cards *17 not available
96% (2817) household cardholders (15,792) 285* had delays
89% ( 2515) households received card at camp **Diagram not proportional to scale
23
Study of Rashtriya Swasthya Bima Yojana Health insurance scheme in India
Insured status of cardholders: Unlike few other insurance schemes, possessing a card does not imply that all the members of the household are insured; each member has to be registered on the card during enrolment failing which they remain non-insured. This is allowed to a limit of five members per household. Among the 15,792 members in the 2815 households that held cards, only 70% were insured (11,028 members or 63% of the original study population) as shown below in Figure 6. Figure 9. Insured status of RSBY cardholders** 15,792 members in 2817 household cardholders 4,766 not insured
70% or 11,028 members insured **Diagram not proportional to scale
The next step is to compare the insured members with the not insured ones in order to further explore the intra-household exclusion that was discovered. Table 9. Baseline characteristics of insured and not insured within cardholder households Characteristics Insured Not insured n=11,028 Gender
868/1000
1159/1000
Under fives
22%
76%
Elderly (above 60years)
78%
22%
Self
96%
4%
Spouse
95%
5%
Grandchild
20%
80%
Never attended school
82%
18%
Class 6 to 10
74%
26%
Housewife
74%
26%
Self employed
82%
18%
Sex ratio
Age group
Relation to head of household
Education
Occupation
n=4,766
Gender-wise there was a significantly higher prevalence of women among the not insured (z=8.36, p<0.0002). However when the groups were disaggregated with respect to their age-group, it was seen that 76% of the under-fives had not been enrolled. This is also seen when looking at the relationship of the not insured with their respective head of households, 80% of the grandchildren were not included. The detailed age-wise distribution is seen in Figure 7. Gender-wise disaggregation showed no significant difference among the children. A positive finding seen was that 78% of the elderly (above 60) had been insured. Most (76%) of the elderly were the head of the household or their
24
Study of Rashtriya Swasthya Bima Yojana Health insurance scheme in India
spouse. Education and occupation were not found be significant in determining insured status in the household.
Proportion of members
Figure 10. Age comparison of insured and not insured members (n=15,786) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%
Not insured Insured
Under 5
6 to 17 18 to 40 41 to 60 Age group (in years)
Above 60
When questioned about the reason for not insuring all the members of the household, the following were the commonly given responses: Table 10. Reasons stated for not insuring members within the household (n=4,766) Reason given
Count
Percent
Not present at time of enrolment
1552
33%
Already 5 people are enrolled
1192
25%
Refused by the enrolment team
584
12%
Name not on the ration card
368
8%
Name not in BPL list
145
3%
Name not in computer records
120
3%
Newborn child/ unborn at time of enrolment
94
2%
Did not know that family member could be enrolled
49
1%
Do not know that all members need to be at the enrolment station
36
1%
Name in a separate smart card/ration card
35
1%
3.1.3. Hospitalisation related details Amongst the 3,120 households surveyed, 541 episodes of hospitalisation were noted in the last year. These can be further divided based on their status with respect to RSBY. This has been shown in the figure below.
25
Study of Rashtriya Swasthya Bima Yojana Health insurance scheme in India
Figure 11. RSBY status of hospitalisations** 541 hospitalisations in last one year amongst 3,120 households A 21 amongst not enrolled
B 88 amongst enrolled but not insured
20 +1not enrolled
520 hospitalisations amongst enrolled households 19 no cards
C 432 amongst enrolled and insured (80%)
501 hospitalisations amongst cardholder households 69 not insured
432 hospitalisations amongst insured members **Diagram not proportional to scale
Hence, three groups are seen namely, A: those not enrolled, B: those who are enrolled but not insured and C: those who are enrolled and insured. Computing the inpatient admission rates (IAR) for the three groups reveals a higher rate among insured members (C) which is statistically significant (z=3.15, p<0.002); the rate being double that among the not insured (B) /not enrolled (A). Table 11. Inpatient admission rate of the three groups Groups
No. of members*
A
B
C
Not enrolled
Enrolled but not
Enrolled and
insured
insured
1,042
5,342
11,028
20
88
432
19/1000
16/1000
39/1000
No. of hospitalisations Inpatient admission rate (IAR) *8 not available
This implies an increase in admissions among insured members which is an indicator of increased access for health services among insured members. 3.1.2. Utilisation of RSBY card/benefits 80% of the hospitalisations reported were amongst insured members. However, being insured does not guarantee that the card is utilised and that the benefits are received. As per the SOP in RSBY, the insured beneficiary can avail benefits only at an empanelled hospital, for hospitalisation and for treatment packages mentioned under the scheme. In this study, among the 432 hospitalisations, only 56% hospitalisations involved utilisation of the RSBY card/scheme. In the remaining 191 (44%) hospitalisations, the scheme was not utilised.
26
Study of Rashtriya Swasthya Bima Yojana Health insurance scheme in India
Table 12. Profile of the hospitalised Characteristics
A
B
Not enrolled No. of hospitalisations Gender Social category
No. of doctors visited prior to admission
Type of hospital visited
21
C
Not insured
Insured
88
432
Proportion of women
60%
56%
57%
SC
20%
25%
22%
ST
5%
2%
0.7%
Direct admission
62%
66%
66%*
One doctor
19%
18%
26%
Two or more
16%
14%
8%
Government
30%
17%
11%
Private
60%
67%
76%
Trust (Charitable)
10%
16%
13%
*n=430 as 2 data not available
Figure 12. Utilisation of RSBY card/scheme C 432 hospitalisations among insured members in the last one year C.1 In 191 or 44% hospitalisations, RSBY card/scheme was not used
C1.2 In 241or 56% hospitalisations, RSBY card/scheme was used
Given below are the reasons stated for the RSBY card/scheme not being utilised by insured members: Table 13. Reasons given by insured members for not using the card (n=191) Reason given Count
Percent
Hospital not empanelled
57
30%
Did not have information about the scheme and use of card
55
29%
Told that the member was not registered on the card
51
27%
Forgot to use RSBY smart card
28
15%
Refusal by service provider
18
9%
Technical problem
15
8%
Government facility
7
4%
Beneficiary of other government scheme for maternal services
6
3%
Others
5
3%
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Study of Rashtriya Swasthya Bima Yojana Health insurance scheme in India
Computing the RSBY utilisation rates, when narrowed down to insured members alone; the scheme utilisation rate is 2.2%. Table 14. Utilisation rate of RSBY Groups
Insured members
Total number of members No. of hospitalisations where
11,028
Cardholder members 15,792
Enrolled members 16,368
241
241
241
2.2%
1.5%
1.5%
scheme utilised Utilisation rate
Please note: Further details of treatment and expenditure are seen mainly across three groups i.e. B not insured, C.1 insured and used scheme and C.2 insured and not used the scheme. The numbers in group A not enrolled are too small to indicate a commonality or pattern among the cases. The quality of care provided under RSBY is dependent on the clinical treatment received and quality of services provided. Table 15. Details of hospitalisation across groups Groups B Not insured
C.1
C.2
Insured and not used
Insured and used
No. of hospitalisations
88
191
241
Government
17% (15)
17% (33)
5% (13)
Private*
67% (59)
74% (141)
78% (187)
Trust
16% (14) 24% (21)
8% (16) 24% (45)
17% (41) 19% (46)
Type of hospital visited
Duration Single day of Average 5.3 4.3 4.2 admission 3 (2,7) 3 (2,6) 4 (2,5) (in days) Median Top diagnoses 1 Pregnancy delivery Pregnancy delivery Hysterectomy (22%)** (30%) (24%) 2 Fracture/injury to limbs Ischaemic heart disease Cataract surgery (10%) (6%) (7%) 3 Ischaemic heart disease Fracture/injury to limbs Pregnancy delivery (8%) (5%) (6%) 4 HIV related (3%) Malaria (5%) Fracture/injury to limbs (5%) 5 Cancer (breast, throat) Typhoid fever (4%) Tumour treatment (3%) /surgery (4%) *1 hospitalisation data not available **n=235
Among group C.1 i.e. insured members who did not use the card, 25% were hospitalised at empanelled hospitals while 59% were not aware of the empanelment status of the hospitals where
28
Study of Rashtriya Swasthya Bima Yojana Health insurance scheme in India
they had been admitted. Among group C.2 i.e. insured members who used the scheme there is a significant decrease in utilisation of government hospitals when compared to the other groups (z=3.977, p<0.0002). There is also an apparent decrease in single day admissions when compared to the other groups; however this was not found to be statistically significant (p>0.2). Overall, 44% of the hospitalised received medical (non-operative) treatment while 40% received surgical treatment and 16% obstetric. When this is disaggregated across hospitalised groups based on their RSBY status, there is a significant doubling in the number of surgical cases (62%) among those who were insured and used the scheme when compared to those who did not (z=8.249, p<0.0002). This has been shown in the figure below. Figure 13. Type of treatment compared with RSBY status 100% 90% 80% 70% 60% Obstetric 50%
Medical
40%
Surgical
30% 20% 10% 0% Not enrolled
Not insured
Insured not used
Insured used
In line with the high surgical cases among group C.2, the most common diagnoses are Hysterectomy, Cataract surgery and spontaneous delivery. Among the other groups, spontaneous delivery is the most common diagnosis as seen in the table above. 10% of group C.2 who used the cards had their cards held back by the hospital post discharge. The commonest reason given for this was that the hospital staff wanted to keep the card till the insurance claim was settled. 85% of group C despite using the card had some out-of-pocket (OOP) expenditure; the median expenditure was US$125 which is the same or similar to the other groups. An attempt was made to compare the cost of treatment for a diagnosis/package to that offered by RSBY to get a better idea of the out-of-pocket expenditure.
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Study of Rashtriya Swasthya Bima Yojana Health insurance scheme in India
Table 16.Hospital related out-of-pocket (OOP) expenditure of different groups9 Type of OOP expenditure
B
C.1
C.2
Direct costs
Not insured
Did not use
Used card
5% (5)
3% (6)
15.3% (33)
Cashless visit Before admission
Rs. 2000 (1000,5000) US$ 36 (18,90) 61% (82)
Rs. 2000 (550,5500) US$ 36 (10,98) 47% (135)
Rs. 2000 (700,3600) US$ 36 (13,64) 43% (173)
During admission
Rs. 5000 (2000, 25000) US$ 90 (36,448) 89% (80)
Rs. 4750 (1200,10500) US$85 (21,188) 88% (136)
Rs. 6000 (3500, 19000) US$107 (63,340) 73% (169)
At discharge
Rs. 2000 (500,5000) US$ 36 (9,90) 74% (80)
Rs. 1000 (500,4000) US$ 18 (9,72) 67% (138)
Rs. 1000 (500,3000) US$ 18 (9,54) 44% (172)
Total direct cost
Rs. 8000 (3000,27000) US$ 143 (54,483) 95% (104)
Rs. 7000 (2750,17500) US$ 125 (49,313) 97% (182)
Rs. 7000 (3200,15000) US$ 125 (57,269) 85% (215)
As seen above in Table 13. Hysterectomy was the commonest diagnosis among insured members who had used the card or group C.2 with 53 cases. The median expenditure for Hysterectomy was found to be Rs.10,000 or US$179 which is the actual cost of the package offered by RSBY. Table 17. OOP expenditure for hysterectomy, cataract surgery and pregnancy delivery Details Hysterectomy Cataract surgery Pregnancy delivery Total no. of cases RSBY package
53
22
18
Rs.10,000 (abdominal)
Rs.3,500 (unilateral)
Rs.2500
9 (17%) cases
10 (45%) cases
5 (28%) cases
Rs. 10,000 (1700, 18000)
Rs. 3,750 (3275,7250)
Rs.4,000 (2800,4700)
US$179 (30,322)
US$67 (59,130)
US$72 (50,84)
Rs.120-35,000
Rs.80-65,000
Rs.1,500-18,000
US$2-627
US$1-1164
US$27-322
rate Nil payment /Cashless Median expenditure Range
9
Currency exchange rates on 13.06.12. Available at URL: http://www.xe.com/ucc/
30
Study of Rashtriya Swasthya Bima Yojana Health insurance scheme in India
Qualitative methods
3.2.
3.2.1 Awareness about RSBY and card Awareness has often been simplified to the extent that awareness of the existence of the scheme is considered sufficient and associated with assumptions of better utilisation. Despite presence of four years in Gujarat, the enrolment rate is still around 51%. Extent and depth of awareness hence was an important question. This had not been captured by the survey and hence was the starting point for the discussions and interviews. The enrolment rate in Patan has also come down from 53% in 2010-11 to 45.3% in 2011-12 in its fourth year.
Enrolment rate (in percentage)
Figure 14. RSBY enrolment rates for Gujarat State from 2008-12
70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0%
2008-09
2009-10
2010-11
2011-12
Policy year Interacting with the community, service providers and other stakeholders revealed that there are two levels of awareness regarding the scheme among the community. One was a basic level of awareness of the card and some knowledge of the scheme which was more prevalent while the other was a more informed awareness of utilisation of the card and services provided by the scheme. Commonly aware details of the scheme: The basic details of the scheme include what is the card, what is it for and whom it is for. Through discussion with the community, it was evident that most of the beneficiaries were familiar with the card irrespective of whether they were enrolled or not enrolled. However, they had not heard about nor associated the card with the name ‘Rashtriya Swasthya Bima Yojana’ or ‘RSBY’. Some of the names they had assigned to the card like ‘Hospital card’, ‘Smart card, ’30,000 rupees card’ and ‘BPL card’ stemmed from their awareness of the scheme while others like ‘SIM card’, ‘Job card’ etc. show the lack of awareness of the scheme. As per the RSBY SOP, the Insurance Company is responsible for conducting an information, education and communication (IEC) campaign in the villages a few months prior to and during the
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Study of Rashtriya Swasthya Bima Yojana Health insurance scheme in India
enrolment camp. In Gujarat, the State health department and the Insurance company have come together to conduct an intensive IEC campaign to introduce posters on buses, pamphlets, etc. In every taluk, an awareness workshop was arranged under the chairmanship of the District Collector. However, there has been lesser IEC effort around enrolment at village level. State admin 01 It is known that it is in the interest of the Insurance Company to generate awareness about the scheme to improve the enrolment rates, however to generate awareness to improve its utilisation is a conflict of interest for them. Largely their campaigns hence, disseminate and target information regarding how to get a card according to both providers and the government officials. The State hence needs to play a larger role and is now planning to take on responsibility of IEC dissemination following enrolment to boost utilisation of the scheme. In our FGDs it was found that most of the community had received information about the card or scheme from the local ASHA, Anganwadi worker (Government worker for day crèches), panchayat members (members from elected village council), and neighbours. Some explicitly mentioned that no systematic campaign or meeting had been conducted for dissemination. Even private practitioners found out about the scheme from fellow practitioners that were empanelled already. Regarding details of the scheme, most beneficiaries were aware of the ‘whom’ and ‘what’ of the scheme .i.e. BPL are eligible up to five members in each household, a scheme for hospitalisation and up to Rs.30,000 coverage. Only few beneficiaries are aware of coverage of pre-existing illness and transportation costs. However they are ignorant of other questions like where and more importantly how. Details of scheme that most are unaware of: Questions of ‘where’ and ‘how’ were found to be without answers among the community. Most respondents were not aware of which doctor or hospital they would visit to get the benefit i.e. which are empanelled by RSBY. They were also found to be largely not aware of the type of services provided in this scheme. This revealed a deficiency of procedure also that booklets with empanelled hospitals’ list which are to be provided at enrolment to each household is not being done. Regarding maternity care and coverage of pre-existing illnesses, very few respondents were found to be aware. The few who were aware did not consider this scheme essential to get these services as other government schemes also cover the same.
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Study of Rashtriya Swasthya Bima Yojana Health insurance scheme in India
3.2.2 Enrolment Procedure In some of the villages, the responses suggested that the enrolment camp was held as per the guidelines with a camp at the village where all BPL villagers gathered. Names, photograph and thumbprints were taken and card issued on the same day. However, in some other villages, no such camp was held. Allegedly ‘eligible’ families were called to the Panchayat office, where following payment of Rs.30, the formalities were completed but card was not issued. It was delivered between one to three weeks by the ASHA. Most respondents who had enrolled mentioned that the personnel at the enrolment camp had been quite cooperative and behaved cordially with everyone. Reasons for not enrolling Lack of awareness: Almost all beneficiaries who were not enrolled stated that the reason they were not enrolled was because they were not present in the village during the camp. The reason for this is that they were not aware of the enrolment camp. They expressed that many villagers often go to the field for agriculture work, or migrate to the town or other districts for work, and this is the reason for their absence. Both enrolled and not enrolled beneficiaries explicitly stated that they had not been informed prior to the camp but those who had been aware were informed on the day of the camp itself. This was the most important reason that explained that most time those absent on that particular day were not enrolled. Some other anecdotes were shared about friends and neighbours who could not enrol in the camp. Due to death of an elderly person, his family was not enrolled as they were busy in performing last rites of the diseased FGD NE In some villages, it was expressed that only ‘select’ households were invited to the panchayat office for enrolling while others were not. The families that lived in the fringe of the village were most likely to get excluded. Loss of wages: While the RSBY beneficiary needs only to pay Rs.30 (54 cents) during the camp to get enrolled, the family needs to forego a day’s wages for this. Many families earn on a daily basis. One member earns up to Rs.150 a day (US$3) and if there are two earning members then that is a total of Rs.300 a day (US$6), a price many find too high to pay. Past experience with RSBY: Past poor experience with the card or scheme was found to be an important factor that led families that were aware to choose to not enrol this year. Some had been enrolled and not received the care, some had the card and never used it while some had tried to use the card but had so much difficulty in the hospitals that had given up. The renewal process in RSBY till date is absent and every year the enrolment process was repeated by the State and Insurance Company. This requires a lot of effort and for a few months, the entire district team gets involved.
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Study of Rashtriya Swasthya Bima Yojana Health insurance scheme in India
Attempts were made a few years back by the State to conduct mop-up drive and promote enrolment of families leftover, however this had not shown good results. Lack of local champions for the scheme: Much of the efforts from the State are at the taluk level and the local panchayats are not involved much. The local leaders (Sarpanch) do not take initiative or show interest in enrolment or providing benefits to the community. Problems with the BPL list: This was considered by the State to be the single most important issue that led to difficult. A government official informed that a study conducted in another district in Gujarat showed that 10% of the people on the list were not found in the field. One of the major issue is the repeated enrolment every yea.r If the BPL list is not being revised every year, the logic of enrolling same BPL family every year is difficult to understand. Admin In rural areas, presence of a well-established panchayat and ration system (public distribution system for food grains) helps in identifying households. However urban areas have high inward migration and no such system. Lack of grievance redressal mechanism in the community: An important concern often expressed was that following the camp, when families that had missed the opportunity wanted to also enrol, they did not know where to go or whom to talk to. This is further elaborated later in the report.
3.2.3 Utilisation of scheme/card Interaction with service providers During enrolment not faced any difficulty ....experience difficulties in getting treatment from hospitals. FGD Empanelled hospitals: As mentioned earlier, most respondents were not aware or not certain about which hospital is empanelled or where to go to avail the benefits. As mentioned above, all respondents had not received the booklet with list of empanelled hospitals at the enrolment camp. This was also reflected in their experiences that in often when they visited hospitals, doctors refused treatment under the scheme. In some villages, with experience few respondents knew few empanelled hospitals but found them to be far from the village making it inconvenient for them. Hence, they often opted to pay higher for service in nearby hospitals instead.
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Study of Rashtriya Swasthya Bima Yojana Health insurance scheme in India
The State has now a total of 1134 private and 432 public empanelled hospitals across the 26 districts, and has brought secondary care within 40km distance of the community due to good roads. They have been mapped using GIS and most are easily accessible by the community. Past experience of utilising RSBY: This provided some interesting perceptions. Some respondents felt that hospitals without the scheme provide better service than hospitals under the scheme; some believed that doctors were not proving quality medicines or treatment under the scheme; some believed that doctors did not value the card. Before the scheme, doctors welcomed patients but due to implementation of the scheme, doctors provide treatment as if they are obliging the patients. FGD The confusion and ignorance of where to go often led to negative experiences in the hospital; rationale behind refusal may have been justified but since it had not been explained to the beneficiaries, it often left a bitter taste. Past poor experience was found to be an important factor as mentioned earlier led many families to not get enrolled this year. Issues with the card Doctors in empanelled hospitals cross-checked and verified the name, photograph, thumbprints and signature of the person with the computer. In case of any mismatch, they refuse treatment. In case of minor errors, they insisted on checking the ration card or voter’s card and keeping hard copies of all in case the Insurance Company raised objections. Some were not willing to take risk of claims being rejected and hence, would not accept the card if all was not in order. This decision was most often based on the delay in settling claims where doubts arise. Beneficiaries reported many mistakes often found with the card: name of women in place of men and vice versa; father’s name in place of son’s name; thumb impressions not matching, five member being enrolled but only three found on the card, woman’s gender changed to man, etc. Doctors also reported that while at least one member’s thumbprint would often match, photographs were seldom seen. Insurance company only see data, not case sheets Mismatches between the patient’s age on the card and reality often occur and according to most doctors, errors like these lead to rejection in claims. Ideally in case of errors, the Company can check the case sheet and conduct exit interview with the patient. However, mismatch in data is assumed to be malpractice on the provider’s behalf and claims are rejected.
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Study of Rashtriya Swasthya Bima Yojana Health insurance scheme in India
Out of pocket expenditure The scheme aims at being cashless at the time of utilisation. However, the difficulties in using the card often led to cardholders needing to pay for the treatment from their pocket. Lack of knowledge on procedures and services, with doctors and hospitals being guarded in accepting cards only for sure claims led to many beneficiaries having to pay for their treatment despite being insured by RSBY. Services provided under RSBY Overall all providers admit that their hospital attendance and admissions have increased since they became empanelled and attribute this to RSBY. Hospitals in smaller towns particularly benefit from this scheme as it ensures utilisation of services and helps sustain the institution. In bigger towns and cities, the effect may not be as significant. Medical packages: All service providers interacted with had difficulties or had stopped providing medical packages under RSBY. The rates are felt to be low and are not fixed like surgical packages. They include bed charges, food to patient, medicines, tests, consultation, etc. Hence, an issue with any one component leads to the claims being settled at lower rates. The hospitals are not used to and often do not maintain detailed documentation of all processes. When insurance companies raise questions about these claims, doctors feel hassled and do not realise that thorough documentation and knowledge about what is included in the package and what is not, can actually minimise these rejections. The State and Insurance Company explain that the packages have been designed and are dependent on specific services included like provision of food to patients and are not fixed rates. Claims from empanelled hospitals which do not provide food to their inpatients will be reimbursed at a lower rate. This is often seen by providers as ‘negotiation to lower price’ but is often justified and is seen in any health insurance scheme even voluntary schemes. Sometimes the provided services are so minimal when compared to the package that they have to be rejected. Quality of medical services hence is scrutinised closely and this makes doctors uncomfortable and often unwilling. Surgical packages: The figures in Patan and in this study show higher proportions of surgical treatment among beneficiaries than others. Day care surgical packages have also been included in the packages. Surgical package rates are fixed and high, and satisfactory for most small and medium private establishments. This is an increasing trend in RSBY and has been a cause for concern for all. Hysterectomy rate have been found to be significantly high among insured and hence leading to suspicion of moral hazard based on past experiences with other schemes. Service providers in Patan also admit an increase in elective surgeries overall but are quick to justify it using the poverty of the beneficiaries as the main reason.
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Study of Rashtriya Swasthya Bima Yojana Health insurance scheme in India
“Poor patient cannot be investigated in detail, so only PAP smear available. Hence, hysterectomy is easier alternative” DOC Insurance companies investigate mismatch in information, high claims ratio, adherence to packages, etc.; they do not conduct clinical audits formally and look for justification of treatment provided based on the clinical condition and prognosis. They need to recruit health professionals to conduct reviews but in some States they often take in doctors from Indian systems of medicine that are unable to question medical discrepancies. Quality of services is checked at some level but one is unable to comment on quality of care provided. Obstetric packages: Presence of other schemes for maternal care leads to confusion in both providers and the community. In some hospitals where other schemes have been running, RSBY is seldom used for deliveries, while in other hospitals they use all the schemes together and gain more income. Maternal services had not been included in the scheme in its initial years as NRHM provided cover for them. However this is now an important component.
3.2.4 Claims in RSBY Beneficiary related issues: The State and Insurance Company very often find fault with claims and services provided by hospitals but often the role of beneficiaries gets ignored. For instance, patients at times do not cooperate with doctors. In small towns and villages, they are ready for day care but not ready to stay overnight. Doctors either do not use the scheme or give in and allow deviation from the rules. Many doctors provided anecdotes of how patients themselves try taking advantage of the problems with the scheme. “People try using old cards. They say, “swipe it, 50% you take and give 50% to me” DOC The mismatches and deficiencies of the card are so common that often some people figure it out and try cheating the system. Some bring a neighbour or acquaintance and pretend that they are a family member listed in the card. When the (photo is usually absent) thumbprint mismatches they blame it on the card and insist that the card be used. Such claims often get rejected eventually and cause the doctor much heartburn. Hence, if it is a major case esp. surgery, provider cross check ration card or voter’s card and keep photocopies of all. Doctors have even reported instances when patients come in cars and show the card.
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Study of Rashtriya Swasthya Bima Yojana Health insurance scheme in India
Reimbursement of claims: As per the SOP of RSBY, claims need to be processed and settled within 21 days of filing them. However delays are common and on average as per providers, they are settled 4-5 weeks after only. Problems with claims most often lead to delays and sometime even rejections. These bring with them investigation into the hospital practice and even suspension at times. To avoid this, all providers have become strict with regard to adherence to rules. Why this fear with claim settlement and investigations? Past experience with insurance companies and the processes are to blame for this. Initially when a provider is empanelled, their awareness of the details of the scheme and packages are poor so often their claims are rejected or settled partly. There have been instances where the delayed claims are delayed for so long that when the Insurance Company offers to settle for less, the providers accept it. Insurance companies and TPAs change every year and old unsettled claims remain pending. “Whatever we get from insurance company for claims, we are happy” Inter-district claims: The smart card is portable and valid in all network hospitals across the country and across insurance companies. In Gujarat, different insurance companies and TPAs function in different districts. When beneficiaries cross districts and use services, the provider sends the claim to the local insurance company who in turn forwards it to the concerned insurance company. These are inter-district claims and are almost always associated with delays. These sometimes pile up and at times, providers even refuse patients from outside the district under RSBY. Paperless scheme: RSBY aims at paperless operation by design. Most packages and services have been standardized and coded so that claims can be settled electronically. This has been claimed to be its strength if one was to consider the paper work that would be otherwise generated. “RSBY is paperless scheme only on paper” In Patan, all insurance companies insist on hard copies of all documents including case sheets for most cases. Providers cooperate with this and send hard copies of all concerned documents and this process adds to the delay in processing claims. Both the government and insurance companies note that the documentation maintained by doctors is weak and incomplete – the main reason for investigations and rejections. Suspension and de-empanelment from the scheme: Gujarat is one of the pioneer states in India to implement a grievance redressal system with a clear mechanism for investigation, suspension and deempanelment. Yet providers are under a constant threat of being suspended from the list. All providers were explicit about this. Lack of awareness of the finer details of the scheme and
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Study of Rashtriya Swasthya Bima Yojana Health insurance scheme in India
comprehending a new concept of insurance inevitably put the providers at a disadvantage. Most private providers especially the small and medium sized institutions benefit with the presence of RSBY and hence go to great lengths to avoid a suspension or even minor problems with claims. In spite of this, if a problem or delay occurs, they are then quick to settle claims formally or informally even at much lower rates than lose the scheme. When a complaint or claim is being investigated the hospital is kept under suspension and cannot implement RSBY. If this happens more than once, the uncertainty adversely affects the attendance at the hospital. If they are clear with their practice why should they fear investigations? The main reason for this is their poor faith in the grievance redressal mechanism (explained later). Both government administrators and providers view the Insurance Company as being claims-centred. While it is in the interest of any Insurance Company to keep the claims at a manageable level to keep profits at a certain level, the perception among both providers and some government administrators that the most of the Insurance Company’s actions are to control claim ratios. Instances of hospitals with high claims being de-empanelled by certain Insurance Company are often heard but exact procedure or reason is not known. Transparency is hence found to be lacking in the process of empanelment and de-empanelment where the Insurance Company is the key stakeholder.
3.2.5 Grievance redressal mechanism Community level: The community level grievance redressal mechanism seems to be near absent. Almost all respondents were not aware of where to go or whom to approach in case of a problem or even a question irrespective of whether their enrolment status. Some approach the local ASHA for any problem but that is not limited to RSBY related issues but to any issue related to health. This is not limited to complaints. While interacting with those who had not been enrolled, the helplessness they expressed was obvious both verbally and non-verbally as they wanted to be protected but being absent on that one day had taken that opportunity from them. Once they learnt about the scheme, the camp and its benefits, they all wanted to join in but none knew how and blamed the government for not taking any steps to enrol those who had been missed. Formal Grievance redressal system for RSBY Gujarat: The grievance redressal system in Gujarat has three tiers as shown in the figure below:
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Study of Rashtriya Swasthya Bima Yojana Health insurance scheme in India
Figure 15. Grievance redressal mechanism in Gujarat
District Steering Committee If not settled
District Grievance Redressal Committee If not settled
State Grievance Committee The District committee consists of the Chief District Health Officer, Nodal officer of District, Insurance Company’s District Coordinator, District Programme Officer for RSBY and the District Quality assurance medical officer. They conduct weekly reviews for the scheme. The District Grievance Redressal Committee (GRC) is headed by the District Commissioner and meets once a month. They assess any complaints by any stakeholder including beneficiaries regarding functioning of the scheme. If someone is found to be at fault, then the GRC issues show cause notice and suspensions. If anyone is not satisfied or unhappy with their decision then they can appeal to the State committee. Most complaints received are about blocking higher packages, blocking multiple packages in a single card and overstay in the hospital. The State administrators insist that the procedure followed for de-empanelment is as prescribed by the Central RSBY guidelines. However, there are no fixed criteria for classifying hospitals based on their performance. Administrators also admit that there are certain areas where Insurance Company has pushed for suspension or de-empanelment of the only one or few hospitals leaving the community without a RSBY provider in vicinities. In addition, the application of rigid guidelines to small and medium sized establishments in small towns and villages is difficult and should be discouraged. The mechanism of mere investigating, suspending and de-empanelling should not be the focus but rather it should shift to a mechanism of monitoring quality of care by providers while facilitating them to improve it. Fraud management: The two main mechanisms of fraud management in the State are through data analysis through predetermined triggers and using field investigations by the nodal agency through surprise visits to hospitals, and by the Insurance Company through audits at hospitals, and residence visits of patients for verification of hospitalisation details.
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Study of Rashtriya Swasthya Bima Yojana Health insurance scheme in India
Table 18. Action against suspended HOSPITALS IN Gujarat (till April 2011) Particulars
No.
Hospitals Audited
112
Show Cause Notices Sent
54
Suspension Letters Sent
13
Hospitals De-empanelled
5
Beneficiaries Verified
500
Service providers: The mechanism may be clear and established and by interacting with the Insurance Company and State officials, it is clear that it is functioning also. The providers were united in their disbelief in the mechanism. Company representatives who visit hospitals for audits rarely interact with the hospital staff or discuss any complaint that they are processing. Providers are most often kept outside the loop till they get the suspension letter out of the blue. This fear and the lack of transparency in the process only put the provider at a more disadvantaged position and a reason why some despite seeing the benefit of the scheme opt out. Multiple or undue delay in processing claims and payments are a common happening and while all providers spoke about it, hardly any had taken it to the GRC. When questioned about it, they all had only one thing to say. “Those who complain have problems.” DOC Most of the providers refused to go into specific details about this. However, it was a unanimous perception among them that there was a link between complaints and suspended. They had concluded this based on an association between physicians filing complaints and them being suspended. Most providers had only interacted with the Insurance Company representatives since empanelment and the absence of government involvement led them to believe that the State had a negligible role in monitoring and some perceived that at the local level there was a tie-up between the government officer and Insurance Company. This is an important reason that makes providers to not speak up or fight for what is due to them, hence further tipping the power in favour of the Insurance Company.
3.2.6 Governance The clarity of roles of different stakeholders seems to be lacking in the field despite presence of guidelines. An important reason for this is the constant evolution of roles particularly for the State.
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Study of Rashtriya Swasthya Bima Yojana Health insurance scheme in India
The State has been essentially limiting its involvement to the State and District level while the field level responsibilities largely are with the Insurance Company and TPA. State Nodal Agency: Gujarat unlike in many other states, there is an interdepartmental task force consisting of Labour, Health and Rural Development Ministries. The key department is the Department of Health and Family Welfare. This gives it an advantage of familiarity with health, hospitals and patients. The Government is expected to review periodic reports from the Insurance Company, conduct medical audits and facilitate periodic third party evaluations. State level implementation: The Government believes in RSBY as a scheme with good design and good intentions but facing problems with implementation. A significant part of the year their time is taken up by the enrolment process. For three months every year, the entire District machinery is involved in this process. There is a need for a simpler process of renewal. With the introduction of the new 64kb cards the Centre maybe closer to a solution. 24x7 enrolment kiosks are also now setup at the taluk level once again to allow for anytime enrolment for those who have missed out in the camps. Two years back the same strategy had failed but with more awareness in the community they have hope. The State also reviews data reports from the insurance company. These reports consist on the Company’s findings on the data while till recently the State did not have direct access to the data. This was remedied recently but is still in the process of implementation. Hence, a lot of the State’s information was largely based on these reports. In a bid to restrict Insurance Companies from controlling claim ratios, this year onwards the nodal agency in Gujarat has introduced discount on premiums if the claims decrease. This can be as high as 33%. District level governance: A District Programme Officer for RSBY has been provided at the District level to help the CDHO. They organise weekly and monthly meetings to discuss issues around enrolment, claims esp. inter-district claims, and grievances. They mainly observe and forward issues to the State; they have not been provided much authority to take action in case of errors. The State does provide them feedback about different hospitals on a case to case basis. However, the District administrators interacted with responded that they often feel as if they act as mere messengers for the State and are unclear about their in implementation and monitoring. Their argument is that for better monitoring the scheme needs to be decentralised to the District level if not closer to the beneficiaries. Local level governance: The government officials’ lack of involvement and sometimes complete absence in attending local meetings and visit hospitals regularly increases the distance between providers and the State. Barring grievance redressal, any information from the beneficiaries also is filtered via the Insurance companies.
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Study of Rashtriya Swasthya Bima Yojana Health insurance scheme in India
Government favours insurance company not medical officers Since they mainly interact with Insurance Companies, their decisions are always perceived to be sided with the companies and based on secondary data alone. As repeatedly seen above, the Insurance Companies have a central role in functioning and monitoring the scheme at the local level.
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Study of Rashtriya Swasthya Bima Yojana Health insurance scheme in India
Chapter 4: Conclusions In this section, we explored the implementation of RSBY in Gujarat based on the three dimensions of universal health coverage (UHC) stated in the World Health Report 2010 i.e. “the proportion of the population to be covered” (breadth of coverage), “the range of services to be made available” (depth of coverage) and “the proportion of the total costs to be met” (height of coverage) as shown in the figure below. Figure 16. Three dimensions to consider when moving towards universal health coverage
10
I.
Population: who is covered and extent of coverage?
In Gujarat State, RSBY covers households living below the poverty line (BPL). This would roughly be 30% of the total population (see table 1). In Patan district, the proportion of eligible population as per the State Government is closer to 44% (see table 1) i.e. nearly half of the total population. However based on the RSBY data, only 23% of the population is estimated to be enrolled. As per the design of the scheme, enrolment is equated to possessing the RSBY smart card and hence every enrolled household, and within each household a maximum of five members are assumed to be covered. These are the numbers used for estimation of coverage of the scheme as well. However the study clears shows that this assumption is a dangerous one as it gives an illusion of coverage for a section of population that in reality is not covered. Despite the design and processes in place, a proportion of households do not receive cards and hence are not covered by the scheIt was found that 8% enrolled households never received the card while 30% members of cardholding households were not registered on the card making them not eligible for using RSBY. Among noninsured members in enrolled households, a significantly higher prevalence of women was seen while 76% of the under-fives had also not been insured. The findings suggest that even within the households despite having a card, a third of the population were not included in the card and hence, 10
World Health Report 2010
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Study of Rashtriya Swasthya Bima Yojana Health insurance scheme in India
excluded from the potential RSBY cover. This dimension of exclusion revealed by the study needs to be further explored as the actual population covered is affected significantly. Based on the household survey alone, it is difficult to comment on the characteristics of the population that enrolled in the scheme or the factors due to which some were able to enroll in the scheme while others were not due to the small number of non-enrolled households included in the study (elaborated in Findings section). However, it is clear from the discussions and interviews that limited awareness of the scheme and its benefits is a significant factor influencing the enrolment coverage of the households and of members within households as well. While superficial awareness of scheme and the card were commonly seen, the enrolment procedure seems to catch mainly those who are immediately available in the village during the camp. Lack of prior intimation and awareness of the enrolment camps and benefits at the grassroots level are implied by the ignorance among those not enrolled. Lack of grievance redressal mechanisms at the village level do not allow those who become aware at a later time during the year to still participate in the scheme. Initially the IEC campaigns were considered to be the main responsibility of the insurance campaigns. Today the State in partnership with the Insurance Company is conducting IEC campaigns at the District and Taluk levels. However discussion with policymakers reveal that the closer one goes to the beneficiary, the poorer the awareness activities are and hence the poorer is the awareness about the scheme. Another significant factor revealed was the poor quality of the BPL list used to identify eligible beneficiaries. RSBY is a scheme that currently targets the BPL population. While experts still argue the correct definition of the poverty line, the list currently used for providing benefits is a decade old and excludes the homeless and sheltered groups.
II.
Services: which services are covered?
There are two aspects to the services covered first, regarding the provision of the services by service providers while the second is regarding the accessibility to eligible beneficiaries. The services provided under RSBY are hospitalizations involving 24hour stay (or at least overnight stay). Today more than 1100 packages are covered including medical, surgical and maternity services till a limit of Rs.30,000 in a year for five members in a family. Preventive and promotive care, ambulatory care and tertiary care are not provided. While outpatient care is the main contributor to catastrophic health expenditure, it is not covered by RSBY. The results of the RSBY pilot in Gujarat and Orissa States are eagerly awaited by all. The step to extend the services provided under the scheme is a welcome one, however, the need is to address the issues related to implementation of the scheme else the services/scheme will remain poorly utilized. Frequent investigations into claims, delay in reimbursement of claims and perception of low rates for medical packages are key issues raised by service providers as challenges to implementation of the smooth scheme. Around twothirds of insured users underwent surgical treatment and this was 2.8 times higher than those who did not use the scheme. The decrease in medical packages allows a relative increase in surgical packages being conducted under the scheme. This leaves space for possible moral hazard which gets amplified in a context of poor regulation of the private sector. From the beneficiaries’ perspective, while they are aware of the scheme in general, they lack awareness about the services offered, how to utilize the card and where to go to do the same. In this study, 44% of beneficiaries with the card did not use their card during hospitalization. Among
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Study of Rashtriya Swasthya Bima Yojana Health insurance scheme in India
hospitalisations, the inpatient admission rate among insured members was found to be significantly high (39/1000) along with utilisation rate of 2.2% when compared to the non-insured and nonenrolled. This suggests an increase in access to services among the insured. However it cannot be commented on how many of these hospitalizations were actually required.
III.
Direct costs: what proportion of the costs is covered?
In this study, 85% RSBY insured had some out of pocket expenditure (OOP) despite being covered by the scheme. No difference was seen when compared to that borne by the non-insured or nonenrolled households. Among the top three packages, 83% of hysterectomy patients, 55% of cataract surgery patients, and 72% of deliveries had some OOP; the median OOP payment to the providers being an additional 100-160% of the actual package rates. Absence of any monitoring at the service provision level lead to patients paying either partly or completely for the care received. Hence RSBY was unable to offer financial protection to the insured beneficiaries.
IV.
Other significant cross-cutting issues:
The grievance redressal mechanism in Gujarat unlike most States is a well-planned three tier system from the district level to the State level described earlier. However, there is no mechanism that reaches out to the beneficiaries of the scheme. In addition to this, despite the existing system, service providers have reported needing to negotiate claims for settlement with the Insurance Companies and work constantly under threat of suspension. There is a perceived lack of the Government's involvement in investigation and resolution of complaints. The role of the State Government in the monitoring the implementation of the scheme is questioned despite investment in HR at all levels. Unlike most other States, in Gujarat the Department of Health is the agency responsible for implementation of the scheme. This provides them an advantage in working with hospitals and patients. However, regulation of claims processing and oversight of the insurance companies have been found to be lacking. While the State agency does provide some centralized oversight, there is no decentralization of the monitoring processes at the district level or at the Taluk level. There is also a need to conduct detailed medical audits to ensure the quality of care provided and prevent moral hazards like unnecessary hysterectomies. Addressing the concerns laid out by this study will help the scheme to mature considerably. Other larger questions of sustainability, permanence and expansion to those above poverty line will also need to be addressed if it is to be considered a tool to achieving UHC in India.
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Study of Rashtriya Swasthya Bima Yojana Health insurance scheme in India
Competing interests None
Authors’ contributions Conceptualised the study
Designed the study
Collected data
Wrote the report
Critical comments on the report
N. Devadasan Tanya Seshadri Nehal Jain Mayur Trivedi D. Saxena R. Nair Prof Di McIntyre Prof Ayako Honda Dr. Aulakh Kaur Prof Bart Criel Dr Werner Soors
Acknowledgements We acknowledge that this study is financially and technically supported by the Alliance for Health Policy and Systems Research, WHO. We also wish to acknowledge the inputs of the Health Systems Financing Department, WHO and the late Guy Carrin, in particular. We wish to acknowledge all the study participants for giving us the time and sharing their views and experiences, the Government of Gujarat State for giving us the permission to do the study, various stakeholders of RSBY in Gujarat for actively participating in the study and the workshop, and the team at IIPHG for coordinating the data collection and workshop. We would also like to acknowledge the contributions to this study by Ms. Nehal Jain,
References Annexes
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Study of Rashtriya Swasthya Bima Yojana Health insurance scheme in India
