SOCIAL EXCLUSION AND RASHTRIYA SWASTHYA BIMA
YOJANA (RSBY - NATIONAL HEALTH INSURANCE SCHEME)
IN MAHARASHTRA, INDIA
H. Thakur*, S. Ghosh, A. Nawkar
School of Health Services Studies, Tata Institute of Social Sciences, India
*harshad@tiss.edu
www.healthinc.eu
• In Maharashtra like majority of other states in India, Ministry of
Labour is administering RSBY, a health insurance scheme
introduced in 2008.
• In Maharashtra, RSBY is currently being withdrawn as a new state
sponsored health insurance scheme – Rajiv Gandhi Jeevandayee
Arogya Yojana (RGJAY) is being started since 2010.
• Recent studies on RSBY highlight the limited success of the
scheme in Maharashtra . Several reasons such as lack of relevant
and accurate data, lack of infrastructure are discussed. However
rigorous research evidence is lacking.
Awareness
Ever enrolled household
•
716 (12%)
Amongst all 6000 household
Smart card holder
•
684( 11%)
Amongst 684 smart card holders
Hospitalization Cases
The data collection was done from December 2012 to February
2013.
Quantitative Method – 22 districts with minimum two years of
scheme implementation were selected. List of BPL households
were selected as per the 2002 list of Ministry of Labor / Rural
Development. 6,000 households across 22 districts (both urban
and rural) covering 29585 individuals were covered. A systematic
multi-stage sampling design adopted in both rural and urban
areas.
Qualitative Method – Five districts were selected to represent
the five geographical regions of Maharashtra. 16 Focus Group
Discussions (FGD) and 34 In Depth Interviews were conducted.
We analyzed the information at different levels with the help of
generic SPEC – by Steps tool (developed by Health Inc.), which
identifies the nature of exclusion at different levels and provides
account of who is excluded / included.
•
•
1295 (22%)
currently enrolled households
Methodology
•
•
Amongst all 6000 households
Objectives of current paper were to evaluate the current status of
RSBY in Maharashtra in terms of proportions covered at each step
like awareness, enrolment, having card, utilisation, etc. and to
compare the urban and rural areas .
•
1781 (30%)
Amongst all 6000 household
Study objectives
•
Key Findings
Total no. of eligible household = 6000
Background and Need for the study
•
222 (32.5%)
•
Amongst 222 hospitalization cases (with smart cards)
Service utilization from
21 (9.5%)
empanelled hospitals
•
Fig 2 – SPEC – by steps
Urban
N
%
Family Type
Nuclear family
Joint
Live single
Extended family & others
Household Size
1 to 5
6 to 10
11 and more
Rural
N
805
1254
49
78
36.8
57.4
2.2
3.6
1406
734
46
Type of household by main occupation
Self-employed (agriculture)
70
Self-employed ( other)
272
Laborers (agriculture)
220
Casual labour
1129
Regular wage or salary
457
Others
38
Religion
Hindu
Muslim
Buddhist
Others
Caste
SC (Scheduled Caste)
ST (Scheduled Tribe)
OBC (Other Backward Castes)
Others
Total
Total
N
%
1342
2148
170
154
35.2
56.3
4.5
4.0
%
2147
3402
219
232
Reasons for limited success
35.8
56.7
3.7
3.9
64.3
33.6
2.1
2533
1212
69
66.4
31.8
1.8
3939
1946
115
65.7
32.4
1.9
3.2
12.4
10.1
51.7
20.9
1.7
884
206
1382
966
287
89
23.1
5.4
36.2
25.3
7.5
2.3
954
478
1602
2095
744
127
15.9
8.0
26.7
34.9
12.4
2.1
•
•
•
•
•
70.2
15.1
14.1
0.6
3211
224
368
11
84.2
5.9
9.7
0.4
4746
554
676
24
79.1
9.2
11.3
0.4
890
420
469
407
40.7
19.2
21.5
18.6
1115
738
1249
712
29.2
19.4
32.8
18.7
2005
1158
1718
1119
33.4
19.3
28.6
18.7
2186
36.4
3814
63.6
6000
100
•
•
Urban
N
%
Fig 1 – Map of Maharashtra (22 districts for household survey,
Qualitative survey in 5 Districts with *)
Information provided by the
enrolling agency
40
34.5
35
Rural
30
25
26.3
21.3
20
15
14.5
13.3
10
7.5
13.9
7.1
Other community members so we
did
Protection against illness
Better access to private hospitals
The out of pocket money is saved
in this arrangement
5
0
Awareness Ever Enrolled
Currently
Enrolled
Have smart
cards
Fig 3 – Awareness and Enrollment according to the place of residence
Total
N
%
%
•
80
Awareness about the empanelled
hospitals
67
Knowledge of benefits in the scheme
One component
93
Two component
108
Three components
36
Don't know anything
54
Main Reason to participate in the scheme
Urban
Rural
N
27.5
344 34.26
424
32.7
•
23.0
293 29.18
360
27.8
32.0
37.1
12.4
18.6
283 28.22
328 32.7
181 18.05
212 21.14
376
436
217
266
29.1
33.7
16.8
20.5
174
80
59.8
27.5
619
209
61.7
20.9
793
289
61.2
22.3
9
3.1
27
2.7
36
2.8
•
•
2.1
27
2.7
33
2.6
Community member asked me
12
4.1
50
5.0
62
4.8
Village head or sarpanch or the
gram sevak asked me to enroll
Others
Total
3
7
291
1.0
2.4
22.5
61
11
1004
6.1
1.1
77.5
64
18
1295
4.9
1.4
100
RSBY scheme in other states of India and similar state sponsored
health insurance schemes should ensure sufficient enrollment
and renewal by proactively educating the vulnerable sections.
There is a need for proper IEC (Information, Education and
Communication).
There is a need to reconsider design of the scheme. The scheme
uses old BPL list prepared in 2002. This prevents inclusion of
many people who are not member of that list and still belong to
BPL class. RSBY might still be continued in Maharashtra by
Ministry of Labour with modified focus along with good and
improved strategy.
The limitation of enrolling only five members per family leads to
exclusion of certain family members (intra-household exclusion).
It is essential to enroll all the members of the family.
The scheme should ensure coverage for maximum duration
possible without requiring annual renewal.
There is a definite need to monitor and evaluate currently
existing health care financing schemes at national / state / local
level.
Further research is required to get answers to many unanswered
questions like – What are the regional variations in awareness,
enrolment and utilisation of RSBY?; and so on.
We can not only depend upon health insurance schemes to
improve the health situation. There is definite need to make
overall socio economic development with more focus on health.
For this we can not depend upon private sector. Govt has to play
proactive role in this.
Bibliography
•
6
Poor planning of RSBY as it was planned at national level without
considering different social and cultural factors in Maharashtra.
Poor implementation by Ministry of Labour in Maharashtra; Here
Ministry of Health was not involved.
Poor awareness among all the expected beneficiaries in the
community especially BPL families as well as stakeholders like
implementers, policy makers, etc.
RSBY provides benefits up to only Rs. 30000/- (approx 500 US$)
per year per household which is quite less.
Ministry of Health in Maharashtra started new health insurance
scheme RGJAY since last 2-3 years with better and improved
features and benefits.
Key Recommendations
•
1535
330
308
13
Figure 2 show that RSBY has a very limited success in
Maharashtra. The proportion of awareness, enrolled population
and utilization of cards is quite low and it decreases with each
step.
Figure 3 shows that the awareness about the scheme and
enrolment for the scheme is lower in urban areas compared to
the rural areas.
It is expected that urban areas will have better awareness and
enrolment compared to rural BPL households. But the findings
show that rural BPL households are marginally better. This may
be due to the fact that the scheme was first launched in rural
areas and urban areas have better availability of health
infrastructure than rural areas.
A majority of enrolled BPL households were not clear about RSBY
eligibility criteria, covered benefits or empanelled hospitals.
However, once aware, they were highly likely to participate in the
programme.
The huge deficiencies in the awareness about the way the
scheme functions may have led to poor enrolment and utilization
by the households. The utilisation of services has remained
substantially poor.
Many households which initially enrolled did not enrol next year.
Renewal of the cards occurred quite infrequently in both urban
and rural households.
Lack of effective Information, Education and Communication
(IEC) activities from the agencies which were entrusted to enrol
the households in the given district emerged as a principal
reason for these outcomes.
•
•
•
•
•
Refer to www.healthinc.eu for more information on Health Inc., case study report on
Maharashtra and other related reports
Refer to www.rsby.gov.in for more information on RSBY in India and Maharashtra
Refer to www.jeevandayee.gov.in for more information on RGJAY in Maharashtra
Sun, Changqing (2011). ‘An Analysis of RSBY Enrolment Patterns: Preliminary
Evidence and Lessons from the Early Experience’ in India’s health insurance scheme
for the poor: Evidence from the early experience of RSBY, Centre for Policy Research,
New Delhi, pp 84-116.
Rathi, P., Mukherji, A., & Sen, G( 2012). ‘Rashtriya Swasthya Bima Yojana: Evaluating
Utilisation, Roll-out and Perceptions in Amaravati District, Maharashtra’. Economic &
Political Weekly, XLVII, 57-64.
SPEC-by-step: the development of a tool for assessing exclusion from social health
protection by Werner Soors, Tanya Seshradi, Fahdi Dkhimi, Harshad Thakur, Bart
Criel, et al (paper in process)
The Health Inc Project is funded by the European Commission’s Seventh Framework Programme FP7/2007 under grant agreement No. 261440. The views and conclusions presented
in this poster are the sole responsibility of the author and do not necessarily reflect the views of the Commission.