Expanding healthcare coverage: An experience from Rashtriya Swasthya Bima Yojna

Background & objective: Given that Ayushman Bharat Yojna was launched in 2018 in India, analysis of Rashtriya Swasthya Bima Yojna (RSBY) become relevant. The objective of this study was to examine the scheme design and the incentive structure under RSBY. Methods: The study was conducted in the districts of Patiala and Yamunanagar in the States of Punjab and Haryana, respectively (2011-2013). The mixed method study involved review of key documents; 20 in-depth interviews of key stakeholders; 399 exit interviews of RSBY and non-RSBY beneficiaries in Patiala and 353 in Yamunanagar from 12 selected RSBY empanelled hospitals; and analysis of secondary databases from State nodal agencies and district medical officers. Results: Insurance companies had considerable implementation responsibilities which led to conflict of interest in enrolment and empanelment. Enrolment was 15 per cent in Patiala and 42 per cent in Yamunanagar. Empanelment of health facilities was 17 (15%) in Patiala and 37 (30%) in Yamunanagar. Private-empanelled facilities were geographically clustered in the urban parts of the sub-districts. Monitoring was weak and led to breach of contracts. RSBY beneficiaries incurred out-of-pocket (OOP) expenditures (?5748); however, it was lower than that for non-RSBY (?10667). The scheme had in-built incentives for Centre, State, insurance companies and health providers (both public and private). There were no incentives for health staff for additional RSBY activities. Interpretation & conclusions: RSBY has in-built incentives for all stakeholders. Some of the gaps identified in the scheme design pertained to poor enrolment practices, distribution of roles and responsibilities, fixed package rates, weak monitoring and supervision, and incurring OOP expenditure.

Out of pocket expenditure among Rashtriya Swasthya Bima Yojana beneficiary and non-beneficiary patients admitted to a tertiary care centre, Berhampur, India: a comparative study

Background: RSBY, a health insurance scheme, was launched by the Indian government to protect BPL families from incurring financial liabilities which are likely to occur due to hospitalization. Objectives was to compare over all OOPE among RSBY beneficiaries and non-beneficiaries and to estimate its extent during hospitalization in different domains among RSBY beneficiaries and non-beneficiaries.Methods: It was a cross-sectional study conducted for 2 months (January-February 2018) among BPL families residing in Ganjam district, Odisha. Multistage random sampling was done. Total sample size was 256, the number of beneficiaries and non beneficiaries taken was 128 each.Results: Non beneficiaries incurred higher overall OOPE higher i.e. 95.3% than the Beneficiaries and it was found to be statistically significant with x²=74.8 and P-value <0.001. Among beneficiaries out of pocket expenditure was found in 46.1% of the study population. 45.3% of beneficiaries had to borrow partially from friends and relatives to fulfil their hospital related expenses followed by 32% borrowing fully for their treatment. Among beneficiaries, most out of pocket expenditure was for life support services as they sought treatment mostly for surgical conditions.Conclusions: Health insurance coverage should be improved by increasing enrolment. People should be made aware about the services covered under the schemes.

Knowledge & Utilization of Rashtriya Swasthya Bima Yojana & Mukhyamantri Amrutam Yojana in a Block of Gandhinagar, Gujarat

Background: Major illness requiring hospitalization in poor family makes the family poorer with further tragic outcomes. In that view, Rashtriya Swasthya Bima Yojna (RSBY) by GOI and Mukhyamantri Amrutam (MA) Yojna by Gujarat Government were launched for Below Poverty Line families. Aims & Objectives: To assess knowledge and utilization regarding these two schemes amongst the registered families. Material & Methods: A community-based survey was carried out in a block of Gandhinagar using 30 clusters sampling. Sample size was calculated taking RSBY utilization rate 2.0%. Results: 98.4% had RSBY card & 83.7% had MA card. Common reasons for not having card were either “card not issued/people did not go to collect card” or “were unaware about the schemes/ card”. Only 1.5% families had valid RSBY cards. Knowledge regarding both the schemes (when & where to use, benefit amount etc.) was very poor (20- 25%). RSBY & MA utilization among valid card holders for last 1 year was 1.2% & 0.2% per enrolled member respectively in last 1 year. In both RSBY & MA, 30 – 40% beneficiaries had out of pocket expenditure, mainly towards transport & food. Few had towards medicines and/or investigations. However, most were satisfied with the services. Conclusion: Looking to the poor knowledge, it is important to carry out IEC activities to make people aware about the schemes which will help increase the utilization.

The need for better evidence to evaluate the health & economic benefits of India’s Rashtriya Swasthya Bima Yojana.

In this review the existing evidence on the impact of Rashtriya Swasthya Bima Yojana (RSBY) is discussed in the context of international literature available on health insurance. We describe potential pathways through which health insurance can affect health and economic outcomes, discuss evidence from other developing countries, and identify potential biases and inconsistencies in existing studies on RSBY impact. Given the relatively recent introduction of RSBY, lack of quality, verifiable data on utilization patterns, and the absence of reliable evaluation studies, there is a need to exercise caution while assessing the merits of the programme. Considering the enormous potential and cost of the programme, we emphasize the need for a rigorous impact evaluation of RSBY. It will not only help capture the real impact of the scheme, but may also be able to estimate the extent of systemic inefficiencies at the level of the consumer.

Innovative social protection mechanism for alleviating catastrophic expenses on multidrug-resistant tuberculosis patients in Chhattisgarh, India.

Background: Patients with multidrug-resistant tuberculosis (MDR-TB) incur huge expenditures for diagnosis and treatment; these costs can be reduced through a well-designed and implemented social health insurance mechanism. The State of Chhattisgarh in India successfully established a partnership between the Revised National TB Control Programme (RNTCP) and the Health Insurance Programme, to form a universal health insurance scheme for all, by establishing Rashtriya Swasthya Bima Yojna (RSBY) and Mukhyamantri Swasthya Bima Yojana (MSBY) MDR-TB packages. The objective of this partnership was to absorb the catastrophic expenses incurred by patients with MDR-TB, from diagnosis to treatment completion, in the public and private sector. This paper documents the initial experience of a tailor-made health insurance programme, linked to covering catastrophic health expenditure for patients with MDR-TB. Methods: In this descriptive study, data on uptake of insurance claims through innovative MDR-TB packages from January 2013 to April 2014 were collected. A simple survey of costs for clinical investigation and inpatient care was conducted across two major urban districts in Chhattisgarh. In these selected districts, three health facilities from the private sector and one medical college from the public sector with a functional drug-resistant tuberculosis (DR-TB) centre were chosen by the RSBY and MSBY State Nodal Agency to complete a simple, structured questionnaire on existing market rates. The mean costs for clinical investigations and hospital stay were calculated for an individual patient with MDR-TB who would seek services from the private or public sector. Results: A total of 207 insurance claims for RSBY and MSBY MDR-TB packages were processed, of which 20 were from private and 187 from public health establishments, covered under the health insurance programme, free of charge. An estimated catastrophic expenditure, of approximately US$ 20 000, was saved through the RSBY and MSBY health insurance mechanism during the study period. Conclusion: The innovative RSBY and MSBY MDR-TB insurance package is a step towards reducing catastrophic expenses associated with treatment for MDRTB.

Post utilization survey of RSBY beneficiaries in civil hospital, Ahmedabad: A cross sectional study.

Background: Poverty is a multi-faced wretched state of deprivation of basic need and facilities. There are different levels to its adverse influence on the individual, family and the community. Thus a Rashtriya Swasthaya Bima Yojana (RSBY) was launched to help these poverty stricken individuals. This study explores into the utilization of Rashtriya Swasthaya Bima Yojana card and their satisfaction. Aims & Objective: Our study explore the awareness level of RSBY beneficiaries with the aims and objective, (1) To analyze the socio-demographic profile and services utilized by beneficiaries; (2) To identify the problems experienced by the beneficiaries and measure the satisfaction level; and (3) Out of pocket expenditure of beneficiaries. Material and Methods: 198 patients were registered between the periods of 01/11/2012 to 28/02/2013 due to some reason 180 beneficiaries were telephonically interviewed about their experience by a pre-tested and pre-designed Performa. The data was collected and analyzed in epi info 7. Results: Male: Female ratio of beneficiaries is 1.4:1. Mean age of beneficiary was around 36 years. 80% beneficiaries were fully satisfied with the services. All the beneficiaries reported that they got the card easily without any hassle. They were not aware about all the benefits of RSBY so they had to spend out of pocket money for some services. Conclusion: RSBY beneficiaries were mostly satisfied with the services provided but there was a major lag in their knowledge regarding the benefits provided under RSBY. They were unaware regarding all benefits under RSBY which they can avail from the scheme. Thus IEC activities should be enhanced to increase the awareness among the RSBY card holders so that they can use better service for themselves and their families.

Is RSBY India’s platform to implementing universal hospital insurance.

Background & objectives: In 2008, India’s Labour Ministry launched a hospital insurance scheme called Rashtriya Swasthya Bima Yojana (RSBY) covering ‘Below Poverty Line’ (BPL) households. RSBY is implemented through insurance companies; premiums are subsidized by Union and States governments (75 : 25%). We examined RSBY’s enrolment of BPL, costs vs. budgets and policy ramifications. Methods: Numbers of BPL are obtained by following criteria of two committees appointed for this task. District-specific premiums are weighted to obtain national average premiums. Using the BPL estimates and national premiums, we calculated overall expected costs of full roll-out of the RSBY per annum, and compared it to Union government budget allocations. Results: By March 31, 2011, RSBY enrolled about 27.8 per cent of the number of BPL households following the Tendulkar Committee estimates (37.6% following the Lakdawala Committee criteria). The average national weighted premium was ` 530 per household per year in 2011. The expected cost of premium to the union government of enrolling the entire BPL population in financial year (FY) 2010-11 would be ` 33.5 billion using Tendulkar count of BPL (or ` 24.6 billion following Lakdawala count), representing about 0.3 per cent (or 0.2%, respectively) of the total union budget. The RSBY budget allocation for FY 2010-11 was only about 0.037 per cent of the total union budget, sufficient to pay premiums of only 34 per cent of the BPL households enrolled by March 31, 2011. Interpretation & conclusions: RSBY could be the platform for universal health insurance when (i) the budget allocation will match the required funds for maintenance and expansion of the scheme; (ii) the scheme would ensure that beneficiaries’ rights are legally anchored; and (iii) RSBY would attract large numbers of premiumpaying (non-BPL) households.