A STUDY TO ANALYSE IMPLEMENTATION OF RSBY IN

CHHATTISGARH

Public Health Resource Network (PHRN)Presentation at EPHP11th December 2010

Authors: Sulakshana Nandi[1], Kanica Kanungo[2], Md. Hashim Khan[3], Haripriya Soibam[4], Tarang Mishra[5], Samir Garg[6].

[1] State Convener, Public Health Resource Network (PHRN), Chhattisgarh

[2] Student, MBA Health Management. Jamia Hamdard

[3] Student. MBA Health Management. Jamia Hamdard

[4] Senior Programme Co-ordinator, Public Health Resource Network (PHRN), New Delhi

[5] Member, Public Health Resource Network (PHRN)

[6] Member, Public Health Resource Network (PHRN)

OBJECTIVE OF THE STUDY

To analyse implementation of RSBY in Chhattisgarh in terms of coverage, enrollment, hospitalisation and awareness levels of the beneficiaries

To find out of pocket expenditure incurred, if any in Public and Private sector facilities by beneficiaries of RSBY

WHAT IS RSBY?

Insurance scheme launched by Ministry of Labour and Employment, Government of India

Started from 1st April 2008, in Chhattisgarh cards distributed from 2009

Provision: Provides health insurance coverage of Rs.30000/- annually for each

Below Poverty Line (BPL) family Coverage of up to five members of the family No age limit Provision of pre and post hospitalization expenses Pre-existing diseases to be covered Includes 708 procedures and 20 Day care procedures Supposed to be cashlessPremium: Beneficiaries need to pay only Rs.30/- as registration fee Central and State Government pay the premium to the Insurer

(around Rs.750 per card, total Rs73 Crore in Chhattisgarh) Central government pays 75% of the premium and State pays 25%

METHODOLOGY Primary data- interviews of 102 people utilising

RSBY in May & June 2010. Secondary data- from official RSBY Website

http://rsby.gov.in/Statewise.aspx?state=13- Selection of district with highest hospitalisation

rate-Durg- Selection of hospitals

2 Public hospitals with high hospitalisation rates 5 Private hospitals- convenience sampling among high

hospitalisation rates- Selection of Beneficiaries- 52 in public and 50 in

private facilitySample size- 4% of Total Hospitalised cases in Durg

district (till 30th April 10) and2% of Total Hospitalised cases in Chhattisgarh (till

30th April 10)

COVERAGE

Need to cover the excluded- NREGS and other unorganised sector workers

Leaving out the poorThree out of these 6 women have a BPL card and therefore are eligible

under RSBY and the rest three are not- can you spot them?

COVERAGE

Enrollment too slow- only 44% of eligible beneficiaries enrolled in first two years of implementation (till April 2010)

Enrollment being done by private agencies- no transparency or grievance redressal mechanisms

37% of respondents had above five members in their family- Whom to leave out?

AWARENESS ABOUT RSBY

75% came to know about the scheme through panchayat members/parshad

Most aware of the amount covered Only 25% aware of card validity period Only 31% aware of the number of family

members covered

ENROLLMENT PROCESS Place of enrollment- local school/panchayat

bhawan No extra travel costs Both thumbprints and photo taken 99% not given RSBY brochure or list of

hospitals Information given only about a certain private

hospital No extra payment (other than Rs 30) for card Only 4 percent got the smart card on the

same day Average days taken to receive the smart

card- 29 For 8% families, members other than the head

of family were left out

EMPANELMENT OF HOSPITALS 147 Private and 181 Public hospitals empanelled (Nov10) Tribal/remote districts are half the number of total districts

but only 13% of the total private hospitals empanelled are in these districts

No private hospitals empanelled in remote districts like Kanker, Koriya, Kawardha and Dantewada- hence no additional facilities through RSBY

40% of the private hospitals empanelled are in Raipur which anyway has functional public health facilities

Some hospitals (mostly CHC) empanelled do not have functional in patient facilities- these CHCs need to be improved

HOSPITALISATION Abysmally low rate of hospitalisation in Chhattisgarh- 5 per

1000 enrolled Claims ratio= claim amount paid/premium earned by

Insurance AgencyLiterature references show that the Claims ratio in health insurance should be around 80% Claims ratio for Durg : 8.9% Claims ratio for Chhattisgarh : 2.8%

(data till 30th April 10)

Durg district data (till May10)- 18% of cases in Public hospitals - 82% of cases in Private hospitals - 11% of cases rejected cases (rejection rate 15% in Public

and 10% in Private hospitals)

HOSPITALISATION 77% of respondents in public hospital were from rural areas

and 66% of respondents in private were from urban areas Mitanins (ASHAs) significantly referring to public hospitals Reasons for coming for treatment mostly general weakness

and feverReason for coming to Hospital %

Weakness 33

Fever 18

Surgical 13

Abdominal Pain 10

Accident 9

ENT 6

Diarrhea/Dysentry/Vomiting 5

C-Section 3

Paralysis 2

Aids 1

  100

HOSPITALISATION Diagnostic tests prescribed to 63%

- 40% in public hospital- 86% in private hospital

75% of the cases, tests done in the hospital itself

For 60% medicines available in the hospital. Rest 40%, RSBY nodal person or Doctor suggested

names of medicines shops

Average days of hospitalisation recorded - 5 25% of the patients not hospitalised but recorded

as hospitalised Private sector discrimination against the poor

fixing quotas of beds

HOSPITALISATION

77% had utilized RSBY for more than one episode

37% not aware of the amount of money blocked by the hospital.

Average amount blocked = Rs 6622- Private hospital= Rs. 7416- Public hospital = Rs. 4988.

99% received transport charges of Rs.100 from the hospital

59% not given RSBY receipt 90% given medicines at discharge

OUT OF POCKET EXPENDITURE 37% incurred out of pocket expenditure 58% going to private hospitals incurred out of

pocket expenditure 17% going to public hospitals incurred out of

pocket expenditure Average out of pocket expenditure= Rs 686

- In public hospital= Rs 309- In private hospital= Rs 1078

Out of the total expenditure in private sector, 63% of the amount was incurred on items not disclosed by the hospital to the patients

OUT OF POCKET EXPENDITURE

Item Average amount spent (Rs)

Public Private Total

Food 117 10 65

Medicines 33 225 127

Diagnostics 15 145 79

Tip to Nurse 7 2 4

Money to Doctor 137 23 81

Others - 674 330

Total 309 1078 686

TRANSPARENCY AND ACCOUNTABILITY ISSUES Incentives to Health staff and Rogi Kalyan Samitis-

paying the well paid, encouraging false and higher claims

Transparency: Names enrolled not available, Case wise data not available, hospital wise data also kept secret, reasons for rejection not disclosed even to hospitals

No grievance redressal mechanism- if you don’t get RSBY card, if photo/name is wrongly printed, if any family members have been left out, if empanelled hospital refuses to admit, if TPA tells that no money left in the card even if never been used (i.e. Card is ‘cashless’), if hospital/TPA retains the smart card

CONCLUSIONS AND RECOMMENDATIONS Health insurance route to deliver services- the experience so

far in Chhattisgarh : Highly cost ineffective-only a handful of patients got any

significant treatment and the government ‘lost’ 73 crore rupees

Accountability of public health system compromised Out of pocket expenditure still persists despite the ‘cashless

scheme’ Private sector is still unregulated

The two critical questions to ask are: Is RSBY leading to the poor getting access to free and good

quality health care? Is it a cost effective model?

This study throws serious doubts on the above, hence it is necessary to undertake larger studies across many states to understand this further

THANK YOU