CHRISMED Journal of Health and Research

ORIGINAL ARTICLE
Year
: 2021  |  Volume : 8  |  Issue : 3  |  Page : 149--154

What went wrong with Rashtriya Swasthya Bima Yojana: An evaluation of the scheme in rural areas of a District in West Bengal, India


Suman Das1, Somnath Naskar2, Dilip Kumar Das2,  
1 Department of Community Medicine, Malda Medical College, Malda, West Bengal, India
2 Department of Community Medicine, Burdwan Medical College, Bardhaman, West Bengal, India

Correspondence Address:
Suman Das
Asanda, P.O. Dehibhursut, Howrah - 712 408, West Bengal
India

Abstract

Context: Rashtriya Swasthya Bima Yojana (RSBY) had been implemented in India to improve access to quality health care, reducing out-of-pocket (OOP) and catastrophic health expenditure. Aims: We aimed to evaluate the current status of RSBY in rural areas of a district in West Bengal. Settings and Design: A cross-sectional study was done in erstwhile “Burdwan Health District,” West Bengal. Subjects and Methods: This study was conducted from September 2016 to August 2018. Primary study units were below poverty line (BPL) families; members of selected families comprised the study subjects. The calculated sample size was 350 families, out of which 324 could be studied covering 22 blocks following multistage sampling technique. Data were collected by interviewing head of the family (HOF). Statistical Analysis Used: Descriptive statistics and logistic regression were used for statistical analysis. Results: Awareness on different benefits and features of RSBY varied widely from 6.8% to 97.2%. Overall current enrollment rate was 79.6%, while 20.4% of families remained nonenrolled. On the multivariable logistic regression, type of family, socioeconomic status of the family, and education of HOF were significant variables predicting nonenrollment. Among enrolled BPL families, 24.0% and 8.1% utilized services under RSBY since their enrollment and in the last 1 year, respectively. OOP expenditure, nonprovision of free food, inadequate posthospital treatment, inattentiveness of doctor and hospital staff, etc., were major difficulties faced in utilization of services. Conclusions: Nonenrollment in RSBY was quite high in the area with few predicting variables. Low level of utilization of services was also noted with some obstacles.



How to cite this article:
Das S, Naskar S, Das DK. What went wrong with Rashtriya Swasthya Bima Yojana: An evaluation of the scheme in rural areas of a District in West Bengal, India.CHRISMED J Health Res 2021;8:149-154


How to cite this URL:
Das S, Naskar S, Das DK. What went wrong with Rashtriya Swasthya Bima Yojana: An evaluation of the scheme in rural areas of a District in West Bengal, India. CHRISMED J Health Res [serial online] 2021 [cited 2022 May 28 ];8:149-154
Available from: https://www.cjhr.org/text.asp?2021/8/3/149/339040


Full Text



 Introduction



In India, despite a level of economic growth, millions of country's poor people are forced to make catastrophic payments in private or public health-care facilities or both to deal with medical emergencies and to access other health-care services with out-of-pocket (OOP) expenditure.[1],[2] Alarmingly, as high as 89.2% of private expenditure on health in India is through OOP expenditure, which is one of the highest in the world.[3],[4] Such direct payments as OOP expenditure unquestionably create inequity as overservicing and underservicing for people who can pay and cannot pay, respectively. On the other hand, another challenge is fulfilling the demands and expectations of services, which the public sector often fails to provide.[5]

In such context, to fulfill the motto of social security and health-care assurance for all, the Government of India introduced Rashtriya Swasthya Bima Yojana (RSBY) with collaborative involvement of both public and private sectors. Since 1st April 2015, Ministry of Health and Family Welfare had implemented RSBY in all the districts of the States in India to mitigate the financial risk and to improve access to quality health care among below poverty line (BPL) families and unorganized sector workers.[6]

This scheme had provision for demand financing, cashless service reimbursable to a provider on a predetermined package rate as a part of the universal health-care system.[6] Beneficiaries under RSBY were entitled to hospitalization coverage of up to ₹30,000/- on a family floater basis with freedom of choice among accredited/empanelled government and private hospitals.[4],[6] While quality health care is subject to regular monitoring, how far the targeted population getting enrolled, utilizing services under RSBY, and facing difficulties or obstacles during utilization are important aspects to be evaluated. Although few evaluation studies on RSBY in some states of the country have been reported, no such study has been conducted in West Bengal. In this backdrop, the present study was conducted to assess the current status of RSBY in respect to enrollment, awareness, extent and pattern of utilization, any OOP expenditure, difficulties faced by the beneficiaries, and the various associated factors in rural areas of erstwhile “Burdwan Health District,” West Bengal.

 Subjects and Methods



A cross-sectional study was conducted in rural areas of erstwhile Burdwan Health District comprising 3 subdivisions (Kalna, Katwa, and Sadar) with 22 community development blocks, from September 2016 to August 2018 with actual data collection for 1 year (May 2017–April 2018). The 22 community development blocks comprised the study area.[7]

Identified BPL families permanently residing in the study area for at least 1 year, were included as study unit. All members of the study unit (BPL families) comprised the study subjects; head of the family (HOF) was the primary respondent. BPL families not willing to participate and selected BPL families not found by two repeated visits for assessment were excluded from the study.

The sample size was calculated using enrollment rate of 71% in erstwhile Burdwan Health District as per government reports, 95% confidence level, and a relative precision of 10%.[6] The minimum required sample size was calculated as n = ([Z1−α/2])2 × P × [1 − P])/d2= ([1.96]2 × 0.71 × 0.29)/(0.1 × 0.71)2 = 156.85 ≈ 157. Considering a design effect of 2 for multistage sampling and an anticipated dropout of 10%, the final sample size came to be 314 + 31.4 = 345.4 ≈ 346.

Multistage sampling was followed to select the study units. First, at least 20% of the blocks from each subdivision of Burdwan Health District were included as follows: 3 out of 12 blocks from Sadar subdivision, 1 out of 5 blocks from Katwa subdivision, and 1 out of 5 blocks from Kalna subdivision through selection by simple random sampling. Thus, a total 5 blocks were selected. In the second stage, from the lists of gram panchayats (GPs) in each of the selected blocks, two GPs were identified randomly. Thus, a total of 10 GPs were selected. In the third stage, an equal number of BPL families were included from each of the 10 identified GPs. From the sampling frame of BPL families in each of the 10 identified GPs, 35 BPL families were selected by simple random sampling. Thus, a total of 350 BPL families were included primarily as study units, and all the family members of these selected units comprised the study subjects.

Ethical clearance was obtained from the Institutional Ethics Committee of Burdwan Medical College, Burdwan, West Bengal. Prior to data collection, the permission and cooperation were sought from district administrative authorities. Informed consent was obtained from each study respondent. Confidentiality and anonymity of information were maintained. HOF was the primary respondent or any adult member in the absence of HOF. A predesigned, pretested schedule was administered to collect data regarding sociodemographic characteristics, awareness related to RSBY, enrollment and utilization of RSBY by interviewing the subjects as well as reviewing available relevant records.

Data were analyzed using the Statistical Package for the Social Sciences (SPSS) [IBM SPSS Statistics for Windows, Version 20.0. (IBM Corp., Armonk, New York, USA]). A logistic regression model was generated using the SPSS software where enrollment of study units (BPL family) was coded as “0” and nonenrollment of study units was coded as “1.” The variables related to study units and HOF which were used in bivariate analysis, were entered in multivariable logistic regression model (binary logistic) by “Enter” method.

 Results



Out of 350 sampled BPL families, finally 324 could be studied, with 7.4% (26/350) dropped out. Twenty-six BPL families could not be studied as the families were not found even by repeated visits.

Most of the BPL families (77.5%) had five or less than five family members; 56.2% were nuclear family and 63% were belonging to lower socioeconomic class according to modified BG Prasad scale. Majority of the HOF were Hindu (79%) by religion, 41% belonged to Scheduled Caste, 60.1% had formal education, while 27.5% were illiterate [Table 1].{Table 1}

Overall, there were 1385 study subjects in the 324 BPL families with an average family size of 4.3. Majority of total study subjects were male (53.8% (745]). Again, 4.1% (57) of total study subjects were under-fives while 18.3% (254) were adolescents and 8.9% (123) were elderly. About one-fourth of the total study subjects (26.5% (367]) were agricultural laborers, 20.9% (290) were students, 27% (374) were homemakers, and 1.3% were not currently working.

Awareness regarding Rashtriya Swasthya Bima Yojana

Awareness regarding different aspects of RSBY scheme was assessed by interviewing one respondent from each of the studied BPL families. All the respondents (100%) heard about RSBY; the most commonly reported sources of information regarding RSBY were panchayat personnel (100%) followed by neighbors, relatives, and friends (43.4%) and health workers (17.3%). Awareness on benefits and features of RSBY are presented in [Table 2]. Free health care on hospitalization in RSBY impaneled hospitals was known to 97.2% of respondents, while only 6.8% were aware about free pre- and posthospital treatment [Table 2].{Table 2}

Enrollment status and Rashtriya Swasthya Bima Yojana-related issues

Overall current enrollment rate was 79.6% (258) among total study units; 66 (20.4%) BPL families remained nonenrolled, among whom 40 (12.4%) BPL families were ever enrolled but not renewed and 26 (8%) were never enrolled.

For more than half of the study units (53.4%), the enrollment venue was located at a distance of ≤ 2km [Table 1]. Further analysis revealed the following findings. Duration of enrollment among the currently enrolled study units ranged from 4 years to 6 years with a mean (standard deviation) duration of 6.21 (±1.455) years. Two hundred and fifty-two (97.7%) currently enrolled study units were provided smart card and booklet on spot during enrollment, while the rest (2.3%) were provided the same within 1 week. The smart card was available to 256 (99.2%) currently enrolled study units, while booklet containing services claiming process and list of impaneled hospitals was not available to 8.1% (21).

Common reported reasons for never enrollment of study units were HOF being out of station during the time of enrollment (53.8%), being unable to show the necessary documents at enrollment station (26.9%), and being unaware about the enrollment date (3.9%). HOF being out of station during the renewal/enrollment session (55%) and availability of similar facilities/benefits in general government health services (17.5%), etc., were commonly reported reasons for nonrenewal of study unit.

In 258 currently enrolled study units, out of 1195 study subjects, 991 (82.9%) were enrolled; 204 (17.1%) were nonenrolled. Among under-five age group, as high as 71.7% (38/53) were nonenrolled; on the contrary, among elderly age group, 8% (16/200) were nonenrolled in the enrolled study units. The most common reported reason for nonenrollment of study subjects was five-person enrollment limit from each BPL family under RSBY (54.9%) followed by being at workplace at the time of enrollment (12.3%), being out of station at the time of enrollment (10.3%) and no given priority because of too young age (5.9%), etc.

The difference of nonenrollment of BPL families was found significantly associated with certain characteristics, i.e. type of family (odds ratio [OR] [95% confidence interval (CI)] =2.709 [1.482–4.952]), socioeconomic status of family (OR [95% CI] =2.298 [1.328–3.978]), caste of HOF (OR [95% CI] =3.006 [1.149–7.865]), and education of HOF (OR [95% CI] =3.168 [1.810–5.546]). In the multivariable logistic regression model, finally type of family (adjusted odds ratio [AOR] [95% CI] =3.486 [1.597–7.610]), socioeconomic status of family (AOR [95% CI] =2.010 [1.075–3.757]), and education of HOF (AOR [95% CI] =4.546 [2.437–8.480]) remained a significant factor in predicting nonenrollment among BPL families [Table 1]. Multivariable logistic regression model was significant as revealed by the omnibus Chi-square statistic (χ2 = 46.797, P < 0.001). Hosmer and Lemeshow test was nonsignificant (0.372), indicating that model was good fit. 21.1% variance of dependent variable was explained by the model, and it was depicted by Nagelkerke R2 = 0.211.

Utilization of Rashtriya Swasthya Bima Yojana

Analysis showed that among enrolled study units, 62 (24.0%) and 21 (8.1%) BPL families utilized services under RSBY since their enrollment and in the last 1 year, respectively. The utilization of RSBY at individual level is depicted in [Table 3]. Analysis among subjects who availed the benefits of hospitalization (71) under the scheme, explored that proportion was more among females (43 [60.6%]), individuals belonging to age group ≥60 years (27 [38.1%]), Hindu religion (55 [77.5%]), Scheduled Caste (29 [40.8%]), joint family (44 [62.0%]), and lower socioeconomic class (54 [76.1%]) as compared to their counterparts.{Table 3}

Among the 22 hospitalized study subjects in the last 1 year, 95.5% availed free health care on hospitalization, 100% availed free drug on hospitalization, 63.6% availed free food, 86.4% availed free investigations, and only 9.1% availed free posthospital treatment adequately.

Difficulties faced in availing services under RSBY were explored among 22 hospitalized study subjects who utilized it in the last 1 year, and the findings are presented in [Table 4]. OOP expenditure was reported by 90.9% (20) of hospitalized study subjects in the last 1 year. On further analysis, it was found that, among all the study subjects who were incurred with OOP expenditure in the last 1 year, every one (100%) had to purchase medicine on discharge; 40% had to purchase food; 15% and 5% had to pay for diagnostic tests and doctor's visit, respectively. The incurred OOP expenditure ranged from ₹100/- to ₹3000/- with a median (interquartile range [IQR]) value of ₹200/- (112.5–300).{Table 4}

 Discussion



Overall purpose of RSBY was enabling BPL families to access to modern-day health-care facilities during hospitalization using a smart card. Awareness about different aspects of the scheme and universal enrollment were essential prerequisites for the said purpose as well as they were supposed to ensure desired benefit to the BPL families and better functioning of the scheme.

In the present study area, general awareness about this scheme was universal and like most of the studies across country.[8],[9],[10] Panchayat personnel played a major role to generate general awareness about RSBY. Almost universal involvement of panchayat in the study area might be due to the implementation of the scheme since 2009 and effort of intersectoral coordination. However, this study found higher awareness about free health care on hospitalization (97.2%) in comparison to other studies in different states, namely Haryana (49%), Gujarat (53%), Jaunpur (59%), and Himachal Pradesh (65%).[8],[9],[11],[12] On the other hand, awareness regarding free pre- and posthospital treatment (6.8%) was reported to be much lower than Jaunpur, Uttar Pradesh (53%), and Shimla and Kangra districts of Himachal Pradesh (36% of hospitalized respondents).[8],[12] Awareness about other aspects of RSBY was also reported to be not universal in the present study like other available studies.[4],[8],[9],[11],[12],[13] These findings highlight the lack of adequate communication in the study area.

According to the latest government available report (July 2018), 56.7% of BPL families were enrolled under this scheme in West Bengal.[6] Compared to this overall enrollment rate, the present study in Burdwan revealed that a higher proportion of BPL families (79.6%) were currently enrolled under RSBY during May 2017–April 2018. Few evaluation studies in some districts of other states also reported a much lower proportion of enrollment, namely 21.6% in Maharashtra during 2010–2012, 38% in Haryana in March 2011, 51% in Uttar Pradesh in 2009, 57.13% in Chhattisgarh in May 2012, 59.1% in Gujarat in March 2011, 68% in Karnataka during 2010–2011, and 39% at Amravati district of Maharashtra in 2010.[9],[10],[11],[12],[14],[15],[16] However, these differences should cautiously be compared and interpreted as the enrollment rates of different studies were of 6/7 years back.

Remarkably, it is of more concern that a substantial proportion of families remained currently nonenrolled due to HOF being out of station at the time of enrollment, unable to show the necessary documents at enrollment station, unaware about the date of renewal/enrollment session as well as availability of similar benefits like RSBY in general government health services, etc., in the present study area. The study in select districts of Bihar, Uttarakhand, and Karnataka and the study by Rajasekshar et al. in Karnataka primarily revealed almost similar reasons for nonenrollment.[4],[15] However, a study at Shimla and Kangra districts in Himachal Pradesh noted that majority of the nonenrolled respondents (37%) could not understand the scheme properly.[8] Besides nonenrollment of family as a unit, normative feature of five-person enrollment limit from each BPL family was noted as an important deciding factor regarding nonenrollment of individual family members.

Regression analysis revealed that nonenrollment was influenced by type of BPL families, socioeconomic class of BPL families, and education of HOF. However, Harshad Thakur in Maharashtra reported that enrollment was less among SC and ST castes compared to other categories.[14]

The findings regarding provision and availability of smart card and booklet were certainly better in the present study area than other studies across country.[9],[11],[13],[14],[15] Still, not-upto-the-mark enrollment indicates that there might be some procedural difficulties and constrains.

Even after nonenrollment, utilization of RSBY in the present study was not so promising. It showed that utilization was much lower at family level than Himachal Pradesh (24% vs. >90%) as well as at the individual level in Jaunpur (7.2% vs. 18%).[8] However, in the present study higher utilization was noted than the study conducted in Maharashtra (0.3%) and in Pathan, Gujarat (4%).[14],[17] The differences might be due to the different selection and sampling techniques followed in the studies.

The present study showed that during the entire period since enrollment, private hospitalization was more preferred than government hospitalization under RSBY (83.1% vs. 14.1%) among the hospitalized study subjects. On the contrary, more hospitalization under RSBY in government hospital than private hospital was noted in Himachal Pradesh (81.4% vs. 1.9%), in Gujarat (52% vs. 7%).[8],[9] Although corroborating with the present study, more private health facilities than government health facilities were availed by enrollees across three states Bihar, Uttarakhand, and Karnataka in India (78.8% vs. 24.4%) and in Chhattisgarh (53.1%–55.1% vs. 44.9%–46.9%).[4],[10] However, such differences in preference for private or government facilities for hospitalization had not been explored in any of these studies.

Among the hospitalized study subjects, the present study revealed that, except for free drug on hospitalization, all other free benefits were not provided appropriately. Similar observations were also reported at select districts in Bihar, Uttarakhand, and Karnataka, in Chhattisgarh as well as in Jaunpur.[4],[10],[12]

In the present study, 90.9% of hospitalized study subjects had incurred money for availing treatment under RSBY with median (IQR) amount of expenditure of ₹200/- (112.5–300) and such OOP expenditure also noted in Amravati district, Maharashtra, by Rathi et al.; in Durg district, Chhattisgarh, by Nandi et al.; in Chhattisgarh by the Council for Tribal and Rural Development; and in Kerala by the Research Institute. Besides, the present study found that mostly the OOP expenditures were in private health facilities.[10],[13],[16],[18]

Other difficulties in utilization of the services like nonattendance of the staff and less follow-up visits, etc., were also of concern. These issues need to be better explored for effective implementation and acceptance of the scheme among the targeted BPL families.

Despite sincere effort, few limitations could not be avoided such as chance of recall bia of study subjects and exclusion of transport cost in calculation of OOP expenditure.

 Conclusions



Such a scheme was adopted with a holistic approach to avoid public and private hospital discrimination, to ensure free benefits as well as to eliminate OOP expenditure etc. But more preference of private health facilities and OOP expenditure indicate the existence of inherent issues in the scheme leading to an obstacle to its success. It highlights insufficient involvement of different stakeholders as well as lack of adequate communication at BPL family level, which might have largely contributed to nonenrollment/nonrenewal in the scheme also. Possibly, all these issues played a role in withdrawal of this scheme within 10 years of implementation and subsumed under Ayushman Bharat on August 2018.[6],[19] However, the lessons learned might be duly considered in implementation of newer schemes.

 Acknowledgment



We sincerely acknowledge the cooperation of Dr. Bijay Prasad Mukhopadhyay, Former Deputy CMOH-I, Purba Bardhaman, and various functionaries of Purba Bardhaman Rashtriya Swasthya Bima Yojana (RSBY cell).

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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