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Health Insurance for the Poor, Or Privatization by Stealth? a Study on the Rashtriya Swasthya Bima Yojana (RSBY) in India

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Health Insurance for the Poor, Or Privatization by Stealth? a Study on the Rashtriya Swasthya Bima Yojana (RSBY) in India Health Insurance for the Poor, or Privatization by Stealth? a Study on the Rashtriya Swasthya Bima Yojana (RSBY) in India The Harvard community has made this article openly available. Please share how this access benefits you. Your story matters Citation Rana, Kumar. 2017. Health Insurance for the Poor, or Privatization by Stealth? a Study on the Rashtriya Swasthya Bima Yojana (RSBY) in India. Master's thesis, Harvard Medical School. Citable link https://nrs.harvard.edu/URN-3:HUL.INSTREPOS:37365173 Terms of Use This article was downloaded from Harvard University’s DASH repository, and is made available under the terms and conditions applicable to Other Posted Material, as set forth at http:// nrs.harvard.edu/urn-3:HUL.InstRepos:dash.current.terms-of- use#LAA HEALTH INSURANCE FOR THE POOR, OR PRIVATIZATION BY STEALTH? A STUDY ON THE RASHTRIYA SWASTHYA BIMA YOJANA (RSBY) IN INDIA KUMAR RANA A Thesis Submitted to the Faculty of The Harvard Medical School in Partial Fulfillment of the Requirements for the Degree of Master of Medical Sciences in Global Health Delivery in the Department of Global Health and Social Medicine Harvard University Boston, Massachusetts. May, 2017 Thesis Advisor: Dr. Joia Mukherjee Kumar Rana Health insurance for the poor, or privatization by stealth? A study on the Rashtriya Swasthya Bima Yojana (RSBY) in India Abstract Avoidable suffering and deaths find their roots in the multiple divisions of society on the basis of race, class, ethnicity, gender and religion. While public inaction in the health sector leads to preventable morbidities and premature mortalities among the most disadvantaged populations, who often accept the disasters as destiny, certain “targeted” actions can worsen the situation. The Rashtriya Swasthya Bima Yojana (RSBY) in India is a case in hand. In India, like many developing countries, out-of-pocket expenditure on health care has a huge financial impact on the poor. As a partial response to the problem, the Government of India launched the RSBY for the poor. The RSBY covers costs for the Below Poverty Line (BPL) and other marginalized families who are enrolled in the program, allowing them access to hospitalized care up to Rs 30,000 (less than $500) in an institution of their choice selected from a list of accredited hospitals and health centers. The present study finds that though announced to serve the poor, in practice it allows the private players to subvert the health sector for their own profit. And for the majority those who have been reached by the RSBY, the experience of getting healthcare under the scheme point towards a delivery which is neither ethical nor equitable. While for a small section of the population the RSBY was found useful, for most of them it hardly had any relevance, and for some it was even counterproductive. People are living in a helpless state, and for them, health equity is a distant dream. The implementation of the RSBY, in the name of helping people avoiding catastrophic health expenditure, has added to the inequitable state of healthcare in particular and social arrangements in general. It seems, the government has successfully made the people believe that ii there is no other option than to depend upon the private market for healthcare. The study finds that, both the design and implementation of the program appear to be a program of complete privatization of health care by stealth. iii Table of Contents Acknowledgements ........................................................................................................................ vi Introduction ..................................................................................................................................... 1 Partial healthcare and opportunity deprivation of the poor ......................................................... 1 Why health equity?...................................................................................................................... 4 Social division and health in India .............................................................................................. 6 Castes, tribes and religious minorities in India ........................................................................... 8 Methods, sample and limitations of the study .............................................................................. 25 Pattern of disease and treatment: reflections from the field ......................................................... 79 Ground level processes and outcomes of the RSBY .................................................................. 100 Conclusion: Insured Health or ensured profit? ........................................................................... 133 References ................................................................................................................................... 152 Appendices .................................................................................................................................. 169 Tables Table 1: Differential health status and health provision in India .................................................... 8 Table 2: Distribution of the sample across villages ...................................................................... 29 Table 3: Distribution of sampled households according to social identity ................................... 31 Table 4: Distribution of sampled households according to occupation ........................................ 32 Table 5: Distribution of sampled households according to social identity and occupation.......... 33 Table 6: Distribution of sampled households according to educational status ............................. 34 Table 7: The process of the study ................................................................................................. 34 Table 8: Measures taken to reduce validity threats to the study ................................................... 38 Table 9: A socio-economic profile of the study area .................................................................... 44 Table 10: Select Health Indicators: Birbhum and West Bengal. Figures are in percentages ....... 45 Table 11: Distribution of Diseases treated in public facilities in Birbhum District ...................... 45 Table 12: Distribution of episodes of communicable diseases registered/treated in public facilities ......................................................................................................................................... 46 Table 13: Distribution of episodes of non-communicable diseases registered/treated in public facilities ......................................................................................................................................... 48 Table 14: Availability and shortages of Doctors and GNMs/ANMs in position* ........................ 51 Table 15: Services availed in the public facilities of Birbhum in the month of August 2016 ...... 54 Table 16: Differential Achievements: Select indicators ............................................................... 55 Table 17: Vacancies of health personnel in India and West Bengal: 2005-2016 ......................... 62 Table 18: Per-thousand reported illness and hospitalization: Kerala-Jharkhand contrast ............ 74 Table 19: Occurrence of outpatient cases in the year preceding the survey ................................. 81 Table 20: Frequency of visits by various health personnel to households ................................... 97 Table 21: Services offered by health workers............................................................................... 98 Table 22: Population hospitalized for illness by availability of RSBY card and gender ........... 103 Table 23: Distribution of patients who availed treatment under RSBY by gender and type of hospital in Birbhum district between September 2015 and August 2016 ................................... 103 Table 24: Type of hospitals visited by members of surveyed households covered by RSBY ... 105 Table 25: Distribution of hospitalization by procedures and type of hospitals availed by RSBY enrollee of Birbhum district in the year April-2015 to March 2016 ........................................... 112 Table 26: Distribution of hospitalization cases according to availability of RSBY card and type of ailment .................................................................................................................................... 117 iv Table 27: Insurance coverage and out-of-pocket spending in hospitalized treatment ................ 121 Table 28: Pattern of out of pocket expenditure for RSBY and non-RSBY patients................... 124 Table 29: Summary of allowable procedures under RSBY and minimum and maximum rates fixed for them by the government ............................................................................................... 126 Table 30: Block wise health provision in Birbhum district ....................................................... 169 Table 31: Linear Regression with RSBY Coverage as an Independent Variable*..................... 170 Table 32: Coverage of RSBY and Some Selected Indicators ..................................................... 170 Figures Figure 1: Design of the study ........................................................................................................ 26 Figure 2: India, West Bengal and Birbhum .................................................................................. 40 Figure 3: Sampled blocks in Birbhum district
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