Addressing Social Exclusion in Health: RSBY Health Insurance in India

Babken Babajanian

20th June 2012

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Outline

1. ODI Research2. Research Focus - RSBY3. Research Questions4. Social Exclusion in India – Dimensions and Drivers6. Policy Questions

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ODI Research

• Social protection and its role in tackling social exclusion of informal workers in Asia

– 3-year multi-country study, funded by EU and AusAid– Will identify the impact of social protection interventions

on social exclusion/inclusion in 4 countries (Afghanistan, Bangladesh, India, and Nepal)

– Expected to inform policy and practice in respective countries as well as generate policy lessons for general application

– Research partner: Indian Institute for Dalit Studies (IIDS)

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Research Focus

• RSBY (Rashtriya Swasthya Bima Yojana) or National Health Insurance Scheme (2008):

– Targets BPL (Below Poverty Line) families

– Renewed every year, covers up to 5 family members

– Nominal registration fee of Rs.30

– 23.5 million BPL families enrolled; 8,300 empanelled hospitals (May 2011)

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Research Focus

RSBY– Provides free hospitalisation and specified day care

surgeries and treatments

– Maternity cover and newborn coverage

– Transportation fee of Rs.100 per hospitalisation

– No paperwork requirement

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Research Questions

• Does the RSBY health insurance scheme improve health care access and utilisation by socially excluded individuals?

• What are the main factors that influence the effectiveness of the scheme?

• Focus on socially excluded informal workers

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Social Exclusion

• SE is a state in which individuals or groups are unable to participate fully in their society and are unable to enjoy a standard of living that is considered normal in the society in which they live.

• People can be excluded from:– productive resources and economic opportunities– essential services, education and health, – social and cultural participation, – political rights, voice and representation

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Drivers of Exclusion in Health Care

• Financial exclusion is the key determinant of limited access and deprivation:– Only 10% of households have at least one member

covered by insurance (National Family Health Survey 2005-06)

– High health costs and out-of-pocket expenditure (including medicines) are the major reason for foregoing care

– Out-of-pocket inpatient care expenditures per episode as a share of income for low income groups - 140% compared to 80% for high income groups in rural areas in 2004 (cited in Balarajan et al 2011)

– Health expenses are the major cause of indebtedness

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Drivers of Exclusion in Health Care

– Ill health and health expenditures contribute to impoverishment

– In 2004-05, 39 million Indians fell into poverty as a result of out-of-pocket expenditures (Selvaraj and Karan 2009)

– Additional costs (foregone wages, transportation, food, child care, etc.)

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Drivers of Exclusion in Health Care

• Physical access to health facilities:

– Uneven concentration of services– Distance – Transport/roads

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Discriminatory Practices in Health

• Discrimination of Dalits in accessing public and private health services, involving (Sabhrawal et al 2012; Sabhrawal 2011):

– Denied admission and medical treatment

– Inadequate/poor quality medical treatment

– Discriminatory attitude

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Discriminatory Practices in Health

• Discrimination is likely to result in:

– Under-utilisation of services– Poor health– Lower productivity and diminished income– Psychological effects– Violation of citizenship rights

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Policy Questions and Implications

• It is important to tackle both financial exclusion and discrimination

• There is some evidence that RSBY tends to enhance access to inpatient care

• ODI research seeks to establish how RSBY benefits socially excluded households and addresses discrimination in health

• ODI research findings will be available in November 2012

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b.babajanian@odi.org.uk