2 3

Table of Contents

1. ExecutiveSummary 6

2. Introduction 7

2.1. Health and Consequences of Diseases 9

2.2. Health Insurance in India 10

2.3. Rashtriya Swasthya Bima Yojana 12

2.4. Poorest Areas Civil Society Programme & RSBY 16

3. PACSIntervention 20

3.1. Phase1:CreatingEnablingEnvironment 20

2.1.1. Advocacy with the Government 20

2.1.2. SelectionofCSOs 21

2.1.3. OrientationandTrainingofCSOs 22

3.2. Phase2:Implementation 23

2.2.1. Pre-EnrolmentStage 25

2.2.2. EnrolmentStage 36

2.2.3 Post-EnrolmentStage 39

4. ConclusionandLessonsLearnt 44

5. Annexures 47

Annexure1:AboutPACS 47

Annexure2:ListofCSOsWorkingonRSBYunderPACS 48

ListofFigures

Figure1:TimelineofhealthinsuranceinIndia 11

Figure2:RSBYstakeholders 13

Figure3:Theeightsub-processesofRSBY 15

Figure4:Supplysideanddemandsideinterventions 19

Figure5:PACSimplementionstructure 22

Figure6:ActivitiesunderRSBY 24

Figure7:PACSinterventionunderRSBY 44

ListofTables

Table1:Percentagedistributionofpersonsbycoverageofhealthexpendituresupport foreachquintileclassofUMPCE 12

Table2:Stakeholdersandtheirroles 14

ThisdocumentisapartoftheKnowledgeProductSeriesofthePoorestAreasCivilSociety(PACS)Programme.ThisdocumentwasdevelopedasanoutcomeofanindependentassignmentcommissionedbyPACSProgramme.

Coordinationandediting:AvinavKumar,HeadofKnowledgeManagementandInnovation,PACSProgramme

Reviewand inputs fromPACSteam:AnuSingh -ProgrammeOfficer Jharkhand,ArtiVerma-StateManagerBihar,JayeetaDasgupta-StateManagerWestBengal,JohnsonTopno-StateManagerJharkhand,PrashantKumarAnchal-StateManagerUttarPradesh,RajkumarBidla-HeadofProgrammes

Photocredits: PACS Programme

PACSProgrammeisaprogrammeofDepartmentforInternationalDevelopment(DFID)GovernmentofUKmanagedbyiFIRSTConsortium.However,theviewsexpressedinthisreportdonotnecessarilyreflecteitherDFID’sortheviewsandofficialpoliciesofthemembersoftheiFIRSTConsortiumandthePACSProgramme.

4 5

ListofAbbreviationsASHA AccreditedSocialHealthActivist

ATM AutomatedTellerMachine

AWW AnganwadiWorkers

BPL Below Poverty Line

CBHI Community Based Health Insurance

CBO CommunityBasedOrganisation

CHC Community Health Centre

CMO ChiefMedicalOfficer

CSO CivilSocietyOrganisation

DFID DepartmentforInternationalDevelopment

DKM DistrictKeyManager

FKO FieldKeyOfficer

GoI Government of India

GP Gram Panchayat

GRC Grievance Redressal Cell

IEC Information,Education&Communication

INR Indian Rupee

IRDA Insurance Regulatory and Development Authority

MGNREGA MahatmaGandhiNationalRuralEmploymentGuaranteeAct

MoLE MinistryofLabourandEmployment

MoU MemorandumofUnderstanding

NGO Non-GovernmentalOrganisations

NRLM NationalRuralLivelihoodMission

NSSO NationalSampleSurveyOffice

OOP OutofPocket

PACS Poorest Areas Civil Society

PAP ProportionofAilingPersons

PHC Primary Health Centre

PPP Public-PrivatePartnership

PRI PanchayatiRajInstitutions

RSBY Rashtriya Swasthya Bima Yojna

SEG SociallyExcludedGroups

SHG Self Help Group

SHI Social Health Insurance

SNA State Nodal Agency

ToT TrainingforTrainers

TPA ThirdPartyAdministrators

UMPCE UsualMonthlyPerCapitaConsumptionExpenditure

UWIN UnrecognisedWorkersIdentificationNumber

WHO WorldHealthOrganisation

ForewordIamhappytopresentthisdocument ‘TakingRSBYtotheSociallyExcluded:LearningfromthePACSProgramme’whichcapturesthekeylearnings,detailsoftheapproachesandstrategiesadopted,theirefficacyfromtheeyesofmultiplestakeholders,includingthecommunitiesinvolvedintheimplementationoftheprogramme.

World’s largest health insuranceprogramme,Rashtriya SwasthyaBimaYojna (RSBY)waslaunchedbytheGovernmentofIndiain2008andgainedmomentumintheyearsthat followed.Coincidingwith theperiodof the initiationof thePACSProgramme itpresentedanopportunitytotakethebenefitsofthehealth insurancetothesociallyexcludedhouseholdswithwhom thePACSProgrammeworked. InRSBY, PACS sawapotentialofprovidingsecurityfromthesuddenfinancialliabilitiesarisingoutofhealthshocksaswellasfacilitatingaccesstoqualityhealthcareincaseofhospitalisationneedsforthesociallyexcludedcommunitiesandthemostneedy.

PACSProgramme,duringitsimplementationperiodof2011-2016,workedonaddressingcritical gaps of awareness, enrolment, barriers and discrimination free access andgrievance redressal inRSBY. Itdid sobybringingmultiple stakeholders including thecommunities,insuranceproviders,governmentandhospitals,togethertoworktowardsreachingthebenefitsoftheschemetothesociallyexcludedcommunities.

Workingincollaborationwiththebiggeststakeholders,particularlytheGovernmentwasthehallmarkoftheapproachwhichthePACSProgrammeadoptedanddemonstrateditsefficacyatscale. Itenabledtheprogrammeanditspartnerstotakeup innovativeinterventions,workonaddressingspecificbottlenecksandbarriersandtryoutstrategieswhichbroughtaboutawarenessandchangeatscale.PACSprogrammeestablishedaspaceforcivilsocietyfacilitationandintermediationwhichotherwisewasnotapartofthedesignofaseeminglystraightforwardschemelikeRSBY.

Ihopethatthisdocumentisabletofurtherstrengthenthediscourseonlookingattheissueofsocialexclusionandaccess toservices inmultipledimensionsandhowtheyimpacteachother.Thisdocumentalsopresentstheefficacyofaconstructiveapproachofworkingcloselywiththestateandhowchangesbroughtaboutby influencingthesystemaremoresustainedandlasting.

Due to the diversity and scale of experiences of the PACS Programme I am sure this documentwillfindvalueintheeyesofmultiplestakeholders,keyamongthembeingthedevelopmentpractitioners,implementersandotherswhohavearesponsibilityofworkingonvariousflagshipprogrammesoftheGovernment.

AnandKumarBolimeraDirector,PACSProgramme

6 7

1ExecutiveSummary

The figure highlights the typical journey and challengesfacedbyeligiblebeneficiariesunderRSBYthrougheachofitsstagesbeforeandafterPACSintervention.

As shown in the figure, often SEGs had no clue aboutthe smart cards and were left uncovered during theenrolmentstage.PACSintervenedtoensurethatalleligiblebeneficiaries were aware of when the enrolment campsare scheduled and that they were present for enrolment. Even when PACS ensured holding of enrolment campsthere were recurring forms of glitches and wrong doings during the process. For instance the insurance companies and TPAs would fill erroneous data in the SMART Card,retainSMARTcardsevenafterregistrationornotcompleteenrolment due to largenumberof enrolees. TherewerealsocaseswhenintimidatingvillagersopposeenrolmentofcertaingroupsthatdiscourageenrolmentofSEGsinRSBY.Besides,evenifsmartcardswereissued,butnoIECmaterialwas distributed with the card, beneficiaries remainedlargelyunawareabout theentitlementsordidnot knowhowtouseit. Inordertomanagethesedifficulties,PACSundertooktheresponsibilityofmonitoring,supervisingandfacilitatingtheprocessofenrolment.PACSensuredthattheenrolmentteamissuedsmartcardstoallbeneficiaryfamiliesonthespot,alongwithalistofempaneledhospitalsanddetailedinformationontreatmentpackage.Toeducatethecommunityregardingtheproperutilisationofsmartcards,relevant IEC material in the form of contextual pictorialbookletswasalsomadeavailableintheenrolmentcamps.

AlthoughsmartcardswereissuedwithIECmaterial,itdidnotnecessarilyassurediscriminationfreeaccesstoqualityhealthservicesinempaneledhospitals.Oftenbeneficiariesweredeniedtreatmentbecauseoffaultycredentialsintheircards or nonfunctioning card machines in the hospitals.Even if some beneficiaries managed to avail treatmentundertheRSBYpackage,theywouldbechargedfor itorhospital authoritieswould retain their cards. Tomitigatethese issues PACS had to develop community basedmonitoringsystemstoensurequalityhealthdeliverybytheserviceprovidersasdescribedinRSBYguidelines.PACSalsocollected feedback from the community regarding theirexperiencesofusingthesmartcards.ThesamewasshareddirectlywiththeSNAsandotherrelevantstakeholderstoimproveuptakeofentitlements.

8 9

TheWorld’s largestopenhealth insuranceprogrammeRashtriya Swasthya Bima Yojna (RSBY)1 was launched by the Ministry of Labour and Employment (MoLE),Government of India (GoI) on 1st April 2008. ThebeneficiariesunderRSBYareentitledtohospitalisationcoverageup toRs.30,000/-and thecoverageextendstofivemembersof the family. Themajorobjectiveofthis health insurance scheme is to provide financialsafety net to the BPL households in the event of expenditures arising out of medical treatment involving hospitalisation.

ThoughRSBYofferedmanybenefits andprotection tolakhsofpoorfamiliesfromfinancialliabilitiesarisingoutofhealthshocks;theprogrammefacessevereissuesinimplementationanddeliveryofbenefits. Itwas foundthat eligible beneficiaries particularly persons fromsocially excluded groups (SEGs) were unclear abouttheprocessesofavailingbenefitsandremainedlargelyunaware about the various entitlements and servicesunder the scheme. Subsequently, it was realisedthat removing financial barriers does not necessarilyguaranteeequitableaccesstohealthcare.Oftenthereareunderlyingsocial,politicalandcultural factorsandprocesses that exclude certain social groups and result in theirdifferentialaccessandinabilitytoutilisehealthcareprovisions.ThispromptedUKGovernment’sDepartmentforInternationalDevelopment(DFID)underitsPoorestAreasCivilSociety(PACS)programmein2009toengageactivelyintheimplementationandmonitoringofRSBYto ensure equitable and discrimination free access toqualityhealthservicesbytheSEGs.

While the ‘lackofdemand/awareness’ for theschemewastheprimarymotivatingfactorforPACStointerveneinthescheme,itwasrealisedthattheschemesufferedfrom various other shortcomings. It was understood that solely increasing the demand would not prove to beaneffectivestrategy if therearegaps inthesupplyside. As a result of which it was crucial to address these challenges in a holistic manner. Thus, a decision wastaken to strengthen the supply side and demand sideinterventionsandsupporttheprogrammethrougheachof its stages:

puppetshowsamongothers.AdditionallycapacitiesofCSOwerealsobuiltonthemainfeaturesoftheschemetoreducetheinformationasymmetry.Likewiseinorderto enhance the enrolment and access to RSBY, PACSundertooktheresponsibilityofmonitoring,supervisingand facilitating the process of enrolment. The roleplayed by PACS ensured that the enrolment processoccurs systematically andwithout anymalfunctioning.Similarly to improve the service delivery under the scheme PACS built awareness among the smart cardholders regarding its utilisation by organising rallies,street plays and film shows. Local folk art was alsoused widely as people could relate to them instantly. Secondly in order to enable utilisation exposure visitsto the hospital were organised to familiarise the communitymemberswiththeprocessofadmittanceinthe hospital. Correspondingly sensitisation workshopswere organised with empaneled hospital authoritiesto change their behaviour and attitude towards thepatientsfromSEGs.

However, it is important tonote thatduring thePACSprogramme,theinterventionsfacedvariouschallenges.Some of the critical challenges faced during theimplementation include lack of coordination amongstakeholders,improperdistributionofnameslipsbeforeenrolmentcamps,discrepanciesinBPLlistforenrolment,inefficientdeploymentofIECactivitiesbytheinsurancecompanies and TPAs, input of inaccurate data in theRSBY card, non-distribution and retention of SMARTcardsevenafterenrolmentbyFKOs,exclusionofremoteareasfromenrolment,poorqualityservicesprovidedbyempaneledhospitalsunderRSBYpackageanddelayandrejectionofclaimsbyinsurancecompanies.

As a response to some of these challenges PACS and itspartnersemployedarangeofinterventionssuchasbuildingcapacitiesofCSOonmonitoringthestandardsofqualityhealthdeliveryby theempaneledhospitals,awarenessgeneration inthecommunitiesbyadoptingtargeted intervention approach and developingappropriate IEC materials in the local context,facilitating state, district and block level consultativemulti-stakeholder meetings, institutionalisation of

GrievanceRedressalCellatdistrictlevelandworkinginclose coordinationwith State Nodal Agency (SNA) forgeneratingthecommonactionplansandstrengtheningthe implementation of the agreed activities under the scheme.

In order to further enhance community participationand ownership towards this scheme a new cadre of human resource called the RSBY Mitras was created.TheconceptofRSBYMitraswasenvisionedtofacilitateandhelpthecommunitytousetheircards intimesofhospitalisation.Theyhadfullinformationandknowledgeabout theprovisionsofRSBYandwereequippedwiththerequiredinformation,includingthelistofhospitalsandservicesthebeneficiariesareentitledto.Howeverit was observed thatwhile their role of hand holdingthe community was beneficial, communities weredeveloping high dependence on them which may not provetobeveryviableforthelongrun.

An important aspect of the intervention was how itled to convergence of different stakeholders involvedin the scheme. The strategy under RSBY interventionfocusedonsupportingthegovernmentandallthePACSpartners were oriented to work in convergence withthe government departments. Similarly, to develop acollaborativeapproachforbetterimplementationoftheschemeatwin-prongedapproachwasadopted;whereinon one hand PACS partners focussed on extensively mobilisingthecommunitiesforenrolmentanduptakeofentitlementsunderRSBY,whileontheotherhand,thedistrict labour department focussed on strengtheningmonitoring systems to make service providers moreresponsiveandaccountable.Succinctly,PACSintervenedat various levels to ensure that the scheme is successful inreachingthecommunitieswhichwereotherwiseleftuncovered or were not aware of the existence of the scheme.ItwasalsoseenthattheinterventiononRSBYledtoincreaseinuptakeofrightsunderotherschemesaswell.Awarenessgenerationinthecommunityunderthe RSBY scheme led to community empowerment makingthemconsciousoftheirrights,ingeneral.

1ICTPost(2015).IndianeedsRSBYlikemodelofhealthcoverage.Accessedfromhttp://ictpost.com/india-needs-rsby-like-model-of-health-coverage/

1 Pre enrolment stage

2 Enrolmentstage

3 Post enrolment stage

Withtheconvictionthatpeoples’organisationcanplayasignificantroleinfacilitatingaccesstotheentitlementsunder the scheme, PACS intended to leverage thesupport of its wide network of civil society partnersspread across the five states of Bihar, Uttar Pradesh,Jharkhand,WestBengalandOrissa.PACSbelievedthatcommunity engagement and ownership would not only lead to increasedaccess,butalso strengthen theaccountabilitymechanisminbuiltinthehealthinsurancescheme.However,sincePACSanditspartnercivilsocietyorganisations(CSOs)werenotinherentstakeholdersinthe scheme, they could not have intervened directlyin the programme. Therefore, PACS initiated thefirst step to create an enabling environment to set astrong foundation for its intervention. In this contextinstitutionalising the process of engagement throughformalagreementsandMoUswiththegovernmentwasakeymilestone,asitallowedforsmoothintroductionoftheCSOsinthescheme.Thisgavethemthecredibilitytoworkwithin the ambit of the schemeand also therequired acknowledgement by other stakeholders.This was followed by the second phase, namely, theimplementation phase, wherein structured approachwasadoptedbyPACSanditspartnersthatcoveredthethreemajoractivities,namely

1 RSBY Awareness

2 RSBYEnrolmentandAccess

3 RSBY Service Delivery

Greaterdemand foruptakeofentitlementsunder theschemewasgeneratedbycreatingawarenessabouttheschemethroughavarietyofcommunicationplatformssuchasmiking,streetplays,nukkadnataks,magicand

10 11

PACSengagedactivelyintheimplementationandmonitoringofRSBYtoensureequitableanddiscriminationfreeaccesstoqualityhealthservicesbythesociallyexcludedgroups

12 13

2Introduction

healthcost.Mostpersonsfromthesepoorerhouseholdswork in the unorganised sector. The uncertain natureof job in the unorganised sector, coupled with theassociatedlowincome,andlackofsavingstofallbackuponafter incurringmedical expenditure, adds to theburden of these poor households and lead them intothe ‘medical poverty trap11.

hospitalisationcasewasINR509inruralIndiaandINR639inurbanIndia.

The cost of medical treatment in India witnessed adouble-digit pace of growth and it has outpaced theaverageinflationinbothruralandurbanareasoverthepast decade6. A major factor causing this rise in medical expenditure in India is the increase in the number ofcases of hospitalisations taking place in private-sectorhospitalsduetoacombinationofpoorqualityofservicesofferedbypublic-sectorhospitalsandtheirgeographicinaccessibility7.

Ghosh (2011) points out that the principal means ofhealthcare financing in India is through out of pocketpayments (OOP)8. These expenditures are also theleadingcauseofhouseholddebtwhichforcespeopletosellassetsorborrowmoney.ThedraftNationalHealthPolicy for India also highlights the growing incidence of catastrophicexpenditureduetohealthcarecosts(18%of all households in 2011-12 as compared to 15% in2004-05).Withover63millionpersons facingpovertyeveryyearduetohealthcarecostsalone,itisestimatedthat catastrophic health expenditures will be a majorcause of poverty in the years to come9.

Medicalexpenditureswillhavethepotentialtonegatethegainsof increasedhouseholdincome.Whileescalatingmedical costsare likely topushmanyhouseholds intopoverty, Ghosh in his study has highlighted that it isagain the poorer households who are making morecatastrophic health payments10. In addition to bearingthe high health costs disproportionately, the poorerhouseholdsarealsoseverelyimpactedbytheescalating

World Health Organisation (WHO) has defined healthas ‘the state of complete physical, mental and socialwell-being and not merely the absence of diseaseor infirmity’2. However, inspite of taking measuresand precautions to remain healthy and free fromdiseases, incidences of diseases or subsequent needformedicalcareandhospitalisationarise in the lifeof every person.

The incidences of diseases have multifarious impactsonthelifeofaperson.Inepidemiologicalparlance,thecollectiveconsequencesofadefineddiseaseorarangeof harmful diseases with respect to disabilities in acommunityisexpressedastheburdenofdisease3. It can bemeasuredusingseveralindicatorssuchasmortality,morbidity,orfinancialcost.

The71stroundsurveyconductedbytheNationalSampleSurveyOffice(NSSO)revealedthattheProportion(per1000)ofAilingPersons(PAP),measuredasthenumber

oflivingpersonsreportingailments(per1000persons)during15-dayreferenceperiod,was89personsinruralIndiaand118personsinurbanIndia4.

Whilemeasurementofmorbidityandmortalityenabletheestimationoftheburdenofdiseaseinpopulations,itis also important to gauge the economic consequences of ill health in order to gain a complete understanding of the impact of diseases. Both macro and microeconomic consequences result from the occurrence of disease in a person. The major macroeconomic impacts includeincreased health expenditures, labor and productivitylosses and reduced investment in human and physical capital formation5. At amicroeconomic level, diseaseslead to an increase in household expenditures on health services and goods and reduction in time spent ongeneratingincome.

The71stroundsurveyconductedbyNSSOfoundthattheaveragemedicalexpenditurepercaseofhospitalisationin the public hospitals was Indian Rupee (INR) 6,120.This expenditure was almost four times higher in thecase of hospitalisation in private hospitals (estimatedINR25,850).Theaveragemedicalexpenditurepernon-

2PreambletotheConstitutionoftheWorldHealthOrganisationasadoptedbytheInternationalHealthConference,NewYork,19-22June,1946;signedon22July1946bytherepresentativesof61States(OfficialRecordsoftheWorldHealthOrganisation,no.2,p.100)andenteredintoforceon7April1948.Accessedon31stDecember2015fromhttp://www.who.int/about/definition/en/print.html3Hessel,F.(2008).BurdenofDisease.InW.Kirch(Ed)EncyclopediaofPublicHealth(pp94-96).Heidelberg:Springer:4GovernmentofIndia(2015).KeyIndicatorsofSocialConsumption:Health,2014.PressNoteonthedatacollectedduringtheperiodJanuarytoJune2014inthe71stroundNSSOsurvey.Accessedon01January2016fromhttp://mospi.nic.in/Mospi_New/upload/nss_pr_health_30june15.pdf5WHO.(2009).WHOGuidetoIdentifyingtheEconomicConsequencesofDiseaseandInjury.Geneva:WHO.

6Bhattacharya,P.andJain,D.(December02,2015).Thegrowingburdenofhealthcarecosts.Accessedon01January2016fromhttp://www.livemint.com/Opinion/DSH1OnDr2LG0zAcHhl29XJ/The-growing-burden-of-healthcare-costs.html7Sen,A.,Pickett,J.,andBurns,L.R.(2015).TheHealthInsuranceSectorinIndia:HistoryandOpportunities.InL.R.Burns(Ed),India’sHealthcareIndustry:InnovationinDelivery,FinancingandManufacturing(pp.361-399).Delhi:CambridgeUniversityPress.8S,Ghosh.(2011).CatastrophicPaymentsandImpoverishmentduetoOut-of-PocketHealthSpending.EconomicandPoliticalWeekly,XLVI(47),63-70.9GovernmentofIndia.(2014).NationalHealthPolicy2015:Draft.Accessedon01January2016fromhttp://www.mohfw.nic.in/showfile.php?lid=301410Catastrophichealthpaymentsreferstothespendingonhealthbyahouseholdleadingtothereductionofitsbasicexpensesoveracertainperiodoftime,sellingofassets,oraccumulationofdebtsinordertodealwiththemedicalexpenditureincurredforoneormoreofitsmembers.11Chowdhury,S.(2009).Healthshocksandurbanpoor:acasestudyofslumsinDelhi.Paperpresentedinthe5thAnnualConferenceonEconomicGrowthandDevelopment.NewDelhi:IndianStatisticalInstitute.Accessedon01January2016fromhttp://www.isid.ac.in/~pu/conference/dec_09_conf/Papers/SamikChowdhury.pdf12Pandhve,H.T.(2012).HealthInsuranceinIndianContext:NeedoftheHour.CommunityMedicine&HealthEducation,2(9),doi:10.4172/2161-0711.1000e109.Accessedon01January2016fromhttp://www.omicsonline.org/health-insurance-in-indian-context-need-of-the-hour-2161-0711.1000e109.pdf13InsuranceRegulatoryandDevelopmentAuthority.(2010).Handbookonhealthinsurance.Accessedon01January2016fromhttp://www.policyholder.gov.in/uploads/CEDocuments/Health%20Insurance%20Handbook.pdf

2.1 Health and Consequences of Diseases

2.2 Health Insurance in India

ThelikelihoodofhealthcarecostspushingfamiliesintothepovertytrapisfurtherincreasedbythefactthatmosthouseholdsinIndiadonothaveanyfinancialprotectionagainst majority of health care needs. According to the findingsofthe71stroundofNSSOsurvey86percentofruralpopulationand82percentofurbanpopulationin India were not covered under any scheme of health expenditure support.

Inthepresentscenario,ithasbeenwidelyarguedthathealth insurancecanbeaway tocopewith the risinghealthcare costs in India12.‘HealthInsurance’hasbeendefined by Insurance Regulatory and DevelopmentAuthority(IRDA)asatypeofinsurancethatessentiallycovers medical expenses. A health insurance policy is ‘a contractbetweenan insurerandan individual/groupinwhichtheinsureragreestoprovidespecifiedhealthinsurance cover at a particular ‘premium’ subject totermsandconditionsspecifiedinthepolicy’13.

The Indian health insurance sector comprises ofGovernmental insurance schemes, Social Health

14 15

Insurance(SHI),VoluntaryPrivateHealthInsuranceandCommunity-BasedHealth Insurance (CBHI). Themajormilestones of health insurance in India are presented in Figure1.Therehasbeenanincreaseinthepopulationcoverageunder thepubliclyfinancedhealth insurance

The71stroundsurveyconductedbyNSSOshowedthat12percenturbanand13percentruralpopulationwasbroughtunderGovernmenthealthprotectioncoveragethrough schemes like RSBY. The data on the coverage

Figure1:TimelineofhealthinsuranceinIndia(Source:Senetal.(2015))

of health expenditure support for each quintile classof usualmonthly per capita consumption expenditure(UMPCE)inruralandurbanIndiaisshowninTable1.

Quintileclass ofUMPCE

Not Covered Government Funded Insurance Scheme

Employer(otherthanGovernment)Supported Health

Protection

ArrangedbyHousehold with

Insurance Company

Others

Table1:PercentagedistributionofpersonsbycoverageofhealthexpendituresupportforeachquintileclassofUMPCE.(Source:NSSO,2014)

1 89.1 10.1 0.7 0.0 0.0

2 88.8 10.7 0.4 0.0 0.0

3 87.4 11.9 0.6 0.0 0.0

4 83.3 15.9 0.5 0.1 0.1

5 81.1 17.0 0.8 0.2 0.2

All 85.9 13.1 0.6 0.3 0.1

UrbanIndia

1 91.4 7.7 0.6 0.2 0.2

2 87.5 10.6 1.3 0.2 0.2

3 84.7 12.9 1.3 0.1 0.1

4 79.7 13.5 3.3 0.1 0.1

5 66.6 15.1 5.6 0.3 0.3

All 82.0 12.0 2.4 3.5 0.2

Rural India

2.3 Rashtriya Swasthya Bima Yojana

RSBYwas launchedbyMoLE,GoI from1stApril2008.ThemajorobjectiveofthishealthinsuranceschemeistoprovideafinancialsafetynettotheBPLhouseholdsin the event of sudden expenditures due to of medical treatmentinvolvinghospitalisation.

TheoriginofRSBYcanbe traced to theenactmentofthe Unorganised Workers Social Security Act (2008).BasedontherecommendationsofthisAct,anumberofCentral Government schemes were launched to provide

social security to workers in the unorganised sector.RSBY was one of the policy initiatives in the healthinsurance arena.

RSBY responded to the long term demand for health insurance models to prevent further impoverishment of BPLfamiliesduetoburgeoningcostsofhospitalisation.The scheme provided financial protection to the BPLfamiliesintheeventofhospitalisationofafamilymember.Theschemeintendedtomitigatethecombinedimpactof health care cost and loss of wages during the period ofhospitalisationonBPL families. It aimed topreventmostof these families frombeingpushed further intothe poverty trap due to medical expenditure.

First General

Insurance Company

Employee State

Insurance Scheme

(ESIS) imple-

mented

Central Govern-

ment Health

Scheme (CGHS)

initiated

General Insurance Corpora-tion (GIC)

started business

Mediclaim Voluntary

Health Insurance

Insurance Regulatory

& Develop-

ment Authority

Yeshasvini Health

Insurance launched in Karnataka

Rajiv Aarogyashri

Scheme launched in

Andhra Pradesh

Rastriya Swathya

Bima Yojana (RSBY)

RSBY Plus launched in

himachal Pradesh, Vajpayee Arogyasri Scheme

launched in Karnataka

19071952

1954

19731986

1999

2003

20072008

2009

schemes fromalmost 55millionpeople in 2003-04 toabout 370 million in 201411. Nearly two thirds (180million)ofthepopulationcoveredundertheseschemesarefromBelowPovertyLine(BPL)category.

16 17

Health insurancecoverunderthisschemewas initiallyprovidedonly to BPL households. In the recent years,severalcategoriesofworkersfromunorganisedsectorslike street vendors, domestic workers, beedi workers,building and construction workers, and workers whohave worked for more than 15 days under MahatmaGandhiNationalRuralEmploymentGuaranteeScheme(MGNREGS)canavailofthebenefitsunderthisscheme.

There are six primary stakeholders involved in theimplementationofthescheme:TheCentralGovernment,State Government, SNA, Insurance Company/ ThirdParty Administrators (TPA), Hospitals and CSOs. Therolesofeachof thesestakeholdersareclearlydefinedintheschemeandrepresentedinthefollowingtable.

Oversightofscheme

SettingUpofNodalAgency

Financing scheme

Settingparameters(benefitspackage,empanelmentcriteria,BPLcriteria,etc.)

Hardwarespecifications(e.g,systems,SmartCard,etc.)

Contract management with Insurer

Accreditation/Empanelmentofproviders

CollectingRegistrationFees

Enrolment

Financialmanagement/planning

Stakeholders Central Government

State Government

SNA CSOInsurer/TPA Providers of care

Roles

Stakeholders Central Government

State Government

SNA CSOInsurer/TPA Providers of care

Roles

Actuarial analysis

Settingrateschedulesforservices/reimbursementrates

Claims processing and payment

Outreach,Marketingtobeneficiaries

Service delivery

Developingclinicalinformationsystemformonitoring/evaluation

Monitoringstate-levelutilisationandotherpatientinformation

MonitoringnationalRSBYInformation

Customer service

Training

Table2:Stakeholdersandtheirroles(Source:RashtriyaSwasthyaBimaYojana-ACaseStudyfromIndia,AnilSwarupandNishantJain)

The beneficiaries under this scheme are required topay INR30asregistrationfeeandtheyareentitledtohospitalisationcoverageuptoINR30,000foraspecifiedsetofdiseasesthatrequirehospitalisation.Thecoveragecanbeextended tofivemembersof the familywhichincludes the head of household, spouse and up tothreedependents.Intheeventofhospitalisation;RSBYbeneficiariesenjoythetriplebenefitsof:

1 Cashless Insurance

2 Paperless Insurance

3 Portability

Under this scheme, a smart card is issued to thebeneficiary familyandtheempaneledhospitalsare IT-enabled.Thebeneficiarycangotoanyoftheempaneledpublicandprivatehospitalsforcashlesstreatment.

The following 8 sub processes (on the next page)represents the process and work flow under RSBY.Each process comprises of process objective, processname, key stakeholders, pre-requisites, processand responsibilities, training, capacity building andinformation,education&communication(IEC)activitiesrequiredasspecifiedbytheguidelines.

RSBY BENEFICIARIES

THE CENTRAL GOVERNMENT

BPL FamiliesStreet VendorsDomestic WorkersBeedi WorkersBuilding & Construction WorkersWorkers who have worked for more than 15 days under MGNREGS

The State Government

Public & Private

Health Care Providers

Insurance Companies

18 19

• Data preparation and pre-enrolment is the firststep in implementationof RSBY. Beneficiarieswhoare eligibale to avail the services under RSBY areidentified during this process and provided withtheRSBYcardat thetimeofenrolment.Themainobjectivesof thisproccess is toensurecreationofde-duplicatedenrolment list forRSBYbycollectingbeneficiary data from departments and ensuringaccuracy and consistency of data collected, bothfromastructuralandtemplateperspective.

• Enrolment is themost important process of RSBYscheme.Itentailssettingupofenrolmentstationsuptothevillagelevelbytheinsurancecompany/smartcardserviceproviderforenrollingthebeneficiariesunder the scheme at the respective districts. Theprimaryobjectivesofthisprocessare,firstlytoreachout tomaximumnumberof targetedbeneficiariesin the enrolment list; secondly, to educate andempower beneficiaries through IEC activities toutilisetheRSBYservicesusingtheRSBYcard;thirdly,to ensure that only intended beneficiaries getenrolled;andlastlytoensurethatdataarisingoutofthisprocessisaccurate,cleanandre-usable.

• The smart card and key management processdeals with master card key generation at MoLE,procurementandpersonalisationofallmasterkeycards as well as beneficiary cards issued duringenrolment.Themajorpurposeofthisprocessistocreate a secure and convenient environment for beneficiary transactions using RSBY smart card. It

Figure3:Theeightsub-processesofRSBY

alsotriestoensuresecurityoftransactiondatafromunauthorised read or write access and to ascertain that all beneficiary cards arepersonalised throughauthorised and authentic personnel, master cardsand equipment. Lastly, it aims to maintain aninventoryofmastercardsthathavebeenissued.

• The premium payment activity is done after all thebeneficiariesfromtheenrolmentlisthavebeenissuedRSBY cards. The premium amount for the insurancecompany is divided between the state and centralgovernmentsbasedontheregionsandalsocalculatedontheconditionthatbeneficiarypostenrolmentdatamatchestheFieldKeyOfficer(FKO)carddata.

• Hospitalmanagement is one of the key processeswithin RSBY that remains constant throughout the lifecycleofRSBY.Onemonthpriortotheenrolmentprocesses, both public and private hospitalsare empaneled by the insurance company andempaneled hospitals are provided with the latest packageratesthroughthetransactionmanagementsoftware installed at eachhospital.Oncehospitalshave treated a beneficiary and discharged him,claimscanberaisedtotheinsurancecompany,whilethe process of empanelment and de-empanelment continues round the year for each insurancecompany.

• A key process within RSBY that remains constantthroughout the life cycle of RSBY is the claim managementprocess.Claimsraisedbybothpublic

and private hospitals to insurance company are alsomonitored through the claimflowapplicationby MoLE, SNA and insurance company. Claimmanagementprocess intents toensure settlementofclaimswithinmutuallyagreedtimelineswithleastnumberofdisputes.Italsotriestoensureseamlesssettlementofclaimsbyclearlydefiningthecriteriaforautomaticapprovalandconditionsunderwhichclaims can be rejected and to reduce number offraud claims.

• The most important link to all processes in RSBYis the complaints and grievance redressal process. Complaintsaregenerallyreceivedfrombeneficiaries,hospitals,PrimaryHealthCentre(PHC)/CommunityHealth Centre (CHC), SNA, District Key Manager(DKM), FKO, insurance company among others.Complains received from various stakeholdersincluding beneficiaries can also be logged at thecall centre and the call centre then directs these complaints to the intended authorities. Eachcomplaint/grievance received is closely monitoredby a dedicated team atMoLE to check resolutiontimes and to intervene if unresolved. The majorpurpose of this process is to set a strong mechanism for redressal of complaints and grievances to ensure efficientdeliveryofservicesunderRSBY.

Kiosks are the front end service delivery channels forRSBY services to thebeneficiaries. Insurance companysetsupandmaintainskiosksthatprovideservicessuchas updation/modification/lost card replacement andissuanceofsplitcardtothebeneficiaries.Thisprocesshelps to provide RSBY administrative services to thebeneficiaryatthedistrictlevelforenhancedbeneficiaryaccessandprovidesconvenienceofmemberaddition/dataupdation/lostcardreplacement/splitcardissuanceto the RSBY beneficiary. Additionally it also registerscomplains or grievances and acts as a window for additionofnewbeneficiariesunderRSBYafterproperverificationfromrespectivedepartment.

14GovernmentofIndia.(2014).RashtriyaSwasthyaBimaYojana(RSBY)OperationalManual.15Narayana,D.(2010).ReviewoftheRashtriyaSwasthyaBimaYojana.EconomicandPoliticalWeekly,XLV(29),13-18.16Wu,Q.(2012).WhatcausethelowenrolmentrateandutilisationofRashtriyaSwasthyaBimaYojana:aqualitativestudyintwopoorcommunitiesinIndia.AdissertationsubmittedtotheLiverpoolSchoolofTropicalMedicineimpartialfulfilmentoftherequirementsfortheawardofMasterofScienceinInternationalPublicHealth(MIPH)degree

DataPreparationand Pre-Enrolment

Enrolment

Smart Card andKMS

WellnessCheckandPayment of Premium

Hospital Menagement

KioskManagement

Compiaint Redressal ManagementSystem

Claims Management

Beingacentrallysponsoredscheme,75percentofthepremiumispaidbycentralgovernment,whileremaining25 per cent of premium is paid by state government.The contribution of central government is 90 percent in case of north-eastern states and Jammu andKashmir.Thisschemeisoperationalin398districtsof25stateswherein about 10,116 hospitals are empaneledacross the country. During Financial Year 2013-14,approximately 2.5 crore families were covered underthe scheme14.

While RSBY is considered a successful Public-PrivatePartnership (PPP) health insurance model; it hasseveralbottlenecks.Literaturesuggestssomeofthekeychallenges associated with this scheme are as follows15:

Enrolmentofalltheeligiblebeneficiariescouldnotbeachieved

• LowenrolmentoffamiliesfromSEGs

•Lackofawarenessregardingtheschemesamongalargesectionofeligiblebeneficiaries

•Demotivation due to unsuccessful utilisation ofsmart cards

•Lowutilisationrate

•Delayinissueofsmartcards

• Inadequatenumberofempaneledhospitalsinthecatchment area

•Delay in installation of IT facilities in empaneledhospitals

•Denial of services by private hospitals for manycategories of illnesses

•Problems for migrants to use the card in areasother than hometown

• Delay in payment of premium to the insurancecompanybytheGovernment

• DecreasingPremium

• Chargingofinformalpayments

• Lackofefficientmechanismofdisputeresolution16

BEnEFICIARIES

20 21

2.4 PACS & RSBY

PACSProgrammeisaninitiativeoftheUKgovernment’sDFID. Under PACS, DFID partnered with Indian civilsocietytohelpSEGsclaimtheirrightsandentitlementsmoreeffectively,sotheyreceiveafairershareofIndia’sdevelopmentgains.AdetaileddescriptiononPACShasbeenattachedinAnnexure1.

There isampleevidenceconfirming thatmanypeoplein India,particularly thepoorestandmostvulnerable,go without effective health care.17 This is mainly becauseaccesstoandutilisationofeffectivehealthcareinterventions in our country continues to be a majorproblem for the underprivileged. Most commonly,insufficient resources, inappropriate allocation,inadequate quality are cited as major impediments to the delivery of effective health care that reaches thepoor.18 However, it is important to understand that accessinconsonancewithamultitudeoffactors,leadstoutilisation.

Factors such as awareness, information, knowledge,sensitivity of the care providers and a conduciveenvironment to enable utilisation of medical servicesand resources strongly determine access and finalutilisation, thus highlighting that merely removingfinancial barriers does not necessarily guaranteeequitableaccesstohealthcare.Thisismainlybecausethereareunderlying social, political, geographical andcultural factors and processes that exclude certain socialgroupsandresult intheirdifferentialaccessandinability to utilise information, bureaucratic processesand health care provisions. Moreover, perception ofself and the capability of care seekers to overcomeinhibitions and obstructions in interactions withproviders and institutions can also majorly affectutilisation among SEGs. For instance, social exclusionin health careprovisionsmaybedue todisrespectful,discriminatory or culturally inappropriate practicesof medical professionals and their organisations.Therefore, identifying and addressing access barriersthatremovethefearandintimidationthattheSEGsfacewhenconfrontedwithhospitalisationiscrucial.

PACS realised that while RSBY was conceptualised and implementedtooffersupporttotheoneswhoneeditthemost (RSBYbeneficiary), thecommunitymemberswere largely unaware of the scheme and its benefits.Duringtheinitialplanningphase,RSBYwasnotidentifiedasoneoftheinterventionareasforPACSandthefocuswas on other health, nutrition and livelihood, relatedentitlements aspart of the strategy tobridge the gapbetween schemes such as Mahatma Gandhi NationalRuralEmploymentGuaranteeAct(MGNREGA),NationalRuralLivelihoodMission(NRLM)andthepoorestinthePACSstate.However,lookingatthewidegapthatexistedbetween service provision and its actual utilisation,alongwiththepotentialoftheexistingPACSnetworktocurbthisgap,PACStookontheopportunitytoworkonRSBYacrossfiveoutofsevenofitsinterventionstates.

TheprospectoftheNationalHealthinsuranceschemeto reduceout of pocket costs and catastrophic healthexpenditures,particularlyfortheSEGs,wastheprimary

17D,Owen.(2007).Accesstohealthcareindevelopingcountries:breakingdowndemandsidebarriers.Cad.SaúdePúblicaVol.23No.12RiodeJaneiro.Retrievedfromhttp://www.scielo.br/scielo.php?script=sci_arttext&pid=S0102-311X200700120000318D,Owen.(2007).Accesstohealthcareindevelopingcountries:breakingdowndemandsidebarriers.Cad.SaúdePúblicaVol.23No.12RiodeJaneiro.Retrievedfromhttp://www.scielo.br/scielo.php?script=sci_arttext&pid=S0102-311X2007001200003

Actual Situation

Intended Objective RSBY Scheme(As designed

by the Government)

Provide benefit to the

poor for hospitalisation

Limited/No Awarness about the Scheme

Existing GAP

motovation for the PACS Programme to support thegovernment for championing the interests of SEG inthecontextof this scheme.PACSefforts in supportingRSBY also emanated from the understanding that most householdsfromSEGslackedfinancialprotection.Intheevent of occurrence of any disease or injury leading to hospitalisation, people from these groups are forcedto make catastrophic out of pocket health paymentsresulting in their sinking further into thepoverty trap.TheenrolmentofpersonsfromSEGsinRSBYwillpreventthem from falling in the hands of unscrupulous money lenderstopaythecostofmedicaltreatment, implyingthatthesepersonswillnotbeforcedtoselltheirassets,includingland,tomeethealthcarecosts.Thereductionin out of pocket medical expenditure may allow formoreinvestmentinotherareaslikeeducation,leadingto empowerment of these groups.

“Health costs are one of the key reasons that push and trap socially excluded communities in a state of poverty. This makes the potential of RSBY truly phenomenal and that is what needs to be harnessed by involving Community Based Organisations.”

-SamSharpe,HeadofDFIDIndia

Understanding the gap in access to the entitlementsunderRSBY,withspecialfocusonthechallengesfacedbytheSEGs,PACStookonthetaskoffacilitatingcommunityengagementunderRSBY.PACSbelievedthatcommunityengagement and ownership would not only lead to increasedaccess,butalsostrengthentheaccountabilitymechanisminbuiltinthehealthinsurancescheme.

With the belief that peoples’ organisation can play asignificantroleinfacilitatingaccesstotheentitlementsunder the scheme, PACS intended to leverage thesupport of its wide network of civil society partnersspread across the five states of Bihar, Uttar Pradesh,Jharkhand,WestBengalandOrissa.

“PACS had been working with the marginalised communities on various issues other than RSBY. While working towards helping the socially excluded communities get better access to their rights, we understood that the government had initiated a health insurance scheme for the benefit of the community. Under this scheme, BPL families and members of the marginalised communities could access free health care services.”

“However, people had no information about the existence of such a scheme. It was unfortunate that people continued to suffer even when there were provisions by the government to access healthcare services. In spite of there being a health scheme for the marginalised groups, they had no access to it due to lack of awareness”

“We decided to take it upon ourselves to bridge this gap, so the scheme could reach the audience it was intended for and the benefits could be enjoyed by those who need it the most – and thus the PACS RSBY intervention was born.”

-RajKumarBidla,HeadofProgrammesPACS

PACS worked towards creation of space for thecommunity organisations to engage actively in theimplementation and monitoring of RSBY scheme byfollowing a twin-pronged approach focusing on supply sideaswellasdemandsideinterventions.

WhatPACSbringstoRSBY

• Strongandvibrantnetworkofcivilsocietygroupsworkingdirectlywithcommunities

• Deeperandwider reach tocommunities throughcivilsocietynetworks

• Range of innovative community participationstrategies for increasinguptakeof servicesunderRSBY

• A perspective from ground giving a realisticassessmentofschemeimplementation

22 23

PACSworkedtowardscreationofspaceforthecommunityorganisationstoengageactivelyintheimplementationandmonitoringofRSBYschemebyfollowingatwin-prongedapproachfocusingonsupplysideaswellasdemandsideinterventions

24 25

While the ‘lackofdemand/awareness’ for theschemewastheprimarymotivatingfactorforPACStointerveneinthescheme,itwasrealisedthattheschemesufferedfrom various other shortcomings. It was understood that solelyincreasingthedemandwouldnotprovetobean

effectivestrategyiftherearegapsinthesupplyside.Itwasimperativetoaddressthesechallengesinaholisticmanner. Thus, a decisionwas taken to strengthen thesupplysideanddemandsideinterventions.

Figure4:Supplysideanddemandsideinterventions

3PACSIntervention

The PACS intervention under RSBY focused onaddressing the gaps throughout the lifecycle of the programme in order to strengthen the supply and demand. However, since PACS and its partner CSOswere not inherent stakeholders in the scheme, theycould not have intervened directly in the programme. Thus,thefirststepforPACSwastocreateanenablingenvironmenttoallowPACStoundertakethisjourneyofbridgingthegapbetweentheschemeanditsutilisation.Thus,creatingenablingenvironmentwasacrucialstepto set the strong foundation for the intervention andwas prerequisite for its success. Thiswas followed bythesecondphase,namely, the implementationphase,wherein PACS supported the programme through each of its stages.

The following sections throw light on each phasedetailingvarioussteps,processesinvolved,innovationsadopted and the challenges faced.

anychangewasnotgoingtobeaneasytask. Inordertocreateanenablingenvironmentfortheintroductionof this new cadre of resources to work under the ambit of the scheme, PACS undertook the following keyactivities.

2.1.1AdvocacywiththeGovernment

Experience suggests that even the most carefullydesigned programmes encounter difficulties whenimplemented.Invariablytherearesituationsorinterplayof unexpected forces which may hinder the roll-out of any programme. And especially with a scheme on the scaleandambitionofRSBY,translationofobjectivesintotangibleoutcomeswasnotgoingtobeapathwithoutmany hurdles. For instance, it was thought that theprovisionofsmartcardanddigitisationwillprovidefora seamless and convenient option to ensure that thebenefitswerereachingthepoorandsociallyexcluded.Butinreality,therewasaconsiderableshortfallbetweenthe registered beneficiaries and actual hospitalisationbecauseoflimitedawarenessamongstthecommunitiesand gaps in coordination among the implementingstakeholders. In this context, the success of RSBYwaslargely dependent on building community awarenessand ownership, in addition to ensuring that serviceprovidersweremoreresponsiveandaccountable.

Inordertosupportthescheme,thefirststepforthePACSwastoconvincethegovernmenttoallowparticipationof the CSOs. They approached the government with

3.1 Phase1:CreatingEnablingEnvironment

In order to address the identified gaps in access ofservicesunderRSBY,PACSworkedtowardsintroducingCSO and defining their role in the scheme. However,inaschemethatalreadyhadadefinedstructurewithspecific roles and responsibilities outlined for eachstakeholder,incorporationofanadditionalstructureor

Supply Demand

• Sensitisation of service providers - SNA, Hospitals, Insurance companies

• Capacity building of government frontline workers on RSBY

• Facilitating interfaces with beneficiaries through consultation/workshops

• Support to run RSBY helpdesks in hospitals

• Motivate hospitals to get empaneled and ensure empaneled hospitals stay motivated to continue RSBY

• Supporting Insurance compaines-programme support, claim settlement, organising health camps, provide IEC material

• Strengthening grievance redressal cell

• Building capacities of civil society organisations on RSBY

• Creating awarness among the community members on RSBY through media and door to door counselling

• Exposure visit to the hospital

• Interface with the service providers

• Community monitoring to ensure quality of health services

ACTIVITIES UNDER RSBY

26 27

a conceptual note on the identified need to createawareness among the communities and the possibleroleofCSOsinsupportingthesame.

Variousmeetingswereconductedtoexplaintheneedtoestablishamechanismtoincreasetheutilisationofthecardsamongthecommunities.Theevidence fromthefieldwassuggestiveofthefactthatthemerepossessionof an RSBY card did not translate into overcoming socio-culturalbarriersorthebarrierofignoranceamongthecommunitymembers.Various instances fromthefieldwere shared with the government stakeholders tosupport the PACS argument.

“Our first meeting with the government officials on the role of CSOs under RSBY was not very fruitful. They did not see a clear role for the civil society in the implementation of the scheme. It took us several meetings and liasoning with various officials to make them understand our point and the rationale for this identified need. It’s only once they understood the existing gap in the scheme that we could discuss a way forward.”

-AvinavKumar, HeadofKnowledgeManagemementand

Innovation,PACS

PACSconsistentlyadvocatedtheneedtosupporttheSEGtouptaketheservicesofferedunderRSBY.PACSofferedtoworkcloselywiththeMoLEtosupportthemintheimplementation of services. At this point theMinistryagreed to use the support from the PACS network tostrengthentheexistingscheme.

PACS signed a formal tripartite Memorandum ofUnderstanding (MoU) with five state governments,namely,WestBengal,Odisha,Bihar,JharkhandandUttarPradeshtoensureeffectivecommunityengagementinthe implementationof the scheme. This formalisationofPACSrole inRSBYthroughsigningofanMoUwasakeymilestonefortheintervention.Itlaidthefoundationfor the beginning of the second phase to bridge thegapsintheexistingsystemtoensurethatcommunities,especially SE groups, could now avail the benefits of the scheme.

PACS, in close coordination with the MoLE, GoI,

partnered with the SNAs for ensuring effectivecommunityengagementinRSBY.Presently,51outofthe90partnersareapartofthestatelevelMOUsandmanypartnersareofficiallyapartofdistrictlevelcommitteesand GRC for RSBY.

AftersingingtheMoUthefirststepininstitutionalsingPACSengagement inRSBYbeganwith theSNA issuinga Government Order indicating PACS involvementin strengthening the implementation of the schemethrough its network of CSOs in selected districts.The Government order also mandated concernedauthorities in the labour departnments to regularlyshare government orders and policies regarding RSBY implementionwithPACS.

2.1.2SelectionofCSOs

Alongwithadvocatingtheircasewiththegovernment,itwasextremelycriticalthatPACSidentifiedthelocalCSOswhowerewilling to takeup the taskof strengtheningRSBY. While PACS leveraged its existing network, aparticipatory and consultative approach was followedtoget inputs fromtheCSOstogaugetheirwillingnessand intent to participate in the intervention. TheexistingnetworksofCSOswereconsultedinastatelevelworkshop tounderstand their perspective. PACS teamdiscussed the various existing gaps under the schemeand the possible roles the CSOs could play to bridge this gap.

After the selection of partner organisations for eachintervention district, a state level consultation wasorganisedineachofthefivestatestodiscusstherolesandresponsibilitiesofCSOs.ThestatelevelconsultationsawextensivedeliberationsandparticipationfromtheCSOpartners.ThisplatformwasalsousedtodeveloparoadmapfortheinterventionareasinRSBYineachstate.

PACSstate levelofficessupported thepartnerCSOs inimplementationof the intervention.ThepartnerCSOsworkedwiththeCommunityBasedOrganisations(CBO)attheGramPanchayatandvillage level.Thefollowingfigure details the implementation structure under theintervention.

As of 2015, PACS worked through a wide network of225 civil society partners in 90 districts, touching 8

millionpeople’s livesacrossfivestatesundertheRSBYintervention.

2.1.3OrientationandTrainingofCSOs

It was clear from the state levelworkshop thatwhilethe CSOs in the five states saw this as a potentialopportunity to serve the community, especially thesociallyexcludedgroups,theythemselveshadverylittleawarenessaboutthescheme.ThenextimportantstepaftertheselectionofCSOswastoorientthemabouttheRSBYprogramme.ItwascriticalfortheCSOshaveanin-depth understanding of the programme and its various components.TotraintheCSOmembersonthenuancesand provisions of the programme, training sessionswereorganised.Asubstantialcomponentofthetrainingwason the roleof theCSOs in theprogrammewhichfocusedontheirresponsibilitiesanddetailedactivitiestobeundertakenbythem.

CSOs play an important role in any intervention atthe community level as they have greater reach and credibility within the community. Therefore, it wasimportant that CSOs were fully informed about theRSBY scheme and its details so they could encourage the communitytoreapfullbenefitsoftheRSBYscheme.Acascade model was used to disseminate the trainings. A group of master trainers were trained in each district witha3dayTrainingforTrainers(ToT)andafollowup

Figure5:PACSimplementionstructure

refresherToT foronedaywasorganised.Thecapacitybuilding of CBOswas then organised by CSOpartnersat the block/ gram panchayat (GP) level. Apart fromthe master trainers, 10 specialised CBOs per districtwere trained on RSBY. These specialised groups wereentrusted with the role of mobilising the community,trackingdropouts fromenrolmentand facilitating thelistingprocess.

3.2 Phase2:Implementation

PACSNationalLevelOffice

CSOPartner Multiple CSOPartner

CSOPartner

CBOs Gram Panchayat Community

CSOPartner

PACSStateLevelOffice

Oncethefoundationforthe interventionwas laid,thesecondphaseincludedtherollingoutoftheinterventionwith CSOs ready to take on the responsibility ofsupporting the communities, creating awareness andensuring that the benefits reach the ones who needit the most. PACS and its partners used a structured approachandcoveredthethreemajoractivities,namely

1 RSBY Awareness

2 RSBYEnrolmentandAccess

3 RSBY Service Delivery

28 29

Identifiedchallengesunderthescheme

• Lackofawareness:Whilepeoplewereawareofthescheme;theylackedtheunderstandingofhowtouseitandwereuninformedaboutthedetailsofthescheme.Mostcardholderswereunclearabouttheprocessesofavailingbenefitsandunawareaboutthevariousentitlementsandservicesundertheschemeasnoneofthiswassharedwiththembyanyone.

• Lackofcoordinationamongstakeholders:BeforePACSintervention,therewaslimitedcoordinationandsynergiesbetweentheinsurer,hospitalsandgovernmentactorsatthecentral,stateanddistrictlevels.Thisresultedinfragmentedownershipwithnenficairysufferingintheprocess.

• Improperdistributionofnameslips:Thenamesslipsof thetarget families forenrolment inRSBYwereoftenfoundtobenotdistributedaccuratelyinthevillages,asaresultofwhich,manyfamilieswereleftoutor missed during enrolled under the scheme.

• DiscrepanciesinBPLlistforenrolment:ErrorsandvariancesinthenamesofeligiblefamiliesinBPLlists,oftenleadtomissingoutofthoseBPLfamilieswhoneedtheschemethemost.Thiscommonlyinstigatedeligiblefamiliestoquestionauthoritiesandcreatechaosandconfusionduringenrolment.

• InefficientdeploymentofIECactivities:IECactivitieswerenotcarriedbytheinsurancecompanies/TPAsresultinginlowornoawarenessabouttheschemeutilisation.PoorcommunicationabouttheenrolmentschedulesledtolowturnoutforenrolmentunderRSBYdefeatingthepurposeofthescheme.Moreoverfluctuations in dates announced for enrolment camps and lack of communication from the insurancecompanies/TPAs to intended beneficiaries led to low participation and dampened interest amongcommunities.

• ErroneousdataintheRSBYCard: Inaccuratedetailssuchaserrors innamesofbeneficiaries,missingorincorrectlymatchedfingerprintontheRSBYCardenteredbyTPAsandverifiedbytheFKOsduringenrolmentprocessoftenforcedcomputeroperatorsanddoctorsinthehospitalstoturndownthepatientsincaseofsucherrorsfoundintheSMARTcards.

• SMARTcardsavailabilityat thetimeofenrolment:DespitetheRSBYguidelinesclearlystatingthat theSMART cards shouldbe immediatelyhandedover to thebeneficiaries just afterenrolment, therewerenumerouscasesofnon-distributionandretentionofSMARTcardsevenafterenrolmentbyFKOs.

• Exclusion of remote areas from enrolment:Going deeper into the remotest areas and setting up forenrolmentinsuchareasisoftenverydifficultandexpensiveforinsurancecompaniesandTPAs.Asaresultof which enrolment camps were not conducted in many geographically excluded areas actually comprising oftheneediestpopulation.

• PoorqualityservicesprovidedunderRSBYpackage:Insomecases,itwasseenthattheservicesprovidedtothebeneficiariesunderRSBYweresubstandard.Itwasfoundthatempaneledhospitalswerenotprovidingfood,medicines,pre-hospitalisationcostsandtransportallowancetotheRSBYpatients,thoughincludedinthepackage.Oftenpatientswerealsomisguidedabouttheprovisionsundertheschemeandhospitals/doctorsclaimedextramoneyoverandabovetheirclaimsfromtheinsurancecompanies.

• Delayandrejectionofclaim:Delayinpaymentsandrejectionofclaimswasreportedtobythehospitals.Thisdelayledtogrowingsingsofdemotivationanddissatisfactionamongsthospitals.

Some of the challenges identified under the schemehavebeendetailedbelow:

Withtheaimto increaseuptake innon-discriminatoryaccesstoRSBYbytheSEGsandBPLhouseholds,PACSintervened at all stages of the scheme. The entirelifecycle of the RSBY programme, from its conceptionto its termination, canbebroadly classified into threestages,namely

1 Pre enrolment stage

2 Enrolmentstage

3 Post enrolment stage

The involvementandsupportprovidedbyPACSundereachstagehasbeendetailedinthesectionbelow.

Figure6:ActivitiesunderRSBY

Pre enrolment

Preparatio of BPL list by SNA

Post enrolmentEnrolment

Route map planning at district level

Publicity of the enrol-ment day (time& place) by technology partner

Enrolment camps are set

Distribution of chits to the beneficiary (2 days before enrolment) by

FKO

A banner in the local language present at the

enrolment station

Eligible beneficiaries give their finger prints and

photos are taken

A booklet on how to use the card given to the

beneficiary

List of left out people is prepared by the FKO

Utilisation of cards by beneficiaries in

empanelled hospitals

FKO identifies the head of the family & authenticates through card & finger print

Beneficiaries registered

Smart card given on the spot

30 31

2.2.1Pre-EnrolmentStage

PACS has been striving to ensure access to qualityhealth care services and infrastructure for socially excluded communities. Itworkswithin a strong rightsandentitlementsframework.TheRSBYinterventionbyPACShas beenundertaken as a step towards fulfillingthis goal. The intervention aims to empower sociallyexcludedcommunitiesbymaking themawareof theirrights and building their capacities to leverage thebenefitsofthescheme.

The first level of intervention to improve the uptakeof entitlements under the scheme was at the pre-enrolment phase. It was based on the understandingthat thefirsthurdle in thepathofeffectiveutilisationof RSBY was the lack of awareness and coordinationamong stakeholders and lack of knowledge about theRSBYschemewithinthelocalcommunities.

As the first step towards addressing this gap, PACSpartners conducted evaluation survey/assessment inthetargetareas tounderstandtheaccess,qualityandutilisationpatternsofRSBYservicesbythecommunity.The findings from the survey helped to identify theoveralldifficultiesfacedinaccessingtheschemeaswellasthearea-specificproblems.Adetailedanalysisoftheoutcomes of these surveys helped design strategies to improve awareness in low enrolment areas and to promoteutilisation inhighenrolmentareas.Basedonthefindingsofthesurveys,PACSintervenedinthepre-enrolment phase in a three-pronged manner.

a.Coordinationandconvergenceinplanning

RSBYschemewas launchedbytheMoLE,GoI in2008.For the effective implementation at the state level,StateNodalAgecies (SNA)were formed.Anumberofotherstakeholders,besidesSNA,werealsoinvolvedinthe implementation of RSBY scheme at the state anddistrict levels. Primary among them were the insurance companies,TPAsandothergovernmentdepartmentslikeHealth,WCDandP&RD.Therewaslimitedcoordinationbetweentheseagenciesaswellasbetweentheinsurer,hospitals, government agencies and the beneficiaries.Such limited coordination amongst stakeholders,particularlyatthedistrictandblocklevel,wasbelieved

to have majorly hindered awareness generation andresulted in fragmented ownership of RSBY.

PACS believed that developing stronger linkages withand between these stakeholders was imperative toensure that the outreach of the RSBY is increased for the benefit of the marginalised community. Towardsthisend,PACShelddiscussionswithallthestakeholderstoensurethatRSBYwasgivendueprioritisationatthegovernment level. As a first step towards formalisingthe collaboration between SNA and PACS, a detailedMOU,withspecialfocustostatespecificconcerns,wasdevelopedandsigned.TheMOUservedasalegitimatebasis for PACS intervention in RSBY and was used asan important tool by the PACS partner to establish alinkwith thedistrictadministration.Since thesystemswere already established in the district under RSBY,PACS partners struggled initially to make their placein the district. They had to work hard to developrapportwiththekeystakeholderssothattheyarenotseen as duplicating anyone’s role. The initial monthswent inwinning the trust of the stakeholders so thatCSOs are viewed as entities to support the effectiveimplementation of the programme. Once the CSOsmadetheirplaceinthedistrict,theyparticipatedintheplanningmeetingswith thekeystakeholders includingdistrict administration, insurance companies andhospitals. These meetings were the platforms wherethe planning for the implementation of the schemealong with discussion on its progress was done. It is in these sessions that the route maps for holding camps were planned for the district. Formal sharing of the route maps with the PACS CSOs was the second keymilestone achieved under the intervention, after thesigning of MoU. Village wise enrolment schedules,including identification of enrolment stations weredrawnup in consultationwith the insurance companyand thedistrictadministrationso that the insurerandsmartcardvendorscancompletethepreparatorytasksintimeandPACSpartnerscanmobilisethecommunitytobepresentforthesessions.ThisprovidedCSOstheinformationonhowandwhentoplanthemobilisationactivitiesinaccordancewiththeenrolmentcamps.

PACSalsoliaisedwithallthekeystakeholdersinvolvedatthedistrictlevelliketheSNA,othergovernmentbodies,TPAs, Insurance companies, among others. To bring

abouttherequiredconvergenceatthestateanddistrictlevels, periodicmeetingswith these stakeholderswasconducted.PACSwasinvolvedinallrelevantstakeholdermeetingsduringtheentireprocessofimplementation.

b. Systemstrengthening

While getting involved in the planning phase, PACSpartner also focussed on strengthening the existingsystems and processes. PACS identified two majorgaps that needed to be addressed urgently. Firstly, itwas found that amajor factor affecting the uptake ofentitlementsunderRSBYwasthelimitedavailabilityofqualityhealthcareservicesininterventionareas.Therewerelimitednumbersofempaneledhospitalsintheseareas and often the beneficiaries had to travel longdistances to reach the empaneled hospitals. It was found thatsometimes,inspiteofhavingasmartcardandbeingawareofitsuse,beneficiarieswereunabletomakeuseof it because there were no empaneled hospitals inthe vicinity. Thiswas amajor hurdle in increasing theuptakeofentitlements.PACStookupthebigchallengeof increasing thenumberof hospitals available to thebeneficiariesbymotivatingandconvincinghospitalstoget empaneled.

Secondly, it was realised that the already empaneledhospitals did not have the prescribed RSBY provisionsat the hospital. Getting hospitals empaneled was achallengeinitself.But,anequallychallengingtaskwastomake sure that these hospitals, including the onesalready empaneled, were well informed about theservices the beneficiaries were entitled to and weresensitive to their needs. Awareness campaigns fordoctorsandhospitalswereconductedbyPACStowardsthisend.Toenablediscrimination-freeaccesstoentitledhealthcareservicesforallsmartcardholders,itwasalsocrucialtoconductsensitisationdrivesintheempaneledhospitals.Sensitisationmeetingswereheldwithdoctors,nursing staff and hospitalmanagement authorities onsocialexclusionanddiscriminationissues.InthewordsoftheProgrammeManagerinUttarPradesh,“Itisnotonlyaccessingtheservicesbutalsodoingitwithdignity”.IECmaterialswerealsomadeavailableatthehospitalsforthecommunity.PACSensuredthattheRSBYdeskintheempaneledhospitalswasfunctionalandrespondedpromptly to the needs of the beneficiaries. PACSconductedatotalof37trainingsforhelpdeskoperatorsinBihar,UttarPradeshandJharkhand.PACSconducteda total numberof 32district level programmes in the

Planning of routes and schedules

Planningofroutesandschedulesisoneofthemostcrucialactivitiesconductedduringthepre-enrolmentstagetoprepareforenrolmentofbeneficiaries.Itmostlyinvolvesobtainingthelistofbeneficiariesandschedulingtheroutesandlocationsforenrolment.TherouteplanispreparedbytheenrolmentteamineverydistrictwhichcomprisesoftheTPA,districtadministration,technologypartnerandmembersofthetalukimplementationcommitteeamongothers.

Ideally, theenrolmentrouteplanningwithall thenecessaryavailablepreenrolmentdatashouldbegintwomonthsaheadof startof thepolicydate tohave leewaytime in caseofanyclimaticdelaysandanyotherobstacles.However,therealityisquitedifferent.

OftentherewouldinstanceswheretheroutemapwouldbesharedatthelastminutewiththeFKOsandCSOsortheInsuranceCompanywouldbeunwillingtosharetheroutemapswiththeCSOs.

InthewordsofVishwatma,SecretaryoftheCSOPeopleforPeaceServiceSociety,fromBahodidistrict,UttarPradesh “Insurance company were unwilling to share the route map with us initially. However, access to route plans was crucial to ensure that community members are mobilised and are motivated to claim rights under RSBY. So, we used the MoU copies to be a part of the meetings where the route maps were planned.”

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states of Bihar, Jharkhand and Uttar Pradesh for thecapacitybuildingofhospitalauthorities,strengtheningthecapacitiesofmorethan539careproviders.

The objective of these trainings/drives was to ensurethat hospitalsweremotivated to comply by the RSBYprovisions,provide treatment to thepatientswith thesmart cardswithoutanydiscriminationand therewassmooth functioning of RSBY transaction software andclaim uploading procedures at the hospital.

c.Supportingthegovernmentstakeholders

Attheblocklevelandbelow,PanchayatiRajInstitutions(PRI)membersalongwithgovernmentfrontlineworkerswereexpectedtoplayanimportantrolefortheeffectiveimplementationoftheschemeandinensuringgreaterutilisationofentitlementsbythecommunity.Butforthis,itwascrucialthatthesestakeholderswerethemselvesfully aware of the schemes and its nuances. PACS found thisimportantlinktobemissingandintervenedatthislevel to spread awareness among the PRI membersabout the schemeandhow itwouldbenefit the localcommunity. Awareness campaigns were conducted and

trainingswereheld,whereverpossible,toeducatethesegovernment frontline functionaries about the schemeand empower them.

It is these workers who interacted directly with thecommunity and were the actual implementors at the community level. So, by involving them directly inthe scheme, PACS ensured greater outreach amongthe community. PACS conducted 74 capacity buildingprogrammes for PRI members and frontline workerswiththetotalpopulationcoverageof3453inthestatesofUttarPradesh,JharkhandandBihar.

Inspiteofextensivetraining,implementingtheschemeatthe community level was riddled with many challlenges. Oneofthemajoronebeinginabilityofthefunctionariestonotifyeligible familiesaboutenrolment campswellin time. The insurance companies collaborate with atechnologypartner for theenrolmentofbeneficiaries.It is the responsibility of the technology partner todisplay the beneficiary household list at prominentlocations in thevillage (grampanchayatoffice, library,schooletc.)beforetheenrolment.Theyalsoannouncethe dates of the enrolment camps in the village using loudspeakers. The technology partner, along with

Hospitalsensitisation,UttarPradesh CapacitybuildingprogrammeforPRImembersandFKOS,UttarPradesh

the FKO from the village distributes chits containingbeneficiarynamestotheeligiblehouseholdstwodaysbeforetheenrolmentcamps.Itisonthebasisofthesechits that thebeneficiaries are enrolled in the camps.However, inmostplaces, thechitsarehandedovertothe Anganwadi Workers (AWW) or Accredited SocialHealthActivist(ASHAs),adaypriortothecamp.Thisdidnotgiveenoughtimetothegovernmentfunctionarytoreachouttothecommunitymembersandoftensomeofthemwouldbeleftout.

ThiswasanothercrucialareaofPACSintervention.PACShelpedtoensurethatthechitsweredistributedintimesothattheeligiblefamiliescouldreachtheenrolmentstations on the scheduled day. At many places, PACSsupportedthegovernmentfunctionariesbyundertakingthe chit distribution with them. Evidence from thefield suggests that there have been instances whenASHA reached out to the PACS partners for support in this process.

For instance, in Majhgaon block in Jharkhand, whenthe ASHA got the chits late at night, she called theRSBYMitra,SumitraHembrom,forhelpasitwouldnot

have been possible for her to distribute all the chitssingle-handedly overnight. Together, the two strivedtoreachallareasthathadtobecoveredinthelimitedtimeframeandmadesurethatalleligiblefamiliesgotthe chits intime. This couldotherwisenot havebeenpossiblebecauseanASHAalonecouldnothavecoveredallthehousesatsuchashortnoticeatnight,particularlyin a naxal affected area. The help of the RSBY Mitrawas crucial as theMitrasmaintained a list of eligiblehouseholds and thus, itwas easy to reach out to thehousehold without cards.

AnotherexamplefromSevapuriblockinUttarPradeshhighlightshowthetwostakeholders,theASHAandtheCBO worked closely to reach out to the community.TheRSBYMitras–NirjaDevi,SitaDeviandSarojDevi-togetherwiththeASHA,wentaroundoncyclesfromdoor-to door and delivered chits to all the eligiblefamilies to ensure that all beneficiaries reach theenrolmentcamp.TheareafacilitatorofGramya,AnjumSiddiqueandPoonamGupta,aswellastheCSOblockcoordinator Ashish Kumar Singh, came together tofacilitate the chit distribution process. They would allgettogetherat theSevapuriSamudayikBhawanevery

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morning and then disperse from there to reach every household in the area. Their sense of responsibility,ownership and determination took them beyond thecallofdutyandhelpedreachouttoallthebeneficiaries.Intheirownwords,“Ekgehrabhawntatmakrishtabangaya tha ASHA aur hum sab RSBYMitra ke beech” (Adeep emotional bond has formed between the ASHAandRSBYMitras.)

Whilesomeoftheseexampleshighlightthecoordinationand partnership established for the chit distributionprocess,PACSstressedonthisprocessbecauseinmostcases,thisstepwasoftenignored.OncetheintimationwasgiventotheASHA,therewasnoonetofollowupifthebeneficiarygottheinformationornot.Thus,itwasimperativetomobilisetheserviceproviderstofocusonthis step.

Anotherfundamentalproblemindeservingbeneficiariesbeing left out of enrolment was that there werediscrepencies in the BPL list itself, which formed thebasisofenrolment.ThiswasprimarilybecausetheBPLlistsupdatedin2003and2005wasusedasthebasisofthe identificationprocess forenrolment in2012-2015.The lagresulted inmanytransformations intheactuallist,whichwerenotreflectedintheofficiallists.

Anotherfactorresponsibleforactualbeneficiariesbeingleftwastheroleofsomeoftheinfluentialpeopleinthevillage.Often,theywouldensurethattheirfriendsandfamilies enrolled for the cards in the name of other deserving candidates. PACS and its partners were determined to address this challenge to ensure that the

deserving candidates were enrolled during the camps. Thiswasachievedbyaddressinggapsatthreelevels–one,timelydistributionof chits toall eligible families,as mentioned above; two, awareness generation atthecommunity level; and three, closemonitoringandsupervisionintheenrolmentcamps,andsupporttotheenrolment team.

d. Mobilisingthecommunity

The biggest impediment in the success of RSBY waslimited awareness among the targeted community regardingtheschemeanditsprovisions.Whilepeopleingeneralmighthavebeenawareofthescheme,theylacked complete understanding and were uninformedaboutthedetailsofthescheme.Itwascommonlyfoundthat many eligible beneficiaries were not fully awareof the scheme and most card holders were unclear about the processes of availing benefits and unawareaboutthevariousentitlementsandservicesunderthescheme.So,inspiteofthemholdingRSBYsmartcards,theydidnotknowhowtouse it.Thiscreatedamajorgap between the number of registered beneficiariesandcasesofactualhospitalisation, thus rendering thescheme ineffective. It was, therefore, essential to notonly increase the number of beneficiaries, but alsoto spread awareness among the existing ones. This thought echoes in the words of Manju Devi fromVaranasi,whosaid,“Garibo ke saath bohut anyay hota hai agar jankari na ho toh“whichtranslatesinto,(Intheabsenceoftherightinformtion,thepooroftenhavetosuffergraveinjustice)

this exercise, CBOs played a major role in awarenessgenerationamongthecommunity.

There were many ways in which this was achieved.Along with door to door communication, awarenesscampaignswereheldinwhichdifferentformsofmediawere used to promote messages regarding RSBY in the community.Awarenessgenerationrallieswereorganisedin association with the CBOs in which maximumparticipation by the community was encouraged.Streetplaysandnukkadnatakswereheldonthisthemeas this was one form of media to which the people connected instantly. Puppet shows and magic shows were organised with special focus on RSBY enrolment andutilisationofbenefits.Atotalof29puppetshows,153streetplayswereconductedatthegrampanchayatlevelinthestatesofBihar,JharkhandandUttarPradesh.TheRSBYvideovanalsoheld1550screeningsreachingapopulationof1,09,200inthesamestates.

SushilaDevi,RSBYMitrafromPratapgarh,highlightedthattheBPLlistswereerroneousandgenerallyPradhansandotherinfluentialpeoplediscriminatedagainstexcludedgroupsandensuredthattheirrelativeswereenrolled,sothattheymayreapthebenefitsunderthescheme.

ShespecificallypointedouthowinsomecasesthedisadvantagedhouseholdsweredeliberatelyexcludedfromparticipatingintheRSBYenrolmentcamps.Thevillageheadswoulddupetheunawarecommunitymembersintobelievingtheywerenoteligible.Inherownwords,“Often Pradhans chase us away saying our names are not there in the BPL lists and instead make cards for their relatives on our names”.

She narrates how she went to every single BPL household in her village to ensure that they are not excluded and otherspeopledonotgetcardsmadeintheirnames.’

Communitysensitisationmeeting,Jharkhand

Involving religious leaders in communitymobilisation

Religious leaders were also roped in the process of mobilising the communitywherever possible. InWestBengal, Mohammad Kamaluddin, a Maulvi in theMosque inMurshidabad district was sensitised abouttheuseofthecard.Onceheunderstoodtheimportanceofcreatingawarenessamongthecommunitymembers,hetookonthetaskofspreadingthemessage.HeusedtheMasjidmikepreandpostAzaan(theMuslimCallforPrayer)totalkabouttheRSBYschemeanditsbenefits.He also conducted sessions on RSBY in the village Madrasatospreadawarenessamongtheyouth.

An active and wide spread awareness campaignwas launched at the community level. This wasundertaken to inform the beneficiaries as well as thegeneral community about RSBY and its provisions. In

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AwarenessgenerationonRSBYthroughpuppetshow,flimscreeingandnukkadnatak,UttarPrdaesh

Reaching across the community

Often, it was seen that once the community understood the message, theybecametheagentsofchangethemselvesandwouldspreadthemessageacrossthecommunity.WhenCheddiSharmaattendedthepuppetshowonRSBYinthevillage,helearntaboutthebenefitsofthescheme.Understandingthescheme,herealisedhowthiscouldhelphisrelativeMunniDeviwhowassufferingfromuterus related issuesbuthadnotbeenable toget treatmentduetofinancialconstraints.

HeimmediatelyinformedhisrelativesandconnectedthemtotheCSOprogrammemanager,Binduji.Uponconnectingwiththefamily,BinduexplainedtothemthedetailsoftheschemeandensuredthatMunniDevi,whohadcomplaintofseverestomachache,wastakentothehospitalandtreatedunderthescheme.Whilethefamilyhadasmartcard,thepatient,whowasthewifeofthecardholder,didnothavehernameonthecard.TheprogrammemanagersupportedthefamilyingettingthepatientsnameincludedintheRSBYcardthroughdistrictkioskattheChiefMedicalOfficer’s(CMO)officewhichmadeitpossibleforMunnitobetakentothehospital,properlydiagnosedandtreatedforherailment.

The storyofMunnihighlightshow the spreadof informationwasnot limitedmerely to people attending the awareness generation sessions, but traveledacrossthecommunitythroughwordofmouth,benefittingmanyintheprocess.OnceMunniwastreated,shewasinspiredtocreateawarenessinherownvillagesothatmanyotherslikehercouldreapthebenefitsofthescheme.

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Localmedia,artandculturewereweavedcarefullyintothesecampaignsandeffortsweremadetoensurethatthe campaigns were contextually relevant so that the local community could easily understand and relate to it. IEC materials were developed and distributedamongthecommunity.Thesematerialsweredesignedinaninnovativemannerandcomprisedofpictographic

representationof steps inenrolmentand inutilisationof smart cards. The mode of communication wasareaspecificandvariedfromstatetostate.Fore.g. inWestBengal, the localmosqueswere also involved inreachingouttothecommunityinabidtocreategreaterawareness.

At the community level, CBOs form the pillarssupporting the RSBY intervention by PACS. They arethemost importantplayer inawarenessgenerationatthe community level Recognising this important role,PACS organised training programmes for the CBOs atregularintervalstoinformandupdatethemaboutthekey provisions of the RSBY as well as the proceduresinvolved in availing benefits under the scheme. ThisenabledtheCBOstoreachouttothecommunitymore

Communityawarenessbuildingprogrammes,UttarPradesh

effectively in termsof awareness generation and thushelpedthecommunitytoavailmaximumbenefitsfromthe scheme.

AveryimportantsteptakenbyPACStowardscommunitymobilisationandawarenessgenerationwasintroducingthe concept of RSBY Mitras, who became the frontrunners in the implementation of the scheme at thecommunity level.

CapcitybuildingprogrammeforCBOmembers,UttarPradesh

RSBYMITRA-ThecommunityRSBYhealthworker

CommunityinvolvementinthedeliveryofhealthservicestoRSBYbeneficiariesisthemostimportantinitiativetowardsenhancingcommunityparticipationandownershiptowardsthisscheme.TheconceptofRSBYMitraswasenvisionedtofulfilthisurgentneedoftheschemeaswellasthecommunity.ThesewellinformedfriendsofthecommunityactedasthebridgebetweentheserviceprovidersandthebeneficiariesintheRSBYscheme.TheseMitraswerevolunteersfromtheCBOsofavillage(asinstitutionalisedbytheCSOpartnersofPACS).OneRSBYMitraisresponsibleforevery50familiesenrolledintheschemewithpossessionofasmartcard.Sincetheybelongedtothecommunityitself,theywere considered tobe the ‘go topersons’ by the communitymembers in caseofneed. Theywould facilitateandhelpthecommunitytousetheircardsintimesofhospitalisation.TheyhadfullinformationandknowledgeabouttheprovisionsofRSBYandwereequippedwiththerequiredinformation,includingthelistofhospitalsandservicesthebeneficiariesareentitledto.Theywerethefirstcontactpointforthecardholders,wherecomplainsandgrievanceswerefirstregistered.

The story of Chhote Lal is another case highlighting how community awareness translates into communityempowerment. Chhote Lal is a small tea stall owner inUdaiyadeeh, Pratapgarh.He had been suffering fromsuddenachesandpainsforoverayearduetoHydrocele.Beingpoor,hecouldneveraffordpropertreatmentforhisconditionandwouldsufferinpain.However,oncehisvillagewascoveredunderthePACSprogramme,communitymembersbecameawareoftheRSBYscheme.Duringaninformaldiscussionattheteastalls,someofthecustomersgottoknowabouthiscondition.Theyinformedhimabouttheschemeandthenearestempaneledhospital.ChoteLalgotintouchwiththeMitraandwithhissupportunderwentasurgery.Henowleadsapain-freelife.Hesays,hehadforgottenwhatitfeelsliketogothroughadaywithoutanypain.Inhiswords,“I had accepted that I will have to live with this pain all my life, so I had stopped complaining. It was only when I got to know about the scheme that I saw a hope to lead a normal life. In addition to free treatment, I got transport reimbursement, food during my stay and medicines for five days. There is no way I could have afforded the treatment myself and am thankful for this scheme.”

Whencommunityawarenesstranslatedintocommunityempowerment

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Since these Mitras were from the community itself,they had a sense of ownership and the community also could easily relate to them. This increased theircredibility.WiththehelpofRSBYMitras,theoutreachoftheschemeextendedtohithertounreachedareas.Like,for example, in thenaxal infested areasof Jharkhand,wheretheschemewaspracticallynon-existentbecauseno CSOs or government functionaries were active inthoseareas.ThecreationofRSBYMitrasledtopositivechange in the intervention areas leading to increasedenrolmentandutilisationofbenefits.

In the words of a community member Tinku KumarMandal from Deogarh, Karon Block “Mitra is kshetra mein ek vardan hai. Mitra ke aane ke baad is programme mein jaan dal diya gaya tha”(Mitrasareabooninthisarea.TheMitrashavemadethisprogrammealiveandvibrant).

PACS Mitras successfully reached the areas seldomcoveredbefore.Thehardtoreachareasweremostlyleftuncoveredand the communityhadno clueabout thesmartcard.However,withthePACSintervention,things

RSBYMitraswiththeirrecordbooks,Jharkahnd

havedrasticallyimproved.AstheProgrammeManagerfromJharkhandsaid“NoICICILombardwouldhavegonetoPalamu,thetribaldistricttoenrolthecommunityforsmartcards.Ourpresencemadeitpossibletoreachthepopulationwhereaccesswasahugechallenge”.

It also surfaced during discussions with differentstakeholders that PACS intervention in terms ofawarenessgenerationamongthestakeholderscreateda rippleeffect.TheCSOshad to intervene in thenon-interventiondistrictsduetodemandfrombeneficiariesand authorities to help in implementation ofprogramme.OftenpeoplefromtheothercommunitiesheardabouttheconceptofMitrafromtheirrelativesintheinterventiondistrictandwouldenquireabouttheirpresenceintheirrespectivedistrict.

Otherthanthat, itwasseenthatoncethecapacityoftheCSOwasbuilt,theydidnotlimitthemselvestothePACSinterventiondistrict.Inplaces,awarenesssessionswere also organised in non PACS districts under the purviewofthelocalCSOs.

SumitraHembrom(28years)livesinDamodarsaivillageinJharkhand,whichisoneofthetribalpopulatedvillageintheNayagaonpanchayat.ThevillageseverelylackedhealthcarefacilitiesandnobodyinthevillageknewabouttheRSBYscheme.PeoplehadneverheardofitbeforetheinterventionbySHARE(aCSOinthearea)underPACSprogramme.VillagersweredeprivedoftheirrightsandentitlementsunderRSBYduetolackofawareness.

SHAREworkedtowardstheformationofaGramSansathanunderPACSwiththeobjectivetosupportthesociallyexcludedcommunities.SumitrawasselectedasaVicePresidentofthecommitteeandalsotheRSBYMitraofthecommunity.SheworkedtirelesslytocreateawarenessamongthecommunitymembersafterreceivingtrainingsunderPACSprogramme.Sheaccompanied17familiestothehospitaltoavailbenefitsatGayetriSevaSadanhospitalatChaibasa.ShedescribeshowherjourneyasaMitranotonlytransformedthevillagebutalsoherlife.Inherwords,“I started working in the village in the year 2013. During the training I realised how my village has been deprived of this scheme which can save so many of us. I took on the task of ensuring that everybody in my community knew about it and ensuring that the community members get the correct treatment under the scheme. It brings me immense satisfaction to say that each and every villager knows about the scheme today. In case anyone faces any challenge, they approach me without any hesitation. ”

SumitraHembromspeakingatadistrictlevelworkdhop,Jharkahnd

SumitraHembrom’sjourneyasaMitra

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RSBYMitra,ShantiMahto,Jharkhand

2.2.2EnrolmentStage

The pre-enrolment activities undertaken to improvelinkages between the stakeholders, promoteempanelment and sensitisation of hospitals, createawarenessamongthecommunityandbuildcapacitiesofthestakeholdersatdifferentlevelslaidthefoundationforthenextstageofintervention.Thiswastheenrolmentstage. ‘Enrolment’ is the process during which theidentity of the beneficiary is authenticated and theyare registered and provided with biometric enabledsmartcard. Enrolment is undertaken by the insurancecompaniesineveryvillagewithbeneficiaryhouseholds.This is doneat thebeginningof eachpolicy year. Theenrolmentofbeneficiariesisprimarilytheresponsibilityoftheinsurancecompany,supportedbytheRSBYSNA.Anenrolment centre is set up at every village to register the beneficiariesonapre-scheduledday.Duringenrolment,the smart cardsare issued to thebeneficiarieson thespot,thesamedayduringregistration.Toinstilasenseof ownership in the beneficiaries, a token registrationfeeofINR30perannumischargedperhousehold.Theentire process has beendesigned to be very compactand quick, taking normally less than 10 minutes perhousehold.

Threesimplestepsoccurduringtheenrolment:

1 Based on the BPL household list finalised by therespective State Government and MoLE, GoI,beneficiaryhouseholdsareidentifiedineachvillage.

2 The beneficiaries, which include the head ofhousehold, spouse and up to three dependentsper BPL family, provide their fingerprints andphotographsattheenrolmentstation.

3 AregistrationfeeofINR30perhouseholdispaidatthecentreandeachhouseholdisissuedabiometricenabledsmartcard.Thecardisissuedinthenameofthe head of the household and contains details of all theenrolledmembers.Keeping inmindthespecialcaseofmigrantworkerandtoease theiraccess tothebenefits, thecardsaresplit forseparateuse inany RSBY empaneled hospital across India.

Thesesmartcardscanthenbeusedbythebeneficiaryhousehold members at any health facility empaneled

under RSBY. Sinc e the smart cards are biometricenabled,itensuresthatonlytheauthenticbeneficiariesuseit,thuspreventingmisuse.

While the above mentioned process of enrolmentindicates how it should have happened in an ideal scenario, thesituationon thefieldwasquitedifferentand faced with several challenges. One of the majorconcernswas the absence of camps in the in remotelocation,andconsequently,absenceofsmartcardswiththe eligible beneficiaries. In general, it was seen thatinsurance companies would not hold enrolment camps inruralareas.ThesituationchangedwhenPACSpartnersintervenedastheyensuredthatremotelocationswerefactored in at the time of making route maps itself.Apart from this,Mitras ensured that the campswereorganised on the mentioned dates. Thus, the role ofPACSwasnotonlytosupportdifferentstakeholdersbutalsotomonitortheworkinthedistrict.

Otherthanthat,inareaswherecampswereheld,thereweremany cases ofmalfunctioning of the smartcardsin terms of thumbprints mismatch. Sometimes, theinsurance companies refused to cover old people or people with chronic diseases. Incorrect informationwas being filled during the registration, adverselyaffectinghospitalisation.Therewereproblemsinaddingbeneficiaries to the existing cards and in renewal ofcards. Often, cards were never handed over duringthe camps - the beneficiaries were registered butnot issued instantly with smartcards on the pretext of malfunctioning machines. At times, the insurancecompaniesrefusedtoworktilllateandlefteventhoughsome of the families were left to be enrolled in thearea.Inmanycases,thoughsmartcardswereissued,no IEC material was distributed with the smart card,resulting in lack of awareness about the entitlementsunder the scheme.

It was these gaps which had surfaced during implementation that PACS, together with its CSOpartners,soughttoaddress.Atthisstage,PACSandtheRSBYMitras played a crucial role in ensuring that theenrolment process occurs systematically and withoutanymalfunctioning.Their rolewasmainlymonitoring,supervisingandfacilitatingtheprocessofenrolment.

ShantiMahto,52yearoldMitralivesinSahtahakavillageinWestSinghbhumdistrictofJharkhandwithherfourdaughters.Shantihasbeenawidowforthelast18yearsandfacedseverehardshipcopingwiththestigmaattachedtobeingawidow.Whileshestruggledtosinglehandedlybringupherfourdaughters,herhusband’sfamilycontinuedtoharassherbyaccusingherofbeingresponsibleforherhusband’sdeathandthreateningtotakeherproperty.Shewasnotonlylookeddownuponinthefamilybutwasalsosociallyexcludedbythecommunity.Thecustomsandtraditionswouldoftenbeinvokedtomarginaliseandisolateher.Shewouldoftenbelabelledasawitchortreatedasanuntouchable.Shewascondemnedtoliveherlifeasasecondclasscitizen.Shelivedinthemarginsofsocietyfor18yearsandwasbroughtbacktomainstreamsocietalnarrativeasaRSBYMitra.

Her life completely changedwhen she tookon the role ofMitra in 2013under the support of theCSOEkalNariShashaktSangathan,aplatformtoempowersinglewomeninJharkahnd.While inthebeginning,villagerswerehesitanttocometoherforhelp,thingsbegantochangegradually.LearninghowtheRSBYcardcouldhelpthem,thecommunitystartedtoseeherinanewlight.Slowly,herpositioninthesocietychangedfrombeingabadlucktothatofasaviour.Intheprocess,shehasnowbecomeamore empowered individual. She said “Mera koi wajood nahi tha, na ghar mein na samaj mein. Kabhi daayan karar diya jati thi ya kabhi chuwa chat sehke, ek Dwyam darj ka zindagi jee rahe thi.” In other words, ‘Today as a Mitra she has overcome and coped with the tragedy of facing years of oppression and emerged a more independent and stronger person with her own identity’.

Shenowcyclesfreelythroughthevillageassistingthoseinneedandfulfillingherduties.SheisnotonlywellacceptedinhersocietybutherserviceasMitraiswellacknowledgedandadmiredbyoneandall.

BeingaRSBYMitrachangedherlife

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TheStateLabourInstitute,Ranchiorganisedaworkshopon the occasion of International Labour Day 2014 incollaborationwithPACS.Theyalso invitedRSBYMitrasfromWestSinghbhumtoacknowledgetheirworkandunderstand their perspective on the progress of theprogramme.Mitrassawthisasanopportunitytoraisesomeoftheconcernsfacedbythemonthefield.Inadaylong workshop, while various discussions were done,someofthecriticalobservationsofthemitraswerealsobroughttothenoticeofthegovernment.

• InShandaya,BadagondiyaPanchayatandBaipi,slipsweredistributedbut the enrolment teamsdid notturnup.InBanamguttu,BadachiriPanchayat,againthe team did not turn up for enrolment.

• InArgundi,LohardaPanchayat,enrolmentwasdonein the first phase, but since then, no teams haveturned up.

• In Tosundri and Ruidih in Ruidih panchayat, manyfamilieswerestilllefttobeenrolled.

• Madkhamhatu, Loharda Panchayat, many familieswereincludedinBPLlistsinthepreviousyearbutnoslips for them in the current year.

• Madkhamhatu, Loharda Panchayat, somebeneficiaries received cards with no information on them.

Mitras played a pivotal role in ensuring that thegovernment takes notice of these issues. The StateLabour Institute took immediate action to resolve theissues and re-organised the camps whereever required. The government also acknowledged the Mitras forsharingtheirinsightsfromthefieldandtheirsupporttothe programme.

In this context, PACS assumed the responsibility ofensuring that all eligible beneficiaries were aware ofwhen the enrolment camps are scheduled and that they were present for enrolment. They helpedwith crowdmanagement, thus making the process quicker andeasier for the insurance companies. TheMitrasmadesurethatthenamesanddetailsofeachbeneficiarywere

correctly entered on the card and that their photographs and thumbprints were correctly taken. They tookcare thatnomemberofeligiblebeneficiary families isexcluded during RSBY enrolment. PACS ensured that the enrolment team issued biometric smartcards toall beneficiary families on the spot, along with a listof empaneled hospitals and detailed information ontreatment package. In case of genuine inability to dosoduetomalfunctioningofmachines,theRSBYMitrasproactively ensured that follow up visits were madeas soon as possible and cards given to the deservingbeneficiaries. Theymade sure that each household ischargedwithonlyINR30asregistrationfee.Inalmostallstates,asaresultofthemonitoringandsupervisionof the partners, the camps continuedtill late at nightand full enrolment was achieved.

“Cards were being issued to the well-off families by taking INR 100 as bribe while the deserving BPL families were left out. We confiscated the register and other items of the organisers and demanded that they stop “selling” the smart cards for money. Some of the members of the organising committee and other powerful people picked up stones and slippers to throw at us. However, the members of the womens’ group unified and did not let them continue with their malpractices. As a result, a camp was organised the next day in which the eligible beneficiaries and their families were enrolled”.

-ShabnamBano, HungamaWomens’Group,villagePureDevajani

Theresponsibilityattheenrolmentcampsdidnotendwith the issuance of smart cards. It was imperativeto educate the community regarding the benefits ofsmartcardand itsproperutilisation.Towards thisend,PACSensuredthatallrelevantIECmaterialwasavailableintheenrolmentcamps.Tofacilitateeasyunderstandingof the process, the IEC materials were primarily inthe form of contextual pictoral booklets. They alsoencouraged the migrant families to demand for split cards,sothattheycouldavailofthebenefitsthattheywereentitledto.

Some big changes have small and simplebeginnings

Averycommonproblemthatarosefrequentlywasthatof fingerprint mismatch of the farmers. This causedproblems in issuing cards to them. This primarilyhappenedduetotheirnatureofwork,whichcauseddirtparticlestoaccumulateintheirhands,therebysmudgingand camouflaging their fingerprints. PACS came upwith a simple solution to this problem. The Mitrasencouraged the farmers to wash their hands properly beforegivingtheirbiometrics,thusmakingsurethatnoeligiblebeneficiaryisdeprivedoftheirrights.

PACS and RSBY Mitras ensured that the stipulatednumber of FKOs accompany the enrolment teams inthe camps (for every 300 beneficiaries expected attheenrolmentcamp,at leastoneFKOisappointed. IncasetheBPLlistforalocationismorethan300,morethan one FKO should be present in the camp). TheMitras also liaisedwith the FKOs andensured that allnon-negotiables like banners, equipment and humanresource are present in the enrolment station. Theyalso assisted the beneficiaries in case they faced anyconfusion. In case of any problems, they assisted theFKOstotakeimmediateactionandalsoliaisedwiththedistrictRSBYcell,ifnecessary.

2.2.3Post-EnrolmentStage

During the enrolment process, the RSBY beneficiariesareissuedbiometricenabledsmartcards.Thesesmartcardscanbeusedby theholders toavailmedicalandhealthservices,includinghospitalisation,inanyhospitalempaneled under the RSBY scheme. The schemealso seeks to reduce any out of pocket expenses byproviding a stipulated travel allowance, free food andmedicines. The smart card holder has to go to thenearest empaneled hospital, and the smart cards areswiped,biometricsconfirmedandservicesareprovided freeofcost.Thisseeminglysimplestepwasriddledwithmany challenges.

The first and biggest hurdle was that the smart cardholders were not aware of the benefits they wereentitledtoandhowtousethesmartcards.Therewasa significant gap in the number of smart cards issuedandtheactualutilisationofbenefits.Therewerecasesreportedwheremanysmartcardholdersbelieved it tobeanAutomatedTellerMachine(ATM)cardandtriedto use it to get cash.

“When people were not aware of the purpose of the card, they made their own presumptions on how to use it. Some people went to the ATM machine to withdraw cash from the card. While some people stored it at a secure place thinking it is some form of identification card.”

-AnandShankarPandey, ProjectCoordinator,PurvanchalGraminSevaSamiti

Evenwhenthebeneficiarieswereawareofthebenefits,theysometimeswerereluctanttogotothehospitalastheyfeltintimidatedbythesurroundings.ThebehaviourandattitudeofthehospitalstafftowardstheSEGsandtheir lack of knowledge proved detrimental for thescheme.Thiswasanother crucial stageatwhichPACSintervened to address these challenges and improve the utilisationofsmartcards.Forthis,PACSundertookthefollowingactivities:

Conductingawarenesssessions:Thefirstandforemoststep in the post enrolment stage was to create awareness among the smart card holders regarding its utilisation.Thebeneficiarycommunity,inspiteofbeingenrolled, did not have sufficient knowledge about thesmartcard,itsprovisionandprocesses,thuslimitingitsutilisation.Towards thisend,awareness sessionswereorganised by PACS and partner CBOs informing themabouttheentitlements,benefitsandprocessesrelatedto the smart card provided to them under the RSBY scheme. Information regarding the list of empaneledhospitals,facilitiesandtreatmentsavailable,proceduretobefollowedwasdisseminatedtothebeneficiariestoenhanceutilisationunderthescheme.

46 47

Tomotivatethepeopletoutilisethebenefitsavailableunder RSBY, PACS organised rallies, street plays, filmshowswithin the community. Local folk art was usedwidely as people could relate to them instantly. IECmaterialslikebrochuresandpamphletsinlocallanguageswere distributed. PACS conceptualised and developedpictorialtoolswhichclearlydepictedtheentireprocessof using a smart card in a systematicmanner. Postersandbannerswereputup invillages toencourageandmotivate people to use their smart cards and availthe benefits that they are entitled to. Some of thesewerespeciallydevelopedbyPACSkeepinginmindthecontextual realities of the marginalised communities.These containedmessages on where the smart cardscould be used, how to use them, health services andfacilitiesthebeneficiariesareentitledto,listofservicedelivery points and,most importantly, where to go iftheyfaceanyproblemsordiscrimination.ApivotalrolewasplayedbytheRSBYMitrasandCSOsinthisprocess.

Enabling utilisation:Apart from organising awareness sessions, PACSpartners alsoworked towardsensuringthatbeneficiariesgettheservicestheyareseeking.Itwasoftenfoundthatthebeneficiariesfromthecommunityfelt intimidatedwith the idea of visiting the hospitalsandaskingthemfrommedicaltreatmenteventhoughtheyhadaccesstothesmartcard.Tohelpcommunityovercomethisapprehension,Mitrasorganisedexposure

visits to the hospital to familiarise the community members with the process of admittance in the hospital. This acquainted them with the utilisationprocessofthesmartcardsaswellaswiththeformalitiesinvolvedintheprocess.Thesevisitshelpedinfamiliarisingthe communitieswith the processes involved in usingthe smart card at the hospital and gave them the confidence to operate the card whenever required. InBihar,JharkhandandUttarPradesh707weeklyvisitsto RSBY emplaned hospitals were conducted at the blocklevel.

Apartfromthehospitalvisits,acrucialrolewasplayedby the RSBY Mitras in bringing the people needingtreatment to hospitals. Managing transport costswasahuge challenge, as theactual cost for travellingwould usually be much more than the prescribedtransportationallowanceofINR100.Butsostrongwastheir sense of responsibility towards the communitythat this did not deter them from doing their duties.Theyfoundasolutiontothisproblemandwouldgathera fewpatients togetherandtake themto thehospitalin a group, thus managing transport costs. The sameprocess was followed during discharge. In the words of an RSBYMitra from Jharkhand, Chaima, “I contact the other Mitras on phone to check if they have any patients. Then we take all the patients together, seven-eight of them. Again on the day of discharge, one person

goes to get them discharged. That’s how we manage transport costs”.

TheMitraswereconstantlyfacedwiththenewchallengesduring the process. Often it was found that hospitalsrejectedhospitalisationdue to identityor informationmismatch.Insuchacase,Mitraswereoftenthe‘gotoperson’ for the beneficiary. They had to facilitate theprocessoffixingthecardbyeithergettingintouchwithdistrict kiosks or by getting a verification done by thePradahan/Munda.Mitras, thus, became champions ofthe community resolving any issue that the community may face in accessing the services.

Sometimes, the beneficiaries could not avail thebenefitsasmachinesusedtoswipethecardswasnot

ExposurevisitofCBOleaderstoHospitals,UttarPradesh

functionallikeatthedistricthospitalinSidharthNagar,Uttar Pradesh.As per a card holder fromBhimaParikvillage,UttarPradesh,thecardswasswiped,butmoneywasalsotakenfromtheholder.

AnotherpracticebeingadoptedbythehospitalstoavoidRSBYpatientswasdelay infirstdiagnosis.Thedoctorswould withhold the diagnosis for more than two days aftertheinitialtests,bywhichtimetheeligibilityunderRSBYwouldbeover.PACSensuredthatsuchpracticesarestoppedandalsoensuredthatotherfacilitiesavailableunder the scheme such as free food and medicines were alsomadeavailabletothesmartcardholders.

Thecardthatsavedmyson

MahmudAlam’swifeRukhsanaBegumhadnoclueaboutthescheme,althoughshehadacard.Whenshewenttohermaidenvillage,shelearntaboutitsusefromaMitra.Sherealisedherfamilycouldusethecardtogetherson’sliversurgerydone.Inherwords,“I had kept this card safely for over a year now. While the government provided us the card, no one told us about its use until the Mitra who worked in my parents village told me about it.”

Oncetheyusedthecard,theytookonthetaskofmakingpeopleawareaboutitsuseintheirvillage.MuhmadAlamsays,“People did not know about the purpose of the card, once we used it for the operation of our child, they understood its importance. We have reached out to most people in our village and almost everyone knows about its benefits now”.

Hissuccessfulutilisationofthesmartcardencouragedmanymorepeoplefromthevillagetousetheircards.Heensureduptakeofentitlementsby14cardsholders in2012-2014.Givenhiscommitment,MahmudAlamwasencouragedtobecomeaMitratosupportthecommunityandspreadawareness.

Organisationofhealthcampstopromoteutilisationofsmartcards

Topromoteutilisationof smart cards,CSOsorganisedhealth camps in villages to screenpatientson thedayofenrolment.In2015,SanjeevNatralayaorganisedthreeeyecheck-upcamps,oneeachinNayaGoanPanchayat,AdhikariPanchayatandTartariaPanchayatinJharkhandatthedayofenrolmentcamps.Villagerswereencouragedtocometothecampforahealthscreening.Around60caseswereidentifiedandtreatedwith the use of smartcard.

48 49

Promotingutilisationofsmartcardsthroughhealthcamps,UttarPradesh

Dispute management/resolving conflict: To ensureeffective utilisation of the scheme, community basedmonitoringsystemsweredevelopedtocollectfeedbackfrom the community regarding their experiences of using the smart cards. This feedback from thecommunity was then shared directly with the SNAs and otherrelevantstakeholders.

A very important step towards resolving conflictswas participation in the GRCs. The GRCs are the keyinstitutions responsible for resolving problems anddifferences that may arise among stakeholders, thusminimising conflict and aiding in smooth functioningoftheRSBYscheme.TheGRChasapanelofprescribedmemberswhichalsoincludedPACSintheinterventionstates.PACSliaisedwiththeGRCsandattendedmonthlymeetingsatthestateanddistrict levelstoensurethatthebenefitsofRSBYreachthebeneficiariesinafairandequitablemannerandthatanyproblemsfacedduringtheprocessareeffectivelyresolved.

RSBYsmartcardusersgroup

Inmost intervention areas, groups of RSBY card userswere formed at gram panchayat level. The groupmembersselectapresidentandasecretaryfromeachgroup and are supposed to conduct meetings everymonth to discuss issues related to smart card and itsutilisation.

A very important step taken by PACS in this respectwas the settingupof a toll freenumber in Jharkhandto provide information related to the scheme andregister any complaints/grievances faced during theprocess.ThiswasdoneincollaborationwithGramvaaniCommunity Media in Jharkhand who would connectthe beneficiary to the nearestMitra for effective andimmediate redressal of the problem. If theMitrawasunabletoresolvetheissue,itwasthenescalatedtothePACScoordinatoratthedistrictlevel,andthenontothestate level.

“Often when the community is unaware, others take

advantage of the situation”, said Majida Begum,

chairperson of the block advocacy group. Her role

includes supporting the community deal with

challenges faced during the use of smart card under

the scheme. She says, “I support the community

members when they are faced with fraudulent acts

while using the smart cards, I use the GRCs and follow

up the cases with the district administration”. She

recollectsone such casewhenherneighbour’s son

wastakentotheempaneledhospitalandchargedfee

forthebloodtestsinspitebeingasmartcardholder.

She says, “when I got to know about the problem,

I called on the toll free number and registered a

complaint. After the compliant, an immediate action

was taken and the money was reimbursed to the

patient’s family”.

The GRCs acts as platforms through which the

commonmancanexpresstheinjusticebeingdoneto

themandalsogiveshim/heraconfidencetospeak

upagainstthewrongbeingdoneinthecommunity.

-MajidaBegum,Chairperson,BlockAdvocacy

Group,Patti,UttarPradesh

InUttarPradesh, the toll freehelplinewas introducedby the government and PACS supported in creatingawareness among the community members about it.PACS put up banners and posters in the villages,wallwritingstopopularisethenumberandencouragedthecommunitytouseitincaseofanyproblems.

Rajkumar Viswakarma, from Pratapgrah states that,“Jab PACS ke wall writing se toll free ka number mila, humne toll free ka dhuwadhar istimal kiya” (Whenwecametoknowofthetoll-freenumberfromPACS’swall-wrtitng,wemadeoptimumuseofitforthegoodofthecommunity)-astorythatechoedineveryinterventionvillageinUttarPradesh.

The storyofGulab, aged30 years, fromvillageDomela, block Sevapuri, Varanasi highlights theeffective roleplayedbytheMitrasinimmediategrievanceredressal.

Gulabwasanasthmaticpatientwhohadbeenunsuccessful in trying togethis condition treated foryears invarious private and government hospitals. During this process, hemet a suspectedmiddleman, Pappu, whoassuredGulabthathecouldgetpropertreatmentataRSBYempaneledhospitalashewasasmartcardholder.HethenaccompaniedGulabtoanempaneledhospitalinVaranasi.Inthehospital,Gulabwasgivenadrip,hisstomachwasbandagedandhewastoldthathehashadanabdominalsurgerybythedoctorincharge.AveryperplexedandstilluntreatedGulabwasdischargedintwodays,afterwhichhehandedovera“commission”toPappu.

ThedisappointedandconfusedGulabrequestedforhelpfromamedicalstudentinreadinghisdischargepapers.Thepapersrevealedthathehadundergoneasurgeryforgallstonesasperthepapersgiventohim.Thisshockingrevelation ledGulab to contact the only trustworthy source he could think of – theRSBYMitras. TheMitrasimmediatelycametohishelpandintervened.TheyconfrontedthehospitalandensuredthatGulabgotpropertreatment.

Itwasclearthatignoranceofthecommunity,asinthiscaseGulab,wasexploitedunderthescheme.ThisiswheretheroleofPACSwassignificanttostrengthenservicesthroughconstantmonitoringandprovidingsupporttothecommunity.

TheroleofMitrasinensuringimmediategrievanceredressal

50 51

PACSinterventioninRSBYwasbasedonastrongrightsbasedframeworkandaimedatimprovingutilisationanduptakeofbenefitsunderthescheme

52 53

AglanceatRSBYhelpline,Jharkhand

During thefirstquarterof2015, therewerea totalof2372incomingcallsontheHelpline;

• Therewere711 calls byRSBYMitrasonGrievanceStatusUpdate, i.e. to listen to recordedgrievancesand give voice updates on status of the grievances

• Thirty-five per cent (35%) of recorded grievanceswere pre-enrolment complaints, which includedproblems likenamesnotappearing in theBPL list,wrong name in the BPL list, no information aboutenrolment dates and venues, camp not held oncorrectdate/time,nocampsheld,noPragyaKendraor Unrecognised Workers Identification Number(UWIN) card registration centre and/or advice andinformationonRSBYscheme.

• Fifty per cent (50%) of recorded grievances werepost-enrolmentcomplaintsrelatedtotheproblemsfacedbythecommunityonnon-issuanceofcardafterenrolment,informationerrorsonthecard,issuesonrenewalofcard,falsecardissuedinsomeoneelse’sname,addingnamesorfamilymemberstothecard,non-operationalRSBYdistrictkiosk.

• Fifteen per cent (15%) of recorded grievanceswere hospitalisation complaints such as refusal oftreatment at empaneled hospital, lack of desiredservicesatempaneledhospital,extramoneytakenby hospital staff, provisions of RSBY not met byhospital, inability to read card/thumb impressionsat hospital, lack of IT facilities to process card at the hospital.

Source:RSBYHelplineSeva-GovernanceIntervention,FirstQuarterlyreport2015

4Conclusion and Lessons Learnt

PACSinterventioninRSBYwasbasedonastrongrightsbased framework and aimed at improving utilisationand uptake of benefits under the scheme. PACS, in

collaboration with other stakeholders, strengthenedcertainexistingpracticesandintroducedinnovativewaysofreachingthemarginalisedcommunities.Itcanbesaid

Figure7:PACSinterventionunderRSBY

Advocacy for institutionalising

support by signing MoU

Planning with the IC and

district administration

Encouraging the use of IEC at the enrolment camp

Ensuring registration

without discrmination

Ensuring disburserment of smart card

Organising tour to the hospitals

Giving timely information to FLW about the

camps

Conducting mobilisation on

the need for enrolment

Facilitating beneficaries to

the hospital

Handling cases of declination of smart cards by

hospitals

Ensuring provision of RSBY

facilities at the hospitals

Supporting grievance redressal systems

Supporting access to provisions

without discrimination

Supporting the IC to reach the hard to reach

areas

Use of IEC material, folk

media

Strengthening Supply side

Strengthening Demand

Community level Intervention

PACS Intervention under RSBY

54 55

that PACS intervened at various levels to ensure that the

schemeissuccessfulinreachingthecommunitieswhich

wereotherwiseleftuncoveredorwerenotawareofthe

existence of the scheme.

It can be surmised that PACS played a key role in

ensuringeffectiveimplementationoftheRSBYscheme

bystrengtheningboththesupplyanddemandthrough

a rangeof activities. PACSensured that they focuson

strengthening the supply side by closelyworkingwith

arangeofserviceprovidersincludingthegovernment,

hospitals and insurance companies. Along with that,

the prime focus was to create demand among the

communitymembersbycreatingawarenessaboutthe

schemethroughavarietyofcommunicationplatforms.

An important aspect of the intervention was how it

led to convergence of different stakeholders involved

in the scheme. The strategy under RSBY intervention

focusedonsupportingthegovernmentandnotworking

in isolation. All the PACS partners were oriented to

work in convergencewith the government during the

intervention. Convergence with existing departments

was seen as the core strategy of this intervention.

As Nasim Ansari from PACS partner Tarun Chetna,

said, “Working with government has always been a

huge challenge for us, primarily because there was no

common platform for us. We had our expectations and

they had their own opinion. While working with the

state government on RSBY, we realise how important it

is to work in coordination with the government”.

Effective liasoningwith thedistrict labourdepartment

particularly with the District Superintendent, Labour

Department/DKMwasdonetodevelopacollaborative

approach for better implementationof the scheme.A

twin-pronged approach was adopted wherein on one

hand,PACSpartnersfocussedonextensivelymobilising

the communities for enrolment and uptake of

entitlementsunderRSBY,whileontheotherhand,the

district labour department focussed on strengthening

monitoring systems to make service providers more

responsiveandaccountable. Simpleyeteffectiveways

fortheinterventionwereexploredandimplementedfor

these purposes.

Collectivemonitoringofhospitals

For instance, in Jharkhand, collectivemonitoring visitstothehospitalswereplannedwiththeDKMandPACSpartners. The strategy for conducting surprise visitsto the hospitals and following up with cases to ensure properredressalof identified issuesprovedtobeveryeffective. Between 2013-2015, frequent visits weremadetohospitalslikeGayatrihospital,SwastikHosptial,MedhaSewaSadan,Bednathinthedistrict.Asaresultofthesevisits,hospitalsstartedensuringthatadoctorwasavailable 24 hours,medicineswere available, patientswere not over charged and other entitlements underRSBY were given to the patients. The main objectiveof these visits, asputby theDKM,was to reduce theopportunities of errors and ensure increased benefitsforbeneficiaries.

Due to the partnership developed under the RSBY scheme, the labour department in Jharkhand nowworks closely with PACS Jharkhand office on variousissues other than RSBY.

ItwasseenthattheinterventiononRSBYledtoincreasein uptake of rights under other schemes as well.AwarenessgenerationinthecommunityundertheRSBYschemeledtocommunityempowermentmakingthemconsciousoftheirrights,ingeneral.Asthecommunitybecamemoreawareandaccessedtheprovisionsunderthescheme,theywereseentobemoreconfidentabouttheir rights. The interventions nurtured their capacityto be awareof their surroundings andother schemesimplementedtheirstates.Inthismanner,thecommunitybecame more aware of its rights and the uptake ofentitlementsunderotherschemesalsoincreased.

It is noteworthy to mention that institutionalisingthe process through formal agreements and MoUswith the government play a crucial role in allowing smooth introduction of the CSOs in the scheme. Thisgives themthecredibility toworkwithin theambitoftheschemeandalsotherequiredacknowledgementbyotherstakeholders.

TheprogrammealsosawtheemergenceofanewcadreofhumanresourcecalledtheRSBYMitrasinJharkhand.

The concept of RSBY Mitras was a step towardsenhancingcommunitypartnershipforparticipationandownership.Theconceptrosefromtheneedtobridgethegapbetweentheserviceprovidersandthesmartcardholdersaccessingthebenefitsofthescheme.InitiatedbyPACSandapprovedbythegovernmentofJharkhand,the concept was successful in creating communitymobilisationand increasingdemandofhealthservicesunderRSBY.Otherthanthat,itisimportanttonotethathavingagrievanceredressalsysteminplaceandmakingitworkeffectivelyencouragestwowaycommunicationensuring that the rights of the community are protected.

It was noted from the intervention that Civil SocietyParticipationhasapotentialtoprovidedvisibleimpetusto the scheme. Community based approaches andcapacity building provides sustainable local solutionsto strengthen the programme. The involvement ofcivil society providers assisted the service providers in ensuring last mile connectivity. CSO with strong local mobilisation have a potential to make the services reach to someof themost diffcult areas andexcludedcommunities.

While PACS was successful in creating its intendedchange, some of the challenges faced by them havebeendetailedbelow.

• A fundamental challenge faced across the stateswas the discrepancies in the BPL lists. Since the lists that were used for the enrolment were updated in 2003and2005,theywerepartiallyredundantwithmany gaps.

• WhileMitrashaveemergedasthetorchbearersofthe scheme at the grass root level and their crucial role has helped tremendously in enhancing the uptakeofbenefits,itwasobservedthatcommunitiesweredevelopinghighdependenceonthem.Whiletheirroleofhandholdingthecommunityhasbeenobserved to be beneficial, over dependence maynotprovetobeaneffectivestrategy.For instance,the communitymembers got so habitual to go tothehospitalwith theMitra, theydidnothavetheconfidencetogoontheirown.Whenaskedifthey

could go to the hospital by themselves after thefirst visit with the Mitra, they insisted on beingaccompaniedbythem.

It is essential to define Mitras’ role as that of afacilitator. Their role should demand that theyempowerthecommunityandbuildtheircapacitytoaccess rightson theirown.Mitra’s should thusbeseen as a support mechanism for the community.

• Itwasfoundthattherewerestate-wisediscrepanciesinissuanceofIDcardstotheMitras.InJharkhandthishadproventobeaneffectivestrategyasthisgaveanidentitytotheMitrasandmadeiteasierforthemto interactwith thedistrictofficials. Thisprovidedthemwithalegitimatebasisforintervention.Havinganofficial identityandrecognition instilsagreatersenseofresponsibilityandownershipintheMitras.

• The success of pre-enrolment and enrolmentactivities depends on the ability to mobilise thecommunity.Butanothermajorfactoraffectingthesuccess of the enrolment camp is the location. Incase of marginalised communities, long distancetranslates into lossof livelihoodfortheday,whichbecomesa strongdemotivating factor for them.Agreaterdistancemayalsobeaproblemindifficultterrains.Therefore,whilepreparingaroutemapforthe intervention, thegovernmentofficialsneed toconsider these factors as well.

• ItisimportanttocommentthatwhilePACSrolewaslimited to strengthening the systems and processes oftheexistingschemes,itwasobservedthatmanyhospitals had not been paid their dues for thecases.Thiswaseitherduetotheirconflictwiththeinsurancecompaniesordistrictadministration.Thereasonsfortheconflictwereunclearanddebatableas eachpartyhave their own story. It canbe saidthat this issuewould require further investigationbeforeconcludingorassumingwhatwerethegaps.

While PACS was not directly involved in the process,this had a direct impact on the service delivery of the programme.

56 57

5Annexure 1AboutPACS

PoorestAreasCivil SocietyProgramme (PACS) isan initiativeof theUKgovernment’sDepartment for InternationalDevelopment(DFID).UnderPACS,DFIDpartneredwithIndiancivilsocietytohelpsociallyexcludedgroupsclaimtheirrightsandentitlementsmoreeffectively,sotheyreceiveafairershareofIndia’sdevelopmentgains.

PACS,initssecondphaseofimplementation(2009-2016),hadbeensupportingtheworkofCSOstopromoteinclusivepolicies,programmesandinstitutionsatlocal,districtandstatelevelsintheareasoflivelihoodsandbasicservices.TheprogrammewasinitiatedbyDFIDin2001tosupportandstrengthencivilsocietytohelpthepoorestandmostvulnerableindepriveddistrictsinIndiatoclaimtheirrights.

Itsfirstphase,whichendedin2008,focusedonreachingallpoorgroupsandtacklingthegeneralcausesofpoverty.ExperiencegainedduringthefirstphaseofPACSshowedclearlythatthepoorinIndiaarenothomogenous:certaincategoriesofpeopleareparticularlymarginalised.Whilethepersistentpovertyofthesegroupscanbepartlyattributedto general causes that createdeprivationamongall poorpeople in India, there are specific factors that aggravatehardshipamongthesociallyexcludedandmakeitharderforthemtoescapepoverty.

ThesecondphaseofthePACSProgrammewasimplementedacrosssevenIndianstates-Bihar,Chhattisgarh,Jharkhand,MadhyaPradesh,Odisha,UttarPradeshandWestBengalcovering90ofthepoorestdistrictsacrossthesestates.ThesearethedistrictsidentifiedasthosehavingpovertylevelshigherthantheaverageforruralIndia.Inadditionasubstantialproportionofthesedistrict’stotalpopulationbelongedtosociallyexcludedgroups.

PACSworkedwith225CSOsduringitsimplementation.TheCSOprojectssupportedbyPACSwereinitaitedinSeptember2011 and concluded by December 2015. This period also witnessed a number of thematic campaigns and otherinterventionscarriedoutbyPACSincollaborationwithmultiplestakehodlersincludingthegovernment.

PACSaimedatreducingthewelfaregapbetweensociallyexcludedgroupsandtherestofthepopulationandachievinggenderequality.TheheterogeneityofthenatureofsocialexclusionrenderedtheimplementationofPACStobespecificandpeoplecentred.DrivingonaCSOsandcommunitybasedapproach,PACSstressedonempoweringthesociallyexcludedgroupstowardsgreaterawarenessandaccesstokeygovernmentschemes.TheselectionofschemeshavebeensuchthatPACStargetsthreemajorfacetsofhumandevelopment:Livelihoods,HealthandNutritionandEducation.Strengtheningnpondiscriminatoryaccessofthesociallyexcludedgroupstotherightsandantitlementsenshrinedinthesegovernmentschemesonthesethreeareas,PACShadstrivedtowardsbridgingthewelfaregapbewteenthemandrestofthepopulation.

PACSProgrammewasmanagedbyaconsortiumoforganisationsledbyChristianAidUKalongwithCaritasIndia,AccessDevelopmentServices,IndianInstituteofDalitStudiesandFinancialManagementServiceFoundation.

ListofCSOsworkingonRSBYinterventionunderPACS

State CSOs

Bihar • CentreforHealthandResourceManagement

• BiharViklangKalyanParishad

• MuzaffarpurVikarMandal

• PrayasGrameenVikasSansthan

• PragatiGrameenVikasSansthan

• Nidan

• Yatharth

• SamagraShikshaEvamVikasSansthan

• IZAD

Jharkhand • ChetnaVikas

• BadlaoFoundation

• SocietyforReformationandAdvancementofAdivasis(ASRA)

• NayaSaveraVikasKendra

• ShramjeeviMahilaSamiti

• SocietyforHumanAssistanceandRuralEmpowerment(SHARE)

• PreranaBharati

• LokChiragSewaSansthan

• Ekjut

• GramodayaChetnaKendra

• JharkhandVikasParishad

• EvangelicalFellowshipofIndiaCommissiononRelief(EFICOR)

Odisha • DevelopmentInstituteforScientificResearch,HealthandAgriculture(DISHA)

• VisionariesofCreativeActionforLiberationandProgress(VICALP)

• SocietyforWelfare,AnimationandDevelopment(SWAD)

• AAINA

• CentreforWorldSolidarity

• Janasahajya

• SocietyforPromotingRuralEducationandDevelopment(SPREAD)

Annexure 2ListofCSOsWorkingonRSBYunderPACS

58 59

State CSOs

Uttar • PurvanchalGrameenSevaSamiti

Pradesh • SahbhagiShikshanKendra

• TarunChetna

• PARTICIPATORYACTIONFORCOMMUNITYEMPOWERMENT(PACE)

• SamudayikKalyanEvamVikasSansthan(SKEVS)

• GramNiyojanKendra

• PanchsheelDevelopmentTrust

• GrameenVikasSansthan

• Aadharshila

• SchoolforPotentialAdvancementandRestorationofConfidence(SPARC)

• Gramya Sansthan

• ShramikSevaKendra(SSK)

• PeopleforPeaceServiceSociety(PPSS)

• PurvanchalRuralDevelopmentandTrainingInstitute(PRDTI)

• NavBharatiNariVikasSansthan

WestBengal • ChildinNeedInstitute

• NariOShishuKalyanKendra

• ShripurMahila-o-KhadiUnnayanSamity(SMOKUS)

• JalpaiguriSevaSadan

60

ThePoorestAreasCivilSociety(PACS)programmeisaninitiativeoftheUKgovernment’sDepartmentfor International Development (DFID). Under PACS, DFID partnered with Indian civil society to helpsociallyexcludedgroupsclaim their rightsandentitlementsmoreeffectively, so they receivea fairershareofIndia’sdevelopmentgains.PACS,initssecondphaseofimplementation(2009-2016),hadbeensupportingtheworkofCSOstopromoteinclusivepolicies,programmesandinstitutionsatlocal,districtandstatelevelsintheareasoflivelihoodsandbasicservices.

RSBY isoneoftheflagshipprogrammesoftheGovernmentonwhichPACSProgrammeworkedfrom2011 to 2015 across its intervention states. This document presents the approaches, strategies,results,achievementsandkeylearningfromtheinterventionalongwiththestoriesofchangefromtheinterventionarea.

PACSKnowledgeProduct

PACSNationalOffice CISRSHouse,14JangpuraB,MathuraRoad,NewDelhi-110014

Phone:+911124272660,24372699 Email:info@pacsindia.org,Website:www.pacsindia.org