A study to analyse implementation of RSBY in Chhattisgarh - Sulakshana Nandi


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  • The State Nodal agency Chhattisgarh is shortly calling RFP for doing evaluation of RSBY in Chhattisarh. All interested in serious research can bid.
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  • As we recall this study was never done by the authors. As we remember this was part of summer assignment work of PG Diploma students from Hamdard university /Jamia milia. The students choose convenient hospitals near their residence and never bother to collect information from State Nodal agency or the District where they have worked. What so ever work done was for meeting the summer assignment requirement. Extrapolating the observations of students by the authors. Looking at the ppt and study? it appears that the authors are in haste to sensationalize with their findings.
    It needs to be mentioned that PHRN also takes part in building capacities of District personnel for District Health planning under NRHM with sessions on RSBY .? Despite this this study reflects poor understanding of the scheme by authors
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  • This study as we recall was never done. The results are extrapolated from the summer assignment of Hamdard University PG diploma student, who could visit only the nearby hospital to her residence and never bothered to collect information from reliable source.
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  • Question is which true picture you are looking for? The picture which shows the success story of RSBY in Chhattisgarh - as f.e. the true success story of the NREGA which tells a story of success and full coverage of the target group, but in reality suffers from a lot of flaws as corruption and delays in pay-out of salaries to the beneficiaries/workers (or should I call them the new governmental slaves)?

    The study seems partly to be founded on data which is gathered by government itself. Hence, if this data is purposive your comment proves the false picture the government information wants to show to the world about RSBY. The collection of the other data seems very sound to me (at least from the information given in the presentation). Therefore I congratulate the authors to give at least a true picture from the field (and not some hypothetic extrapolations of data and results done behind a desk in some government office).
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  • The authors should do more basic work with a sound methodology. The data collected is purposive and biased and does not reflect the true picture.
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A study to analyse implementation of RSBY in Chhattisgarh - Sulakshana Nandi

  1. 1. A STUDY TO ANALYSE IMPLEMENTATION OF RSBY IN CHHATTISGARH <ul><li>Public Health Resource Network (PHRN) </li></ul><ul><li>Presentation at EPHP </li></ul><ul><li>11 th December 2010 </li></ul><ul><li>Authors: Sulakshana Nandi [1] , Kanica Kanungo [2] , Md. Hashim Khan [3] , Haripriya Soibam [4] , Tarang Mishra [5] , Samir Garg [6] . </li></ul><ul><li>[1] State Convener, Public Health Resource Network (PHRN), Chhattisgarh </li></ul><ul><li>[2] Student, MBA Health Management. Jamia Hamdard </li></ul><ul><li>[3] Student. MBA Health Management. Jamia Hamdard </li></ul><ul><li>[4] Senior Programme Co-ordinator, Public Health Resource Network (PHRN), New Delhi </li></ul><ul><li>[5] Member, Public Health Resource Network (PHRN) </li></ul><ul><li>[6] Member, Public Health Resource Network (PHRN) </li></ul>
  2. 2. OBJECTIVE OF THE STUDY <ul><li>To analyse implementation of RSBY in Chhattisgarh in terms of coverage, enrollment, hospitalisation and awareness levels of the beneficiaries </li></ul><ul><li>To find out of pocket expenditure incurred, if any in Public and Private sector facilities by beneficiaries of RSBY </li></ul>
  3. 3. WHAT IS RSBY? <ul><li>Insurance scheme launched by Ministry of Labour and Employment, Government of India </li></ul><ul><li>Started from 1 st April 2008, in Chhattisgarh cards distributed from 2009 </li></ul><ul><li>Provision: </li></ul><ul><li>Provides health insurance coverage of Rs.30000/- annually for each Below Poverty Line (BPL) family </li></ul><ul><li>Coverage of up to five members of the family </li></ul><ul><li>No age limit </li></ul><ul><li>Provision of pre and post hospitalization expenses </li></ul><ul><li>Pre-existing diseases to be covered </li></ul><ul><li>Includes 708 procedures and 20 Day care procedures </li></ul><ul><li>Supposed to be cashless </li></ul><ul><li>Premium: </li></ul><ul><li>Beneficiaries need to pay only Rs.30/- as registration fee </li></ul><ul><li>Central and State Government pay the premium to the Insurer (around Rs.750 per card, total Rs73 Crore in Chhattisgarh) </li></ul><ul><li>Central government pays 75% of the premium and State pays 25% </li></ul>
  4. 4. METHODOLOGY <ul><li>Primary data- interviews of 102 people utilising RSBY in May & June 2010. </li></ul><ul><li>Secondary data- from official RSBY Website http://rsby.gov.in/Statewise.aspx?state=13 </li></ul><ul><li>- Selection of district with highest hospitalisation rate-Durg </li></ul><ul><li>- Selection of hospitals </li></ul><ul><ul><ul><li>2 Public hospitals with high hospitalisation rates </li></ul></ul></ul><ul><ul><ul><li>5 Private hospitals- convenience sampling among high hospitalisation rates </li></ul></ul></ul><ul><li>Selection of Beneficiaries- 52 in public and 50 in private facility </li></ul><ul><li>Sample size- 4% of Total Hospitalised cases in Durg district (till 30 th April 10) and </li></ul><ul><li>2% of Total Hospitalised cases in Chhattisgarh (till 30 th April 10) </li></ul>
  5. 5. COVERAGE <ul><li>Need to cover the excluded- NREGS and other unorganised sector workers </li></ul>Leaving out the poor Three out of these 6 women have a BPL card and therefore are eligible under RSBY and the rest three are not- can you spot them?
  6. 6. COVERAGE <ul><li>Enrollment too slow- only 44% of eligible beneficiaries enrolled in first two years of implementation (till April 2010) </li></ul><ul><li>Enrollment being done by private agencies- no transparency or grievance redressal mechanisms </li></ul><ul><li>37% of respondents had above five members in their family- Whom to leave out? </li></ul>
  7. 7. AWARENESS ABOUT RSBY <ul><li>75% came to know about the scheme through panchayat members/parshad </li></ul><ul><li>Most aware of the amount covered </li></ul><ul><li>Only 25% aware of card validity period </li></ul><ul><li>Only 31% aware of the number of family members covered </li></ul>
  8. 8. ENROLLMENT PROCESS <ul><li>Place of enrollment- local school/panchayat bhawan </li></ul><ul><li>No extra travel costs </li></ul><ul><li>Both thumbprints and photo taken </li></ul><ul><li>99% not given RSBY brochure or list of hospitals </li></ul><ul><li>Information given only about a certain private hospital </li></ul><ul><li>No extra payment (other than Rs 30) for card </li></ul><ul><li>Only 4 percent got the smart card on the same day </li></ul><ul><li>Average days taken to receive the smart card- 29 </li></ul><ul><li>For 8% families, members other than the head of family were left out </li></ul>
  9. 9. EMPANELMENT OF HOSPITALS <ul><li>147 Private and 181 Public hospitals empanelled (Nov10) </li></ul><ul><li>Tribal/remote districts are half the number of total districts but only 13% of the total private hospitals empanelled are in these districts </li></ul><ul><li>No private hospitals empanelled in remote districts like Kanker, Koriya, Kawardha and Dantewada- hence no additional facilities through RSBY </li></ul><ul><li>40% of the private hospitals empanelled are in Raipur which anyway has functional public health facilities </li></ul><ul><li>Some hospitals (mostly CHC) empanelled do not have functional in patient facilities- these CHCs need to be improved </li></ul>
  10. 10. HOSPITALISATION <ul><li>Abysmally low rate of hospitalisation in Chhattisgarh- 5 per 1000 enrolled </li></ul><ul><li>Claims ratio= claim amount paid/premium earned by Insurance Agency </li></ul><ul><li>Literature references show that the Claims ratio in health insurance should be around 80% </li></ul><ul><ul><li>Claims ratio for Durg : 8.9% </li></ul></ul><ul><ul><li>Claims ratio for Chhattisgarh : 2.8% </li></ul></ul><ul><li>(data till 30 th April 10) </li></ul><ul><li>Durg district data (till May10) </li></ul><ul><ul><li>- 18% of cases in Public hospitals </li></ul></ul><ul><ul><li>- 82% of cases in Private hospitals </li></ul></ul><ul><ul><li>11% of cases rejected cases (rejection rate 15% in Public and 10% in Private hospitals) </li></ul></ul>
  11. 11. HOSPITALISATION <ul><li>77% of respondents in public hospital were from rural areas and 66% of respondents in private were from urban areas </li></ul><ul><li>Mitanins (ASHAs) significantly referring to public hospitals </li></ul><ul><li>Reasons for coming for treatment mostly general weakness and fever </li></ul>Reason for coming to Hospital % Weakness 33 Fever 18 Surgical 13 Abdominal Pain 10 Accident 9 ENT 6 Diarrhea/Dysentry/Vomiting 5 C-Section 3 Paralysis 2 Aids 1   100
  12. 12. HOSPITALISATION <ul><li>Diagnostic tests prescribed to 63% </li></ul><ul><ul><li>- 40% in public hospital </li></ul></ul><ul><ul><li>- 86% in private hospital </li></ul></ul><ul><li>75% of the cases, tests done in the hospital itself </li></ul><ul><li>For 60% medicines available in the hospital. </li></ul><ul><li>Rest 40%, RSBY nodal person or Doctor suggested names of medicines shops </li></ul><ul><li>Average days of hospitalisation recorded - 5 </li></ul><ul><li>25% of the patients not hospitalised but recorded as hospitalised </li></ul><ul><li>Private sector discrimination against the poor fixing quotas of beds </li></ul>
  13. 13. HOSPITALISATION <ul><li>77% had utilized RSBY for more than one episode </li></ul><ul><li>37% not aware of the amount of money blocked by the hospital. </li></ul><ul><li>Average amount blocked = Rs 6622 </li></ul><ul><ul><ul><li>- Private hospital= Rs. 7416 </li></ul></ul></ul><ul><ul><ul><li>- Public hospital = Rs. 4988. </li></ul></ul></ul><ul><li>99% received transport charges of Rs.100 from the hospital </li></ul><ul><li>59% not given RSBY receipt </li></ul><ul><li>90% given medicines at discharge </li></ul>
  14. 14. OUT OF POCKET EXPENDITURE <ul><li>37% incurred out of pocket expenditure </li></ul><ul><li>58% going to private hospitals incurred out of pocket expenditure </li></ul><ul><li>17% going to public hospitals incurred out of pocket expenditure </li></ul><ul><li>Average out of pocket expenditure= Rs 686 </li></ul><ul><ul><li>- In public hospital= Rs 309 </li></ul></ul><ul><ul><li>In private hospital= Rs 1078 </li></ul></ul><ul><li>Out of the total expenditure in private sector, 63% of the amount was incurred on items not disclosed by the hospital to the patients </li></ul>
  15. 15. OUT OF POCKET EXPENDITURE Item Average amount spent (Rs)   Public Private Total Food 117 10 65 Medicines 33 225 127 Diagnostics 15 145 79 Tip to Nurse 7 2 4 Money to Doctor 137 23 81 Others - 674 330 Total 309 1078 686
  16. 16. TRANSPARENCY AND ACCOUNTABILITY ISSUES <ul><li>Incentives to Health staff and Rogi Kalyan Samitis- paying the well paid, encouraging false and higher claims </li></ul><ul><li>Transparency: Names enrolled not available, Case wise data not available, hospital wise data also kept secret, reasons for rejection not disclosed even to hospitals </li></ul><ul><li>No grievance redressal mechanism- if you don’t get RSBY card, if photo/name is wrongly printed, if any family members have been left out, if empanelled hospital refuses to admit, if TPA tells that no money left in the card even if never been used (i.e. Card is ‘cashless’), if hospital/TPA retains the smart card </li></ul>
  17. 17. CONCLUSIONS AND RECOMMENDATIONS <ul><li>Health insurance route to deliver services- the experience so far in Chhattisgarh : </li></ul><ul><li>Highly cost ineffective-only a handful of patients got any significant treatment and the government ‘lost’ 73 crore rupees </li></ul><ul><li>Accountability of public health system compromised </li></ul><ul><li>Out of pocket expenditure still persists despite the ‘cashless scheme’ </li></ul><ul><li>Private sector is still unregulated </li></ul><ul><li>The two critical questions to ask are: </li></ul><ul><li>Is RSBY leading to the poor getting access to free and good quality health care? </li></ul><ul><li>Is it a cost effective model? </li></ul><ul><li>This study throws serious doubts on the above, hence it is necessary to undertake larger studies across many states to understand this further </li></ul>
  18. 18. THANK YOU