Awareness, Accessibility and Barriers in Utilization of Rastriya Swasthya Bima Yozna Services among BPL Families in Puri District, Odisha

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This is primary research as a part of my Independent Research project done in Puri district of Orissa among BPL families that gives the glimpse of reality of social welfare scheme.

This is primary research as a part of my Independent Research project done in Puri district of Orissa among BPL families that gives the glimpse of reality of social welfare scheme.

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  • 1. Independent Research Project Report OnAwareness, Accessibility and Barriers in Utilization of Rastriya Swasthya Bima Yozna Services among BPL Families in Puri District, OdishaSubmitted by Project Guide:Sudheer Kumar (U310051) Dr. S. PeppinPGDM RM-2 Xavier Institute of Management(2010-12) Bhubaneswar
  • 2. DeclarationThis is to state that this research has been conducted by me as part of the curricula for theIndependent Research Project of PGDM-RM from Xavier Institute of Management,Bhubaneswar. All the data and information stated in this report are compiled from questionnairesurvey, various field observations and information gathered through interviews and interactionwith various information providers and the report is completely an outcome of the extensive fieldwork in Puri district during the period of study. (Signature) 1
  • 3. AcknowledgementI would like to take this opportunity to thank my guide Dr. S. Peppin for extending a very helpfulhand throughout the project duration and constantly guiding and providing support me throughoutthe project.My grateful thanks are also extended to staff and employee of SWAD NGO for their co-operationand their helpful behavior in data collection. I thank all my friends and colleague for theircooperation and help, especially Prabin Kumar Nath and Prachit Chaturvedi for helping me indata collection.I would like to take this opportunity to thank all the respondents for patiently answering my hourlong questionnaire and still not have any grudges against me in the end.Lastly but by no means the least, I would like to extend my hearty thank you note to SRC facultyProf. Bishnu Prasad Mishra and Prof. Jeevan J. Arakal for approving my research project andXavier Institute of Management for providing such an opportunity to me. 2
  • 4. ContentsCHAPTER 1 INTRODUCTION..................................................................................................................... 61.1 BACKGROUND ............................................................................................................................ 61.2 OVERVIEW OF HEALTH STATUS .......................................................................................................... 71.2.1 HEALTH STATUS IN INDIA ..........................................................................................................................71.2.2 HEALTH STATUS IN ORISSA ........................................................................................................................81.3 NEED FOR SOCIAL HEALTH INSURANCE SCHEME: ................................................................... 101.4 EARLY INITIATIVES:................................................................................................................. 11CHAPTER 2 RASHTRIYA SWASTHYA BIMA YOJNA (RSBY) ............................................................................. 122.1 NOTEWORTHY ASPECT OF RSBY SCHEME ............................................................................................ 132.1.1 EMPOWERING BENEFICIARIES ..................................................................................................................132.1.2 BUSINESS MODEL FOR ALL STAKEHOLDERS .................................................................................................132.1.2.1 Insurers ..........................................................................................................................................132.1.2.2 Hospital ..........................................................................................................................................142.1.2.3 Intermediaries................................................................................................................................142.1.2.4 Government ...................................................................................................................................142.1.3 SMART CARD ........................................................................................................................................142.1.4 PORTABILITY .........................................................................................................................................142.1.5 CASH‐LESS............................................................................................................................................142.2 BENEFITS UNDER RSBY SCHEMES ..................................................................................................... 152.3 SERVICE DELIVERY MECHANISM ....................................................................................................... 152.3.1 ESTABLISHING PARTNERSHIPS BETWEEN THE GOI AND STATES/UTS...............................................................152.3.2 ESTABLISHING STATE NODAL AGENCIES.....................................................................................................162.3.3 ESTABLISHING PARTNERSHIPS WITH INSURANCE COMPANIES .........................................................................162.3.4 ESTABLISHING THIRD PARTY ADMINISTRATORS (TPAS) .................................................................................162.3.5 EMPANELLING HOSPITALS .......................................................................................................................162.3.6 ENROLLING BPL FAMILIES .......................................................................................................................162.4 OVERVIEW OF RSBY IN ORISSA:.............................................................................................. 172.5 OVERVIEW OF RSBY IN PURI DISTRICT ............................................................................................... 172.6 FACTORS THAT INFLUENCE TO TAKE UP THIS TOPIC: ............................................................... 18CHAPTER 3 LITERATURE REVIEW AND METHODOLOGY FOLLOWED .............................................. 193.1 LITERATURE REVIEW: ..................................................................................................................... 193.2 RESEARCH QUESTION: .................................................................................................................... 213.3 PURPOSE OF STUDY: ...................................................................................................................... 213.4 KEY INFORMATION AREA: ............................................................................................................... 213.4.1 AWARENESS: ........................................................................................................................................223.4.2 PSYCHOGRAPHIC: ..................................................................................................................................223.4.3 LATENT FACTOR: ...................................................................................................................................223.4.4 UTILIZATION: ........................................................................................................................................22 3
  • 5. 3.4.5 ACCESSIBILITY: ......................................................................................................................................223.5 RESEARCH DESIGN: ....................................................................................................................... 233.5.1 RESEARCH METHODOLOGY ......................................................................................................................233.5.1.1 Sampling: .......................................................................................................................................233.5.1.2 Data Collection:..............................................................................................................................233.5.1.3 Data Analysis: .................................................................................................................................233.6 POPULATION OF STUDY: .......................................................................................................... 243.7 SCOPE OF STUDY: ......................................................................................................................... 243.8 ROLE OF RESEARCHER: ................................................................................................................... 24CHAPTER 4 FINDINGS & ANALYSIS.......................................................................................................... 254.1 QUANTITATIVE ASSESSMENT ........................................................................................................... 254.1.1 NO OF FAMILY MEMBER .........................................................................................................................254.1.2 EDUCATION QUALIFICATION OF FAMILY: ....................................................................................................264.1.2.1 Education qualification of head of family ......................................................................................264.1.2.2 Highest qualification of family member ........................................................................................264.1.3 HOUSEHOLD TYPE ..................................................................................................................................274.1.4 DISTANCE OF NEAREST EMPANELLED HOSPITAL...........................................................................................284.2 AWARENESS ASSESSMENT .............................................................................................................. 284.2.1 AWARENESS LEVEL ................................................................................................................................294.2.2 SOURCE OF INFORMATION ......................................................................................................................294.2.3 COMFORTABLE TO USE RSBY SMART CARD ................................................................................................304.2.4 FREQUENCY OF USING RSBY SMART CARD .................................................................................................314.2.5 SATISFACTION LEVEL ..............................................................................................................................324.2.6 UNABLE TO AVAIL TREATMENT DUE TO LACK OF MONEY ...............................................................................334.2.7 RENEWING OF SCHEME ...........................................................................................................................334.3 BARRIERS THAT AFFECT THE ACCESSIBILITY AND UTILIZATION OF SCHEME MOST: ........................................... 344.4 CLUSTER ANALYSIS ........................................................................................................................ 38CHAPTER 5 CASE STUDIES, INFERENCE AND CONSTRAIN IDENTIFIED ................................................................ 425.1 CASE STUDIES .............................................................................................................................. 425.1.1 CASE STUDY 1: DHANESWAR ROUT ..........................................................................................................425.1.2 CASE STUDY II: SPANDHAN MEDICAL CENTER ............................................................................................445.1.3 CONSTRAINTS IDENTIFIED: ......................................................................................................................46CHAPTER 6 KEY FINDINGS, RECOMMENDATION AND CONCLUSION ................................................................. 486.1 KEY FINDINGS .............................................................................................................................. 486.2 RECOMMENDATIONS ..................................................................................................................... 506.3 CONCLUSION ............................................................................................................................... 526.4 REFERENCES: ............................................................................................................................... 536.5 ANNEXURE 1 RSBY QUESTIONNAIRE ................................................................................................. 556.6 ANNEXURE 2 FACTOR ANALYSIS CORRELATION TABLE ............................................................................. 576.7 ANNEXURE 3 DENDOGRAM OF CLUSTER ANALYSIS ................................................................................ 59 4
  • 6. AbbreviationsRSBY: Rastriya Swasthya Bima YoznaBPL: Below poverty LineAPL: Above poverty LineNE state: North East stateGDP: Gross Domestic ProductionLMIC: lower middle income countryHIC: High Income countryTPA: Third Party AdministratorFKO: Field Key OfficerDKO: District Key OfficerGOI: Government of IndiaMOLE: ministry of labor and employementUT: Union TerritoryNGO: Non Government OrganizationESIS: Employee State Insurance SchemeCGHS: Central Government Health Scheme 5
  • 7. Chapter 1 Introduction1.1 BackgroundIndia‟s remarkable growth in last decade made it geopolitical power in south Asia. India, in lastdecade, is among one of the fastest emerging economies in the world. It is second fastest growingeconomy of world after china and emerging superpower in Asia. The Indian economy is theworlds ninth-largest economy by nominal GDP and it is forth largest economy of world inaccordance with purchasing power parity. This unprecedented growth story leads to a prosperousmiddle class and large number of high net worth individuals and lot of billionaires. But thisgrowth story has ominous side too; India is second most populous country in world withpopulation 1.21 billion just behind china. Apart from it, India is home of world largest number ofpoor, one out of every five poor people in the world is an Indian. Though poverty is on thedecline, there are still more than 385 million people living BPL in India – many more than the311 million people in the total population of the world‟s third most populous country, the UnitedStates. Thus, the skewed growth leads to discrimination in society and unequal distribution ofresources. In this context, one of the biggest sufferers is rural India as it lacks the basic social andinfrastructure services in healthcare, roads, education and drinking water.It is a well-known fact that India is, next only to China, the second largest country in terms ofpopulation in the world. But the health status of a great majority of the people is far fromsatisfactory as compared to China and other developed countries. However, over the last fivedecades or so, India has built up health infrastructure and manpower at primary, secondary andtertiary care in government, voluntary and private sectors and made considerable progress inimproving the health of its population (Ray 2003; Bhat and Babu 2004).Although there is unprecedented growth in last decade, still the World Bank classifies India aslower middle income countries (LMICs) but, it still has far to go before it enters the ranks of highincome countries (HICs). In 2009, HICs had average GNIs per capita of US$ 37,000 (30 timesIndia‟s) or US$ 36,213 (15 times India‟s) in terms of purchasing power parity (World Bank,2011). So above all, India is still a low income country and home of largest number of poor, so itis great challenge for country to provide basic services like health, education etc. India consists of28 states and 7 union territories, Orissa, officially Odisha since November 2011, is one of 6
  • 8. the states of India, It is located between the parallels of 17.49N and 22.34N latitudes andmeridians of 81.27E and 87.29E longitudes. It is bounded by the Bay of Bengal on the east;Madhya Pradesh on the west and Andhra Pradesh on the south. It has a coast line of about 450kms. It extends over an area of 155,707 square km, accounting about 4.87 of the total area ofIndia. It is the modern name of the ancient nation of Kalinga, which was invaded bythe Maurya Emperor Ashoka in 261 BC. The modern state of Orissa was established on 1 April1936, as a province in India, and consists predominantly of Oriya speakers.1 April is thereforecelebrated as Utkal Divas. Cuttack remained the capital of the state for over many centuries untilApril 13, 1948 when Bhubaneswar was officially declared as the new capital of Orissa,replacing Cuttack. Bhubaneswar is the present capital Orissa is the ninth largest state by area inIndia, and the eleventh largest by population.Puri being a coastal district of Orissa, is famous for its Historic antiquities, Religious sanctuaries,Architectural Grandeur, Sea-scape beauty, moderate climate. This district comprises 1714revenue villages. It has one subdivision, (Puri Sadar), 11 tehsils and 11 blocks. The Puri districtlies between the latitudes 19°28N to 26°35N and longitudes 84°29E to 86°25E. It has ageographical area of 3051 km2 or 264988 Ha.1.2 Overview of Health StatusBetter health, education, equal and wider job opportunities to all, trustworthy and transparentpeople‟s intuitions, sustainable and cleaner environment, dignity, self-esteem and life security,among others, are key manifestations of the quality of growth. Quantity and Quality are the twoimportant dimensions of human population in any country. In general, all the countries arecommitted to improving quality of population, a better welfare standard measure. For improvingquality of life a good health of population is mandatory. Health is defined as a state of completephysical, mental, and social well-being and not merely the absence of disease or infirmity. Thehealth status is usually measured in terms of life expectancy at birth, infant mortality rate, fertilityrate, crude birth rate and crude death rate.1.2.1 Health Status in IndiaOver the last five decades or so, India has built up health infrastructure and manpower at primary,secondary and tertiary care in government, voluntary and private sectors and made considerable 7
  • 9. progress in improving the health of its population but still the health status of great majority ofpeople are far from satisfactory. India is one of the major countries where communicable diseasesare still not under control. The incidence of new fatal diseases such asAIDS/HIV, hepatitis-A is on the increase and tuberculosis and malaria still take a high toll.India‟s public health expenditures are less than 1.5% of its GDP (prior to launching NRHM,expenditures were 0.9% GDP), and the WHO ranks India 171st out of 175 nations on publichealth spending.Young children in India suffer from some of the highest levels of stunting, underweight, andwasting observed in any country in the world, and 7 out of every 10 young children are anemic.The percentage of children under age five years who are underweight is almost 20 times as highin India as would be expected in a healthy, well-nourished population and is almost twice as highas the average percentage of underweight children in sub-Saharan African countries. Althoughpoverty is an important factor in the poor nutrition situation (NFHS-3)There are 52 million undernourished children in India. 44% of Indian children under five areunderweight and 48% stunted due to chronic malnutrition; this means India is home to 46% of theworld‟s underweight children and 32% of the world‟s stunted children India has the highestnumber of maternal deaths in the world. The national maternal mortality rate (MMR) is 254 per100,000 live births, an absolute number of 68,000 per year. Comparatively, China‟s MMR is 45).There is disparity between states, and some states far exceed national MMR, including Assam(480) and Uttar Pradesh (440). The majority of deaths are preventable through safe deliveries andadequate maternal care. Nearly 67% of the population in India does not have access to essentialmedicines1.2.2 Health Status in OrissaOrissa is one such state in India that stained with poor socio economic status of the inhabitants.Lower income, poor housing facility of education and discrimination are some of the factor atcontribute to the poor living standard including the poor status of the people in the state, although,the degree of contribution of these factors in deciding the living standard of people vary acrosssocial and ethnic groups. So basic health indicator in Orissa are showing very poor figure ascompare to national average 8
  • 10. The Death Rates in Orissa is highest in the country which stands at 9.2 as against 7.4 of thecountry as a whole that is at least 2 points below the national death rate. Orissa contributes 23%of malaria cases, 40 % of PF cases and 50% of malaria deaths of the country. In Orissa, 371persons per 100,000 are estimated to have medically treated tuberculosis Almost half of thechildren under five in Orissa are stunted or chronically malnourished (45%) and Underweight(40.7%). About 19.5% children are wasting or acutely malnourished. The Total Fertility Rate ofthe State is 2.4. The Infant Mortality Rate is 69 and Maternal Mortality Ratio is 303 (SRS 2004 -2006) which are higher than the National average. The Sex Ratio in the State is 972 (as comparedto 933 for the country). Comparative figures of major health and demographic indicators are asfollows:Table I: Demographic, Socio-economic and Health profile of Orissa State as compared toIndia figuresS. No. Item Orissa India1 Total population (Census 2001) (in million) 36.80 1028.612 Decadal Growth (Census 2001) (%) 16.25 21.543 Crude Birth Rate (SRS 2008) 21.4 22.84 Crude Death Rate (SRS 2008) 9.0 7.45 Total Fertility Rate (SRS 2008) 2.4 2.66 Infant Mortality Rate (SRS 2008) 69 537 Maternal Mortality Ratio (SRS 2004 - 2006) 303 2548 Sex Ratio (Census 2001) 972 9339 Population below Poverty line (%) 47.15 26.1010 Schedule Caste population (in million) 6.08 166.6411 Schedule Tribe population (in million) 8.15 84.3312 Female Literacy Rate (Census 2001) (%) 50.5 53.7 9
  • 11. For more than three-quarters of households in Orissa, the public medical sector, mainlycommunity health centers (CHC), rural hospitals, or Primary Health Centers (PHC), are the mainsources of health care. The public medical sector is the main source of health care for 62% ofurban households and 79% of rural households.1.3 Need for Social Health Insurance Scheme:The world health report 2008 emphasized universal coverage as one of the four pillars of primaryhealth care and said such coverage required patient-centered care with no financial or otherbarriers preventing access to care (WHO, 2008).Article 25 of the Universal Declaration of Human Rights (1948) which states that everyone has aright to the health care and social protection they need to maintain their own and their family‟shealth and well-being in the event of illness, disability or old age.Universal coverage is an essential and accepted objective for most countries. It enshrines the keyelements of how health systems can contribute to the betterment of health in general, whileensuring that people centeredness remains at their core. So universal coverage and accessible toall health service in India is upmost requirement, as there is 37% population leaving below thepoverty line. But mostly social health insurance schemes in India only restricted to formal sectoremployees. However, about 94% of the Indian workforce or 400 million people are working inthe informal sector. An extensive research programme undertaken across parts of India(Rajasthan, Gujarat and Andhra Pradesh) and Africa (Ghana, Uganda and Kenya) found that illhealth and health-related expenses were the most common reasons given by the poor for theirown descent into, and inability to escape from, poverty (Krishna 2003, 2004, Krishna et al 2004,2005). It has been increasingly recognized that health insurance is one way of providingprotection to poor households against the risk of health spending leading to poverty.Households pay for the majority of healthcare costs in India. Covering healthcare expenses is aprimary cause of indebtedness in India, and can push people deeper into poverty. It is known thatmany people, including the poor, prefer to access services in the private sector. This preferencecan intensify the financial pressure faced by many, as the private sector is more costly. HealthInsurance is a way to help and lessen the burden of paying for healthcare by spreading the costs ofhealth across a group of people. 10
  • 12. 1.4 Early initiatives:There are few schemes that were started by various state governments, NGOs; e.g. Arogyashreescheme run by the Andhra Pradesh Government, Yeshaswini in the state of Karnataka, SEWA inGujarat, Ahmadabad by an NGO, the Employee State Insurance Scheme (ESIS) and CentralGovernment Health Scheme (CGHS) by the central government. ESIS and CGHS are importanthealth insurance scheme in India. All these forms currently exist in the country but only in smallpockets and cater to specific groups; there was felt a clear absence of a pan-India model. Most ofthe community-based insurance schemes have been found to suffer from poor design andmanagement, they fail to include the poorest-of-the poor, have low membership and requireextensive financial support. So for universal coverage and to include poorest of poor govt. ofIndia with collaboration of state government has started RSBY scheme across pan India coverage. 11
  • 13. Chapter 2 Rashtriya Swasthya Bima Yojna (RSBY)India is home to more than 1.2 billion people and almost one-third live below the poverty line(BPL), as defined by the Government of India. On 2 October 2007, the Government launched anational insurance scheme or, in Hindi, Rashtriya Swasthya Bima Yojana (RSBY). The scheme‟sfirst five-year target is, by the end of 2012, to provide all India‟s BPL families with enough healthinsurance to avoid catastrophic health expenses due to serious illness or injury. After officialannouncement of RSBY on 2 October 2007, there were six months of preparation before roll-outbegan on 1 April 2008.RSBY was finally rolled out in 2008 by Ministry of Labor and Employment (MoLE),Government of India (GoI) to provide health insurance coverage for Below Poverty Line (BPL)families with objective of To improve access of BPL families to quality medical care fortreatment of diseases involving hospitalization and surgery through an identified network ofhealth care providers.The Govt. of India contributes 75% of the premium (90% for Jammu & Kashmir and North-Eastern states) in case of BPL families. The Ministry of Labor and Employment, Govt. of Indiamonitors implementation of the scheme across the country. The responsibility for implementationof the scheme rests with the States.As RSBY is an insurance-backed healthcare scheme, the states, through a transparent biddingprocess, select an insurance company to enroll the beneficiaries and to underwrite thehospitalization expenses for a year for an annual charge (premium). The state Governmentscontributes 25 % (10 % in the case of J&K and North East states). So it is a public/private healthinsurance scheme implemented to help below poverty line (BPL) families with financialobligations related to hospitalization & fulfills ailment expense so that it can improve their healthstatus. The RSBY scheme grew out of the understanding of the social and financial importance ofprotecting BPL families from the effects of illness. As of November 2010, more than 16 millionfamilies and nearly 5,000 hospitals across 26 Indian states have enrolled in RSBY. 12
  • 14. RSBY provides the BPL beneficiaries:• Financial protection against hospitalization expenses• Improved access and choice of quality hospitals (public and private)• Cashless utilization of benefits through use of a smart cardJust over three years later, at the end of May 2011, its active partners include most of India‟s 35States and Union Territories, more than half of their 640 Districts, eleven private insurancecompanies, many third party administrators, and almost 8,300 public and private hospitals. Morethan 23 million BPL families are enrolled in RSBY and in possession of the scheme‟s electronicSmart Cards, allowing them to go to any one of those 8,300 hospitals and receive treatment withno cash or paperwork required.2.1 Noteworthy aspect of RSBY schemeThis is scheme of difference with many noteworthy aspects; in this scheme every stakeholder hassome rights and obligation. It is different from other scheme due to following aspects2.1.1 Empowering beneficiariesRSBY provides freedom of choice to the patient in the selection of hospitals: They can access anypublic or private provider in the network across the country. So the beneficiary has full freedomto choose any of hospital that is very different from other social schemes.2.1.2 Business model for all stakeholdersThe scheme is designed as a business model, with incentives built in for each stakeholder so everystakeholder profit depend on other and every stakeholder use it with dignity unlike other socialscheme in which one agency is giver and other is taker2.1.2.1 InsurersThe insurer is paid a premium for each household enrolled in RSBY, therefore giving the insureran incentive to enroll as many households as possible from the BPL list. So enrollment andawareness is done by insurer with full effort to maximize their benefits. 13
  • 15. 2.1.2.2 HospitalA hospital has the incentive to provide treatment to large number of beneficiaries as it is paid perbeneficiary treated. Even public hospitals have an incentive to treat beneficiaries under RSBY asmoney from the insurer will flow directly to the public hospital. Insurers, in contrast, will monitorparticipating hospitals in order to prevent unnecessary procedures or fraud resulting in excessiveclaims.2.1.2.3 IntermediariesThe inclusion of intermediaries, such as NGOs and MFIs, was intentional since they have agreater stake in assisting BPL households. Intermediaries will be paid for the services they renderin reaching out to the beneficiaries.2.1.2.4 GovernmentIncluding public sector providers in the RSBY delivery network creates healthy competitionbetween public and private providers which in turn provides incentives for public providers toimprove their service delivery.2.1.3 Smart CardEvery beneficiary family is issued a biometric enabled Smart Card containing their fingerprintsand photographs. All the hospitals empanelled under RSBY are IT enabled and connected to theserver at the district level. This will ensure a smooth data flow regarding service utilizationperiodically. The Smart Card also ensures that only true beneficiaries can use sevices, reducingfraud.2.1.4 PortabilityOne key feature of RSBY is that a beneficiary who has been enrolled in a particular district willbe able to use his/her Smart Card in any RSBY empanelled hospital across India. This makes thescheme beneficial to the many poor families that migrate from one place to the other.2.1.5 Cash‐lessRSBY transactions are completely cashless. Beneficiaries do not pay cash for any services unlessthey exceed the annual allowance of Rs. 30,000/‐. Provider‐to‐insurer dealings are also paperless,as all claims are processed and paid electronically. 14
  • 16. 2.2 Benefits under RSBY schemesRSBY beneficiaries are covered for hospitalization expenses of up to Rs. 30,000/‐ per family peryear. The family can include up to five members (including a husband, a wife, and threedependents). Most of the surgical and medical conditions for which hospitalization is necessaryare covered in the scheme. Package rates for 727 inpatient surgical procedures, includingmaternity and newborn care have been pre‐defined. In addition, beneficiaries are covered foroutpatient surgeries which can be done on an outpatient basis. The benefit also includes one daypre‐ and five day post‐hospitalization expenses. There is also a transportation benefit that providesRs. 100 per visit to the beneficiary; total transport assistance cannot exceed Rs. 1000/‐ per annumand it is part of the total Rs. 30,000/‐ coverage. Now Outpatient charge of Rs 50 per day is alsoavail that was not included earlier.All pre‐existing diseases are covered from the first day of enrollment with some exclusions.RSBY does not cover:  Congenital external diseases  Drug and alcohol induced illness  Sterilization and fertility related procedures2.3 Service Delivery MechanismRSBY scheme is highly technologically based and has pan India operation so delivering such acomplex service with so many stakeholder is very challenging job. The following process are heldto deliver the service to BPL families2.3.1 Establishing partnerships between the GOI and States/UTsMemoranda of understanding (MOUs) usually specify that the GOI, represented by the MoLE,covers 75 percent of the premium charged by insurance companies and rest premium is bear bystate government. In addition, the GOI provides technical guidance and assistance to State/UTgovernments and their Nodal Agencies; guides and supports monitoring and evaluation (M&E) inStates/UTs and does M&E countrywide. 15
  • 17. 2.3.2 Establishing State Nodal AgenciesEach State gives a Nodal Department responsibility for implementing RSBY. Often they chooseState departments or agencies responsible for labour, health or rural development. The NodalDepartment then establishes or identifies a Nodal Agency to which it delegates responsibility foradministering RSBY. Nodal Agencies work in concert with or on behalf of States Governments2.3.3 Establishing partnerships with insurance companiesNodal Agency call for bids from insurance companies and establish expert committees to evaluatethe technical and financial merits of all bids, and then choose no more than one insurancecompany to enroll BPL families in each selected District and send selected bids to the GOI‟sApproval and Monitoring Committee. When approved, contract with the selected insurancecompanies is finalized.2.3.4 Establishing third party administrators (TPAs)Contracts with insurance companies often specify that they can subcontract with Third PartyAdministrators (TPAs) to carry out some of their responsibilities if they needed and TPAs maysubcontract to others party if required. Microfinance institutions (MFIs) or NGOs are the usualfront-line subcontractors and their subcontracts vary widely in content but typically focus onspreading the RSBY message and enrolling BPL families in towns and villages2.3.5 Empanelling hospitalsInsurance companies have primary responsibility for empanelling and de-empanelling hospitalsand keeping up-to-date lists of hospitals, that should be provide to BPL families when they enrolland receive their insurance Smart Cards.2.3.6 Enrolling BPL familiesEnrollment and awareness are the prime responsibility of insurer or insurance company, BPLfamilies must be made aware of RSBY, the benefits it has to offer, which families are eligible toapply, and the number and characteristics of family members who can be named as beneficiaries.Insurance companies have primary responsibility for providing this awareness but maysubcontract to TPAs. In either case, Nodal Authorities and FKOs provide guidance and support. 16
  • 18. 2.4 Overview of RSBY in Orissa:Despite the emergence of a number of health insurance programmes and health schemes, only 2percent of households in Orissa report that they have any kind of health insurance that covers atleast one member of the household. Three types of programmes dominate: medicalreimbursement from employers, the Employee State Insurance Scheme (ESIS), and other healthinsurance through the employer. Eight percent of urban households are covered by some healthinsurance, whereas health insurance coverage is rare among rural households (0.6%). Ten percentof households in the highest wealth quintile have some type of health insurance (NFHS-3) sothere is huge need of RSBY scheme in Orissa.RSBY coverage in Odisha is below the expectation, in odisha, there is 12,33,054 BPL family inwhich 4,09,739 family are enrolled under RSBY scheme. Total no of family member in theseenrolled family is 11,55,374, so total enrollment in Odisha is approximately 33%, that is far fromexpected achievement. RSBY cover only six districts in Odissa and its coverage in these districtsare as follow:District Enrollment as a percentage of BPL populationPuri 52%Nuapada 49%Nayagada 63%Kalahandi 47%Jarushgada 62%Deogara 66%2.5 Overview of RSBY in Puri DistrictPuri is one of the costal districts in Orissa, it has total 249721 BPL Families in that 13176 familiesare enrolled under RSBY scheme. There is 18 public and 8 private hospital are empanelled forRSBY patient. This year policy begin July1, 2011 and it will end on June 30,2012. ICICILombard is insurer for Puri district and FINO work as TPA for RSBY in Puri district. TillJan15,2012 total 942 cases of hospitalization has came under RSBY scheme with total value ofRs. 5025180. Details of RSBY for Puri District are following 17
  • 19. Blocks of Total BPL Family Total Enrollment in % Puri District family enrolled member 1 Astrang 10592 7467 21910 70.50 2 Brahamgiri 12201 4827 14321 39.56 3 Delang 16994 11726 34783 69.00 4 Gop 23073 13544 32072 58.70 5 Kakatpur 10413 6779 14108 65.10 6 Kanas 16585 10915 33252 65.81 7 Krushnaprasad 9005 6680 23517 74.18 8 Nimapada 23562 17278 40663 73.33 9 Pipli 16287 11325 29544 69.53 10 Satyabadi 15394 9520 28680 61.842.6 Factors that influence to take up this topic:I have read a lot about the success story of NREGA and RSBY so these stories motivated me toknow about the ground reality of these schemes and their effectiveness and accessibility for poor.As RSBY is unique and first health insurance scheme that has pan India coverage and it involve alot of stakeholder e.g. BPL families, health service provider, IT companies, insurance company,state and central government, so I want to know that after so much of stakeholder and complexity,scheme is giving its message clearly or not, how much it is effective for a poor people, how muchthey are aware about these schemes, how much they utilize the facilities and service provided bythis scheme and what are the barriers in utilization of this scheme so to know all these I choosethis topic for my research. 18
  • 20. Chapter 3 Literature Review and methodology followed3.1 Literature review:RSBY was started in April 2008 with a target of five year to include all the BPL families underthis scheme; this scheme is implemented in every state of India. The implementation of scheme inKarnataka, drawing an attention and study was done on eligible households and interviews wereconducted with empanelled hospitals in the state (IMPLEMENTING HEALTH INSURANCEFOR THE POOR: THE ROLLOUT OF RSBY IN KARNATAKAD Rajasekhar, Erlend Berg, Maitreesh Ghatak, R Manjula and Sanchari Roy, 2009)Six months after initiation, an impressive 85% of eligible households in the sample were awareof the scheme, and 68% had been enrolled. However, the scheme was hardly operational andutilisation was virtually zero in Karnataka region. A large proportion of beneficiaries were yet toreceive their cards, and many did not know how and where to obtain treatment under the scheme.Moreover, hospitals were not ready to treat RSBY patients. As is typical for the implementationof a government scheme, many of the problems discussed can be related to a misalignment ofincentives This paper shows the problem faced in implementation, delay in smart card and variousproblem faced by hospitals like training of staff for RSBY scheme, delay in payment of hospitalsby insurance companies.Rashtriya Swasthya Bima Yojna (RSBY) or the National Health Insurance Program can play animportant role in improving the quality of care through regularization and financial incentives.Following a roadmap that encourages hospitals to adopt small but incremental changes over timecan go a long way in improving the quality of health care (Can Rashtriya Swasthya Bima Yojnahelp bridge the quality chasm? Sonam Sethi). This paper looks at the early experience of hospitalsin Delhi as a starting point for the discussion. Surveyed hospitals complained of a lack of trainingand delays in the reimbursement of their expenses. Many were refusing to treat patients under thescheme until the issues were resolved, and others were asking cardholders to pay cash.These studies show that there is increase in accessibility of healthcare services for BPL familiesafter implementation of RSBY scheme, and there out of pocket expenditure is reduced after they 19
  • 21. started get benefit from RSBY scheme. It also shows that there is increase in health infrastructureafter implementation of this scheme (Rashtriya Swasthya Beema Yojna (RSBY): Panacea for thepoor (National Health Insurance Plan) Sheila Rai and Niha Rai). The front end of the scheme isquite simple but the back-end, especially in the context of Information Technology applications,is quite complex involving a number of players, both in the public and private sector domains.Vertical and horizontal coordination poses the biggest challenge even after the stabilization of avariety of software that was being used to roll out the scheme. The back-end data basemanagement throws up a different challenge in terms of developing the structure and putting inplace the hardware. There are some issues yet to be resolved.These papers show misalignment of various departments in this scheme. So these paper focusmore on hospital and implementation part and didn‟t show what the benefit poor get from thisscheme, are they aware about scheme or not, what are the problem they faced in utilization ofservices of RSBY. These studies and papers shows all the aspect of RSBY scheme but still thereis some gap exist, there is no study that address the state Odisha so there is pertinent need to takea look at Odisha RSBY schemes, and all the study focus on general awareness of scheme no elsestudy focus on in depth awareness about services, use of service and effectiveness of service,improvement of health status after implementation of scheme. So to feel these gaps this study isconducted.As investment on health increases, the productive capacity of the working population, and hencethe level of income tends to rise and to that extent it contributes to a decline in the incidence ofpoverty (Reddy and Selvaraju 1994). With rapid improvement in health, particularly of the poor“vicious circle” of poverty can be converted into “virtuous circle” of prosperity (Mayer 1999;Mayer 2000;Bloom et al 2004) 20
  • 22. 3.2 Research question:RSBY scheme is new and it was started three year ago, so evaluation of such a huge beneficiarybase scheme in early phase is not possible. So this study focuses on the trend of the scheme,benefits and problems which a beneficiary has to face in usage services of this scheme. Afterstudying the relevant literature and paper and find the gap between earlier studies followingquestions arise those are addressed in this study:  What is level of awareness of RSBY and its services among BPL families?  What are barriers in accessibility of RSBY scheme?  How much people are satisfied with scheme3.3 Purpose of study:RSBY is a scheme with difference, in this scheme the poor and below poverty line people arebeneficiaries. So the beneficiaries are underserved segment of society, they have very low literacylevel and have little accessibility of other media source, so generation of awareness in thissegment is very difficult task, the focus of this study is on awareness among beneficiary and itaddress their problem that are faced in accessing and utilization of services of scheme. Thepurpose of study is to find out:  Awareness of scheme among BPL families  Accessibility of RSBY by BPL families  Problem faced in utilization of scheme services  Satisfaction level for scheme among beneficiaries3.4 Key Information Area:Key Information areas are the areas which are specifically targeted in this study to find the answerof research question. Due to time and resources constrain, consider all area is impossible forresearcher so I prioritize these area to find the answer or solution of research questions 21
  • 23. 3.4.1 Awareness:This capture the level of awareness among people about the scheme , it give us the details likeonly heard about RSBY, superficial knowledge about scheme, detail knowledge of scheme, knowthe various benefits and how to use it. So this area differentiate beneficiary according toknowledge about scheme and awareness for scheme, this key information area help to analyze thesource of awareness among people who have high level of awareness3.4.2 Psychographic:Through this Key Information area, we want to uncover and understand the decision-makingprocesses for health care; there priority level regarding their and their family health, how theyprioritize health care and what is their behavior toward the ailment or disease. When they thinkthat a person needs a consultation from doctor, and when they feel the need of admission inhospital, what is their first line of treatment, their behavior and perception when somebody fell illin their families?3.4.3 Latent factor:This factor help to understand the attributes which influence beneficiary decision and often whatfactors influences in a higher degree of their decision making process. For similar ailment anddisease the behavior and way to adopt the treatment is different from one person to other person.The attitude toward health and precaution are different from person to person. So the cluster ofbeneficiary according to similarity and difference is targeted in this key information area.3.4.4 Utilization:This key information is important to understand the utilization of services, there are variousattributes that affects utilization of services literacy, attitude, availability of services, serviceprovider attitudes etc.3.4.5 Accessibility:Accessibility is one of the important key area for this service it provide the ideas that how muchthis scheme is user friendly, this area is has lot of attributes like easy process of enrollment,availability of required document, government and insurance company support, distance ofhospital from residential area, behavior of medical staff in hospital etc. 22
  • 24. 3.5 Research Design:3.5.1 Research methodologyThis study will utilize Exploratory Research approach; this approach depicts the existenceposition of scheme and tries to explore the awareness, accessibility and utilization of schemesservices by its beneficiary and explore its effect on the BPL families. It describe pattern ofrelationship among different variables. In this study, no attempt is made to change behavior orcondition, research is done in existing condition without any external interference. This studyfollows the cross-sectional studies variables of interest in a sample of subjects are assayed onceand the relationships between them are determined and analyze.3.5.1.1 Sampling:This study use a stratified random sampling procedure, to make sure that sample haveproportional representation of population subgroups, it has identified three Block of puri districtaccording to geographical location in Puri: One Block is Pipli that is nearest to capital of Odisha,Bhubaneswar, second block is satyabadi that is nearest to Puri city and Third is Nimapada thatblock has good connectivity but no nearby city except block town Nimapada other factor tochoose Nimapad is, it has highest percentage of enrolled BPL families. From each block threevillages are selected: One village is under 5 Km far from block headquarters, Second village ismore than 15 Km far from block headquarter and connected with pucca road, third village is alsomore than 15 KM from block headquarter but not well connected with pucca road. From eachvillage there is 10 samples are taken for this study. This approach helpful to validate andgeneralize the responses to a population, for this, it is important to have a representative sample.3.5.1.2 Data Collection:Collection of data is through self administrative questionnaire survey method with close and semiclose ended questions, these structured questions to assess people‟s awareness, accessibility,satisfaction level and barriers in utilization in RSBY services.3.5.1.3 Data Analysis: 23
  • 25.  No of beneficiaries segments exist in population based on different Awareness level, Psychographic using Cluster analysis of SPSS package.  Univariate and bivariate analysis to know the effect of awareness and accessibility of services on the success of scheme.  Taking the variables “influence the accessibility and utilization of scheme and their importance level” we can identify the number of „Factors‟ emerging out from the Factor Analysis using SPSS package.3.6 Population of Study:The population of study is BPL families of Puri District in Odisha, those are eligible forenrollment under RSBY schemes. As government has implemented this scheme in six district ofOrissa: Puri, Nuapada, Nayagada, Kalahandi, Jarushgada, Deogara. But my study of population isBPL families of Puri district.3.7 Scope of Study:  This study help to know the awareness among BPL families for this scheme  It help in to know which one is most effective method to spread awareness  It gives the idea about the effectiveness and utilization of scheme services by BPL families.  This study provides the insight of scheme and how this scheme can be more user friendly for beneficiaries.  It reveal the barriers in utilization of services of RSBY so that they can overcome to make service more effective  It reveals the satisfaction level among beneficiaries.3.8 Role of researcher:  Identify the district, block and village for data collection  Collecting the data and information through self administrative questionnaire  Process these information and data in unbiased way  Analyze these data and reach at conclusion that gives the result of study. 24
  • 26. Chapter 4 Findings & AnalysisThis chapter is based on the information collected through field survey and interactions withVillagers and BPL families. The key findings have been divided into three sections. Section-4.1presents the quantitative assessment; Section-4.2 deals with the Awareness assessment andsatisfaction level; Section- 4.3 analyze various barriers in utilization and accessibility of scheme;Section 4.4 deals with cluster of similar demographical characters. The results are based on thedata collected from 9 GPs of the three sample Blocks of the Puri District. Detailed methodologyand procedure of data collection have already been discussed in the preceding chapter. The dataare analysed through various statistical methods, such as univariate, bivariate, factor, clusteranalysis and results are demonstrated through tables and graphs to draw meaningful inferences.4.1 Quantitative Assessment4.1.1 No of family memberThe numbers of family members in household are classified into five segments: 1-2, 3-5, 6-8, 9-12 and greater than 12. The table below shows the frequency and percentage of household thatfalls in different segmentsFamily members Frequency Percent1-2 3 3.43-5 48 55.26-8 30 34.59-12 6 6.9Total 87 100.0 Thistable reflects that around 55% of household has average size fall under 3-5, and RSBY covers thehealth insurance up to five member of a single family. So from above table it can be infer that 25
  • 27. 59% household are fully insured under this scheme and rest 41% household are partially coveredby this scheme.4.1.2 Education qualification of family:Education plays an important role in society, a more educated society provide the opportunity forhigher efficiency and effectiveness of a social scheme and they are more susceptible to adopt andunderstand new scheme so in this study the whole family is divide into two part; first is head offamily and second is rest of the family members.4.1.2.1 Education qualification of head of familyThe analysis reveals that a large number of populations in BPL families are either illiterate or upto the primary standard. So it is very difficult to implement a scheme in a population that has solow education level. Frequency Percentilliterate 11 12.6up to primary standard 39 44.8up to matriculation 32 36.8up to higher secondary 5 5.7Total 87 100.0The analysis of study reveals that 11% of head of family are illiterate so implementation becomese difficult when decision maker in target beneficiary family has low level of education. It showsthat up to 60% population is below primary level only 5.7 % head of family has education abovematriculation level so implementing such grass root scheme is a very difficult part.4.1.2.2 Highest qualification of family member 26
  • 28. Frequency Percent up to primary standard 8 9.2 up to matriculation 56 64.4 up to higher secondary 20 23 above higher secondary 3 3.4 Total 87 100Education play a significant role in successful of any scheme so this study also analyze thehighest qualification of any of member in family, as that person can play an important role inawareness generation and understanding the benefit of schemes. So this analysis gives a positivesign, only 9.2% enrolled family education level is below primary standard.4.1.3 Household type Frequency Percent Self employed in non 13 14.94 Agriculture Agriculture Labor 18 20.68 Other Labor 24 27.58 Self employed in Agriculture 29 33.33 other 3 3.44 87 100 TotalThe sources of income of sample households has been classified into five categories, namely, Selfemployed in non Agriculture, Agriculture Labor, Other Labor, Self employed in Agriculture, 27
  • 29. others. This study highlights that major source of income is associated with agriculture, only 18%household has non agriculture source of income.4.1.4 Distance of nearest empanelled Hospital Distance Frequency Percent 0-5 21 24.1 5-10 25 28.7 10-20 27 31 20-30 11 12.6 >30 3 3.4 Total 87 100Distance of empanelled hospital is very crucial in accessibility of scheme, this study reveal that52% of sample household are under the circumference of 10 Km of empanelled hospital rest 42%are more than 10 Km from empanelled hospital. Nearest hospital is one of the important factorsfor accessibility of scheme so the figure shown in the analysis seems satisfactory regardingdistance of nearest hospital.As in the selection of sample village distance is one of the factors, so the data collection has itsown limitation.4.2 Awareness AssessmentAwareness is one of the most important factor in social scheme so this section analyze variousattribute and reveal the level of awareness among BPL families. 28
  • 30. 4.2.1 Awareness Level Awareness Frequency Percent only registered 5 5.7 know about empanelled hospitals 15 17.2 know about amount of treatment 28 32.2 know about empanelled hospitals and amount for treatment 28 32.2 understand and avail the benefit of scheme 11 12.6 Total 87 100The information collected from sample household reveal that only 12.6% household has completeunderstanding of procedure and can avail the benefit independently. Other are partially know aboutthe scheme but didn‟t understand the complete process and 5.7% of people are complete unawareabout the scheme they don‟t know how to use smart card they just registered for scheme andcomplete unaware about it. 4.2.2 Source of information Source of information Frequency Percent poster/wall painting 6 6.9 word to mouth 7 8 NGO/panchayat/block/govt officials 27 31 Doctor/hospital staff/ANM/Asha/Health worker/Aganwadi 17 19.5 loudspeaker announcement/nukkad natak 30 34.5 Total 87 100 29
  • 31. Providing information in rural area and specially BPL families is major challenge because theydon‟t have mass media source. This study tried to find out which source is most effective forspreading the information, so I gather the data regarding information of registration camp as thatis first contact point for this scheme. The analysis reveals that 34.5% came to know regardinginformation camp from loudspeaker announcement, after that 31% came to know through NGOperson/ Panchayat official/ Block official / govt. officials so it is another source of effectivecommunication. Third source of spreading information is through Doctor/ hospital staff/ ANM/ASHA/ Health worker/ Aganwadi worker, it contribute 19.5% of total share. This can be utilizemore because these person are directly related to health so their communication could be moreeffective if strategy effectively.4.2.3 Comfortable to use RSBY smart card Comfortable in using smart card Frequency Percent yes 33 38.3 no 54 61.7This analysis reveal that only 38.3% of sample household are comfortable in using the smart cardeither they have used it once or aware about how they can use in future if they will go toempanelled hospital rest 61.7% are not comfortable in using these smart card so it is matter ofconcern that they are posses these but are not comfortable in using the card so there is need ofawareness regarding using this scheme. 30
  • 32. 4.2.4 Frequency of using RSBY smart card Frequency Percent 0 64 73.6 1-3 18 20.7 4-6 5 5.7 6-10 0 0 >10 0 0 Total 87 100The above table and pie chart show the frequency of using RSBY smart card by card holder intreatments of their ailment throughout the year. These data are quite shocking out 87 samples 64told that they never use these SBY smart cards. So total 73.6% of sample household never usethese card it is unbelievable that no one in family in whole year wasn‟t ill so the main reason thattold by villagers are awareness about scheme and unresponsiveness of empanelled hospital. Only5.7% of total household use these smart card more than 3 times so it give the question mark insuccess of scheme. The majority of population who use their smart card did only do for theirmajor ailment and surgical process. I didn‟t find a single person who took the benefit of OPDservice under RSBY scheme. 31
  • 33. 4.2.5 Satisfaction level Satisfaction level Frequency Percent Highly dissatisfied 26 29.9 somewhat dissatisfied 23 26.4 neither satisfied nor dissatisfied 4 4.6 somewhat satisfied 23 26.4 Highly satisfied 11 12.6 Total 87 100It is significant from figure that more number of people are dissatisfied then number of peoplesatisfied; 30% people among sample household are highly dissatisfied they think that this schemeis of no use for them, around 27% people are somewhat dissatisfied. There is good sign that12.6% of people are highly satisfied with this scheme; they said that they got very good treatmentwithout any expenditure and their ailment was cured due to this scheme. Most of them tooksurgical treatment of their old and chronic illness so their responses are quite positive. Somepeople are somewhat satisfied they think that some third person has taken the benefit of thisscheme so they also can avail the benefit of this scheme in future also and their out of pocketexpenditure is only Rs 30 so they are not expecting so much from this scheme and they aresatisfied that if some major illness happen in future they can avail treatment with this scheme. 32
  • 34. 4.2.6 Unable to avail treatment due to lack of money untreated due lack of money Frequency Percent yes 54 62.1 no 33 37.9 Total 87 100This information shows that 62% of family in sample household didn‟t get treatment in past dueto lack of money so it shows the importance of scheme. Even some of family a member is severeill but they couldn‟t afford treatment so they didn‟t avail the treatment. So the requirement of thisscheme was very much among BPL families.4.2.7 Renewing of scheme Renewing of scheme Frequency Percent yes 84 96.6 no 3 3.4 Total 87 100There are many loopholes in this scheme, people are not satisfied with services, they are not fullyaware about the scheme its benefit, its utilization. There is lot of misconception about thisscheme, for some people it is very hard to believe that private hospital also give treatment without 33
  • 35. any expenditure from their pocket. The result of renew of scheme shows almost everyone want torenew this scheme, doesn‟t matter the benefit of scheme avail to them or not. This shows that theRs 30 doesn‟t matter for BPL families and they are willing to pay this amount for security infuture; few people are hopeful that they will get benefit of this scheme in future.4.3 Barriers that affect the accessibility and utilization of scheme most:There are 15 factor that were assumed to play main hurdle in accessibility and utilization ofscheme, to find what are main influential factor among these factor in this research factor analysisis used. Factor analyses are performed by examining the pattern of correlations (or covariance)between the observed measures. Measures that are highly correlated (either positively ornegatively) are likely in influenced by the same factors, while those that are relativelyuncorrelated are likely influenced by different factors. Here, Exploratory factor analysis (EFA)techniques been used with objective of1. The number of common factors influencing a set of measures.2. The strength of the relationship between each factor and each observed measure.The initially data studied under principal component matrix and six factor are emerging out fromthe data containing 15 variables taken in questionnaire to know the attributes considered whileselection the most important barriers among these 15 barriers. To get more accurate correlationbetween the attribute the „Varimax‟ method off rotation has been used.KMO and Bartletts TestKaiser-Meyer-Olkin Measure of Sampling Adequacy. .608Bartletts Test of Sphericity Approx. Chi-Square 235.363 df 105 Sig. .000 34
  • 36. KMO measure explain 60.8%, it is acceptable limit so we can run the factor analysis on givendata. After getting correlated table and screen plot by factor analysis, verimax is used to get moreaccurate data. The rotated component matrix the six components in all through these 15 attributesare chosen to explain.It is evidenced from the Scree plot that only 6 components have Eigen value over one hence thenumber of attribute can be group under these six latent factors. So six components are chosen toexplain the barrier and find out through total variance table that how much they are explained.The scree plot shows that six factor are significant and other are not so much in importance andother are not so much significant so they could be ignored. 35
  • 37. Total Variance ExplainedCom Initial Eigenvalues Extraction Sums of Squared Loadingspone Total % of Cumulative Total % of Cumulativent Variance % Variance %1 2.829 18.858 18.858 2.829 18.858 18.8582 1.862 12.411 31.269 1.862 12.411 31.2693 1.664 11.091 42.360 1.664 11.091 42.3604 1.304 8.694 51.054 1.304 8.694 51.0545 1.170 7.798 58.852 1.170 7.798 58.8526 1.009 6.727 65.578 1.009 6.727 65.5787 .884 5.892 71.4708 .804 5.360 76.8319 .721 4.806 81.63710 .613 4.084 85.72111 .520 3.469 89.19012 .514 3.429 92.61913 .467 3.112 95.73114 .366 2.442 98.17315 .274 1.827 100.000Extraction Method: Principal ComponentAnalysis.This table reveal that first six component explain 65.57% of constrain of accessibility andutilization. The first component explains 18.85% of events and second components explain12.41% of events so the cumulative frequency for first and second event is 31.29%. similar waythird component explain 11.09% of events and forth component explain 8.6% of events; fifth andsixth components explain 7.79% and 6.72% of event. So cumulatively these six componentsexplain 65.57% of event and to find out these six components we will go through componentedmatrix. 36
  • 38. Rotated Component Matrixa Component 1 2 3 4 5 6Amount charged for .842RegistrationTime Taken To .816Deliver Smart CardReputation of .767HospitalOther Medical .719 .354FacilitiesResponsiveness of .507 -.308 -.375 .326HospitalDistance of Nearest .818Empanelled HospitalConnectivity of .324 .732HospitalDocument Reqired for -.379 .536 -.432RegistrationInformation .891RegardingRegistrationBehaviour for .361 .600Enrollmnet StaffDetailed Information .625RSBYExtra Expenses .566Occurred DuringTreatmentPost Transaction .377 .305 .346 -.381Balance InformationDistance of .729Enrollment CenterTime taken for .482 .564RegistrationExtraction Method: Principal Component Analysis. Rotation Method: Varimax with KaiserNormalization.a. Rotation converged in 15 iterations.This rotated component matrix provide the various attribute in these six different componentsome attribute have correlation with more than one component so these attribute are in different 37
  • 39. components so individually these attribute are more significant. On the basis of rotatedcomponent matrix the following table arrange attribute in different component.Component 1 Component-2 Component 3 Component 4 Component 5 ( Component 6 ((Hospital (Accessibility (Scheme (registration Smart card Accessibility ofServices) of Hospital) Awareness) process limitation) registration) limitation)Reputation of Distance of Detailed Behavior of Amount charged Distance ofHospital Nearest Information Enrollment for Registration Enrollment Empanelled RSBY Staff Center HospitalOther Medical Connectivity Extra Information Time Taken To Time taken forFacilities of Hospital Expenses Regarding Deliver Smart Registration Occurred Registration Card During TreatmentResponsiveness Documentof Hospital Required for RegistrationComponent are selected on basis of factor loading value more than 0.5 and larger the factorloading value in case it exceed 0.5 in multiple components. So the first component includes theattributes like reputation of hospital in which RSBY patient are treated with other hospitals in thatarea, medical facilities in empanelled hospital, responsiveness of empanelled hospital so theseattribute combined form component that explain 18% of barriers in accessibility of RSBYscheme. In similar way we can explain rest of the component 2,3,4,5 and 6.4.4 Cluster AnalysisEight variables in form statements in the questionnaire are taken into account during thePsychographic segmentation of the customers of RSBY scheme beneficiaries. The variables are:  Education Qualification of head of family  Number of members in family  Highest Education Qualification of any of family member  Household Type  Awareness Level  Source of information for RSBY and Registration Process 38
  • 40.  Distance of nearest empanelled hospital  Frequency of using RSBY smart card for treatmentFinal Cluster Centers Cluster 1 2 3 4Education Qualification of Head of 2 2 3 2FamilyNumber of famiy members 2 2 2 2Highest qualification of any 3 3 3 3memberHousehold Type 2 4 2 3Awareness Level 2 3 4 4Source of Information 3 4 5 2Distance of Empanelled Hospital 2 3 2 2Frequency of using Smart Card 1 1 2 1Each variable data is validated in scale of 1 to 5 (1=insignificant, 2=little significant, 3=Moderately Important, 4= significant 5=most significant) in ordinal scale in the surveyquestionnaireThe data run through SPSS package for Hierarchical cluster analysis, from the icicle plot,agglomeration table and Dendogram (Appendix-2) it is observed that the customers forming threeclusters based on the following variables. Then by using K-Means method of Quick Cluster withreference of three clusters the Final Cluster centres derived. The Segment characteristics aredefined according to the average value of variables given in form of statements.Number of Cases in each Cluster PercentCluster 1 17 19.54 2 32 36.78 3 14 16.09 4 24 27.58Valid 87Missing 0 39
  • 41. Demographic cluster 1Number of families in this cluster: 17Characteristic of cluster 1 is as follow:Education Qualification of Head of Family is up to primary standardAverage number of member in family is between 3 to 5.Highest qualification of any member in the family is up to matriculation.The main occupation of family member is agriculture labor in this clusterThis cluster family has registered for the RSBY scheme and they also know about the empanelledhospitals in their nearby areasThe members of this cluster get the information regarding RSBY scheme and registration processthrough NGO personnel/ Panchayat official/ Block official/ Govt. officialsDistance of Empanelled Hospital from their home is 5-10 KMMember of this cluster never used their RSBY smart card for treatment purposeDemographic cluster 2Number of families in this cluster: 32Education Qualification of Head of Family is up to primary standardNumber of family members is in between three to fiveHighest qualification of any member is up matriculationMain occupation of household is agriculture with own landAwareness Level they are aware about registration process and total amount that can be used fortreatment purposeThey came to know about scheme and registration process through Doctor/ Hospital staff/Aganwadi staff/ ANMDistance of Empanelled Hospital is in between ten kilometer to twenty kilometerThey have never used RSBY Smart Card for treatment purpose 40
  • 42. Demographic cluster 3Number of families in this cluster: 14Education Qualification of Head of Family is up to the matriculation levelNumber of family members in this cluster is in between three to fiveHighest qualification of any member is up to the matriculation levelHousehold Type is agriculture laborMembers of this cluster are aware about the empanelled hospital nearby area and total amountthat can be used for treatment purposeSource of Information is through loudspeaker announcementDistance of Empanelled Hospital in between 5-10 KM from their villageMembers of this cluster have taken the treatment from hospital through RSBY scheme andfrequency of using smart card is up to three times in a yearDemographic cluster 4:Number of families in this cluster: 24Education Qualification of Head of Family is up to primary levelNumber of family members is in between three to fiveHighest qualification of any member is up to matriculationMain occupation of family is labor in non agricultureMember of this cluster are aware about nearby RSBY empanelled hospital and total amount thatcan be used in treatment purposeSource of Information about the scheme and registration is word to mouthDistance of Empanelled Hospital from their village in between five to ten KilometerThey never used their smart card for treatment 41
  • 43. Chapter 5 Case studies, Inference and Constrain IdentifiedIn this chapter, the initial discussion will be focused on case studies/stories that reflect the benefitand constrain of RSBY scheme, it also bring in the viewpoint of both positive and negative side.Second part is to draw inference through these study and in third section identified constrain forthis scheme is described.5.1 Case StudiesThis section includes two case studies, First case study is of a beneficiary to get beneficiaryviewpoint and second case study is of hospital to get viewpoint of service provider.5.1.1 Case study 1: Dhaneswar RoutIt is a case of agriculture labor namely Dhaneswar Rout, 36 years old, with a family of six,including his wife and four children to support. He is residential of village Nuva Sahi in satyabadiblock of Puri District. His village, Nuva Sahi, is situated 4 KM from sakhi Gopal town. He got hisschooling upto 9th standard and his wife had completed primary education. His children arecurrently undergoing schooling in the local educational institutions. 42
  • 44. He has enrolled under RSBY scheme in July, 2010 and he renewed this scheme in October, 2011.During interaction with him, it was revealed that he didn‟t face any problem in registration forscheme; he received smart card at the time of registration. In similar way he renewed this schemein 2011 without any hurdle of documentation. So registration process is easygoing and userfriendly, he only carry his BPL card at enrollment camp and he got registration and smart card.He is quite satisfied with behavior of registration official, he told that they were quite cooperativeand process was less time taking.When he was asked about from where he gets to know about this scheme, his reply was “Fromloudspeaker announcement he came to know that a BPL family can get health card in Rs 30”. Sohe went to registration camp and got smart card. After getting smart card, he was not aware aboutthe benefit of smart card, how to use this card and where to use this card. He was suffering fromhernia since last four year bur he didn‟t go for its treatment due to lack of money.Then one day he went to medical shop for pain reliever medicine to get relieve from hernia pain,during interaction with chemist he came to know about the benefit of scheme and he came toknow his family can avail up to Rs 30,000 treatment through this smart card and he also came toknow that his family can take go for surgical treatment with the help of this card without payingexpenditure of treatment. He was surprised; he couldn‟t believe on his ear at that time, he againasked the chemist that what he has told is true? Chemist assured him and also gives the referenceof Gopinath Hospital, Saki Gopal, and told Mr. Dhaneswar that he can get treatment in thishospital. Gopinath Hospital is just 4 KM from his home so going there and doing inquiry is not abig issue for him so he went to Gopinath hospital for seeking treatment of Hernia.But again there was setback for Mr. Dhaneswar, Gopinath Hospital staff told him that thishospital provide treatment under RSBY scheme last year ( in year 2010-11) but this year theydidn‟t get permission for treatment under this scheme. When he asked about other hospital, fromwhere he can get treatment, the staff of Gopinath Hospital told about govt. hospital Sakhi Gopaland Sanjeevani Hospital Puri. He doesn‟t have faith on govt. hospital so he decided to go atSanjeevani Hospital Puri for his Hernia surgical treatment.In November 2011, he got successful surgery of Hernia and his ailment was cured due to RSBYscheme. His was quite satisfied from the treatment at Sanjeevani Hospital and result of surgicaloperation. Now he is completely cured from his disease and living life happily. He is very much 43
  • 45. satisfied with this scheme now and he will take further treatment, in case it required, for hisfamily members too. He will renew this scheme next year too.Inference: This case study reveal that how this scheme is very much beneficial for the poorpeople those can‟t afford the expenditure of treatment and how this scheme transform the life ofpoor family. Mr. Dhaneswar was suffering from a painful disease and didn‟t go for treatment dueto lack of money, if this scheme is not there he will continue to go suffer from the pain andailment so RSBY scheme relieved him from severe pain and chronic illness.But the other aspect is that he got treatment after one year of getting smart card, he can avail sametreatment one year before if he was aware about the benefits of scheme. So awareness delayed histreatment and there are lot of people like Mr. Dhaneswar who couldn‟t get benefit and still livewith their disease due to lack of proper knowledge and awareness.Third point is there is gap between renew of empanelled hospital license for treatment underRSBY scheme so people are confused this situation also happened with Dhaneswar when didn‟tget treatment from Gopinath Hospital, if he wouldn‟t go for Sanjeevani Hospital, that is 20 KMfrom Sakhi Gopal, he wouldn‟t get benefit so availability of nearby hospital is major issues inavailing the treatment and benefit of schemeForth, people don‟t have faith in govt. hospital they continue their suffering but don‟t go for govt.hospital as they though no one bothers for their treatment I govt. hospital.5.1.2 Case Study II: Spandhan Medical CenterSpandhan Medical CenterOmfed Road,Ganesh Bazar,Nimapara,PuriMr. B. P. Panda (Hospital Administrator)Spandhan Medical center is one of the empanelled hospital in Puri district, it was empanelled inJune 2010 and in year 2010-11, it provide treatment around 180 patient. This hospital has verygood reputation in around area and people come after long travelling to avail the treatment fromthis hospital. It is also one of three hospitals in Nimapada block that provide treatment to RSBYbeneficiary. This hospital has good infrastructure and medical facility like ECG, X-ray,Laboratory facilities. So a lot of patient get benefit and get cured from the treatment of this 44
  • 46. hospital. Due to good infrastructure and with availability of all the facilities it get the permissionto treat the patient under RSBY scheme in June 2010. So it started operation with RSBY patientalso and nearly 180 patient get treatments from this hospital, hospital got its bill reimbursed fromerstwhile insurer New India Assurance during year 2010-11.As the patient get benefitted the number of RSBY patient increasing day by day due to word tomouth publicity and it also helpful in increasing the awareness among BPL families as onesuccessful treated is good example in front of one village and lot of people in that particularvillage are come to know about the benefit of scheme.Everything is going fine; number of patient increasing, people came to know more about thebenefit of scheme. So more patient come for treatment but the hospital got the permission for 10beds so he can‟t avail treatment for more than 10 patients in a single day although it has capacityof 25 beds. So spandhan medical center applied for 20 beds but it didn‟t get permission toincrease its capacity. So some of the RSBY patient had to go back without getting treatment somehad to come many time to get the treatment. So dissatisfaction level among RSBY holder hadincreased.As patient were going back without getting treatment so hospital image was tarnished but hospitaladministration didn‟t have any option except wait and watch. But another setback came whenOrissa govt. bid for insurance contract for year 2011-12, in year 2010-11 the insurer provider wasNew India Assurance but in year 2011-12 ICICI Lombard won the bidding for Puri District andstarted operation from July1, 2011. After stating the operation of ICICI Lombard they follow newpolicy. They asked every empanelled hospital to stop treatment until they would not upgrade theirsoftware because they are using advanced technology so if RSBY smart card was swapped withold software, then they are unable to reimburse their bills. So every hospital stop treatment ofpatient and patient disappointment increased, although there are some hospitals that get upgradedsoftware within one month, like Ananda Hospital, nimapada; few hospitals got this upgradedsoftware after 3-4 month like Seva Nursing Home, GOP. And there are few hospitals that are stillwaiting for their upgraded software like Spadan Medical Center.Spandhan Medical Center is classical case, where hospital has every infrastructure for treatmentbut they are not getting permission due to lackadaisical attitude of insurance company. Thehospital density is already thin in Orissa and if these type of case happen then worst affected werebeneficiary of scheme. If we take the case of Nimapada district, there is three private empanelled 45
  • 47. hospitals on RSBY website for RSBY treatment but only one hospital is functional and total no ofregistered people under this scheme is 407663 so treating 407663 person through one privatehospital is impossible task.Inference: from this study it can be reveal that there is scarcity of hospital that are empanelledunder this scheme. And few that are eligible and empanelled are not functional so RSBY patienthas to travel a lot to get treatment and most of the time they were disappointed due tounavailability of bed in hospital and sometime they found that treatment is not available inparticular hospital, they confused more and believe on this scheme decrease. Although awarenesslevel is quite low, if it would be high then also, they did not get treatment due unavailability ofhospital bed. So increase the number of bed and proper monitoring is upmost factor to avail thetreatment for everyone. There is some where not a single private hospital function for RSBYscheme.5.1.3 Constraints Identified: 1. Low awareness among the beneficiaries partly because of their illiteracy, ignorance and partly because registration team didn‟t explain the procedure and benefits well so the villagers are in dark about their benefits and entitlements under the Scheme. 2. The scheme is not fully operable in remote areas; Distance of empanelled hospital from villages is very far in the remote areas, so to get treatment they have to travel a very long distance. 3. There is very few number of RSBY empanelled hospital in area. In Puri district, there is only 26 empanelled hospitals that has to 13176 enrolled families. So the total overall ratio of hospital is very low for RSBY scheme. In parallel these hospital also provide treatment to other patient so effective number of bed for these hospital is also less. 4. People are not getting very good response from public hospital and they prefer to go in private hospital. So the perception of people for treatment in government hospital is not good. This is the reason, private hospital that are operating under RSBY scheme are crowded. 46
  • 48. 5. People are more inclined toward getting treatment from private hospital, but the number of empanelled private hospital are very less, only eight private hospitals in Puri district are empanelled under this scheme.6. There is discontinuation of scheme and some time hospital refused to provide treatment and delay treatment, this also de-motivated the villages as they travel so much and wouldn‟t get any treatment. So come again without any guarantee of treatment discourage villagers to use this scheme 47
  • 49. Chapter 6 Key Findings, Recommendation and Conclusion6.1 Key Findings 1. Rashtriya Swasthya Bima Yozna provide the benefit to five member in a family, if there is more than five member in a family, Head of family has to select five member so only these members can get benefitted from this scheme. This study reveal that 41.4% of sample families have more than five members so this is not sufficient to cover all the family members health insurance 2. This study finds that 57.4% of head of family has education level below primary standard so illiteracy also plays constrain for awareness spread and utilization of scheme. But the good sign is that only 9.2% of family have education level up to primary rest of 90.8% families have at least one member in family is more educated than primary standard. So overall literacy level is increased so now it is easy for spreading awareness as new generation is more literate. 3. Beneficiary of this scheme is divided into five category in this study, and result of this study reveal that major chunk of beneficiary around 48 % are labor those are associated with agriculture and non agriculture. Second category come of household those major source of income is agriculture they contribute 33% of population. So if this scheme implement according to plan the labor class will get more benefit. 4. For 47% of surveyed household the distance of nearest hospital is more than 10 KM from their village. So accessibility of hospital is major issue for people. Only 24% of household has empanelled hospital under five kilometer of range. 5. Only 12.6% of household completely understand the procedure involve in this scheme. Others have only basic knowledge about this scheme, and 5.7% of household only registered they don‟t know what is this scheme all about. So awareness issue should be taken into consideration. 6. Loudspeaker announcement is major source for information regarding registration process and awareness for scheme. Loudspeaker announcement carry 35% chunk in all the source 48
  • 50. after that source of information is NGO personnel/ Panchayat representative. Health staff comes at third position that carry a portion of 19.5% of population so there is more need to health staff participation as it is directly involved with scheme so there involvement would be more effective.7. The utilization of scheme by beneficiary is very low, 73.6% of surveyed families never use smart card, and they only registered after that there have never use it. So low utilization is major concern for this scheme, people are not get benefiting by this scheme. No one in surveyed families use their smart card more than five times in a year. Majority of population use this service once or twice. So there is no utilization or under utilization of scheme.8. Out of total household surveyed 38.3 % are comfortable in using RSBY smart card rest are not comfortable to using these card.9. There is mixed response for satisfaction level among RSBY beneficiary. There are 39% of household that are satisfied with this scheme, out of these 39% only 12.6% are highly satisfied. If go through dissatisfaction level around 30% are highly dissatisfied.10. There is 62% BPL of family those didn‟t get treatment of their family due to lack of money in past so need of scheme is very much.11. There is good response that 97% of families wants to renew this scheme, although lot of dissatisfaction for this scheme yet people are ready to renew this scheme. The major factor to renew this scheme is low cost involved and easy, less time taking registration process.12. Barriers in utilization of scheme: To find barriers in utilization, factor analysis is used and following barrier are identified:  Hospital Reputation  Responsiveness of Hospital  Medical facility available in empanelled hospital  Distance of empanelled hospital  Connectivity of hospital  Awareness regarding RSBY scheme  Extra expense bear by patient during treatment  Information regarding registration  Behavior of registration staff 49
  • 51. 13. Cluster Analysis: There is four clusters were formed on the basis of demography and utilization of scheme, we can draw following finds through this study:  Cluster 3 has used their RSBY smart card other three cluster didn‟t use their smart card, the distinguish factor in cluster 3 is education qualification of head of family, this cluster have good awareness level, so source of information for this cluster was loudspeaker announcement and this cluster member know about the scheme, total amount and empanelled hospital in their area. Although this cluster major occupation is non agriculture labor but due to good education level of head of family, so this group has higher awareness than other cluster and the house hold utilize their smart card for registration. So a good education level is up most important factor in implementation and effective utilization of scheme.  Cluster 4 main occupation is non agriculture labor and their head of family education standard is not so high but still they have good awareness level. The important point in this cluster that education qualification of family members is higher than head of family so this would be one of attribute for higher level of awareness.6.2 Recommendations  Conducting Genuine Social Audit by Gram Sabha There should be a provision of conduct of social audit by the members of the Block Committee. Social audit should comprise verification of all records of hospitals, quality of treatment and other medical facility available in hospital both in private and public. Social audit helps to detect gaps and leakages; identifies strengths and weaknesses; empowers the villagers to put forward their rights and entitlements in an effective manner; and ensures greater accountability of officials and elected representatives of gram Panchayats.  Capacity Building of ANM/Aganwadi Staff by identifying the relevant inputs and then providing them intense training on this scheme. On and Off-field trainings to the GP officials is critical to understand as to how to plan, and create awareness. 50
  • 52.  Awareness generation: As report suggest that most effective way to spread awareness is through Loudspeaker/Nukkad Natak as it involves directly the villagers and provide good penetration. Increase number of hospitals and beds: There is few empanelled hospital in Puri District, only eight private hospital empanelled in which many are not operating for RSBY due to various reason. There should be more empanelled hospital to cater needs of RSBY beneficiary. Message alert service for RSBY smart card transaction: During interaction with villagers this fact came in light that people are more concern about the deduction in money from there smart card after treatment. They are concerned that if hospital deduct large amount of money from there card when they go for mild treatment, so they don‟t take treatment and only go for taking treatment of severe disease. So recommendation for this problem is there should be message alert service for every transaction from smart card so that people can come to know about any transaction done by hospital. It will increase the transparency and faith of people in system. Encourage more number of hospitals in rural areas: There are few hospital and that are limited to block or in town. There is not a single empanelled hospital that is present in remote rural area so govt. should motivate the private hospital to go in rural sector, provide incentive to those who are working in rural area Increase the OPD service in private clinic: Very few people are utilizing OPD facility in RSBY. The reason no nearby hospital. So govt. should allow register doctor to accept OPD treatment through smart card Wall painting of benefit of scheme in each village and list of nearby empanelled hospital in each village and toll free number Mobile OPD van: Mobile OPD van is a good alternative to provide OPD service to villagers, it is more effective and economic to provide OPD treatment once in weak in each village. This type of van can be started by insurer with the collaboration of hospitals and govt. 51
  • 53. 6.3 ConclusionIndia tryst with health insurance programme is go back to the late 1940 and early 1950 when twoof the most important scheme has started: Central Government Health Scheme,Employees‟ StateInsurance Scheme. But to covering poorest of poor, there was no health insurance scheme soRSBY include national wide BPL families. This study also reveals that large number of familydidn‟t get treatment due to lack of money so there is need for this kind of scheme in society.Although this scheme is very much affordable, this is the reason, everyone is ready to renew thescheme in next year but still accessibility of scheme is question mark. There is very fewempanelled hospitals that are not able to cater the need of all the registered family so providingquality service is important issue in implementation of scheme. Complete knowledge about thescheme is another issue that should take into consideration only few people have completeinformation and few people are comfortable to use RSBY services. The enthusiasm of registeredis not good due to delay of treatment and uncertainty in treatment, people travel a long distance toget treatment but when they didn‟t get good response from hospital, it disappoint them that bringdown their motivation level. The structure of RSBY scheme is very well planned if it take carefew glitches and overcome barrier that is described in this report this scheme would play a veryimportant role to improve status of health of BPL families. 52
  • 54. 6.4 REFERENCES:RSBY website: http://www.rsby.gov.in/index.aspxRSBY Orissa portal http://rsbyorissa.in/Krishna, A. (2004) „Escaping Poverty and Becoming Poor: Who Gains, Who Loses, and Why?‟World Development, Vol. 32,RSBY (2009) Tender document, Template for use by state governments.World Health Organization National Health Accounts. India. 2006.Ministry of Health & Family Welfare. National Health Accounts, India. New Delhi: Governmentof India, 2006 : 1-79.Ministry of Health & Family Welfare. National Health Accounts, India. New Delhi: Governmentof India, 2006 : 1-79.van Doorslaer E, ODonnell O, Rannan-Eliya RP, Samanathan A, Adhikari SR, Garg CC, et al.Effect of payments for health care on poverty estimates in 11 countriesSolome K Bakeera: Community perceptions and factors influencing utilization of healthServices, International Journal for Equity in HealthEarle L. Snider: Factors Influencing Health Service Knowledge among the Elderly,Journal of Health and Social Behavior, Vol. 21, No. 4 (Dec., 1999), pp. 371-377Asia: an analysis of household survey data. Lancet 2006; 368:1357-61.Ministry of Health & Family Welfare. National Rural Health Mission: Mission document. NewDelhi: Government of India, 2005Moving Toward Universal Health Coverage R A S H T R I Y A S W A S T H Y A B H I M A YO J A N A (R S B Y)Bhat, Ramesh and Sumesh K. Babu (2008), “Health Insurance and Third Party Administrators:Issues and Challenges”, Economic and Political Weekly, Vol. 39, No 28, July 10-16. 53
  • 55. The world health report 2010 - Health systems financing: the path to universal coverageGovernment of India, (2005) “Financing and Delivery of Health Care Services in India”, NationalCommission on Macroeconomics and Health, Ministry of Health and family Welfare,Government of India.RUDRAGOUDA R. BIRADAR: Status of human health in india: Emerging issues in the era ofglobalizationRajasekhar, D, Erlend Berg and R Manjula (2009):“Health Expenditure and the Poverty Line:Some Perspectives”, paper presented in the seminar on “Institutional Aspects of Pro-Poor Policy:Revising the Indian Poverty Line”, Institute for Social and Economic Change, Bangalore, 15December.World Bank, (2008) “Governing Mandatory Health Insurance: Learning fromExperience”,Washington, D.C.Bergkvist S., (2008) “Moving towards Universal Health Coverage: Aarogyasri Case Study”.India‟s progress towards the healthcare MDGs: State of planetwebsitehttp://blogs.ei.columbia.eduHealth Financing: Access Health International (http://www.accessh.org/)Mediclain- e-mediclaim portal (http://blog.emediclaim.com/rashtriya-swasthya-bima-yojana-rsby/) 54
  • 56. 6.5 ANNEXURE 1 RSBY QUESTIONNAIRE RSBY QuestionnaireName: Gender:Village Block:Name of Head of family: Households URN no. 1. Educational qualification of head of family: 1. Illiterate 2. Up to primary standard 3. Up to matriculation 4. Up to higher secondary 5. Above higher secondary 2. No of members in family: 1. 1-2 2. 3-5 3. 6-8 4. 9-12 5. >12 3. Highest education qualification of any of family member: 1. Illiterate 2. Up to primary standard 3. Up to matriculation 4. Up to higher secondary 5. Above higher secondary 4. Household Type 1. Self-employed in non-agriculture 2. Agricultural labour 3. Other labour 4. Self-employed in agriculture 5. Others ____________________ 5. What do you know about RSBY scheme? 1. Only registered, no further information 2. Registered, know where to use RSBY smart card and have information regarding empanelled hospital in area. 3. Know about RSBY total amount Rs. 30,000 per annum can be used for family members treatment 4. Know both total amount as well as empanelled hospital list 5. Complete understand the procedure involved in availing the benefits of the scheme 6. From where you get to know about RSBY scheme? 1. From Posters/ Wall painting 2. From Word of mouth 3. From NGO personnel/ Panchayat or Block 4. From Doctor/ Hospital staff/ ANM/ Official /Govt. Officials ASHA/health workers/ Aganwadi 5. Loudspeaker announcement/ Nukkad Natak 6. Others _____________ 7. How far is the nearest empanelled hospital from your house (in Kilometer) 1. 0-5 2. 5-10 3. 10-20 4. 20-30 5. > 30 8. Have you received RSBY smart card 1. Yes 2. No If yes 9. Are you comfortable using the RSBY smart card 55
  • 57. 1. Yes 2. No10. How many times you have used RSBY smart card during last year 1. 0 2. 1-3 3. 4-6 4. 6-10 5. > 1011. How do you consider the importance of following barriers in relation to RSBY Scheme (1=insignificant, 2=little significant, 3= Moderately Important, 4= significant 5=most significant) S. No Aspects 1 2 3 4 5 1. Distance of enrollment center from house 2. Information regarding enrollment camp 3. Time taken in Registration process 4. Documents required for Registration process 5. Amount charge for registration 6. Behavior of enrollment representative/ staff 7. Time taken to deliver smart card 8. Information regarding the benefits & details of scheme 9. Distance of nearest empanelled hospital 10. Road/Rail connectivity of hospital from village 11. Response of Hospital for treatment 12. Reputation of Hospital 13. Other medical facility available for RSBY patient in hospital (X-ray, ECG, ambulance service etc) 14. Extra expenses incurred during treatment 15. Post transaction balance information12. Has it ever happened that a family member was ill and amount left in smart card wasn’t sufficient 1. Yes 2. No13. If yes, What is that total amount that you have paid so far in treatment of RSBY enrolled persons (in RSBY) _________________14. How would you rate your satisfaction about the treatment provided at the hospital? 1. Very dissatisfied 2. Somewhat Dissatisfied 3. Neither satisfied nor dissatisfied 4. Somewhat Satisfied 5. Very Satisfied15. Where would you have gone if scheme had not been there? 1. To the same hospital 2. To any other private hospital 3. To government hospital 4. Doctor’s private clinic 5. Nowhere 6. Other ( specify) ________ 56
  • 58. 16. Has it ever happened that a very serious illness in your family could not be treated at a hospital because of lack of money? 1. Yes 2. No 17. Will you consider renewing the Scheme next year? 1. Yes 2. No6.6 ANNEXURE 2 FACTOR ANALYSIS CORRELATION TABLECorrelation Matrix Dist Infor Tim Doc Am Beh Tim Det Dista Co Res Re Ot Extra Post anc mati eta ume ount avio eTa aile nceof nn pon pu her Expen Tran eof onRe ken ntRe char urfo ken dIn Near ect sive tat Me sesOc sacti Enr gard for qire gedf rEnr ToD for estE ivit nes ion dic curre onBa oll ingR Reg dfor orRe oll elive ma mpan yof sof of alF dDuri lance me egist istr Regi gistr mn rSm tio nelle Ho Hos Ho aci ngTre Infor ntC ratio ati strat atio etSt artC nRS dHos spi pit spi liti atme mati ent n on ion n aff ard BY pital tal al tal es nt on erC Dista 1.0 - .25 - .067 .18 .047 .18 .042 .10 .00 .00 .17 .112 .009o nceof 00 .045 4 .115 4 0 4 6 7 9r Enrollr mente Centel rati Infor - 1.00 - .096 - .31 .025 - .177 .03 - .02 .11 -.047 .307o matio .04 0 .00 .079 0 .04 3 .10 6 5n nReg 5 9 5 1 ardin gRegi strati on Timet .25 - 1.0 .084 .428 .32 .264 .20 .256 .25 .05 - .22 .072 .194 akenf 4 .009 00 4 0 8 2 .01 9 orReg 5 istrati on Docu - .096 .08 1.00 - .09 - - .307 .10 .10 - - -.132 .138 ment .11 4 0 .126 4 .034 .10 7 3 .27 .20 Reqir 5 3 6 8 edfor Regis tratio 57
  • 59. nAmou .06 - .42 - 1.00 .44 .498 .17 .108 .20 - .08 .15 .117 .209ntcha 7 .079 8 .126 0 0 7 3 .11 9 5rgedf 8orRegistrationBeha .18 .310 .32 .094 .440 1.0 .187 .12 .315 .12 - .04 .11 .076 .168viourf 4 4 00 8 5 .13 1 5orEnr 3ollmnetStaffTime .04 .025 .26 - .498 .18 1.00 .08 .111 .06 - - .02 -.075 .228Take 7 4 .034 7 0 2 8 .16 .07 4nToD 1 8eliverSmartCardDetail .18 - .20 - .177 .12 .082 1.0 .144 .11 - .01 .10 .198 -.005edInf 0 .045 0 .103 8 00 3 .08 5 8orma 8tionRSBYDista .04 .177 .25 .307 .108 .31 .111 .14 1.000 .45 .00 - - .008 .196nceof 2 6 5 4 7 4 .00 .12Near 3 3estEmpannelledHospitalConn .10 .033 .25 .107 .203 .12 .068 .11 .457 1.0 .12 .22 .18 .093 .255ectivi 4 8 5 3 00 6 7 6tyofHospitalRespo .00 - .05 .103 - - - - .004 .12 1.0 .19 .26 .050 .191nsive 6 .101 2 .118 .13 .161 .08 6 00 8 3nesso 3 8fHospitalReput .00 .026 - - .089 .04 - .01 -.003 .22 .19 1.0 .36 .088 .138ation 7 .01 .276 1 .078 5 7 8 00 6ofHos 58
  • 60. pital 5 Other .17 .115 .22 - .155 .11 .024 .10 -.123 .18 .26 .36 1.0 .180 .190 Medi 9 9 .208 5 8 6 3 6 00 calFa cilitie s Extra .11 - .07 - .117 .07 - .19 .008 .09 .05 .08 .18 1.000 -.010 Expen 2 .047 2 .132 6 .075 8 3 0 8 0 sesOc curre dDuri ngTre atme nt PostT .00 .307 .19 .138 .209 .16 .228 - .196 .25 .19 .13 .19 -.010 1.00 ransa 9 4 8 .00 5 1 8 0 0 ction 5 Balan ceInf orma tion6.7 ANNEXURE 3 DENDOGRAM OF CLUSTER ANALYSIS* * * * * * * * * * * * * * * * * * * H I E R A R C H I C A L C L U S T E R A N A LY S I S * * * * * * * * * * * * * * * * * * *Dendrogram using Average Linkage (Between Groups) Rescaled Distance Cluster Combine C A S E 0 5 10 15 20 25 Label Num +---------+---------+---------+---------+---------+ Shishir Rout 8 ─┬─────┐ Sujit Rout 27 ─┘ ├─┐ Shukar swain 19 ─────┬─┘ ├─┐ Bulli Pradhan 59 ─────┘ │ ├───┐ Parsanna Jena 81 ─────────┘ │ │ Sandiyarani Bhoi 37 ───────────┘ ├─┐ Buli Nayak 9 ─────────┬─────┤ │ Dhaneswar jena 86 ─────────┘ │ │ DHANESWAR ROUT 24 ───────────────┘ ├───────────┐ Laxmi Bhoi 7 ─┬───────┐ │ │ Bejabansik Acharya 26 ─┘ ├───┐ │ │ Neelakant das 39 ─────────┘ ├───┘ │ 59
  • 61. Utsav Nayak 69 ─────────────┘ │Brajo Pradhan 30 ─────┐ │Srujana Rout 82 ─────┼───┐ │Birender mallick 20 ─────┘ ├─────┐ ├───┐Banaja Pradhan 78 ─────────┘ ├─────────┐ │ │Dillip Rout 29 ─────┬───────┐ │ │ │ │Jaganath Maharana 50 ─────┘ ├─┘ │ │ │Sadashiv swain 46 ─────┬───┐ │ │ │ │Amulya Barik 57 ─────┘ ├───┘ │ │ │Artha ahija 54 ───┬─────┤ │ │ │Sarensua 55 ───┘ │ │ │ │Srikant Beherera 42 ─────┬───┘ ├───┘ │Narahari Senapati 43 ─────┘ │ │ 49 ─────┬─────────┐ │ │Gopal Pradhan 67 ─────┘ ├───┐ │ │Sarat Behera 65 ─────────┬─────┘ │ │ │Sujit Rout 77 ─────────┘ │ │ ├───┐Arbinda jena 31 ───┬─────┐ │ │ │ │Litu das 34 ───┘ ├─┐ ├─────┘ │ │ 48 ─────┬─┐ │ │ │ │ │Subhakana 84 ─────┘ ├─┘ ├───┐ │ │ │Bignesh Jena 32 ───────┘ │ │ │ │ │Narayan Barik 51 ───────────┘ ├───┘ │ │ 47 ─────┬─┐ │ │ │Sibendhu 80 ─────┘ ├─────┐ │ │ │Sanjugupta Bhoi 35 ─────┬─┘ ├─┘ │ │Bira Bhoi 36 ─────┘ │ │ │Shukanti Pradhan 22 ─────────────┘ │ ├─┐Pramod Pal 10 ───┬───┐ │ │ │Rabinder Mallick 13 ───┘ ├───────────────┐ │ │ │Tilotuma Pradhan 23 ───────┘ ├─────────┘ │ │Ramesh Mallick 11 ─────┬───────┐ │ │ │Tirotoma Rout 25 ─────┘ ├─────────┘ │ │Rabindra Jena 16 ─────────────┘ │ │Bhagapata Pradhan 63 ───────┬─────────────┐ │ │Shadhu Pradhan 64 ───────┘ ├───────────┐ │ │Jyoti swain 12 ───────┬─────────────┘ │ │ │Chandan swain 15 ───────┘ │ │ │Basant Kr Mallick 3 ───────────────┬─────────┐ ├───┘ │P. C. Pradhan 76 ───────────────┘ ├───┐ │ │Ramesh pradhan 18 ───────────────┬─────────┘ │ │ │Pusna Bhoi 38 ───────────────┘ ├───┘ │Dhundo Swain 14 ───────────────┬───────────┐ │ │Mriglekh Bhoi 28 ───────────────┘ │ │ │Bal Krishna nayak 45 ───────┬─────────────────┐ ├─┘ │Kanucharan Sahu 53 ───────┘ │ │ ├───┐Amulya Pradhan 61 ───────┬───────┐ │ │ │ │Balran bhoi 85 ───────┘ ├─────┐ ├─┘ │ │Ajay Pradhan 66 ───────┬───────┘ │ │ │ │Jaganath Maharana 70 ───────┘ │ │ │ │Sulochana Behera 41 ─────┬───┐ ├───┘ │ │chandranam maharana 52 ─────┘ ├───────┐ │ │ │Narendra sahu 56 ─────────┘ │ │ │ │Sabita Pradhan 58 ───┬───┐ │ │ │ │Gopal Khatri 73 ───┘ ├─┐ ├───┘ │ │Balram Khatri 74 ───────┘ ├───┐ │ │ │Rajato Swain 6 ─────┬─┐ │ │ │ │ ├─┐Partha 79 ─────┘ ├─┘ ├───┘ │ │ │Kelu Chara Parida 40 ───────┘ │ │ │ │Divakar Mehra 44 ─────┬─────┐ │ │ │ │Sanjay Pradhan 68 ─────┘ ├─┘ │ │ │Bider Pradhan 62 ─────┬─┐ │ │ │ │Laxminarayan Pradhan 71 ─────┘ ├───┘ │ │ ├───┐ 60
  • 62. Rajan Barik 60 ───────┘ │ │ │ │Maharana Bhoi 33 ─────────────┬─────────────────────────┘ │ │ │Balram Rout 87 ─────────────┘ │ │ │Prakesh Jena 17 ─────────────┬───────┐ │ │ │Shekh Sansoor 21 ─────────────┘ ├─────────────────────┘ │ │Bulli swain 2 ─────────────────────┘ │ │Satyajit 83 ─────────────────────────────────────────────┘ │Budhnath Swain 4 ───────────────┬─────────────┐ │Dhrubo Nayak 5 ───────────────┘ ├─┐ │rasmi rakha mallick 1 ─────────────────────┬───────┘ ├─────────────────┘Parshram Pradhan 75 ─────────────────────┘ │Bharat Swain 72 ───────────────────────────────┘ 61