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ORIGINAL ARTICLE  
Year : 2020  |  Volume : 45  |  Issue : 2  |  Page : 135-138
 

What lessons should pradhan mantri jan arogya yojana learn from the shortfalls of rashtriya swasthya bima yojana: The case of rashtriya swasthya bima yojana in Chhattisgarh


Department of Humanities and Social Sciences, Humanities and Science Block, IIT Madras, Chennai, Tamil Nadu, India

Date of Submission12-Mar-2019
Date of Acceptance25-Feb-2020
Date of Web Publication2-Jun-2020

Correspondence Address:
Dr. P Shirisha
Plot No. 22, S2, 2nd Floor, Swagatam Sneham Apartments, 3rd Cross Main Road, Rajalakshmi Nagar, Velachery, Chennai - 600 042, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijcm.IJCM_95_19

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   Abstract 


Context: Publicly funded health insurance has been rolled out by many states as well central government. As it is being seen as a way of protection against catastrophic health expenditure. Rashtriya Swasthya Bima Yojana (RSBY) has been one such attempt succeeded by the recent scheme Ayushman Bharat, which provides coverage of 5 lacs for each family per year. Aims: To assess RSBY on issues of equity across the state of Chhattisgarh. Materials and Methods: The district-wise secondary data for Chhattisgarh were obtained from the official state website of RSBY maintained by the Government of Chhattisgarh. The data were utilized to estimate the claim ratio (procedure wise as well as district wise), enrollment pattern, rate of hospitalization, and average costs of hospitalization across the district to compare the change in trends since 2011 till 2017. Results: There is an overall increase in enrollment, utilization, and number of empanelled hospitals. Also, a higher conversion ratio (i.e., increased proportion of the below poverty line households enrolled) shows a positive sign of improved coverage. All the districts faired on an average, barring Sukma with lowest enrollment rate (55%) probably due to poor accessibility and political disturbances. Conclusions: Although there has been an increase in the overall utilization, procedure-wise claims, and enrollment, there are signs of inequity, namely the skewed distribution of empanelled hospitals. Therefore, good or bad, RSBY offers important lessons to be learned for Ayushman Bharat.


Keywords: Chhattisgarh, enrollment out-of-pocket, equity, health insurance, hospitalization, Mukhyamantri Swasthya Bima Yojana, Rashtriya Swasthya Bima Yojana, utilization rate


How to cite this article:
Shirisha P. What lessons should pradhan mantri jan arogya yojana learn from the shortfalls of rashtriya swasthya bima yojana: The case of rashtriya swasthya bima yojana in Chhattisgarh. Indian J Community Med 2020;45:135-8

How to cite this URL:
Shirisha P. What lessons should pradhan mantri jan arogya yojana learn from the shortfalls of rashtriya swasthya bima yojana: The case of rashtriya swasthya bima yojana in Chhattisgarh. Indian J Community Med [serial online] 2020 [cited 2020 Sep 22];45:135-8. Available from: http://www.ijcm.org.in/text.asp?2020/45/2/135/285669





   Introduction Top


“Incidence of catastrophic expenditure due to health care costs is growing and is now being estimated to be one of the major contributors to poverty” as stated by 2015 GOI report.[1] The latest National Sample Survey Office (NSSO) survey found average total medical expenditure for treatment per hospitalization case during stay at hospital as Rs. 18,268. Around 70% of India's population rely on savings/household incomes, which is “out-of-pocket” expenditure if they are not covered by any insurance scheme for hospitalization.[2] In Chhattisgarh, the proportion of households facing catastrophic health expenditure is 6.6% below the national average for India, which is 13%.[1] Hence, to cover the eligible population against financial shocks, central government and various state governments came up with publically financed health insurance schemes: Rashtriya Swasthya Bima Yojana (RSBY) (Central Government), CMCHISTN (Tamil Nadu), Vajpayee Arogyashree (Andhra Pradesh), Rajiv Gandhi Jeevandayee Arogya Yojana (Maharashtra), and Rajiv Arogyashri (Karnataka). PFHIS has brought fundamental changes in public financing and health services provisioning as India traditionally has tax-based financing.[3] The recent one is Pradhan Mantri Jan Arogya Yojana (PMJAY), which was rolled out in 2018 and covers approximately 50 million individuals. Each family is covered for an amount of Rs. 5,00,000/years and it is an entitlement-based system where the beneficiaries have been selected based on the socioeconomic caste census data (2011). The share of expenditure between center and state is 60:40, barring few states such as Chhattisgarh, Odisha, and Madhya Pradesh which have opted out of the scheme and other states have signed MoU with the center. It provides coverage for secondary and tertiary procedures to the eligible people through empanelled hospitals (both private and public) which will be incentivized if they fulfill certain criteria for quality.

Rashtriya Swasthya Bima Yojana in India and Chhattisgarh

At present, Chhattisgarh has opted out of PMJAY; only RSBY and Mukhyamantri Swasthya Bima Yojana (MSBY) are functional throughout the state. RSBY was launched by the Ministry of Labour and welfare in 2008, but since 2015, it has been transferred to the Ministry of Health and Family Welfare. The scheme provides coverage of around Rs. 30,000/per family (a maximum of 5 members) per year.[4] Earlier it was meant for only below poverty line (BPL) households, the scheme was later extended to cover unorganized sector workers too. The beneficiaries have to pay Rs. 30 as premium, while the rest of premium is borne by central and state government as per their sharing ratio based on competitive bidding.[5] The state of Chhattisgarh has 40.8% BPL households as of 2011 when the scheme was being rolled out only in six districts and thereafter was expanded to whole of the state of Chhattisgarh, now it covers all twenty-seven districts. “MSBY” is the PFHIS rolled out by Chhattisgarh state government to cover those left out families not covered under RSBY. The basic objective of both the schemes is to provide financial protection to the vulnerable population and provision of quality health care by involvement of expanding private sector. Under both the schemes, a cover of Rs. 50,000/years is provided to each family on a floater basis (a maximum of 5 family members).[6] The official report on evaluation of various aspects of RSBY and MSBY in four districts of Chhattisgarh observed the absence of potential beneficiaries present in the village, did not apply, or had long waiting periods as the main reasons for nonenrollment.[7] The main objectives of the study is to see whether the scheme has any equity issues [Figure 1].[8]
Figure 1: Specialty-wise claim status[8]

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   Materials and Methods Top


The district-wise data of Chhattisgarh from January 2017 to September 2017 were obtained from the official state website of RSBY maintained by the Government of Chhattisgarh on the equity aspects: enrollment pattern, claim distribution, number of empanelled hospitals, as well as number of hospitalization. First, the hospitals were segregated district wise and whether they were public or private from the year when the scheme was rolled out till 2017–2018 from the list provided in the official website and then the total number, so these estimates indicate the distribution of the health services region wise and sector wise. The scheme was rolled out in a phased manner.i.e. in the initial stages of the scheme only few districts were covered later it was extended to all the remaining districts.

Claims ratio which is nothing but the ratio of the number of eligible BPL families who enrolled in the scheme to the total number of eligible BPL families present in the district, was estimated from the 1st year of the scheme till 2017-18. The utilization rate was estimated district wise as the total number of families enrolled in the district to that of the total number of hospitalization (assuming that there are five members in the family). The average cost of hospitalization has been termed as cost incurred per hospitalization based on total cost incurred in the district by the total number of hospitalizations in that particular district. Chhattisgarh government has grouped the districts under five major divisions: Raipur, Bilaspur, Surguja, Bastar, and Durg; therefore, the study represents various results in the [Table 1] and [Table 2] in similar fashion.
Table 1: Number of empanelled public and private hospitals district wise

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Table 2: Utilization of the scheme ( for the policy year 2017)

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   Results Top


The share of public and private empanelled hospitals

There is a manifold increase in the number of empanelled private hospitals. In the beginning of the scheme, it was 207 against 327 public hospitals.[9] At present, out of the 1115 empanelled hospitals, 567 are private. Distribution of private hospital as shown in [Table 1] is quite skewed; around 305 of 542 hospitals are located in only two districts. Most private hospitals fixed a quota for BPL patients, beyond which they refused to admit patients under RSBY.

Conversion rate

Round-wise enrollment

Based on the latest NSSO survey (71st round), Chhattisgarh has the highest proportion of population covered by insurance (around 39.3%) as compared to the national average of 15% just next to Andhra Pradesh (62.8%).[2] The findings corroborate with the estimates of our study too. Both enrollment status (77% under RSBY vs. 23% under MSBY) and claim settlement status (66.9% under RSBY, 33% under MSBY) are higher for RSBY than MSBY, because the latter covers for those families not covered under RSBY. However, the average claim ratio is around 12% and rate of enrollment has increased from 42.97% to 82.97%. The minimum conversion rate in the districts is more than 70%, with few as high as 94% of the eligible population enrolled. Still, there exists disparity in enrollment in rural and urban areas. All the divisions have equal or more than 80% enrollment. The findings of a study show that only 43% of the urban slum population in Raipur city continued to lack coverage.[10] Therefore, it is necessary that one not only looks at the number but the distribution too. However, the study did not find any significant difference in enrollment across gender and social groups.[11],[12]

Utilization of the scheme

If we take hospitalization rates as a proxy for utilization, definitely, there has been an increase in utilization rates. During 2011, when RSBY was still at its nascent stage, the state average for hospitalization rate was 0.83% (20,403 cases). The initial hospitalization rates were lower, because the scheme was rolled out only at select districts and the enrollment rates were also lower. Six years later, i.e., in 2017, the hospitalization rate is 2.89% (729,562).[11] Raipur (14.78%) has the highest hospitalization rate, followed by Bilaspur (9.33%) and the lowest rate was in Sukma (0.33%) [Table 2]. According to a postenrollment evaluation study conducted in 4 districts of Chhattisgarh, Just one-fourth or less of the respondents knew about use of the card. And, an even smaller proportion, i.e., 7.9% to 11.1%, of total cases had knowledge on list of empanelled hospitals.[7] Another study on utilization of RSBY among women in Raipur slums observed that only one-third of the families were able to utilize the card.[10] Just less than half of the families interviewed used the smart card, the main reasons cited for such a high number of non-usage were either the facility did not ask for a card during admission, the card was not renewed or facility not being empaneled.[12],[13]

Procedure-wise claim distribution

A total of 805 surgical cases are listed under scheme including both inpatient and day care; however, few procedures are excluded: medical procedures which need hospitalization for <24 h, conditions that are treated at home, congenital external diseases, drug- and alcohol-induced illness, vaccination, war, nuclear invasion, suicide, naturopathy, Unani, Siddha, and Ayurveda. Dental procedures outnumber all other procedures in the claims settled, followed by ophthalmology, gynecology, and general medicine-related claims [Figure 1]. Other procedures such as oncology, pediatrics, general surgery, and urology have lesser share in the claims.

However, as per the Indian Council of Medical Research report on disease burden for Chhattisgarh, communicable, maternal, neonatal, and noncommunicable diseases were leading causes of death and disabilities across all age groups, not dental diseases. Another issue is whether the uptake of health services reflects the actual health needs or is it “supplier-induced demand.”[13] The institutions are not accredited for specific services; institutions/doctors could choose conditions that have profitable package rates. The doctors also reported largely treating conditions which are simple/uncomplicated.[14] The explanation for higher proportion of dental treatment in claim distribution could be a result of “cherry-picking” of cases based on cost–benefit ratio, simple cases over complicated cases.[15] The evidence was found under “Vajpayee Arogyashree Scheme” where complicated cases were referred to public hospitals and “financially remunerative” cases preferentially selected.[16]

Cost of hospitalization

Average cost of hospitalization has been estimated by costs of hospitalization in each district by total number of hospitalizations in each district.[16] The average cost of hospitalization for the state of Chhattisgarh was Rs. 4850. Among all districts, Kawardha reported the highest hospitalization costs Rs. 11,109 and lowest was Dantewada Rs. 2519. There is wide variation among the highest and lowest, while in the rest of the districts, the average cost of hospitalization is around Rs. 3000–6000. The average cost of hospitalization estimated in an earlier study under the scheme in Chhattisgarh is almost similar to current estimate.[16] While in 2011, eight districts had average cost of hospitalization is higher than the state average, currently it has increasedWhile in 2011, eight districts had an average cost of hospitalization higher than the state average, which has currently increased to 11 districts.


   Discussion and Conclusion Top


The statistics show an overall increase in enrollment, utilization, and number of empanelled hospitals in both RSBY and MSBY schemes. However, if we suppose that if there is 1% utilization of the scheme by the 500 million beneficiaries, the shortfall in the amount when compared to its budgetary allocation is quite huge for PMJAY. Under PMJAY, the number of families would be still higher than before, and therefore the equity aspect of the scheme becomes quintessential. The state has seen a higher conversion ratio (i.e., increased proportion of the BPL households enrolled) and all the districts seem to do better on an average, except Sukma (55%). The concentration of about 56% of the total private empanelled hospitals in just about two districts shows the skewed distribution (Bilaspur, Raipur). It implies that come what may, the rural areas or difficult to reach areas will always be underserved and it further hits the marginalized population the most. This is a word of caution for the PMJAY scheme, which envisages to include yet more number of health facilities. Increasing the number of facilities is not equivalent to increasing the depth of coverage in an equitable manner. Until this aspect will be ignored, schemes will always miss on its most vulnerable population. Also, RSBY was supposed to be a cashless scheme similar to PMJAY, to prevent any out of pocket expenditure. However, it was found that in Chhattisgarh, 58% of the respondents who used private health-care services and 17% of those who used government health-care services incurred out-of-pocket expenses.[14] An official report on utilization under RSBY in Chhattisgarh also noted that private hospitals have “commercialized” the scheme.[7] As, private sector has gigantic share in the health sector ever since the era of privatization, and has become a force to reckon with, establishing a robust regulatory framework for the private sector should be the prerogative for such schemes. Another important lesson for PMJAY where the amount of coverage is 10 times higher than RSBY with no cap on the family size is to check for supplier induced demand. It could very well be the case that in the principal-agent role, the agent (doctor) will decide on the patient's behalf and therefore, and many providers would exploit the scheme. Discrimination has been reported against the RSBY beneficiaries by the doctors in public hospitals, who view them as an extra burden while the private sector sees as an extra source of income and hence there is no discrimination of the beneficiaries there[7] Under, PMJAY. Moreover, 80% of the population depends on exclusively private treatment for outpatient cases, and it accounts for higher out-of-pocket expenditures according to the NSSO 71st round,[2] but the outpatient services were neither a part of RSBY and nor of PMJAY. Therefore, it leaves much of the problem of health expenditures unsolved, to be addressed by the people themselves. The inclusion of tertiary procedures, ambulatory services and promoting their delivery through the private empaneled hospitals would increase the costs and undermine the sustainability of such schemes in long-run[17] Another interesting pattern to note is that the dental diseases do not figure in the top 10 diseases causing disability and mortality across all ages and sex.[12] However, procedure-wise “dental treatment” has the highest claims of all, followed only by ophthalmic and gynecological cases.[13] Hence, if PMJAY proceeds further without addressing these issues, it is bound to meet the same fate as its predecessor.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Government of India. National Health Policy 2015 Draft (p. 3). New Delhi: Government of India; 2015. Available from: https://www.nhp.gov.in/sites/default/files/pdf/draft_national_health_policy_2015.pdf. [Last retrieved on 2018 Nov 10].  Back to cited text no. 1
    
2.
Ministry of Statistics and Programme Implementation. Health in India. New Delhi. (2014). Available from http://mospi.nic.in/sites/default/files/publication_reports/nss_rep574.pdf. [Last retrieved on 2018 Mar 04].  Back to cited text no. 2
    
3.
Berman P, Ahuja R, Bhandari L. The Impoverishing Effect of Healthcare Payments in India: New Methodology and Findings. Economic and Political Weekly. 2010; 45:65-71.  Back to cited text no. 3
    
4.
Rent P, Ghosh S. Understanding the 'cash-less,' Nature of Government-sponsored Health Insurance Schemes: Evidence from Rajiv Gandhi Jeevandayee Aarogya Yojana in Mumbai. SAGE Open 2010;5:1-10.  Back to cited text no. 4
    
5.
RSBY; 2018. Available from: http://rsbycg.nic.in/healthrsby/. [Last retrieved on 2018 Jun 05].  Back to cited text no. 5
    
6.
Ravi S, Ahluwalia R, Bergkvist S. Health and Morbidity in India (2004-2014). Brookings India Research Paper No. 092016; 2016.  Back to cited text no. 6
    
7.
Jain N. A descriptive analysis of the RSBY data for the first phase. In: Palacios R, Das J, Sun C, editors. India's Health Insurance Scheme for the Poor: Evidence from the Early Experience of the Rashtriya Swasthya Bima Yojana. New Delhi: Centre for Policy Research; 2011. p. 38-64.  Back to cited text no. 7
    
8.
Rashtriya Swasthya Bina Yojana Mukhyamantri Swasthya Bima Yojana. Government Chhattisgarh Shasan. Available from: http://cg.nic.in/healthrsby/Default.aspx. [Last accessed on 2018 Jun 05].  Back to cited text no. 8
    
9.
Nandi S, Kanungo K, Khan M, Soibam H, Mishra T, Garg S. A study of Rashtriya Swasthya Bima Yojana in Chhattisgarh, India. In Bringing Evidence into Public Health Policy (EPHP) 2010: Five Years of National Rural Health Mission. BMC: BMC. (2012). doi.10.1186/1753-6561-6-S1-O5.  Back to cited text no. 9
    
10.
Nandi S, Nundy M, Prasad V, Kanungo K, Khan H, Haripriya S, et al. The implementation of RSBY in Chhattisgarh, India: A study of the Durg district. Health Cult Soc 2012;2:40-70.  Back to cited text no. 10
    
11.
Sun. C, Analysis of RSBY Enrollment Pattern: Preliminary Evidence and Lessons From Early Experiences, RSBY Working Paper Series, Working Paper no. 2. 2010.  Back to cited text no. 11
    
12.
Nandi S, Dasgupta R, Garg S, Sinha D, Sahu S, Mahobe R. Uncovering coverage: Utilisation of the universal health insurance scheme, chhattisgarh by women in slums of Raipur. Indian J Gender Stud 2016;23:43-68.  Back to cited text no. 12
    
13.
ICMR PHFI Institute for health metrics. India: Health of the Nation's States; 2018. p. 95-8. Available from: http://www.healthdata.org/sites/default/files/files/policy_report/2017/India_Health_of_the_Nation%27s_States_Report_2017.pdf. [Last accessed on 2018 Jun 20].  Back to cited text no. 13
    
14.
Dasgupta R, Nandi S, Kanungo K, Nundy M, Murugan G, Neog R. What the good doctor said: A critical examination of design issues of the RSBY through provider perspectives in Chhattisgarh, India. Soc Change 2013;43:227-43.  Back to cited text no. 14
    
15.
Normand C, Weber A. Social Health Insurance. 2nd ed. Geneva: World Health Organization; 1994.  Back to cited text no. 15
    
16.
Centre for Tribal and Rural Development. Final report on evaluation of the 'Rashtriya Swasthya Bima Yojana scheme' in Chhattisgarh; 2012. Available from: http://rsbychhattisgarh.in/WebSite/Upload Doc/70.pdf. [Last retrieved on 2017 Jun 09].  Back to cited text no. 16
    
17.
La Forgia G, Nagpal S. Government-Sponsored Health Insurance in India: Are You Covered?. World Bank (2012). Available from http://documents.worldbank.org/curated/en/644241468042840697/Government-sponsored-health-insurance-in-India-are-you-covered. [Last retrieved on 2018 Mar 04].  Back to cited text no. 17
    


    Figures

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    Tables

  [Table 1], [Table 2]



 

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