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Addressing Social Exclusion in Health:
RSBY Health Insurance in India
Babken Babajanian
20th June 2012
Outline
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ODI Research
Research Focus - RSBY
Research Questions
Social Exclusion in India – Dimensions and Drivers
Policy Questions
ODI Research
• Social protection and its role in tackling social
exclusion of informal workers in Asia
– 3-year multi-country study, funded by EU and AusAid
– Will identify the impact of social protection interventions
on social exclusion/inclusion in 4 countries (Afghanistan,
Bangladesh, India, and Nepal)
– Expected to inform policy and practice in respective
countries as well as generate policy lessons for general
application
– Research partner: Indian Institute for Dalit Studies
(IIDS)
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Research Focus
• RSBY (Rashtriya Swasthya Bima Yojana) or National
Health Insurance Scheme (2008):
– Targets BPL (Below Poverty Line) families
– Renewed every year, covers up to 5 family members
– Nominal registration fee of Rs.30
– 23.5 million BPL families enrolled; 8,300 empanelled
hospitals (May 2011)
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Research Focus
RSBY
– Provides free hospitalisation and specified day care
surgeries and treatments
– Maternity cover and newborn coverage
– Transportation fee of Rs.100 per hospitalisation
– No paperwork requirement
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Research Questions
• Does the RSBY health insurance scheme improve health
care access and utilisation by socially excluded individuals?
• What are the main factors that influence the effectiveness
of the scheme?
• Focus on socially excluded informal workers
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Social Exclusion
• SE is a state in which individuals or groups are unable to
participate fully in their society and are unable to enjoy a
standard of living that is considered normal in the society in
which they live.
• People can be excluded from:
– productive resources and economic opportunities
– essential services, education and health,
– social and cultural participation,
– political rights, voice and representation
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Drivers of Exclusion in Health Care
• Financial exclusion is the key determinant of limited access
and deprivation:
– Only 10% of households have at least one member
covered by insurance (National Family Health Survey
2005-06)
– High health costs and out-of-pocket expenditure
(including medicines) are the major reason for foregoing
care
– Out-of-pocket inpatient care expenditures per episode as
a share of income for low income groups - 140%
compared to 80% for high income groups in rural areas
in 2004 (cited in Balarajan et al 2011)
– Health expenses are the major cause of indebtedness
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Drivers of Exclusion in Health Care
– Ill health and health expenditures contribute to
impoverishment
– In 2004-05, 39 million Indians fell into poverty as a
result of out-of-pocket expenditures (Selvaraj and Karan
2009)
– Additional costs (foregone wages, transportation, food,
child care, etc.)
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Drivers of Exclusion in Health Care
• Physical access to health facilities:
– Uneven concentration of services
– Distance
– Transport/roads
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Discriminatory Practices in Health
• Discrimination of Dalits in accessing public and private
health services, involving (Sabhrawal et al 2012; Sabhrawal
2011):
– Denied admission and medical treatment
– Inadequate/poor quality medical treatment
– Discriminatory attitude
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Discriminatory Practices in Health
• Discrimination is likely to result in:
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Under-utilisation of services
Poor health
Lower productivity and diminished income
Psychological effects
Violation of citizenship rights
Policy Questions and Implications
• It is important to tackle both financial exclusion and
discrimination
• There is some evidence that RSBY tends to enhance access
to inpatient care
• ODI research seeks to establish how RSBY benefits socially
excluded households and addresses discrimination in health
• ODI research findings will be available in November 2012
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ODI is the UK’s leading independent think tank on
international development and humanitarian issues.
We aim to inspire and inform policy and practice to
reduce poverty by locking together high-quality
applied research and practical policy advice.
The views presented here are those of the speaker,
and do not necessarily represent the views of ODI or
our partners.
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