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Addressing Social Exclusion in Health:
RSBY Health Insurance in India
Babken Babajanian
20th June 2012
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
– Research partner: Indian Institute for Dalit Studies
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)
Research Focus
– 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
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
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
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
– High health costs and out-of-pocket expenditure
(including medicines) are the major reason for foregoing
– 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
Drivers of Exclusion in Health Care
– Ill health and health expenditures contribute to
– In 2004-05, 39 million Indians fell into poverty as a
result of out-of-pocket expenditures (Selvaraj and Karan
– Additional costs (foregone wages, transportation, food,
child care, etc.)
Drivers of Exclusion in Health Care
• Physical access to health facilities:
– Uneven concentration of services
– Distance
– Transport/roads
Discriminatory Practices in Health
• Discrimination of Dalits in accessing public and private
health services, involving (Sabhrawal et al 2012; Sabhrawal
– Denied admission and medical treatment
– Inadequate/poor quality medical treatment
– Discriminatory attitude
Discriminatory Practices in Health
• Discrimination is likely to result in:
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
• 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
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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