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IMPACT: International Journal of Research in 
Humanities, Arts and Literature (IMPACT: IJRHAL) 
ISSN (P): 2347-4564; ISSN (E): 2321-8878 
Vol. 6, Issue 11, Nov 2018,137-142 
© Impact Journals 


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ANALYSIS OF VIABILITY IN HEALTH DELIVERY: A STUDY OF RASHTRIYA 
SWASTHYA BIMA YOJANA (RSBY) IN SELECT DISTRICTS OF WEST BENGAL, INDIA 


Parcimita Roy 

Associate Professor, Department of Social Work, Visva-Bharati, Sriniketan Birbhum, West Bengal, India 


Received: 29 Oct 2018 Accepted: 03 Nov 2018 Published: 24 Nov 2018 

ABSTRACT 

Universal Health Insurance (UHC) has been the aim of many developing countries to provide for all its 
citizens. To mitigate the burden of hospitalization expenses in India, the government introduced the Rashtriya Swasthya 
Bima Yojana (RSBY). It is a flagship program of the government. It provides hospitalization coverage to the poor people in 
India. This study focuses on the working of the RSBY scheme in four selected districts of West Bengal namely Birbhum, 
Burdwan, North 24 Parganas, and South 24 Parganas. The viability of the scheme was discussed in terms of the 
functioning of the scheme. The different factors for determining viability are conversion ratio, a facility for referrals and 
settlement of claims. The selected districts had different experiences with the selected variables. It was a good learning to 
know about the viability issues as it gives an important hint about the functioning and the sustainability of the scheme. 

KEYWORDS: RSBY Scheme, Hospitalization Coverage, Viability Issues 

INTRODUCTION 

It is a recognized fact that there is an all-out effort by the countries across the globe to promote universal health 
insurance coverage (UHC) for all its citizens. The initiative was ideologically strengthened by the Millennium 
Development Goals (MDGs) and the Right to Health criterion in the Rights Based Approach (RBA) to development. 
In implementing the programmes for universal coverage it was majorly seen that the government of each country had taken 
an active role in providing funds and in the provision of a health provision network. However, it was a universal truth that 
most governments irrespective of being in a developed or a less developed country faced the problem of inadequacy or a 
fluctuation in capital, physical and human resources. There had been efforts from the private and the civil society sector 
actors to supplement the efforts of the government. But the private sector served mostly the affluent and the civil society 
organizations supported marginalized communities at a very microscopic level. Thus there was a felt need for an 
alternative method of healthcare provision. A system of health insurance for the poor across the country could provide the 
much needed financial support for the treatment of beneficiaries against the burden of medical expenditure. In India, the 
Rashtriya Swasthya Bima Yojana (RSBY) was introduced for the poor with the vision of universal coverage across the 
population. It was a unique scheme with a very modern design in its implementation and coverage which tried to solve the 
hospitalization burden of the poor. Hence, understanding RSBY and its performance were very essential. 

To mitigate the burden of hospitalization expenses in India, the government introduced the Rashtriya Swasthya 
Bima Yojana (RSBY). It is a flagship program of the government. It provides hospitalization coverage to the poor people 


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Paramita Roy 


138 


in India. It is impressive not only in its scale of operation but also in its innovative approach in providing services like use 
of smart card technology in cashless treatment and initiation of the public-private partnership in the delivery of health 
services. The prospective beneficiaries are provided with Rs 30,000 limit coverage for hospitalization expenses. 
The pre-existing ailments are covered and there is no age limit. There is a need to pay a nominal sum of Rs.30 annually as 
premium. The rest of the premium is paid by the central and state governments in the ratio of 75:25. There is a list of 
empanelled hospitals including government hospitals and private nursing homes/hospitals that meet the necessary 
Information Technology (IT) requirements. There is a regular data flow among the government and the service providers 
regarding the utilization of services and settlement of claims. 

Narayana in 2010, a compared proportion of the eligible families in the BPL category with the fraction of those 
hospitalized who were covered. The study showed that the proportion of poor families who were enrolled varied across the 
states, between 39% in Maharashtra to 81% in Kerala. States such UP and Bihar reported poor enrollment. So did 
hospitalization rates which varied from 3.91 hospitalizations a year per 1,000 persons in Punjab to 26.17 in Kerala. 
There was a big inequality in the value of hospitalization across states and between districts within the states. The reason 
cited was the inadequacy of empanelled hospitals as well as the low proportion of private hospitals. Another somewhat 
different observation but nonetheless significant was the fact there is a need for a greater system of disclosure by a 
disaggregated value of hospitalization by diseases treated, services provided etc. is required for a meaningful analysis. 

Similar studies on the scheme in different places in India report on the level of awareness, accessibility, and 
utilization of the scheme by the RSBY cardholders. A lot of issues like the feasibility of the scheme, the coordination 
between the different stakeholders and the uniformity in delivering of services have made their presence felt in the research 
reports on RSBY (Krishnaswamy and Ruchismita, 2011; Dror and Vellakkal, 2012; Selvaraj and Karan, 2012; Sheshadri, 
2013). 

RSBY is thus a modest effort to provide protection to the poor against the hazards of hospitalization in returns for 
a nominal fee. The poor also expect better treatment as they can access the private hospitals and nursing homes. 
The implementation of the scheme will be successful only when poor patients will enjoy accessibility and a good quality of 
care from healthcare from the healthcare providers. Such an improved treatment in health outcomes will usually depend 
on a host of structural, procedural and contextual factors. 

The present study attempts to understand the various factors that have led the growth of the health insurance 
industry in India and focuses particularly on the performance of the RSBY in India. With the Rights Based Approach 
(RBA) and the consequent Universal Health Coverage (UHC) policies adopted in most countries, India should now try to 
successfully implement schemes like RSBY which is designed keeping in mind the Right to Health and the gradual 
inclusion of all into the health protection network. This doctoral study is thus very contextual and justified and can 
supplement the policy decisions at improving and improvising the scheme in the future. 

Again, West Bengal, one of the popular provinces for its unique socio-political history had witnessed very uneven 
and slow progress in achieving standards in the health sector. Though the Government of West Bengal had taken various 
policy initiatives to encourage better health care through the Health Sector Strategy (HSS, 2004-2013) and a mention of 
the need to ” facilitate RSBY and other insurance schemes particularly for the BPL and other unorganized section” (Focus 
Area 1, Plan of Action, 2011-15, Health and Family Welfare Department, Government of West Bengal), there was under- 


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Analysis of Viability in Health Delivery: A Study of Rashtriya Swasthya Bima Yojana (RSBY) 139 

in Select Districts of West Bengal, India _ 

funding of the schemes and the delivery systems were plagued by vacancies, absenteeism, urban/rich bias in distribution 
and use of facilities, lack of drugs and other essential support, low motivation of the staff and inefficient management 
capacity (WB, HSDI, 2005). As RSBY is the only programmer which covers the BPL population in West Bengal, 
exploring its situation was the need of the hour. From the review of previous studies on RSBY, it was learned that there 
were sporadic research reports carried out for very few states. There was no study on West Bengal, though the scheme was 
in operation in the state since 2008. The selected districts (namely Birbhum, Burdwan, North 24 Parganas, and South 24 
Parganas), too, had no studies on RSBY at the time of data collection. 

Further, from the previous review of literature, it was seen that the challenge was to overcome the problem of 
pooling of resources to build a common fund and distribute the risks and also to appropriately choose among the different 
designs for a new scheme and continuously improve the scheme based on evaluative studies on it. The significance of the 
working of any scheme was seen to be context-specific as it involved a good partnership between the 
member-beneficiaries, the local service providers and the administration. Thus the importance of a detailed and systematic 
investigation in different fields and research settings was necessary as the effect of the scheme on the prospective 
beneficiaries would vary significantly with differences in state-specific infrastructure of the health systems. Innovation and 
adaptation would vary according to locale-specific client groups, socio-cultural and political systems, the availability of 
medical infrastructure etc. Thus in-depth research studies on different aspects of the RSBY scheme need to be carried out. 

This study focuses on the working of the RSBY scheme in four selected districts of West Bengal namely 
Birbhum, Burdwan, North 24 Parganas, and South 24 Parganas. All the districts were almost contiguous and they could 
capture the mobility of the RSBY patients between the districts. During the pilot study, the researcher found that there was 
inter-district traveling for want of better treatment from the hospitals. The four districts also captured a mix of 
socio-economic classes in Bengal. Birbhum was a predominantly rural district with the lowest GDP than the other districts. 
South 24 Parganas was the next highest in the percentage of the rural population and ranked just above Birbhum in GDP 
earnings. Burdwan had developed into a semi-urban district with moderately better GDP earnings than Birbhum and South 
24 Parganas. The remaining district, that is. North 24 Parganas was predominantly an urban area with the highest GDP in 
West Bengal. The rural-urban criterion was significant in selecting the districts so as to capture the differences in the 
availability of healthcare services. The selection of districts was also done keeping in mind the completion of at least two 
phases of the scheme. 

The viability of the scheme was discussed in terms of the functioning of the scheme. The different factors for 
determining viability are as explained as follows: 

I. CONVERSION RATIO 

The conversion ratio of the scheme was an indication of the ideological basis of reaching out to the target group of 
the BPL population. In this aspect. North 24 Parganas was the least impressive with only 19.8% of the target group 
covered. Birbhum managed to target 77% of the BPL population of the district (Table 1). 


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Paramita Roy 


140 


Table 1: Conversion Ratio 


District 

Eligible BPL People 
col.(l) 

No. Enrolled 
col. (2) 

Conversion Ratio*,** 
(col.(2)/col.(l))*100 

Birbhum 

557486 

429091 

76.97 

Burdwan 

972156 

678053 

69.75 

N24Pgns 

873041 

172838 

19.8 

S24Pgns 

706669 

343831 

48.66 


* For the concept see Krishnaswamy and Ruchismita (2011) 

** Researcher’s own calculation 
(Conversion Ratio 

=Ratio of number of individuals enrolled to the number of eligible BPL persons) 

II. FACILITY TO RECEIVE REFERRALS 

The aspect of viability also tried to understand whether the scheme had inherent built-in strengths to continue the 
onus of treatment with the given physical infrastructure. As many of the health service providers were small hospitals or 
nursing homes, they very often lacked the necessary expertise and technological infrastructure to treat the patients or to 
undergo surgeries. They had to then take recourse to the referral services. Table 2 shows the percentage of visited 
hospitals/nursing homes that received referral facilities from other health providers. The table shows that Burdwan and 
North 24 Parganas received the maximum referrals as compared to very low referrals received by Birbhum and South 24 
Parganas. 


Table 2: Facilities to Receive Referrals 


District 

No.of Hospitals Who Received Referrals (%) 

Birbhum 

2% 

Burdwan 

40% 

N24Pgns 

51% 

S24Pgns 

12% 


Source: Researcher’s fieldwork, 2013. 


III. SETTLEMENT OF CLAIMS 

The settlement of claims was an important aspect of the viability of any health insurance scheme. In Table 3 it 
was observed that the percentage of claims settled was impressive across the phases in all the districts. However, there was 
a slightly decreasing trend in the percentage of settled claims across the different phases. Even then it should also be 
noticed that since the absolute values were quite big there still were quite large values of claims still to be settled in the 
later phases. But overall the performance of the hospitals, insurance agents and the concerned government authorities had 
managed the system of reporting, processing and disbursing of claims efficiently. This held great hope in the future 
sustainability of the scheme. 


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Analysis of Viability in Health Delivery: A Study of Rashtriya Swasthya Bima Yojana (RSBY) 141 

in Select Districts of West Bengal , India _ 


Table 3 Pending Claim Details 


District 

Total Claims of 
Hospitals in the District 

(Rs.) 

Claims Settled by 
the Insurance Co. (Rs.) 

% of Claims 
Settled* 

Pending Claim 

Birbhum Phase I 

33150425 

32631925 

98.44 

518500 

Phase II 

137734337 

134205687 

97.44 

3528650 

Phase III 

216029721 

201269109 

93.17 

14760612 

Phase IV 

NA 

NA 

NA 

NA 

Burdwan Phase I 

77675948 

71786433 

92.42 

5889515 

Phase II 

124735467 

115977242 

92.98 

8758225 

Phase 

III 

232535921 

212336621 

91.31 

20199300 

Phase IV 

221679637 

204758912 

93.71 

13951575 

Phase V 

NA 

NA 

NA 

NA 

N24Pgns.PhaseI 

23937142 

21032567 

87.87 

2904575 

Phase II 

63358574 

62568774 

98.75 

789800 

Phase III 

67052400 

65407400 

97.55 

1645000 

Phase IV 

66131950 

61284775 

92.67 

4847175 

S24PgnsPhaseI 

83194100 

81514900 

97.98 

1679200 

Phase II 

23755675 

22158225 

93.28 

1597450 


Source: Adapted from http://rsbvwb.sov.in/html/claim.php as on 14.04.2014 
* Researcher’s own calculation 

CONCLUSIONS 


There had been a rapid increase in enrolment in the second phase of the working of the scheme. 
However, the trend in enrolment had slowed down after that in most of the districts. The conversion ratio (ratioof the 
number of individuals enrolled to the number of eligible BPL persons) was the best in Birbhum which proved that more 
than 70% of the BPL population in the district have been enrolled as beneficiaries. This ratio was noticeably lower in 
North 24 Parganas. Rrishnaswamy and Ruchismita (2011) found the average conversion ratio* to be 51% in India. 
In this sample, Birbhum and Burdwan were much above the national average. South 24 Parganas was a close low whereas 
North 24 Parganas was much below the national average at being only approximately 20%. The bug hospitals received 
referred cases. These cases were primarily seen in Burdwan and North 24 Parganas. Birbhum had a low 2% of referred 
cases and South 24 Parganas had 12% of referred cases. All the districts had short-term claims (claims less than a month) 
pending but Birbhum was the worst with over 2000 claims pending. The only district that had long-term claims (claims 
more than a month) pending was North 24 Parganas. 

RSBY had stood out in terms of its technical edge and transparency in most of the cases. It had done well in terms 
of targeting and outreaching. The design to increase membership can be made flawless by strengthening the monitoring 
and supervision of the scheme. The networking with the private health providers, the insurance companies, the 
government, and the beneficiary needs a good management and governance. The fact that there were very less claims 
pending put a good beginning to the future responsibility of making the scheme financially viable. 
The research also put forward the hope for the districts that are laggards in socio-economic parameters. 
In fact, Birbhum, one of the poorer districts have scored well in terms of accessibility and effectiveness. It can be implied 
intuitively that the poorer districts can be made as role models as receivers of benefits of a particular scheme. 
This can give strength to the bonding between the providers and the receivers and guarantee support from the beneficiaries. 


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Paramita Roy 


142 


The ‘performance indices’ can make clear the progress of different areas on a uniform measurement scale. 

REFERENCES 

1. Dror, D. and Vellakkal, S. (2012), Is RSBY India’s platform to implementing universal hospital insurance? 
Indian Journal of Medical Research 135, pp 56-63. 

2. Krishnaswamy, K. & Ruchismita, R. (2011), RSBY Working Paper Performance Trends and Policy 
Recommendations: An Evaluation of the Mass Health Insurance Scheme of Government of India, RSBY 
Working http://www.slideshare.net/IFMRCIRM/rashtriya-swasthya-bima-yojana-performance- 

3. Narayana, D. (2010), Review of Rashtriya Swasthya Bima Yojana, Economic and Political Weekly, 17, XLV (29). 

4. Selvaraj, S. and A. Karan (2012) Why Publicly-Financed Health Insurance Schemes Are In effective in Providing 
Financial Risk Protection, Economic and Political Weekly, XLVII (60). 

5. Seshadri, T. Et al, (2013), The Karnataka case study report. Project report of Health Inc project submitted to 
European Commission. Institute of Public Health, Bangalore.pp 63. 

6. West Bengal: Health Systems Development Initiative, (2005) Programme Memorandum Government of West 
Bengal Government of India DFID, UK. www.wbhealth.gov. in/. ../hsdi-dfid%20programme 


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