Impact of Publicly Financed Health Insurance Scheme (Rashtriya Swasthya Bima Yojana) from Equity and Efficiency Perspectives

Executive Summary Catastrophic health expenses result in impoverishment of a large number of people every year in India. This often forces the resource-poor households to forego treatment due to lack of affordability. Providing quality health care to all at an affordable cost is a policy commitment for India as it is a signatory of the Alma Ata Declaration. The Government of India is working towards providing universal health coverage through its National Health Policy. As part of universalization of health care, the government had launched a publicly financed health insurance scheme, Rashtriya Swasthya Bima Yojana (RSBY), to provide affordable and quality health services. The present study dealt with understanding the impact of the scheme for improving health care-seeking and reducing burden of health expenditure among resource-poor families through a matched controlled cross-sectional study. The study tried to assess whether RSBY had improved care-seeking and reduced incidences of catastrophic health expenditure (CHE) and health expenditure-induced poverty among the insured population and also tried to explore whether the benefits were equitable. It was conducted in purposively selected two blocks of Ranchi district in Jharkhand with 1,643 households below poverty line (BPL). Both enrolled and non-enrolled households were selected randomly for the study after matching with some key matching criteria. It was found that RSBY neither increased in-facility treatment (hospitalization) nor reduced the likelihood of CHE among the enrolled households. More importantly, it significantly increased the incidence of health expenditure-induced poverty among the households who were above the poverty line before incurring any health expenditure. From equity perspective, care-seeking was much lower among the economically weaker households compared to the better-off households. Similarly, incidences of CHE and health expenditure-induced poverty were also found to be higher among the weaker sections. The study shows that RSBY did not achieve its objective of improving care-seeking and providing financial security to the enrolled households, and more importantly to the economically weaker sections of the society. Other studies have also found that one of the factors for high out-of-pocket expenditure in health is a weak public health delivery system which forces people to seek care from private providers. Hence, it is important for the policymakers to critically evaluate whether such insurance models will actually ensure better financial security for the households from excessive health expenditure and whether strengthening the existing public health delivery system would be a better option.