increasing awareness among rsby beneficiaries: results...
TRANSCRIPT
Increasing Awareness among RSBY Beneficiaries:
Results from a Pilot in Karnataka
Raghav Puri and Changqing Sun
May 2014
1. Introduction
The Rashtriya Swasthiya Bima Yojna, Government of India’s national health insurance
scheme, was launched in April 2008 with the objective of protecting poor households
from the financial burden arising due to health shocks. Under RSBY, each household can
enrol up to five members and get inpatient health insurance coverage of INR 30,000
(USD 510) annually. The average household premium that ranges from INR 400-600
(USD 6-10) is fully subsidized by the government and the household only pays a
registration fee of INR 30 (USD 0.5). RSBY covers all pre-existing diseases and allows
beneficiaries to avail inpatient healthcare at RSBY-empanelled hospitals (both, public
and private) across the country. Today, six years later, approximately 37.2 million
households are enrolled under RSBY1.
At the state level, the rolling out of RSBY begins with a competitive bidding process for
the selection of Insurance Companies (IC) that will implement the scheme in specific
districts (more than one IC can be selected in each state). Once selected, the ICs along
with a Third Party Administrator (TPA) and a Smart Card Service Provider (SCSP) start
enrolling households according to the list of eligible households provided by the state
government. As the ICs receive premium payments based on the total numbers of
households enrolled, they have an incentive to enrol all eligible households. When an
eligible household visits the enrolment station, they pay INR 30 as a registration fee and
the enrolment team captures biometric thumb impressions and photographs of all
members present. The IC then prints and activates a RSBY smart card, updated with the
photographs and biometric information, and hands it over to the household. The IC also
provides each family with an information pamphlet that has a list of all RSBY-
empanelled hospitals in the district.
1 Figures from rsby.gov.in (as on 30 April 2014)
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Once the household has their RSBY card, they can avail inpatient treatment at any of the
RSBY empanelled hospitals across the country. When RSBY cardholders are admitted to
an empanelled hospital, the hospital blocks the required package depending on what
treatment the patient requires. This package has a fixed rate and covers the cost of
treatment, accommodation, medicines and food. As RSBY is a cashless health insurance
scheme, the hospital is required to settle the claim with the IC. This process of availing
benefits under RSBY is referred to as utilisation. The RSBY backend data management
system (RSBY-MIS) captures all enrolment and utilisation data and serves as an
important tool for monitoring the implementation of the scheme.
Early evidence of RSBY suggests that while most people, especially those who are
enrolled in RSBY, are aware that a program called RSBY exists, they are not aware of
what they are entitled to under RSBY. This lack of awareness has been cited as an
important reason for the high enrolment rates but low utilisation in some districts (Jain
2012). A study by GIZ (2013) in three states – Bihar, Karnataka and Uttarakhand –
found that 55, 45 and 65 per cent of enrolled beneficiaries interviewed had ‘very poor
knowledge of RSBY’ in the respective states. According to Rajashekhar et al (2011),
many beneficiaries who had enrolled in Karnataka did not receive the RSBY information
pamphlet during enrolment. The study also revealed that many households that had
enrolled in the scheme did not receive their RSBY smart cards. The gap in educating
beneficiaries about health insurance benefits has been observed in other programs as
well. Based on over 18 years’ experience of VimoSEWA, a micro insurance programme
implemented by the Self-Employed Women’s Association, Desai (2009) suggests that
constant education and community involvement – in both implementation and
monitoring – are key to ensuring that benefits actually reach the poor.
A common theme that emerges from these studies is the important role of information
in the effective implementation of a health insurance program such as RSBY. The lack of
information and the inability of intended beneficiaries to absorb the information that is
being provided are important hurdles in reducing health expenses and increasing
access to healthcare among poor households through RSBY.
2. RSBY in Karnataka
RSBY was first rolled out in five districts of Karnataka in February 2010. The
Department of Labour and Employment is responsible for implementing the scheme in
the state. During the first phase of implementation, 179 hospitals were empanelled and
1.5 million BPL households enrolled under RSBY. The coverage of the scheme was
further expanded to all thirty districts of Karnataka in the second phase of
implementation which started in October 2011. Table 1 provides key performance
indicators (enrolment and utilisation rates) for RSBY in Karnataka. The enrolment rate
is only 42% while the national average is about 50%. While the state utilization rate is
2.1%, again below the national average, there seems a large variation across districts.
Among the three districts where the IEC intervention was carried out, Kolar district’s
utilization rate is three times that of Chamarajanagara.
Table 1: Performance2 of RSBY in Karnataka
Karnataka Chamarajanagara Chitradurga Kolar
Eligible Households
4,145,164 97,870 130,695 126,232
Enrolled Households
1,745,461 40,319 65,913 48,325
Enrolment Rate (%)
42.1 41.2 50.4 38.3
Hospitalisation Cases
36,268 484 1,402 1,841
Utilisation Rate (%)
2.1 1.2 2.1 3.8
Empanelled Hospitals (Private)
874 (546) 12 (8) 15 (9) 20 (14)
Note: Figures above are for the financial year 2012-13 (1 April-31 March)
3. Literature Review
There is very limited literature available on RSBY information, education and
communication (IEC) activities. Das and Leino (2011) and Johnson and Kumar (2011)
provide some interesting insights from field experiments of RSBY IEC activities in Delhi
and Jharkhand, respectively. While the former used RSBY information pamphlets to
increase RSBY enrolment among eligible households, the latter conducted health camps
with the aim of reaching out to eligible households about the scheme. The studies are
important as information pamphlets and health camps are the most widely used IEC
2 Source: Figures from RSBY Connect (April 2013 Edition) and Karnataka Labour Department
activities by state governments and ICs in increasing awareness about RSBY among
eligible households.
While both studies did not find any considerable change in either enrolment or
utilisation rates due to the interventions, Das and Leino (2011) observed that
households visited by the survey team, as part of a survey being conducted
simultaneously with the experimental IEC campaign, were 60 per cent more likely to
enrol in RSBY. This suggests that IEC tools that are more targeted and involve direct
interaction with beneficiaries might work better. This finding is further corroborated by
the GIZ (2013) study that shows how enrolled beneficiaries listed village-level
functionaries, NGOs and community-based organizations (CBOs) as their main source of
information about RSBY.
A more recent study by Platteau and Ontiveros (2013) aims to understand the factors
responsible for low uptake and contract renewal of health insurance programs in poor
countries. The study presents findings from a household survey of eligible beneficiaries
of a micro insurance program in India. The study found that “deficient information
about the insurance product and the functioning of the scheme, poor understanding of
the insurance concept and the resulting low use of the insurance product by eligible
households” were the main factors for low rates of renewal. It concluded by identifying
“understanding failure” as the key issue in providing health insurance to poor
households. It is important to note that this micro insurance program required
beneficiaries to pay the premium amount whereas under RSBY the government
subsidies the premium and beneficiaries are only expected to pay a minimal
registration fee. However, its emphasis on the importance of the role of information in a
health insurance program is relevant to this study.
As the coverage of RSBY increases across the country, state governments will require
innovative IEC methods to reach out to RSBY beneficiaries. While a consensus is
emerging on directly reaching out to beneficiaries and moving beyond the conventional
IEC methods, such as information pamphlets, there is a need to further identify cost-
effective IEC methods that are successful in informing RSBY beneficiaries about the
various benefits of the scheme, which leads to better utilization.
To address this gap in evidence of effecting IEC methods that directly engage with
beneficiaries of RSBY, two field experiments were conducted in three districts of
Karnataka between September 2012 and February 2013 to test different IEC methods
that use NGOs as facilitators in increasing awareness. The interventions and the
methodology used to evaluate the impact of these interventions have been discussed in
the next two sections. The sixth section presents the results from this experiment and
the last section discusses both IEC methods.
4. Interventions
The IEC interventions were implemented in 353 villages, spread across three districts of
Karnataka, by MYRADA, the partner NGO for this study. The first intervention was
rolled out in two districts of Karnataka (Chitradurga and Kolar) in September 2012. The
two districts were selected based on the following factors: among the ten districts
where MYRADA has strong ground level presence already; has relatively high
proportion of Scheduled Caste and Scheduled Tribe population; and the RSBY program
performance in terms of enrolment and utilisation rates was lower or at most similar to
than that of Karnataka as a whole. This intervention involved Self-Help-Group (SHG)
Federations as a medium for dissemination of information to households eligible for
RSBY. MYRADA, like most NGOs working with SHGs, is organised at four levels – district
office, Community Managed Resource Center (CMRC) that functions as a block-level
office, SHG Federation, and SHG. The NGO has field staff (also referred to as CRPs or
Community Resource Persons).
The SHG Federation centred trainings involved trainings at three different levels (see
also Graph 1):
1. Training of Trainers – This day-long event includes a training session on RSBY and
the IEC intervention. It was attended by all CMRC managers and CRPs in the district.
The training started with the screening of the RSBY video (in local language
Kannada) and a presentation about the scheme by representatives from the
insurance company and the Department of Labour and Employment. This was
followed by a detailed discussion on how to conduct SHG Federation trainings and
preparation of field implementation plans (dates and timings of SHG Federation
trainings) by all CMRCs. These trainings were attended by 40-50 NGO staff.
2. Federation Training – Federation trainings were organised a week after the
district-level training as this gave the CMRCs time to inform SHG federations about
the training dates. On average, each Federation has 12 to 15 SHGs, and each SHG
usually sends 1 or 2 member representative to attend the trainings. While the
majority of the SHG Federation trainings took place at the CMRC, in some cases the
trainings were held in a village public venue such as anganwadi center or
government school. In the trainings, the RSBY video was screened and followed by a
reading of the RSBY pamphlet, the primary IEC tool for the trainings3. This
pamphlet was important as it would ensure that the same message was conveyed in
all trainings. After the training was over, each participant was provided RSBY
pamphlets for distribution to their peer SHG members (and non-SHG RSBY
beneficiaries) in their respective villages.
3. SHG Meeting – On their return to the village, the trained SHG members distributed
the RSBY pamphlets to other SHG members (and non-SHG RSBY cardholders in
their village) and discussed the important points listed on the pamphlet. As CRPs
visit each SHG once every month (to collect payments, check the accounts register
and provide information on new programs), it is their responsibility to follow-up on
whether the SHG members had received the RSBY pamphlets. During this visit, the
CRP would answer any questions that members from the SHG (or non-SHG RSBY
cardholders, invited to the meeting by SHG members) might have about RSBY.
3 See Appendix I for an example of the training material.
One major advantage of this approach is its scalability as SHGs across the country are
organised under federations and a member of each SHG attends monthly federation
meetings. However, a challenge that emerged during the implementation of federation
trainings was that SHG members and RSBY beneficiaries may not overlap as much and
do not overlap at all in some SHGs. If SHGs did not have any member who was eligible
for RSBY, then there would not be much interest in understanding RSBY during the
training. In such cases, the likelihood of SHG members to further disseminate
information at the village level would be less than the ideal situation when SHG
members were expected to reach out to households that were eligible for RSBY but not
linked to SHGs.
Based on the experience of rolling out this intervention in the first two districts, the
intervention was modified and implemented in the third district (Chamarajanagara) in
December 2012 at the request of the Department of Labour and Employment. The
district was specifically selected because it has the second lowest utilization rate among
30 districts. To address the abovementioned concern, the IEC intervention was modified
to streamline the training structure by dropping SHG federation trainings and instead
having the NGO trainer visit each village and train all RSBY beneficiaries (SHG and non-
SHG) directly. In SHG federation trainings, SHG members from 3-4 different villages
would attend a typical training, while in this case trainings had to be organised in each
village. Though this approach translated into more number of trainings, it ensured that
all RSBY beneficiaries were directly trained by the NGO field staff. This intervention, if
successful, would also be easier to implement in areas where the NGO does not have
SHG networks.
5. Methodology
To assess the impact of the IEC intervention, the intervention was rolled out in two
phases by dividing the target villages in two groups4. In Chitradurga and Kolar Districts,
federations from Group 1 villages were trained in the first week of September while the
remaining federations from Group 2 villages were trained in the last week of October,
with a lag of 50 days.
4 See Appendix III for a detailed map illustrating the rollout of IEC intervention in Kolar District.
As the two groups were selected randomly, the difference in the utilization rates of the
two groups during the 50 days window is the expected impact due to the IEC
intervention (see Graph 2 below). Furthermore, the changes in the utilization rates of
the two groups in the 50 days following the training of Group 2 villages would confirm
the measurement of the impact as well as the sustainability of such impact. Because the
SHG-Federation-CMRC partnership does not cover all villages in the same blocks, there
are a good number of villages that did not receive the same intervention. Although these
villages may not be similar to the target villages, the change in the utilization rate for
these no-intervention villages could serve as a reference measure of change over time in
general.
In this study, the utilisation rate is calculated as the percentage of RSBY households
having enrolled members hospitalised under RSBY during the specified period. The data
source is the enrolment and transaction database provided by the Ministry of Labour
and Employment which is the Nodal Ministry responsible for RSBY program
implementation at the central government level. This definition is used almost
exclusively by the Nodal Ministry and the State Nodal Departments when measuring the
RSBY utilization performance.
Similarly, in Chamarajanagara, village-trainings were implemented in two phases.
Trainings were held in group 1 and group 2 villages in late December and late February,
respectively. Table 2 provides basic information about the two groups in all three
districts.
Table 2: Sample Characteristics
District Chamarajanagar Chitradurga Kolar Round 1 2 1 2 1 2 # of GPs/villages 32 34 41 41 93 92 Average # of households
194 137 178 82 24 31
Average distance to district headquarter (km)
53.2 49.2 27.0 38.2 13.5 18.3
Average distance to block headquarter (km)
32.4 26.4 9.1 21.3 6.2 7.8
Average distance to nearest PHC (km)
8.1 4.5 2.4 5.6 18.5 26.3
Average distance to nearest private RSBY hospital (km)
25.4 22.1 8.8 21.2 44.8 42.9
The two groups are not exactly similar in terms of accessibility to urban amenities
including health care service providers. The Group 2 villages in the first two districts,
particularly in Chitradurga, are located further away from the district headquarters
where most prominent RSBY hospitals are located. Similarly the average distances to
the block headquarters, the nearest PHC, and the nearest private RSBY hospital are also
larger, except for the nearest private RSBY hospital in Kolar. Apparently, when villages
were randomly assigned to the two groups, the NGO staff did not follow through the
strict rule and a number of exceptions were made to put villages located very close to
CMRCs (where the training of SHG federations took place) into Group 1. The exception
decisions were made because it is impractical to stop the villages randomly assigned to
Group 2 attend the IEC intervention for the Group 1 villages as SHG members living in
villages very close to the CMRC often drop by. This difficulty also motivated the
modification to the IED approach taken in the third district.
6. Results
Table 3 and Table 4 show the results for Chitradurga and Kolar Districts, respectively.
The Group 1 villages received the IEC intervention in the first week of September. By
the last week of October or within 50 days after receiving the IEC intervention, the
utilisation rate (i.e. the percentage of RSBY households using their RSBY cards for
hospitalisation) for Group 1 villages in Chitradurga and Kolar had increased by 0.53 and
0.22 than the previous 50 days, respectively. So indeed the SHG trainings have had a
strong positive impact on the utilisation rate. During the same time period, the
utilisation rate in Group 2 villages that were yet to receive the same IEC intervention
saw only minor changes (a decrease of 0.05 in Chitradurga but an increase of 0.03 in
Kolar). So were the changes observed for the “control” villages. Then in the last week of
October, Group 2 villages received the intervention. By mid-December, the utilisation
rate in Group 2 villages had only increased by 0.07 and 0.05, respectively while the
corresponding change in the utilisation rate of the control group was -0.02 and -0.14.
Another standing out change is of Group 1 villages. While the utilization rate of Group 1
villages continued to increase (though less than that of the first 50 days) in Chitradurga ,
the utilization rate of Group 1 villages decreased in Kolar and incidentally was back to
the same level before the intervention.
Table 35: Chitradurga District
# of RSBY households
U0 U1 U2 U1-U0 U2- U1
group1 8855 0.44 0.97 1.23 0.53 0.26 group2 4081 0.81 0.76 0.83 -0.05 0.07 “control” 39260 0.30 0.35 0.33 0.05 -0.02
Table 4: Kolar District
# of RSBY households
U0 U1 U2 U1-U0 U2- U1
group1 4164 0.14 0.36 0.14 0.22 -0.22 group2 3950 0.15 0.18 0.23 0.03 0.05 “control” 19192 0.31 0.32 0.18 0.01 -0.14
It is evident that the IEC intervention had a strong impact for Group 1 villages, but much
smaller impact for Group 2 villages. One likely explanation could be that the two villages
are actually not exactly the same in some aspects that were not controlled properly
when randomly selecting villages into the two groups. As shown in Table 2, on average
the two groups are different in terms of accessibility to urban amenities including
5 See Appendix II for explanation of results
health care service providers. The Group 2 villages in both districts, more so in
Chitradurga than in Kolar, are located further away from the district headquarters
where most prominent RSBY hospitals are located. Similarly the average distances to
the block headquarters, the nearest PHC, and the nearest private RSBY hospital are also
larger, except for the nearest private RSBY hospital in Kolar. Apparently, when villages
were randomly assigned to the two groups, the NGO staff did not follow through the
strict rule and a number of exceptions were made to put villages located very close to
CMRCs (where the training of SHG federations took place) into the Group 1. The
exceptions were made to avoid the situation that the villages randomly assigned to
Group 2 may attend the IEC intervention for the Group 1 villages since SHG members
living in villages very close to the CMRC often drop by.
Another important observation is that the increase in utilisation rate in Group 1 during
the first 50 days after the IEC intervention seems not sustained in the following period.
As households in these two districts were receiving RSBY cards for the first time, the
sudden rise and fall in utilization could be partially due to beneficiary households’
unmet demand for hospitalization treatment, which was addressed relatively quickly
once they received the required information to use RSBY.
In the third district Chamarajanagara, village trainings were organized at Gram
Panchayat (GP) level, in the last week of December for Group 1 and in the last week of
February for Group 2 (Table 5). The utilisation rate for Group 1 GPs had increased by
0.89 by mid-February or 50 days after receiving the IEC intervention, more than ten
times than the previous rate. The results also confirm that the strong impact of the IEC
intervention would decrease subsequently; therefore it is unlikely that one-time
intervention would permanently increase the utilization rate to a higher level.
Table 5: Chamarajanagara District
# of RSBY
households U0 U1 U2 U1-U0 U2- U1
group1 5952 0.07 0.96 0.54 0.89 -0.42 group2 4999 0.28 0.24 0.82 -0.04 0.58 control 11591 0.28 0.20 0.10 -0.09 -0.09
One more important determinant for any state government to choose between the two
IEC interventions would be the cost of implementing each. In this experiment, the
approximate cost per training at federation level and at village level was INR 1600 and
INR 1250, respectively. If the number of people that received RSBY information through
these trainings is taken into consideration, then the ‘cost per person informed’ is INR 5
and INR 24, respectively. Although the ‘cost per person informed’ for village trainings is
high, this IEC method provides a lot of flexibility in how it is rolled out.
7. Conclusion
The important role of information in the successful implementation of a health
insurance program for the poor was explored through the experiment with RSBY IEC
interventions in Karnataka. While the IEC intervention clearly was shown to have a
strong impact on the utilization rate subsequently, the impact would be neither
sustained over time nor uniform across different conditions, which play a role in the
health care seeking decision of RSBY beneficiaries. Furthermore, even though the village
level training in Chamarajanagar clearly was more effective in increasing utilization
among RSBY beneficiaries than the SHG federation trainings in the other two districts,
the former is also more expensive.
The Chamarajanagar approach has an advantage in terms of targeting to RSBY-eligible
households as trainers visit each village and train households that have enrolled in
RSBY. With the Chitradurga than in Kolar approach, there is a possibility that the
representative sent by SHGs for the federation meeting may not be RSBY beneficiary
and, therefore, not be interested in learning about RSBY. Another limitation of SHG
federation trainings is that they rely on the SHG members trained at the federation
meeting to return to their villages and disseminate the information to other SHG
members and, more importantly, non-SHG members eligible for RSBY. However, as
states consider expanding RSBY to more groups (for instance, Karnataka has decided to
provide a RSBY card to state BPL households), the SHG federation approach may work
better because more SHG members will become eligible for RSBY.
The cost consideration is also an important factor. If the state government has limited
financial resources, then it can identify villages with low RSBY utilization and ask the
partner NGO to carry out trainings in the selected villages. This flexibility is not always
available with SHG federation trainings as SHG members are very aware of the activities
being conducted in their networks and would not appreciate if only some SHGs in
selected villages are receiving training. This was an important learning in this study as
the partner NGO insisted that a ‘phase-in’ randomisation design is adopted because all
SHGs in their network should get the treatment.
Even though SHG federation trainings are easier and less expensive to implement, they
require high RSBY coverage among SHG members to be as effective as village trainings.
As RSBY coverage expands across the country and more districts come under its ambit,
village trainings should be viewed as an essential one-time investment to ensure that
beneficiaries are aware of their entitlements under RSBY.
References
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Desai, Sapna. “Keeping Health in Health Insurance” Economic and Political Weekly, XLIV,
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Appendix I
Training material
1. RSBY Training Video produced by Karnataka RSBY team (http://youtu.be/jIbypmLdZqQ)
2. RSBY Pamphlet
3.
3. Village Training in progress at a government school in Kothlavadi Village,
Chamarajanagara District by MYRADA field staff on 18 February 2013.
Appendix II
Notes on Time Line
Chitradurga and Kolar
Villages 1 IEC in early Sep, 2012 Utilisation rates under RSBY: U0 Jul-Aug, 2012 U1 Sep-Oct, 2012 U2 Nov-Dec, 2012
Villages 2 IEC in early Nov, 2012
Other Villages No IEC
Chamarajanagara
GPs 1 IEC in late Dec, 2012 Utilisation rates under RSBY: U0 Nov-Dec, 2012 U1 Jan-Feb, 2013 U2 Mar-Apr, 2013
GPs 2 IEC in late Feb, 2013
Other GPs No IEC
Note: Ui is calculated as percentage of total RSBY households having enrolled members hospitalized in period i.
Appendix III
Rollout of IEC intervention in Kolar District