Expanding healthcare coverage: An experience from Rashtriya Swasthya Bima Yojna

BACKGROUND & OBJECTIVES: Given that Ayushman Bharat Yojna was launched in 2018 in India, analysis of Rashtriya Swasthya Bima Yojna (RSBY) become relevant. The objective of this study was to examine the scheme design and the incentive structure under RSBY. METHODS: The study was conducted in the districts of Patiala and Yamunanagar in the States of Punjab and Haryana, respectively (2011-2013). The mixed method study involved review of key documents; 20 in-depth interviews of key stakeholders; 399 exit interviews of RSBY and non-RSBY beneficiaries in Patiala and 353 in Yamunanagar from 12 selected RSBY empanelled hospitals; and analysis of secondary databases from State nodal agencies and district medical officers. RESULTS: Insurance companies had considerable implementation responsibilities which led to conflict of interest in enrolment and empanelment. Enrolment was 15 per cent in Patiala and 42 per cent in Yamunanagar. Empanelment of health facilities was 17 (15%) in Patiala and 37 (30%) in Yamunanagar. Private-empanelled facilities were geographically clustered in the urban parts of the sub-districts. Monitoring was weak and led to breach of contracts. RSBY beneficiaries incurred out-of-pocket (OOP) expenditures (₹5748); however, it was lower than that for non-RSBY (₹10667). The scheme had in-built incentives for Centre, State, insurance companies and health providers (both public and private). There were no incentives for health staff for additional RSBY activities. INTERPRETATION & CONCLUSIONS: RSBY has in-built incentives for all stakeholders. Some of the gaps identified in the scheme design pertained to poor enrolment practices, distribution of roles and responsibilities, fixed package rates, weak monitoring and supervision, and incurring OOP expenditure.