A card to life

Rashtriya Swasthya Bima Yojna, one of the largest mass health insurance programmes in the world, addresses the health concerns of the poor and unorganised workers
Samarth Pathak Jhajjar (Haryana)/Bijnore (UP)

The general ward of Beena Prakash hospital, situated in the small, breezy town of Bijnore in western Uttar Pradesh, has been bustling for the past few months. Locals claim that this heightened buzz of patients is "unprecedented". What is even more unusual is that most of the patients belong to the Below Poverty Line (BPL) category and have been at the receiving end of government apathy towards the rural health sector for decades.

The reason behind this buzz at the hospital is the ambitious and result-oriented Rashtriya Swasthya Bima Yojna (RSBY) scheme launched by the government of India in April 2008.

Eight-year-old Santosh is one of the patients who have come to the hospital. This mentally challenged boy's left leg was severely burnt in an accident a few months ago. The government hospital near his village let him off with just applying an ointment, Burnol. His family didn't have the money to get him a good treatment in private hospitals. So, they were forced to see Santosh suffer.

Hope knocked on their doors in the form of RSBY. Santosh's father, Sudheer Kumar, said, "Some people from the RSBY had come to our village a few months ago to explain the scheme. We were initially apprehensive, but once we understood what a smart card can do, there was excitement in the village." He added, "Had it not been for the scheme, I don't know what I would do. My son could have been crippled. I am indebted to this scheme. It's like a lifeline for poor families like mine."

The RSBY is a scheme with many firsts to its credit. It is arguably one of the largest mass health insurance programmes in the world. It effectively addresses the health concerns of those in the BPL category and also the poor, unorganised workers. The RSBY provides a health insurance amounting to Rs 30,000 per year to five members of every BPL family. This is done through smart cards which, with a unique fingerprint identification system, make them practically foolproof.

Each smart card is pre-loaded with Rs 30,000, and contains digitised signatures of the head of family and the officer issuing the card. It also has details like addresses, names and photographs of the dependents. It is issued to the head the family, who selects three other members from his family, other than his spouse, to be included in the scheme.

Given the large-scale migration of labour across India, there is also a provision of a 'split smart card'. This means that a migratory worker can access health facilities even outside his own state, and his family can receive the benefits of the scheme at the same time.
The smart card costs Rs 30, but this has not hindered the 45.97 lakh people who are now 'smart card holders', according to statistics given by the ministry of labour. This means that 230 lakh people have already been covered under the RSBY.  

Along with NREGA, loan waiver scheme and scholarships to Muslims, the rural health insurance scheme helped the Congress reap rich dividends in the general elections. Spurred by its success, the government is extending the cover to social and economic segments, too.

The brain behind the RSBY is Anil Swarup, director-general, labour welfare in the ministry of labour and employment. Speaking to Hardnews, Swarup said that the major reason behind distress in the farm sector is absence of a healthcare system to treat illnesses that affect the people often. The scheme was meant to fix this problem.

"We plan to expand this scheme to 600 districts across India in future and make healthcare accessible to all. A unique feature of the scheme is that it is cashless and this was initiated to root out corruption at the grassroots level. In the RSBY, if Rs 100 is allotted to a person, he gets the entire amount. This is where the efficacy of the scheme lies," he remarked.

The flow of funds is fairly simple. The Centre pays 75 per cent of the premium to the insurance companies while the remaining share is borne by the state governments. The insurance companies, in turn, verify the claims of the empanelled hospitals, meet the patient and transfer the amount to the hospital's account.

What is the basis of distributing the smart cards? Government sources reckoned that its distribution depends on the insurance companies. "Once they agree to provide insurance cover on our rates, they can then distribute the cards and take the premium from the government. It is a foolproof process."

The simplicity of providing insurance has been noticed in USA, too. A report in the Wall Street Journal elicited a response from the new Obama administration, which is trying to find a way to fulfill an electoral promise to give quality healthcare to its marginalised poor.
The RSBY has created a revolution of sorts in areas where health facilities have been dysfunctional since a long time. A majority of the rural populace has had to make do with the local government hospitals and dispensaries (which have either not been established in many areas, or lack proper treatment facilities). The RSBY gives them an option to 'choose' a hospital of their choice. They can now access even private hospitals and nursing homes. However, the scheme only applies when a person is admitted to a hospital and not for common ailments as cough and cold.

Thus, a BPL worker is covered against costs incurred by surgery, food, room/bed costs, and medicines only if he/she is admitted (Rs 100 is also granted as transportation charges to patients). In case, a person is not admitted, he/she needs to pay the entire amount. If the cost of treatment incurred exceeds Rs 30,000, the patient pays for the extra costs.

Both public and private nursing homes are selected in an area after a stringent quality check by the insurance company operating in that region. Only after they pass the stringent checks, they are empanelled in the RSBY. The smart card works only in hospitals assigned under the scheme. To minimise chances of hospitals and doctors fleecing the poor (and often illiterate) patients, the rates of treatments for different diseases are fixed. A list of common ailments is prepared state-wise, and rates are applied as per the Central Government Health Scheme.

Hence, all that a patient has to do is to reach the nearest empanelled hospital, show the smart cards and get treated without paying a dime. The simplicity in the procedure, Hardnews learnt, is being met with astonishment, disbelief and awe in many villages where the scheme has been implemented.

The village of Dadanpur, 12 kilometres from the Jhajjar district of Haryana, is no different. Here, field workers of ICICI Lombard, the insurance company operating here, are explaining to a group of villagers about the usage of smart cards. "But, how is it possible? Even for a fracture, the clinics charge Rs 3,000. Then, how can they charge a lesser amount?" is a common query.

However, they all agree on one point: no other scheme (not even the NREGA), has generated this kind of excitement amongst the people of Dadanpur. They all agree that the village dispensaries (which in many villages do not even exist), government hospitals and camps organised by NGO's are not very effective in solving the health problems of the poor. They are keen to know more about the scheme, the RSBY has become a hot topic.

The credit for this large-scale awareness in all states where the scheme has been implemented goes to the field workers of the insurance companies who have been assigned the responsibility to convince the people about the potential of the RSBY and also to distribute cards at the grassroots level. Most travel 250 miles a day on an average, visit villages and meet people from morning to night.

Devendra Kumar is one of the main field workers in the Jhajjar area. "I look after 200 villages in this belt, and most of them have shown positive response towards the scheme. It feels good to see people so receptive and eager to learn more. It shows that the scheme has credibility," he said.

Similarly, in Bijnore, it is Devendra Singh who does the field work. He said, "Creating awareness is important. For this, we target the village sarpanch and the block development officer (BDO), who is in regular touch with the people. If they are convinced and cooperate, things become easier. Also, if one person from this village goes and uses his card to get treated, it would start a cycle and make this scheme a success."

The potential in the RSBY has also been seen in the small village of Guniapur, 20 kilometres from Bijnore. Bharat Singh, a landness labourer, suffered a bout of asthma last month. He went to the hospital, was admitted for a night and received free treatment. When he returned, he was treated no less than a hero and the word about the RSBY's success spread like wildfire. Success of this programme is bolstering the spread and acceptability of the scheme. Beneficiaries realise that there is no "catch" in the smart card. Grinning, Bharat said, "It is an easy procedure. All one has to do is to muster up the courage to travel the distance. After that, it's the doctor's headache."

Hardnews learnt of a few loopholes, which, if corrected, could make the RSBY practically foolproof. "Travelling the distance" is a common complaint of the people. In many cases, this has even turned people off. From Dadanpur, the nearest empanelled hospitals lie nearly 40 miles away in either Bahadurgarh or Rewari districts. (This, despite the fact that Jhajjar has numerous clinics and nursing homes. It means that in Jhajjar healthcare facilities could not pass the quality checks, that is something the district administration must seriously look into.)

Lack of hospitals and medical care centres in towns and villages is a serious problem. However, as this scheme is market-driven, more and more entrepreneurs, realising that a lot of government and insurance money is flowing in this sector, are setting up hospitals. "There is a flow of Rs two crore each year in small towns towards healthcare. This is an exciting business model for businessmen. As more smart cards are distributed more hospitals will emerge," claimed a government official.

Most villagers commute to hospitals either on buses (the condition of Haryana and UP roadways is common knowledge), or hire a car from the influential upper castes. Also, travelling this distance, especially, in cases when a woman is in labour or a patient has had a cardiac attack/asthma bout, could turn fatal. (Even though a few hospitals have offered free ambulance services and provision of Rs 100 as transportation charges is widely accepted, the problem persists.)

Meanwhile, doctors are already flooded with patients who want to make money out of it. Dr Prakash, a surgeon in Bijnore, told Hardnews, "Several patients have come to me saying doctor sahab, you take 15,000 and we'll take the other half. It cannot be done unless the patient, doctor and the insurance agent are colluding. If they are proposing this at this stage itself, I am afraid soon they might even come up with a loophole."

Another problem lies in the BPL census data provided by the government. Insurance companies as well as the district administration officials claim that this causes problems in the identification of BPL families. Lack of proper research, human errors and lack of clarity in the reports deny the BPL status to many impoverished families. As the RSBY is limited to the BPL category, this raises concerns in the dynamics of village politics. In a few villages in Haryana and UP, villagers demanded that either the smart card be given to everyone who deserved to be included in the BPL category or to none at all. The field workers in some places were even beaten up by villagers.

Rameshwar Singh, district key manager of Jhajjar, told Hardnews, "Census reports are certainly a problem. But we regularly keep in touch with the BDO who lets us know of discrepancies. We try our best to ensure that the needy get BPL status and then we issue a new smart card. Since the RSBY is a new concept and it is the first phase, it would take time for people to get used to it."
The RSBY, by sorting out health problems of the people living below poverty line has the potential to end farmers' distress and increase their productivity. Healthier India would revolutionise the level of productivity and also lend dignity to those struggling at the margins

This story is from the print issue of Hardnews: JULY 2009

Comments

card to life

The people of India really needs the health card. It will be beneficial for all especially the poor and the middle class people.