1. Addressing Social Exclusion in Health: RSBY Health Insurance in India Babken Babajanian 20 th June 2012

2. Outline 1.ODI Research 2.Research Focus - RSBY 3.Research Questions 4.Social Exclusion in India – Dimensions and Drivers 6. Policy Questions 2

3. ODI Research Social protection and its role in tackling social exclusion of informal workers in Asia – 3-year multi-country study, funded by EU and AusAid – Will identify the impact of social protection interventions on social exclusion/inclusion in 4 countries (Afghanistan, Bangladesh, India, and Nepal) – Expected to inform policy and practice in respective countries as well as generate policy lessons for general application – Research partner: Indian Institute for Dalit Studies (IIDS) 3

4. Research Focus RSBY (Rashtriya Swasthya Bima Yojana) or National Health Insurance Scheme (2008): – Targets BPL (Below Poverty Line) families – Renewed every year, covers up to 5 family members – Nominal registration fee of Rs.30 – 23.5 million BPL families enrolled; 8,300 empanelled hospitals (May 2011) 4

5. Research Focus RSBY – Provides free hospitalisation and specified day care surgeries and treatments – Maternity cover and newborn coverage – Transportation fee of Rs.100 per hospitalisation – No paperwork requirement 5

6. Research Questions Does the RSBY health insurance scheme improve health care access and utilisation by socially excluded individuals? What are the main factors that influence the effectiveness of the scheme? Focus on socially excluded informal workers 6

7. Social Exclusion SE is a state in which individuals or groups are unable to participate fully in their society and are unable to enjoy a standard of living that is considered normal in the society in which they live. People can be excluded from: – productive resources and economic opportunities – essential services, education and health, – social and cultural participation, – political rights, voice and representation 7

8. Drivers of Exclusion in Health Care Financial exclusion is the key determinant of limited access and deprivation: – Only 10% of households have at least one member covered by insurance (National Family Health Survey 2005-06) – High health costs and out-of-pocket expenditure (including medicines) are the major reason for foregoing care – Out-of-pocket inpatient care expenditures per episode as a share of income for low income groups - 140% compared to 80% for high income groups in rural areas in 2004 (cited in Balarajan et al 2011) – Health expenses are the major cause of indebtedness 8

9. Drivers of Exclusion in Health Care – Ill health and health expenditures contribute to impoverishment – In 2004-05, 39 million Indians fell into poverty as a result of out-of-pocket expenditures (Selvaraj and Karan 2009) – Additional costs (foregone wages, transportation, food, child care, etc.) 9

10. Drivers of Exclusion in Health Care Physical access to health facilities: – Uneven concentration of services – Distance – Transport/roads 10

11. Discriminatory Practices in Health Discrimination of Dalits in accessing public and private health services, involving (Sabhrawal et al 2012; Sabhrawal 2011): – Denied admission and medical treatment – Inadequate/poor quality medical treatment – Discriminatory attitude 11

12. Discriminatory Practices in Health Discrimination is likely to result in: – Under-utilisation of services – Poor health – Lower productivity and diminished income – Psychological effects – Violation of citizenship rights 12

13. Policy Questions and Implications It is important to tackle both financial exclusion and discrimination There is some evidence that RSBY tends to enhance access to inpatient care ODI research seeks to establish how RSBY benefits socially excluded households and addresses discrimination in health ODI research findings will be available in November 2012 13

14. ODI is the UKs leading independent think tank on international development and humanitarian issues. We aim to inspire and inform policy and practice to reduce poverty by locking together high-quality applied research and practical policy advice. The views presented here are those of the speaker, and do not necessarily represent the views of ODI or our partners. 111 Westminster Bridge Road, London, SE1 7JD T: +44 207 9220 300 www.odi.org.uk b.babajanian@odi.org.uk