Awareness, Accessibility and Barriers in Utilization of Rastriya Swasthya Bima Yozna Services among BPL Families in Puri District, Odisha

Independent Research Project Report
On
Awareness, Accessibility and Barriers in Utilization of Rastriya
Swasthya Bima Yozna Services among BPL Families in Puri
District, Odisha

Submitted by Project Guide:
Sudheer Kumar (U310051) Dr. S. Peppin
PGDM RM-2 Xavier Institute of Management
(2010-12) Bhubaneswar

Declaration
This is to state that this research has been conducted by me as part of the curricula for the
Independent Research Project of PGDM-RM from Xavier Institute of Management,
Bhubaneswar. All the data and information stated in this report are compiled from questionnaire
survey, various field observations and information gathered through interviews and interaction
with various information providers and the report is completely an outcome of the extensive field
work in Puri district during the period of study.

(Signature)

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Acknowledgement
I would like to take this opportunity to thank my guide Dr. S. Peppin for extending a very helpful
hand throughout the project duration and constantly guiding and providing support me throughout
the project.

My grateful thanks are also extended to staff and employee of SWAD NGO for their co-operation
and their helpful behavior in data collection. I thank all my friends and colleague for their
cooperation and help, especially Prabin Kumar Nath and Prachit Chaturvedi for helping me in
data collection.

I would like to take this opportunity to thank all the respondents for patiently answering my hour
long questionnaire and still not have any grudges against me in the end.

Lastly but by no means the least, I would like to extend my hearty thank you note to SRC faculty
Prof. Bishnu Prasad Mishra and Prof. Jeevan J. Arakal for approving my research project and
Xavier Institute of Management for providing such an opportunity to me.

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Contents
CHAPTER 1 INTRODUCTION..................................................................................................................... 6
1.1 BACKGROUND ............................................................................................................................ 6
1.2 OVERVIEW OF HEALTH STATUS .......................................................................................................... 7
1.2.1 HEALTH STATUS IN INDIA ..........................................................................................................................7
1.2.2 HEALTH STATUS IN ORISSA ........................................................................................................................8
1.3 NEED FOR SOCIAL HEALTH INSURANCE SCHEME: ................................................................... 10
1.4 EARLY INITIATIVES:................................................................................................................. 11
CHAPTER 2 RASHTRIYA SWASTHYA BIMA YOJNA (RSBY) ............................................................................. 12
2.1 NOTEWORTHY ASPECT OF RSBY SCHEME ............................................................................................ 13
2.1.1 EMPOWERING BENEFICIARIES ..................................................................................................................13
2.1.2 BUSINESS MODEL FOR ALL STAKEHOLDERS .................................................................................................13
2.1.2.1 Insurers ..........................................................................................................................................13
2.1.2.2 Hospital ..........................................................................................................................................14
2.1.2.3 Intermediaries................................................................................................................................14
2.1.2.4 Government ...................................................................................................................................14
2.1.3 SMART CARD ........................................................................................................................................14
2.1.4 PORTABILITY .........................................................................................................................................14
2.1.5 CASH‐LESS............................................................................................................................................14
2.2 BENEFITS UNDER RSBY SCHEMES ..................................................................................................... 15
2.3 SERVICE DELIVERY MECHANISM ....................................................................................................... 15
2.3.1 ESTABLISHING PARTNERSHIPS BETWEEN THE GOI AND STATES/UTS...............................................................15
2.3.2 ESTABLISHING STATE NODAL AGENCIES.....................................................................................................16
2.3.3 ESTABLISHING PARTNERSHIPS WITH INSURANCE COMPANIES .........................................................................16
2.3.4 ESTABLISHING THIRD PARTY ADMINISTRATORS (TPAS) .................................................................................16
2.3.5 EMPANELLING HOSPITALS .......................................................................................................................16
2.3.6 ENROLLING BPL FAMILIES .......................................................................................................................16
2.4 OVERVIEW OF RSBY IN ORISSA:.............................................................................................. 17
2.5 OVERVIEW OF RSBY IN PURI DISTRICT ............................................................................................... 17
2.6 FACTORS THAT INFLUENCE TO TAKE UP THIS TOPIC: ............................................................... 18
CHAPTER 3 LITERATURE REVIEW AND METHODOLOGY FOLLOWED .............................................. 19
3.1 LITERATURE REVIEW: ..................................................................................................................... 19
3.2 RESEARCH QUESTION: .................................................................................................................... 21
3.3 PURPOSE OF STUDY: ...................................................................................................................... 21
3.4 KEY INFORMATION AREA: ............................................................................................................... 21
3.4.1 AWARENESS: ........................................................................................................................................22
3.4.2 PSYCHOGRAPHIC: ..................................................................................................................................22
3.4.3 LATENT FACTOR: ...................................................................................................................................22
3.4.4 UTILIZATION: ........................................................................................................................................22

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3.4.5 ACCESSIBILITY: ......................................................................................................................................22
3.5 RESEARCH DESIGN: ....................................................................................................................... 23
3.5.1 RESEARCH METHODOLOGY ......................................................................................................................23
3.5.1.1 Sampling: .......................................................................................................................................23
3.5.1.2 Data Collection:..............................................................................................................................23
3.5.1.3 Data Analysis: .................................................................................................................................23
3.6 POPULATION OF STUDY: .......................................................................................................... 24
3.7 SCOPE OF STUDY: ......................................................................................................................... 24
3.8 ROLE OF RESEARCHER: ................................................................................................................... 24
CHAPTER 4 FINDINGS & ANALYSIS.......................................................................................................... 25
4.1 QUANTITATIVE ASSESSMENT ........................................................................................................... 25
4.1.1 NO OF FAMILY MEMBER .........................................................................................................................25
4.1.2 EDUCATION QUALIFICATION OF FAMILY: ....................................................................................................26
4.1.2.1 Education qualification of head of family ......................................................................................26
4.1.2.2 Highest qualification of family member ........................................................................................26
4.1.3 HOUSEHOLD TYPE ..................................................................................................................................27
4.1.4 DISTANCE OF NEAREST EMPANELLED HOSPITAL...........................................................................................28
4.2 AWARENESS ASSESSMENT .............................................................................................................. 28
4.2.1 AWARENESS LEVEL ................................................................................................................................29
4.2.2 SOURCE OF INFORMATION ......................................................................................................................29
4.2.3 COMFORTABLE TO USE RSBY SMART CARD ................................................................................................30
4.2.4 FREQUENCY OF USING RSBY SMART CARD .................................................................................................31
4.2.5 SATISFACTION LEVEL ..............................................................................................................................32
4.2.6 UNABLE TO AVAIL TREATMENT DUE TO LACK OF MONEY ...............................................................................33
4.2.7 RENEWING OF SCHEME ...........................................................................................................................33
4.3 BARRIERS THAT AFFECT THE ACCESSIBILITY AND UTILIZATION OF SCHEME MOST: ........................................... 34
4.4 CLUSTER ANALYSIS ........................................................................................................................ 38
CHAPTER 5 CASE STUDIES, INFERENCE AND CONSTRAIN IDENTIFIED ................................................................ 42
5.1 CASE STUDIES .............................................................................................................................. 42
5.1.1 CASE STUDY 1: DHANESWAR ROUT ..........................................................................................................42
5.1.2 CASE STUDY II: SPANDHAN MEDICAL CENTER ............................................................................................44
5.1.3 CONSTRAINTS IDENTIFIED: ......................................................................................................................46
CHAPTER 6 KEY FINDINGS, RECOMMENDATION AND CONCLUSION ................................................................. 48
6.1 KEY FINDINGS .............................................................................................................................. 48
6.2 RECOMMENDATIONS ..................................................................................................................... 50
6.3 CONCLUSION ............................................................................................................................... 52
6.4 REFERENCES: ............................................................................................................................... 53
6.5 ANNEXURE 1 RSBY QUESTIONNAIRE ................................................................................................. 55
6.6 ANNEXURE 2 FACTOR ANALYSIS CORRELATION TABLE ............................................................................. 57
6.7 ANNEXURE 3 DENDOGRAM OF CLUSTER ANALYSIS ................................................................................ 59

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Abbreviations

RSBY: Rastriya Swasthya Bima Yozna

BPL: Below poverty Line

APL: Above poverty Line

NE state: North East state

GDP: Gross Domestic Production

LMIC: lower middle income country

HIC: High Income country

TPA: Third Party Administrator

FKO: Field Key Officer

DKO: District Key Officer

GOI: Government of India

MOLE: ministry of labor and employement

UT: Union Territory

NGO: Non Government Organization

ESIS: Employee State Insurance Scheme

CGHS: Central Government Health Scheme

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Chapter 1 Introduction
1.1 Background
India‟s remarkable growth in last decade made it geopolitical power in south Asia. India, in last
decade, is among one of the fastest emerging economies in the world. It is second fastest growing
economy of world after china and emerging superpower in Asia. The Indian economy is the
world's ninth-largest economy by nominal GDP and it is forth largest economy of world in
accordance with purchasing power parity. This unprecedented growth story leads to a prosperous
middle class and large number of high net worth individuals and lot of billionaires. But this
growth story has ominous side too; India is second most populous country in world with
population 1.21 billion just behind china. Apart from it, India is home of world largest number of
poor, one out of every five poor people in the world is an Indian. Though poverty is on the
decline, there are still more than 385 million people living BPL in India – many more than the
311 million people in the total population of the world‟s third most populous country, the United
States. Thus, the skewed growth leads to discrimination in society and unequal distribution of
resources. In this context, one of the biggest sufferers is rural India as it lacks the basic social and
infrastructure services in healthcare, roads, education and drinking water.

It is a well-known fact that India is, next only to China, the second largest country in terms of
population in the world. But the health status of a great majority of the people is far from
satisfactory as compared to China and other developed countries. However, over the last five
decades or so, India has built up health infrastructure and manpower at primary, secondary and
tertiary care in government, voluntary and private sectors and made considerable progress in
improving the health of its population (Ray 2003; Bhat and Babu 2004).

Although there is unprecedented growth in last decade, still the World Bank classifies India as
lower middle income countries (LMICs) but, it still has far to go before it enters the ranks of high
income countries (HICs). In 2009, HICs had average GNIs per capita of US$ 37,000 (30 times
India‟s) or US$ 36,213 (15 times India‟s) in terms of purchasing power parity (World Bank,
2011). So above all, India is still a low income country and home of largest number of poor, so it
is great challenge for country to provide basic services like health, education etc. India consists of
28 states and 7 union territories, Orissa, officially Odisha since November 2011, is one of

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the states of India, It is located between the parallels of 17.49'N and 22.34'N latitudes and
meridians of 81.27'E and 87.29'E longitudes. It is bounded by the Bay of Bengal on the east;
Madhya Pradesh on the west and Andhra Pradesh on the south. It has a coast line of about 450
kms. It extends over an area of 155,707 square km, accounting about 4.87 of the total area of
India. It is the modern name of the ancient nation of Kalinga, which was invaded by
the Maurya Emperor Ashoka in 261 BC. The modern state of Orissa was established on 1 April
1936, as a province in India, and consists predominantly of Oriya speakers.1 April is therefore
celebrated as Utkal Divas. Cuttack remained the capital of the state for over many centuries until
April 13, 1948 when Bhubaneswar was officially declared as the new capital of Orissa,
replacing Cuttack. Bhubaneswar is the present capital Orissa is the ninth largest state by area in
India, and the eleventh largest by population.

Puri being a coastal district of Orissa, is famous for its Historic antiquities, Religious sanctuaries,
Architectural Grandeur, Sea-scape beauty, moderate climate. This district comprises 1714
revenue villages. It has one subdivision, (Puri Sadar), 11 tehsils and 11 blocks. The Puri district
lies between the latitudes 19°28'N to 26°35'N and longitudes 84°29'E to 86°25'E. It has a
geographical area of 3051 km2 or 264988 Ha.

1.2 Overview of Health Status
Better health, education, equal and wider job opportunities to all, trustworthy and transparent
people‟s intuitions, sustainable and cleaner environment, dignity, self-esteem and life security,
among others, are key manifestations of the quality of growth. Quantity and Quality are the two
important dimensions of human population in any country. In general, all the countries are
committed to improving quality of population, a better welfare standard measure. For improving
quality of life a good health of population is mandatory. Health is defined as a state of complete
physical, mental, and social well-being and not merely the absence of disease or infirmity. The
health status is usually measured in terms of life expectancy at birth, infant mortality rate, fertility
rate, crude birth rate and crude death rate.

1.2.1 Health Status in India
Over the last five decades or so, India has built up health infrastructure and manpower at primary,
secondary and tertiary care in government, voluntary and private sectors and made considerable

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progress in improving the health of its population but still the health status of great majority of
people are far from satisfactory. India is one of the major countries where communicable diseases
are still not under control. The incidence of new fatal diseases such as
AIDS/HIV, hepatitis-A is on the increase and tuberculosis and malaria still take a high toll.
India‟s public health expenditures are less than 1.5% of its GDP (prior to launching NRHM,
expenditures were 0.9% GDP), and the WHO ranks India 171st out of 175 nations on public
health spending.
Young children in India suffer from some of the highest levels of stunting, underweight, and
wasting observed in any country in the world, and 7 out of every 10 young children are anemic.
The percentage of children under age five years who are underweight is almost 20 times as high
in India as would be expected in a healthy, well-nourished population and is almost twice as high
as the average percentage of underweight children in sub-Saharan African countries. Although
poverty is an important factor in the poor nutrition situation (NFHS-3)
There are 52 million undernourished children in India. 44% of Indian children under five are
underweight and 48% stunted due to chronic malnutrition; this means India is home to 46% of the
world‟s underweight children and 32% of the world‟s stunted children India has the highest
number of maternal deaths in the world. The national maternal mortality rate (MMR) is 254 per
100,000 live births, an absolute number of 68,000 per year. Comparatively, China‟s MMR is 45).
There is disparity between states, and some states far exceed national MMR, including Assam
(480) and Uttar Pradesh (440). The majority of deaths are preventable through safe deliveries and
adequate maternal care. Nearly 67% of the population in India does not have access to essential
medicines

1.2.2 Health Status in Orissa
Orissa is one such state in India that stained with poor socio economic status of the inhabitants.
Lower income, poor housing facility of education and discrimination are some of the factor at
contribute to the poor living standard including the poor status of the people in the state, although,
the degree of contribution of these factors in deciding the living standard of people vary across
social and ethnic groups. So basic health indicator in Orissa are showing very poor figure as
compare to national average

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The Death Rates in Orissa is highest in the country which stands at 9.2 as against 7.4 of the
country as a whole that is at least 2 points below the national death rate. Orissa contributes 23%
of malaria cases, 40 % of PF cases and 50% of malaria deaths of the country. In Orissa, 371
persons per 100,000 are estimated to have medically treated tuberculosis Almost half of the
children under five in Orissa are stunted or chronically malnourished (45%) and Underweight
(40.7%). About 19.5% children are wasting or acutely malnourished. The Total Fertility Rate of
the State is 2.4. The Infant Mortality Rate is 69 and Maternal Mortality Ratio is 303 (SRS 2004 -
2006) which are higher than the National average. The Sex Ratio in the State is 972 (as compared
to 933 for the country). Comparative figures of major health and demographic indicators are as
follows:

Table I: Demographic, Socio-economic and Health profile of Orissa State as compared to
India figures

S. No. Item Orissa India

1 Total population (Census 2001) (in million) 36.80 1028.61

2 Decadal Growth (Census 2001) (%) 16.25 21.54

3 Crude Birth Rate (SRS 2008) 21.4 22.8

4 Crude Death Rate (SRS 2008) 9.0 7.4

5 Total Fertility Rate (SRS 2008) 2.4 2.6

6 Infant Mortality Rate (SRS 2008) 69 53

7 Maternal Mortality Ratio (SRS 2004 - 2006) 303 254

8 Sex Ratio (Census 2001) 972 933

9 Population below Poverty line (%) 47.15 26.10

10 Schedule Caste population (in million) 6.08 166.64

11 Schedule Tribe population (in million) 8.15 84.33

12 Female Literacy Rate (Census 2001) (%) 50.5 53.7

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For more than three-quarters of households in Orissa, the public medical sector, mainly
community health centers (CHC), rural hospitals, or Primary Health Centers (PHC), are the main
sources of health care. The public medical sector is the main source of health care for 62% of
urban households and 79% of rural households.

1.3 Need for Social Health Insurance Scheme:
The world health report 2008 emphasized universal coverage as one of the four pillars of primary
health care and said such coverage required patient-centered care with no financial or other
barriers preventing access to care (WHO, 2008).
Article 25 of the Universal Declaration of Human Rights (1948) which states that everyone has a
right to the health care and social protection they need to maintain their own and their family‟s
health and well-being in the event of illness, disability or old age.
Universal coverage is an essential and accepted objective for most countries. It enshrines the key
elements of how health systems can contribute to the betterment of health in general, while
ensuring that people centeredness remains at their core. So universal coverage and accessible to
all health service in India is upmost requirement, as there is 37% population leaving below the
poverty line. But mostly social health insurance schemes in India only restricted to formal sector
employees. However, about 94% of the Indian workforce or 400 million people are working in
the informal sector. An extensive research programme undertaken across parts of India
(Rajasthan, Gujarat and Andhra Pradesh) and Africa (Ghana, Uganda and Kenya) found that ill
health and health-related expenses were the most common reasons given by the poor for their
own descent into, and inability to escape from, poverty (Krishna 2003, 2004, Krishna et al 2004,
2005). It has been increasingly recognized that health insurance is one way of providing
protection to poor households against the risk of health spending leading to poverty.
Households pay for the majority of healthcare costs in India. Covering healthcare expenses is a
primary cause of indebtedness in India, and can push people deeper into poverty. It is known that
many people, including the poor, prefer to access services in the private sector. This preference
can intensify the financial pressure faced by many, as the private sector is more costly. Health
Insurance is a way to help and lessen the burden of paying for healthcare by spreading the costs of
health across a group of people.

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1.4 Early initiatives:
There are few schemes that were started by various state governments, NGOs; e.g. Arogyashree
scheme run by the Andhra Pradesh Government, Yeshaswini in the state of Karnataka, SEWA in
Gujarat, Ahmadabad by an NGO, the Employee State Insurance Scheme (ESIS) and Central
Government Health Scheme (CGHS) by the central government. ESIS and CGHS are important
health insurance scheme in India. All these forms currently exist in the country but only in small
pockets and cater to specific groups; there was felt a clear absence of a pan-India model. Most of
the community-based insurance schemes have been found to suffer from poor design and
management, they fail to include the poorest-of-the poor, have low membership and require
extensive financial support. So for universal coverage and to include poorest of poor govt. of
India with collaboration of state government has started RSBY scheme across pan India coverage.

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Chapter 2 Rashtriya Swasthya Bima Yojna (RSBY)
India is home to more than 1.2 billion people and almost one-third live below the poverty line
(BPL), as defined by the Government of India. On 2 October 2007, the Government launched a
national insurance scheme or, in Hindi, Rashtriya Swasthya Bima Yojana (RSBY). The scheme‟s
first five-year target is, by the end of 2012, to provide all India‟s BPL families with enough health
insurance to avoid catastrophic health expenses due to serious illness or injury. After official
announcement of RSBY on 2 October 2007, there were six months of preparation before roll-out
began on 1 April 2008.
RSBY was finally rolled out in 2008 by Ministry of Labor and Employment (MoLE),
Government of India (GoI) to provide health insurance coverage for Below Poverty Line (BPL)
families with objective of To improve access of BPL families to quality medical care for
treatment of diseases involving hospitalization and surgery through an identified network of
health care providers.

The Govt. of India contributes 75% of the premium (90% for Jammu & Kashmir and North-
Eastern states) in case of BPL families. The Ministry of Labor and Employment, Govt. of India
monitors implementation of the scheme across the country. The responsibility for implementation
of the scheme rests with the States.

As RSBY is an insurance-backed healthcare scheme, the states, through a transparent bidding
process, select an insurance company to enroll the beneficiaries and to underwrite the
hospitalization expenses for a year for an annual charge (premium). The state Governments
contributes 25 % (10 % in the case of J&K and North East states). So it is a public/private health
insurance scheme implemented to help below poverty line (BPL) families with financial
obligations related to hospitalization & fulfills ailment expense so that it can improve their health
status. The RSBY scheme grew out of the understanding of the social and financial importance of
protecting BPL families from the effects of illness. As of November 2010, more than 16 million
families and nearly 5,000 hospitals across 26 Indian states have enrolled in RSBY.

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RSBY provides the BPL beneficiaries:

• Financial protection against hospitalization expenses

• Improved access and choice of quality hospitals (public and private)

• Cashless utilization of benefits through use of a smart card

Just over three years later, at the end of May 2011, its active partners include most of India‟s 35
States and Union Territories, more than half of their 640 Districts, eleven private insurance
companies, many third party administrators, and almost 8,300 public and private hospitals. More
than 23 million BPL families are enrolled in RSBY and in possession of the scheme‟s electronic
Smart Cards, allowing them to go to any one of those 8,300 hospitals and receive treatment with
no cash or paperwork required.

2.1 Noteworthy aspect of RSBY scheme
This is scheme of difference with many noteworthy aspects; in this scheme every stakeholder has
some rights and obligation. It is different from other scheme due to following aspects

2.1.1 Empowering beneficiaries
RSBY provides freedom of choice to the patient in the selection of hospitals: They can access any
public or private provider in the network across the country. So the beneficiary has full freedom
to choose any of hospital that is very different from other social schemes.

2.1.2 Business model for all stakeholders
The scheme is designed as a business model, with incentives built in for each stakeholder so every
stakeholder profit depend on other and every stakeholder use it with dignity unlike other social
scheme in which one agency is giver and other is taker

2.1.2.1 Insurers

The insurer is paid a premium for each household enrolled in RSBY, therefore giving the insurer
an incentive to enroll as many households as possible from the BPL list. So enrollment and
awareness is done by insurer with full effort to maximize their benefits.

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2.1.2.2 Hospital
A hospital has the incentive to provide treatment to large number of beneficiaries as it is paid per
beneficiary treated. Even public hospitals have an incentive to treat beneficiaries under RSBY as
money from the insurer will flow directly to the public hospital. Insurers, in contrast, will monitor
participating hospitals in order to prevent unnecessary procedures or fraud resulting in excessive
claims.

2.1.2.3 Intermediaries
The inclusion of intermediaries, such as NGOs and MFIs, was intentional since they have a
greater stake in assisting BPL households. Intermediaries will be paid for the services they render
in reaching out to the beneficiaries.

2.1.2.4 Government
Including public sector providers in the RSBY delivery network creates healthy competition
between public and private providers which in turn provides incentives for public providers to
improve their service delivery.

2.1.3 Smart Card
Every beneficiary family is issued a biometric enabled Smart Card containing their fingerprints
and photographs. All the hospitals empanelled under RSBY are IT enabled and connected to the
server at the district level. This will ensure a smooth data flow regarding service utilization
periodically. The Smart Card also ensures that only true beneficiaries can use sevices, reducing
fraud.

2.1.4 Portability
One key feature of RSBY is that a beneficiary who has been enrolled in a particular district will
be able to use his/her Smart Card in any RSBY empanelled hospital across India. This makes the
scheme beneficial to the many poor families that migrate from one place to the other.

2.1.5 Cash‐less
RSBY transactions are completely cashless. Beneficiaries do not pay cash for any services unless
they exceed the annual allowance of Rs. 30,000/‐. Provider‐to‐insurer dealings are also paperless,
as all claims are processed and paid electronically.

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2.2 Benefits under RSBY schemes
RSBY beneficiaries are covered for hospitalization expenses of up to Rs. 30,000/‐ per family per
year. The family can include up to five members (including a husband, a wife, and three
dependents). Most of the surgical and medical conditions for which hospitalization is necessary
are covered in the scheme. Package rates for 727 inpatient surgical procedures, including
maternity and newborn care have been pre‐defined. In addition, beneficiaries are covered for
outpatient surgeries which can be done on an outpatient basis. The benefit also includes one day
pre‐ and five day post‐hospitalization expenses. There is also a transportation benefit that provides
Rs. 100 per visit to the beneficiary; total transport assistance cannot exceed Rs. 1000/‐ per annum
and it is part of the total Rs. 30,000/‐ coverage. Now Outpatient charge of Rs 50 per day is also
avail that was not included earlier.

All pre‐existing diseases are covered from the first day of enrollment with some exclusions.
RSBY does not cover:

 Congenital external diseases
 Drug and alcohol induced illness
 Sterilization and fertility related procedures

2.3 Service Delivery Mechanism
RSBY scheme is highly technologically based and has pan India operation so delivering such a
complex service with so many stakeholder is very challenging job. The following process are held
to deliver the service to BPL families

2.3.1 Establishing partnerships between the GOI and States/UTs
Memoranda of understanding (MOUs) usually specify that the GOI, represented by the MoLE,
covers 75 percent of the premium charged by insurance companies and rest premium is bear by
state government. In addition, the GOI provides technical guidance and assistance to State/UT
governments and their Nodal Agencies; guides and supports monitoring and evaluation (M&E) in
States/UTs and does M&E countrywide.

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2.3.2 Establishing State Nodal Agencies
Each State gives a Nodal Department responsibility for implementing RSBY. Often they choose
State departments or agencies responsible for labour, health or rural development. The Nodal
Department then establishes or identifies a Nodal Agency to which it delegates responsibility for
administering RSBY. Nodal Agencies work in concert with or on behalf of States Governments

2.3.3 Establishing partnerships with insurance companies
Nodal Agency call for bids from insurance companies and establish expert committees to evaluate
the technical and financial merits of all bids, and then choose no more than one insurance
company to enroll BPL families in each selected District and send selected bids to the GOI‟s
Approval and Monitoring Committee. When approved, contract with the selected insurance
companies is finalized.

2.3.4 Establishing third party administrators (TPAs)
Contracts with insurance companies often specify that they can subcontract with Third Party
Administrators (TPAs) to carry out some of their responsibilities if they needed and TPAs may
subcontract to others party if required. Microfinance institutions (MFIs) or NGOs are the usual
front-line subcontractors and their subcontracts vary widely in content but typically focus on
spreading the RSBY message and enrolling BPL families in towns and villages

2.3.5 Empanelling hospitals
Insurance companies have primary responsibility for empanelling and de-empanelling hospitals
and keeping up-to-date lists of hospitals, that should be provide to BPL families when they enroll
and receive their insurance Smart Cards.

2.3.6 Enrolling BPL families

Enrollment and awareness are the prime responsibility of insurer or insurance company, BPL
families must be made aware of RSBY, the benefits it has to offer, which families are eligible to
apply, and the number and characteristics of family members who can be named as beneficiaries.
Insurance companies have primary responsibility for providing this awareness but may
subcontract to TPAs. In either case, Nodal Authorities and FKOs provide guidance and support.

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2.4 Overview of RSBY in Orissa:
Despite the emergence of a number of health insurance programmes and health schemes, only 2
percent of households in Orissa report that they have any kind of health insurance that covers at
least one member of the household. Three types of programmes dominate: medical
reimbursement from employers, the Employee State Insurance Scheme (ESIS), and other health
insurance through the employer. Eight percent of urban households are covered by some health
insurance, whereas health insurance coverage is rare among rural households (0.6%). Ten percent
of households in the highest wealth quintile have some type of health insurance (NFHS-3) so
there is huge need of RSBY scheme in Orissa.

RSBY coverage in Odisha is below the expectation, in odisha, there is 12,33,054 BPL family in
which 4,09,739 family are enrolled under RSBY scheme. Total no of family member in these
enrolled family is 11,55,374, so total enrollment in Odisha is approximately 33%, that is far from
expected achievement. RSBY cover only six districts in Odissa and its coverage in these districts
are as follow:

District Enrollment as a percentage of BPL population
Puri 52%
Nuapada 49%
Nayagada 63%
Kalahandi 47%
Jarushgada 62%
Deogara 66%

2.5 Overview of RSBY in Puri District
Puri is one of the costal districts in Orissa, it has total 249721 BPL Families in that 13176 families
are enrolled under RSBY scheme. There is 18 public and 8 private hospital are empanelled for
RSBY patient. This year policy begin July1, 2011 and it will end on June 30,2012. ICICI
Lombard is insurer for Puri district and FINO work as TPA for RSBY in Puri district. Till
Jan15,2012 total 942 cases of hospitalization has came under RSBY scheme with total value of
Rs. 5025180. Details of RSBY for Puri District are following

17

Blocks of Total BPL Family Total Enrollment in %
Puri District family enrolled member
1 Astrang 10592 7467 21910 70.50
2 Brahamgiri 12201 4827 14321 39.56
3 Delang 16994 11726 34783 69.00
4 Gop 23073 13544 32072 58.70
5 Kakatpur 10413 6779 14108 65.10
6 Kanas 16585 10915 33252 65.81
7 Krushnaprasad 9005 6680 23517 74.18
8 Nimapada 23562 17278 40663 73.33
9 Pipli 16287 11325 29544 69.53
10 Satyabadi 15394 9520 28680 61.84

2.6 Factors that influence to take up this topic:
I have read a lot about the success story of NREGA and RSBY so these stories motivated me to
know about the ground reality of these schemes and their effectiveness and accessibility for poor.
As RSBY is unique and first health insurance scheme that has pan India coverage and it involve a
lot of stakeholder e.g. BPL families, health service provider, IT companies, insurance company,
state and central government, so I want to know that after so much of stakeholder and complexity,
scheme is giving its message clearly or not, how much it is effective for a poor people, how much
they are aware about these schemes, how much they utilize the facilities and service provided by
this scheme and what are the barriers in utilization of this scheme so to know all these I choose
this topic for my research.

18

Chapter 3 Literature Review and methodology followed

3.1 Literature review:

RSBY was started in April 2008 with a target of five year to include all the BPL families under
this scheme; this scheme is implemented in every state of India. The implementation of scheme in
Karnataka, drawing an attention and study was done on eligible households and interviews were
conducted with empanelled hospitals in the state (IMPLEMENTING HEALTH INSURANCE
FOR THE POOR: THE ROLLOUT OF RSBY IN KARNATAKA
D Rajasekhar, Erlend Berg, Maitreesh Ghatak, R Manjula and Sanchari Roy, 2009)
Six months after initiation, an impressive 85% of eligible households in the sample were aware
of the scheme, and 68% had been enrolled. However, the scheme was hardly operational and
utilisation was virtually zero in Karnataka region. A large proportion of beneficiaries were yet to
receive their cards, and many did not know how and where to obtain treatment under the scheme.
Moreover, hospitals were not ready to treat RSBY patients. As is typical for the implementation
of a government scheme, many of the problems discussed can be related to a misalignment of
incentives This paper shows the problem faced in implementation, delay in smart card and various
problem faced by hospitals like training of staff for RSBY scheme, delay in payment of hospitals
by insurance companies.
Rashtriya Swasthya Bima Yojna (RSBY) or the National Health Insurance Program can play an
important role in improving the quality of care through regularization and financial incentives.
Following a roadmap that encourages hospitals to adopt small but incremental changes over time
can go a long way in improving the quality of health care (Can Rashtriya Swasthya Bima Yojna
help bridge the quality chasm? Sonam Sethi). This paper looks at the early experience of hospitals
in Delhi as a starting point for the discussion. Surveyed hospitals complained of a lack of training
and delays in the reimbursement of their expenses. Many were refusing to treat patients under the
scheme until the issues were resolved, and others were asking cardholders to pay cash.
These studies show that there is increase in accessibility of healthcare services for BPL families
after implementation of RSBY scheme, and there out of pocket expenditure is reduced after they

19

started get benefit from RSBY scheme. It also shows that there is increase in health infrastructure
after implementation of this scheme (Rashtriya Swasthya Beema Yojna (RSBY): Panacea for the
poor (National Health Insurance Plan) Sheila Rai and Niha Rai). The front end of the scheme is
quite simple but the back-end, especially in the context of Information Technology applications,
is quite complex involving a number of players, both in the public and private sector domains.
Vertical and horizontal coordination poses the biggest challenge even after the stabilization of a
variety of software that was being used to roll out the scheme. The back-end data base
management throws up a different challenge in terms of developing the structure and putting in
place the hardware. There are some issues yet to be resolved.
These papers show misalignment of various departments in this scheme. So these paper focus
more on hospital and implementation part and didn‟t show what the benefit poor get from this
scheme, are they aware about scheme or not, what are the problem they faced in utilization of
services of RSBY. These studies and papers shows all the aspect of RSBY scheme but still there
is some gap exist, there is no study that address the state Odisha so there is pertinent need to take
a look at Odisha RSBY schemes, and all the study focus on general awareness of scheme no else
study focus on in depth awareness about services, use of service and effectiveness of service,
improvement of health status after implementation of scheme. So to feel these gaps this study is
conducted.
As investment on health increases, the productive capacity of the working population, and hence
the level of income tends to rise and to that extent it contributes to a decline in the incidence of
poverty (Reddy and Selvaraju 1994). With rapid improvement in health, particularly of the poor
“vicious circle” of poverty can be converted into “virtuous circle” of prosperity (Mayer 1999;
Mayer 2000;Bloom et al 2004)

20

3.2 Research question:
RSBY scheme is new and it was started three year ago, so evaluation of such a huge beneficiary
base scheme in early phase is not possible. So this study focuses on the trend of the scheme,
benefits and problems which a beneficiary has to face in usage services of this scheme. After
studying the relevant literature and paper and find the gap between earlier studies following
questions arise those are addressed in this study:

 What is level of awareness of RSBY and its services among BPL families?
 What are barriers in accessibility of RSBY scheme?
 How much people are satisfied with scheme

3.3 Purpose of study:
RSBY is a scheme with difference, in this scheme the poor and below poverty line people are
beneficiaries. So the beneficiaries are underserved segment of society, they have very low literacy
level and have little accessibility of other media source, so generation of awareness in this
segment is very difficult task, the focus of this study is on awareness among beneficiary and it
address their problem that are faced in accessing and utilization of services of scheme. The
purpose of study is to find out:

 Awareness of scheme among BPL families

 Accessibility of RSBY by BPL families

 Problem faced in utilization of scheme services

 Satisfaction level for scheme among beneficiaries

3.4 Key Information Area:
Key Information areas are the areas which are specifically targeted in this study to find the answer
of research question. Due to time and resources constrain, consider all area is impossible for
researcher so I prioritize these area to find the answer or solution of research questions

21

3.4.1 Awareness:
This capture the level of awareness among people about the scheme , it give us the details like
only heard about RSBY, superficial knowledge about scheme, detail knowledge of scheme, know
the various benefits and how to use it. So this area differentiate beneficiary according to
knowledge about scheme and awareness for scheme, this key information area help to analyze the
source of awareness among people who have high level of awareness

3.4.2 Psychographic:
Through this Key Information area, we want to uncover and understand the decision-making
processes for health care; there priority level regarding their and their family health, how they
prioritize health care and what is their behavior toward the ailment or disease. When they think
that a person needs a consultation from doctor, and when they feel the need of admission in
hospital, what is their first line of treatment, their behavior and perception when somebody fell ill
in their families?

3.4.3 Latent factor:
This factor help to understand the attributes which influence beneficiary decision and often what
factors influences in a higher degree of their decision making process. For similar ailment and
disease the behavior and way to adopt the treatment is different from one person to other person.
The attitude toward health and precaution are different from person to person. So the cluster of
beneficiary according to similarity and difference is targeted in this key information area.

3.4.4 Utilization:
This key information is important to understand the utilization of services, there are various
attributes that affects utilization of services literacy, attitude, availability of services, service
provider attitudes etc.

3.4.5 Accessibility:
Accessibility is one of the important key area for this service it provide the ideas that how much
this scheme is user friendly, this area is has lot of attributes like easy process of enrollment,
availability of required document, government and insurance company support, distance of
hospital from residential area, behavior of medical staff in hospital etc.

22

3.5 Research Design:

3.5.1 Research methodology
This study will utilize Exploratory Research approach; this approach depicts the existence
position of scheme and tries to explore the awareness, accessibility and utilization of schemes
services by its beneficiary and explore its effect on the BPL families. It describe pattern of
relationship among different variables. In this study, no attempt is made to change behavior or
condition, research is done in existing condition without any external interference. This study
follows the cross-sectional studies variables of interest in a sample of subjects are assayed once
and the relationships between them are determined and analyze.

3.5.1.1 Sampling:
This study use a stratified random sampling procedure, to make sure that sample have
proportional representation of population subgroups, it has identified three Block of puri district
according to geographical location in Puri: One Block is Pipli that is nearest to capital of Odisha,
Bhubaneswar, second block is satyabadi that is nearest to Puri city and Third is Nimapada that
block has good connectivity but no nearby city except block town Nimapada other factor to
choose Nimapad is, it has highest percentage of enrolled BPL families. From each block three
villages are selected: One village is under 5 Km far from block headquarters, Second village is
more than 15 Km far from block headquarter and connected with pucca road, third village is also
more than 15 KM from block headquarter but not well connected with pucca road. From each
village there is 10 samples are taken for this study. This approach helpful to validate and
generalize the responses to a population, for this, it is important to have a representative sample.

3.5.1.2 Data Collection:
Collection of data is through self administrative questionnaire survey method with close and semi
close ended questions, these structured questions to assess people‟s awareness, accessibility,
satisfaction level and barriers in utilization in RSBY services.

3.5.1.3 Data Analysis:

23

 No of beneficiaries segments exist in population based on different Awareness level,
Psychographic using Cluster analysis of SPSS package.
 Univariate and bivariate analysis to know the effect of awareness and accessibility of
services on the success of scheme.
 Taking the variables “influence the accessibility and utilization of scheme and their
importance level” we can identify the number of „Factors‟ emerging out from the Factor
Analysis using SPSS package.

3.6 Population of Study:
The population of study is BPL families of Puri District in Odisha, those are eligible for
enrollment under RSBY schemes. As government has implemented this scheme in six district of
Orissa: Puri, Nuapada, Nayagada, Kalahandi, Jarushgada, Deogara. But my study of population is
BPL families of Puri district.

3.7 Scope of Study:
 This study help to know the awareness among BPL families for this scheme
 It help in to know which one is most effective method to spread awareness
 It gives the idea about the effectiveness and utilization of scheme services by BPL
families.
 This study provides the insight of scheme and how this scheme can be more user friendly
for beneficiaries.
 It reveal the barriers in utilization of services of RSBY so that they can overcome to make
service more effective
 It reveals the satisfaction level among beneficiaries.

3.8 Role of researcher:
 Identify the district, block and village for data collection
 Collecting the data and information through self administrative questionnaire
 Process these information and data in unbiased way
 Analyze these data and reach at conclusion that gives the result of study.

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Chapter 4 Findings & Analysis
This chapter is based on the information collected through field survey and interactions with
Villagers and BPL families. The key findings have been divided into three sections. Section-4.1
presents the quantitative assessment; Section-4.2 deals with the Awareness assessment and
satisfaction level; Section- 4.3 analyze various barriers in utilization and accessibility of scheme;
Section 4.4 deals with cluster of similar demographical characters. The results are based on the
data collected from 9 GPs of the three sample Blocks of the Puri District. Detailed methodology
and procedure of data collection have already been discussed in the preceding chapter. The data
are analysed through various statistical methods, such as univariate, bivariate, factor, cluster
analysis and results are demonstrated through tables and graphs to draw meaningful inferences.

4.1 Quantitative Assessment

4.1.1 No of family member
The numbers of family members in household are classified into five segments: 1-2, 3-5, 6-8, 9-
12 and greater than 12. The table below shows the frequency and percentage of household that
falls in different segments

Family members Frequency Percent

1-2 3 3.4

3-5 48 55.2

6-8 30 34.5

9-12 6 6.9

Total 87 100.0

This
table reflects that around 55% of household has average size fall under 3-5, and RSBY covers the
health insurance up to five member of a single family. So from above table it can be infer that

25

59% household are fully insured under this scheme and rest 41% household are partially covered
by this scheme.

4.1.2 Education qualification of family:
Education plays an important role in society, a more educated society provide the opportunity for
higher efficiency and effectiveness of a social scheme and they are more susceptible to adopt and
understand new scheme so in this study the whole family is divide into two part; first is head of
family and second is rest of the family members.

4.1.2.1 Education qualification of head of family
The analysis reveals that a large number of populations in BPL families are either illiterate or up
to the primary standard. So it is very difficult to implement a scheme in a population that has so
low education level.

Frequency Percent

illiterate 11 12.6

up to primary standard 39 44.8

up to matriculation 32 36.8

up to higher secondary 5 5.7

Total 87 100.0

The analysis of study reveals that 11% of head of family are illiterate so implementation becomes
e difficult when decision maker in target beneficiary family has low level of education. It shows
that up to 60% population is below primary level only 5.7 % head of family has education above
matriculation level so implementing such grass root scheme is a very difficult part.

4.1.2.2 Highest qualification of family member

26

Frequency Percent

up to primary standard 8 9.2

up to matriculation 56 64.4
up to higher secondary 20 23

above higher secondary 3 3.4
Total 87 100

Education play a significant role in successful of any scheme so this study also analyze the
highest qualification of any of member in family, as that person can play an important role in
awareness generation and understanding the benefit of schemes. So this analysis gives a positive
sign, only 9.2% enrolled family education level is below primary standard.

4.1.3 Household type

Frequency Percent

Self employed in non
13 14.94
Agriculture
Agriculture Labor 18 20.68
Other Labor 24 27.58
Self employed in Agriculture 29 33.33
other 3 3.44

87 100
Total

The sources of income of sample households has been classified into five categories, namely, Self
employed in non Agriculture, Agriculture Labor, Other Labor, Self employed in Agriculture,

27

others. This study highlights that major source of income is associated with agriculture, only 18%
household has non agriculture source of income.

4.1.4 Distance of nearest empanelled Hospital

Distance

Frequency Percent
0-5 21 24.1
5-10 25 28.7
10-20 27 31
20-30 11 12.6
>30 3 3.4
Total 87 100

Distance of empanelled hospital is very crucial in accessibility of scheme, this study reveal that
52% of sample household are under the circumference of 10 Km of empanelled hospital rest 42%
are more than 10 Km from empanelled hospital. Nearest hospital is one of the important factors
for accessibility of scheme so the figure shown in the analysis seems satisfactory regarding
distance of nearest hospital.

As in the selection of sample village distance is one of the factors, so the data collection has its
own limitation.

4.2 Awareness Assessment
Awareness is one of the most important factor in social scheme so this section analyze various
attribute and reveal the level of awareness among BPL families.

28

4.2.1 Awareness Level

Awareness
Frequency Percent
only registered
5 5.7
know about empanelled
hospitals
15 17.2
know about amount of
treatment 28 32.2
know about empanelled
hospitals and amount
for treatment 28 32.2
understand and avail
the benefit of scheme
11 12.6
Total 87 100

The information collected from sample household reveal that only 12.6% household has complete
understanding of procedure and can avail the benefit independently. Other are partially know about
the scheme but didn‟t understand the complete process and 5.7% of people are complete unaware
about the scheme they don‟t know how to use smart card they just registered for scheme and
complete unaware about it.

4.2.2 Source of information
Source of information
Frequency Percent
poster/wall painting
6 6.9
word to mouth 7 8
NGO/panchayat/block/govt
officials 27 31
Doctor/hospital
staff/ANM/Asha/Health
worker/Aganwadi 17 19.5
loudspeaker
announcement/nukkad
natak 30 34.5
Total 87 100

29

Providing information in rural area and specially BPL families is major challenge because they
don‟t have mass media source. This study tried to find out which source is most effective for
spreading the information, so I gather the data regarding information of registration camp as that
is first contact point for this scheme. The analysis reveals that 34.5% came to know regarding
information camp from loudspeaker announcement, after that 31% came to know through NGO
person/ Panchayat official/ Block official / govt. officials so it is another source of effective
communication. Third source of spreading information is through Doctor/ hospital staff/ ANM/
ASHA/ Health worker/ Aganwadi worker, it contribute 19.5% of total share. This can be utilize
more because these person are directly related to health so their communication could be more
effective if strategy effectively.

4.2.3 Comfortable to use RSBY smart card
Comfortable
in using smart
card

Frequency Percent
yes
33 38.3
no
54 61.7

This analysis reveal that only 38.3% of sample household are comfortable in using the smart card
either they have used it once or aware about how they can use in future if they will go to
empanelled hospital rest 61.7% are not comfortable in using these smart card so it is matter of
concern that they are posses these but are not comfortable in using the card so there is need of
awareness regarding using this scheme.

30

4.2.4 Frequency of using RSBY smart card

Frequency Percent
0 64 73.6
1-3 18 20.7
4-6 5 5.7
6-10 0 0
>10 0 0
Total 87 100

The above table and pie chart show the frequency of using RSBY smart card by card holder in
treatments of their ailment throughout the year. These data are quite shocking out 87 samples 64
told that they never use these SBY smart cards. So total 73.6% of sample household never use
these card it is unbelievable that no one in family in whole year wasn‟t ill so the main reason that
told by villagers are awareness about scheme and unresponsiveness of empanelled hospital. Only
5.7% of total household use these smart card more than 3 times so it give the question mark in
success of scheme. The majority of population who use their smart card did only do for their
major ailment and surgical process. I didn‟t find a single person who took the benefit of OPD
service under RSBY scheme.

31

4.2.5 Satisfaction level

Satisfaction
level Frequency Percent
Highly
dissatisfied 26 29.9
somewhat
dissatisfied 23 26.4
neither
satisfied nor
dissatisfied 4 4.6
somewhat
satisfied 23 26.4
Highly
satisfied 11 12.6
Total 87 100

It is significant from figure that more number of people are dissatisfied then number of people
satisfied; 30% people among sample household are highly dissatisfied they think that this scheme
is of no use for them, around 27% people are somewhat dissatisfied. There is good sign that
12.6% of people are highly satisfied with this scheme; they said that they got very good treatment
without any expenditure and their ailment was cured due to this scheme. Most of them took
surgical treatment of their old and chronic illness so their responses are quite positive. Some
people are somewhat satisfied they think that some third person has taken the benefit of this
scheme so they also can avail the benefit of this scheme in future also and their out of pocket
expenditure is only Rs 30 so they are not expecting so much from this scheme and they are
satisfied that if some major illness happen in future they can avail treatment with this scheme.

32

4.2.6 Unable to avail treatment due to lack of money

untreated due lack of money

Frequency Percent
yes
54 62.1
no
33 37.9
Total
87 100

This information shows that 62% of family in sample household didn‟t get treatment in past due
to lack of money so it shows the importance of scheme. Even some of family a member is severe
ill but they couldn‟t afford treatment so they didn‟t avail the treatment. So the requirement of this
scheme was very much among BPL families.

4.2.7 Renewing of scheme

Renewing of scheme

Frequency Percent
yes
84 96.6
no
3 3.4
Total
87 100

There are many loopholes in this scheme, people are not satisfied with services, they are not fully
aware about the scheme its benefit, its utilization. There is lot of misconception about this
scheme, for some people it is very hard to believe that private hospital also give treatment without

33

any expenditure from their pocket. The result of renew of scheme shows almost everyone want to
renew this scheme, doesn‟t matter the benefit of scheme avail to them or not. This shows that the
Rs 30 doesn‟t matter for BPL families and they are willing to pay this amount for security in
future; few people are hopeful that they will get benefit of this scheme in future.

4.3 Barriers that affect the accessibility and utilization of scheme
most:

There are 15 factor that were assumed to play main hurdle in accessibility and utilization of
scheme, to find what are main influential factor among these factor in this research factor analysis
is used. Factor analyses are performed by examining the pattern of correlations (or covariance)
between the observed measures. Measures that are highly correlated (either positively or
negatively) are likely in influenced by the same factors, while those that are relatively
uncorrelated are likely influenced by different factors. Here, Exploratory factor analysis (EFA)
techniques been used with objective of
1. The number of common factors influencing a set of measures.
2. The strength of the relationship between each factor and each observed measure.
The initially data studied under principal component matrix and six factor are emerging out from
the data containing 15 variables taken in questionnaire to know the attributes considered while
selection the most important barriers among these 15 barriers. To get more accurate correlation
between the attribute the „Varimax‟ method off rotation has been used.

KMO and Bartlett's Test
Kaiser-Meyer-Olkin Measure of Sampling Adequacy. .608

Bartlett's Test of Sphericity Approx. Chi-Square 235.363

df 105

Sig. .000

34

KMO measure explain 60.8%, it is acceptable limit so we can run the factor analysis on given
data. After getting correlated table and screen plot by factor analysis, verimax is used to get more
accurate data. The rotated component matrix the six components in all through these 15 attributes
are chosen to explain.

It is evidenced from the Scree plot that only 6 components have Eigen value over one hence the
number of attribute can be group under these six latent factors. So six components are chosen to
explain the barrier and find out through total variance table that how much they are explained.
The scree plot shows that six factor are significant and other are not so much in importance and
other are not so much significant so they could be ignored.

35

Total Variance Explained
Com Initial Eigenvalues Extraction Sums of Squared Loadings
pone Total % of Cumulative Total % of Cumulative
nt Variance % Variance %
1 2.829 18.858 18.858 2.829 18.858 18.858
2 1.862 12.411 31.269 1.862 12.411 31.269
3 1.664 11.091 42.360 1.664 11.091 42.360
4 1.304 8.694 51.054 1.304 8.694 51.054
5 1.170 7.798 58.852 1.170 7.798 58.852
6 1.009 6.727 65.578 1.009 6.727 65.578
7 .884 5.892 71.470
8 .804 5.360 76.831
9 .721 4.806 81.637
10 .613 4.084 85.721
11 .520 3.469 89.190
12 .514 3.429 92.619
13 .467 3.112 95.731
14 .366 2.442 98.173
15 .274 1.827 100.000
Extraction Method: Principal Component
Analysis.

This table reveal that first six component explain 65.57% of constrain of accessibility and
utilization. The first component explains 18.85% of events and second components explain
12.41% of events so the cumulative frequency for first and second event is 31.29%. similar way
third component explain 11.09% of events and forth component explain 8.6% of events; fifth and
sixth components explain 7.79% and 6.72% of event. So cumulatively these six components
explain 65.57% of event and to find out these six components we will go through componented
matrix.

36

Rotated Component Matrixa
Component
1 2 3 4 5 6
Amount charged for .842
Registration
Time Taken To .816
Deliver Smart Card
Reputation of .767
Hospital
Other Medical .719 .354
Facilities
Responsiveness of .507 -.308 -.375 .326
Hospital
Distance of Nearest .818
Empanelled Hospital
Connectivity of .324 .732
Hospital
Document Reqired for -.379 .536 -.432
Registration
Information .891
Regarding
Registration
Behaviour for .361 .600
Enrollmnet Staff
Detailed Information .625
RSBY
Extra Expenses .566
Occurred During
Treatment
Post Transaction .377 .305 .346 -.381
Balance Information
Distance of .729
Enrollment Center
Time taken for .482 .564
Registration
Extraction Method: Principal Component Analysis.
Rotation Method: Varimax with Kaiser
Normalization.
a. Rotation converged in 15 iterations.

This rotated component matrix provide the various attribute in these six different component
some attribute have correlation with more than one component so these attribute are in different

37

components so individually these attribute are more significant. On the basis of rotated
component matrix the following table arrange attribute in different component.
Component 1 Component-2 Component 3 Component 4 Component 5 ( Component 6 (
(Hospital (Accessibility (Scheme (registration Smart card Accessibility of
Services) of Hospital) Awareness) process limitation) registration)
limitation)
Reputation of Distance of Detailed Behavior of Amount charged Distance of
Hospital Nearest Information Enrollment for Registration Enrollment
Empanelled RSBY Staff Center
Hospital
Other Medical Connectivity Extra Information Time Taken To Time taken for
Facilities of Hospital Expenses Regarding Deliver Smart Registration
Occurred Registration Card
During
Treatment
Responsiveness Document
of Hospital Required for
Registration

Component are selected on basis of factor loading value more than 0.5 and larger the factor
loading value in case it exceed 0.5 in multiple components. So the first component includes the
attributes like reputation of hospital in which RSBY patient are treated with other hospitals in that
area, medical facilities in empanelled hospital, responsiveness of empanelled hospital so these
attribute combined form component that explain 18% of barriers in accessibility of RSBY
scheme. In similar way we can explain rest of the component 2,3,4,5 and 6.

4.4 Cluster Analysis
Eight variables in form statements in the questionnaire are taken into account during the
Psychographic segmentation of the customers of RSBY scheme beneficiaries. The variables are:
 Education Qualification of head of family
 Number of members in family
 Highest Education Qualification of any of family member
 Household Type
 Awareness Level
 Source of information for RSBY and Registration Process

38

 Distance of nearest empanelled hospital
 Frequency of using RSBY smart card for treatment
Final Cluster Centers
Cluster
1 2 3 4
Education Qualification of Head of 2 2 3 2
Family
Number of famiy members 2 2 2 2
Highest qualification of any 3 3 3 3
member
Household Type 2 4 2 3
Awareness Level 2 3 4 4
Source of Information 3 4 5 2
Distance of Empanelled Hospital 2 3 2 2
Frequency of using Smart Card 1 1 2 1

Each variable data is validated in scale of 1 to 5 (1=insignificant, 2=little significant, 3=
Moderately Important, 4= significant 5=most significant) in ordinal scale in the survey
questionnaire

The data run through SPSS package for Hierarchical cluster analysis, from the icicle plot,
agglomeration table and Dendogram (Appendix-2) it is observed that the customers forming three
clusters based on the following variables. Then by using K-Means method of Quick Cluster with
reference of three clusters the Final Cluster centres derived. The Segment characteristics are
defined according to the average value of variables given in form of statements.

Number of Cases in each Cluster Percent
Cluster 1 17 19.54
2 32 36.78
3 14 16.09
4 24 27.58
Valid 87
Missing 0

39

Demographic cluster 1

Number of families in this cluster: 17

Characteristic of cluster 1 is as follow:

Education Qualification of Head of Family is up to primary standard

Average number of member in family is between 3 to 5.

Highest qualification of any member in the family is up to matriculation.

The main occupation of family member is agriculture labor in this cluster

This cluster family has registered for the RSBY scheme and they also know about the empanelled
hospitals in their nearby areas

The members of this cluster get the information regarding RSBY scheme and registration process
through NGO personnel/ Panchayat official/ Block official/ Govt. officials

Distance of Empanelled Hospital from their home is 5-10 KM

Member of this cluster never used their RSBY smart card for treatment purpose



Education Qualification of Head of Family is up to primary standard

Number of family members is in between three to five

Highest qualification of any member is up matriculation

Main occupation of household is agriculture with own land

Awareness Level they are aware about registration process and total amount that can be used for
treatment purpose

They came to know about scheme and registration process through Doctor/ Hospital staff/
Aganwadi staff/ ANM

Distance of Empanelled Hospital is in between ten kilometer to twenty kilometer

They have never used RSBY Smart Card for treatment purpose

40



Education Qualification of Head of Family is up to the matriculation level

Number of family members in this cluster is in between three to five

Highest qualification of any member is up to the matriculation level

Household Type is agriculture labor

Members of this cluster are aware about the empanelled hospital nearby area and total amount
that can be used for treatment purpose

Source of Information is through loudspeaker announcement

Distance of Empanelled Hospital in between 5-10 KM from their village

Members of this cluster have taken the treatment from hospital through RSBY scheme and
frequency of using smart card is up to three times in a year

Demographic cluster 4:


Education Qualification of Head of Family is up to primary level

Number of family members is in between three to five

Highest qualification of any member is up to matriculation

Main occupation of family is labor in non agriculture

Member of this cluster are aware about nearby RSBY empanelled hospital and total amount that
can be used in treatment purpose

Source of Information about the scheme and registration is word to mouth

Distance of Empanelled Hospital from their village in between five to ten Kilometer

They never used their smart card for treatment

41

Chapter 5 Case studies, Inference and Constrain
Identified
In this chapter, the initial discussion will be focused on case studies/stories that reflect the benefit
and constrain of RSBY scheme, it also bring in the viewpoint of both positive and negative side.
Second part is to draw inference through these study and in third section identified constrain for
this scheme is described.

5.1 Case Studies
This section includes two case studies, First case study is of a beneficiary to get beneficiary
viewpoint and second case study is of hospital to get viewpoint of service provider.

5.1.1 Case study 1: Dhaneswar Rout
It is a case of agriculture labor namely Dhaneswar Rout, 36 years old, with a family of six,
including his wife and four children to support. He is residential of village Nuva Sahi in satyabadi
block of Puri District. His village, Nuva Sahi, is situated 4 KM from sakhi Gopal town. He got his
schooling upto 9th standard and his wife had completed primary education. His children are
currently undergoing schooling in the local educational institutions.

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He has enrolled under RSBY scheme in July, 2010 and he renewed this scheme in October, 2011.
During interaction with him, it was revealed that he didn‟t face any problem in registration for
scheme; he received smart card at the time of registration. In similar way he renewed this scheme
in 2011 without any hurdle of documentation. So registration process is easygoing and user
friendly, he only carry his BPL card at enrollment camp and he got registration and smart card.
He is quite satisfied with behavior of registration official, he told that they were quite cooperative
and process was less time taking.
When he was asked about from where he gets to know about this scheme, his reply was “From
loudspeaker announcement he came to know that a BPL family can get health card in Rs 30”. So
he went to registration camp and got smart card. After getting smart card, he was not aware about
the benefit of smart card, how to use this card and where to use this card. He was suffering from
hernia since last four year bur he didn‟t go for its treatment due to lack of money.
Then one day he went to medical shop for pain reliever medicine to get relieve from hernia pain,
during interaction with chemist he came to know about the benefit of scheme and he came to
know his family can avail up to Rs 30,000 treatment through this smart card and he also came to
know that his family can take go for surgical treatment with the help of this card without paying
expenditure of treatment. He was surprised; he couldn‟t believe on his ear at that time, he again
asked the chemist that what he has told is true? Chemist assured him and also gives the reference
of Gopinath Hospital, Saki Gopal, and told Mr. Dhaneswar that he can get treatment in this
hospital. Gopinath Hospital is just 4 KM from his home so going there and doing inquiry is not a
big issue for him so he went to Gopinath hospital for seeking treatment of Hernia.
But again there was setback for Mr. Dhaneswar, Gopinath Hospital staff told him that this
hospital provide treatment under RSBY scheme last year ( in year 2010-11) but this year they
didn‟t get permission for treatment under this scheme. When he asked about other hospital, from
where he can get treatment, the staff of Gopinath Hospital told about govt. hospital Sakhi Gopal
and Sanjeevani Hospital Puri. He doesn‟t have faith on govt. hospital so he decided to go at
Sanjeevani Hospital Puri for his Hernia surgical treatment.
In November 2011, he got successful surgery of Hernia and his ailment was cured due to RSBY
scheme. His was quite satisfied from the treatment at Sanjeevani Hospital and result of surgical
operation. Now he is completely cured from his disease and living life happily. He is very much

43

satisfied with this scheme now and he will take further treatment, in case it required, for his
family members too. He will renew this scheme next year too.
Inference: This case study reveal that how this scheme is very much beneficial for the poor
people those can‟t afford the expenditure of treatment and how this scheme transform the life of
poor family. Mr. Dhaneswar was suffering from a painful disease and didn‟t go for treatment due
to lack of money, if this scheme is not there he will continue to go suffer from the pain and
ailment so RSBY scheme relieved him from severe pain and chronic illness.
But the other aspect is that he got treatment after one year of getting smart card, he can avail same
treatment one year before if he was aware about the benefits of scheme. So awareness delayed his
treatment and there are lot of people like Mr. Dhaneswar who couldn‟t get benefit and still live
with their disease due to lack of proper knowledge and awareness.
Third point is there is gap between renew of empanelled hospital license for treatment under
RSBY scheme so people are confused this situation also happened with Dhaneswar when didn‟t
get treatment from Gopinath Hospital, if he wouldn‟t go for Sanjeevani Hospital, that is 20 KM
from Sakhi Gopal, he wouldn‟t get benefit so availability of nearby hospital is major issues in
availing the treatment and benefit of scheme
Forth, people don‟t have faith in govt. hospital they continue their suffering but don‟t go for govt.
hospital as they though no one bothers for their treatment I govt. hospital.

5.1.2 Case Study II: Spandhan Medical Center

Spandhan Medical Center

Omfed Road,Ganesh Bazar,Nimapara,Puri
Mr. B. P. Panda (Hospital Administrator)
Spandhan Medical center is one of the empanelled hospital in Puri district, it was empanelled in
June 2010 and in year 2010-11, it provide treatment around 180 patient. This hospital has very
good reputation in around area and people come after long travelling to avail the treatment from
this hospital. It is also one of three hospitals in Nimapada block that provide treatment to RSBY
beneficiary. This hospital has good infrastructure and medical facility like ECG, X-ray,
Laboratory facilities. So a lot of patient get benefit and get cured from the treatment of this

44

hospital. Due to good infrastructure and with availability of all the facilities it get the permission
to treat the patient under RSBY scheme in June 2010. So it started operation with RSBY patient
also and nearly 180 patient get treatments from this hospital, hospital got its bill reimbursed from
erstwhile insurer New India Assurance during year 2010-11.
As the patient get benefitted the number of RSBY patient increasing day by day due to word to
mouth publicity and it also helpful in increasing the awareness among BPL families as one
successful treated is good example in front of one village and lot of people in that particular
village are come to know about the benefit of scheme.
Everything is going fine; number of patient increasing, people came to know more about the
benefit of scheme. So more patient come for treatment but the hospital got the permission for 10
beds so he can‟t avail treatment for more than 10 patients in a single day although it has capacity
of 25 beds. So spandhan medical center applied for 20 beds but it didn‟t get permission to
increase its capacity. So some of the RSBY patient had to go back without getting treatment some
had to come many time to get the treatment. So dissatisfaction level among RSBY holder had
increased.
As patient were going back without getting treatment so hospital image was tarnished but hospital
administration didn‟t have any option except wait and watch. But another setback came when
Orissa govt. bid for insurance contract for year 2011-12, in year 2010-11 the insurer provider was
New India Assurance but in year 2011-12 ICICI Lombard won the bidding for Puri District and
started operation from July1, 2011. After stating the operation of ICICI Lombard they follow new
policy. They asked every empanelled hospital to stop treatment until they would not upgrade their
software because they are using advanced technology so if RSBY smart card was swapped with
old software, then they are unable to reimburse their bills. So every hospital stop treatment of
patient and patient disappointment increased, although there are some hospitals that get upgraded
software within one month, like Ananda Hospital, nimapada; few hospitals got this upgraded
software after 3-4 month like Seva Nursing Home, GOP. And there are few hospitals that are still
waiting for their upgraded software like Spadan Medical Center.
Spandhan Medical Center is classical case, where hospital has every infrastructure for treatment
but they are not getting permission due to lackadaisical attitude of insurance company. The
hospital density is already thin in Orissa and if these type of case happen then worst affected were
beneficiary of scheme. If we take the case of Nimapada district, there is three private empanelled

45

hospitals on RSBY website for RSBY treatment but only one hospital is functional and total no of
registered people under this scheme is 407663 so treating 407663 person through one private
hospital is impossible task.
Inference: from this study it can be reveal that there is scarcity of hospital that are empanelled
under this scheme. And few that are eligible and empanelled are not functional so RSBY patient
has to travel a lot to get treatment and most of the time they were disappointed due to
unavailability of bed in hospital and sometime they found that treatment is not available in
particular hospital, they confused more and believe on this scheme decrease. Although awareness
level is quite low, if it would be high then also, they did not get treatment due unavailability of
hospital bed. So increase the number of bed and proper monitoring is upmost factor to avail the
treatment for everyone. There is some where not a single private hospital function for RSBY
scheme.

5.1.3 Constraints Identified:

1. Low awareness among the beneficiaries partly because of their illiteracy, ignorance and
partly because registration team didn‟t explain the procedure and benefits well so the
villagers are in dark about their benefits and entitlements under the Scheme.
2. The scheme is not fully operable in remote areas; Distance of empanelled hospital from
villages is very far in the remote areas, so to get treatment they have to travel a very long
distance.
3. There is very few number of RSBY empanelled hospital in area. In Puri district, there is
only 26 empanelled hospitals that has to 13176 enrolled families. So the total overall ratio
of hospital is very low for RSBY scheme. In parallel these hospital also provide treatment
to other patient so effective number of bed for these hospital is also less.
4. People are not getting very good response from public hospital and they prefer to go in
private hospital. So the perception of people for treatment in government hospital is not
good. This is the reason, private hospital that are operating under RSBY scheme are
crowded.

46

5. People are more inclined toward getting treatment from private hospital, but the number of
empanelled private hospital are very less, only eight private hospitals in Puri district are
empanelled under this scheme.
6. There is discontinuation of scheme and some time hospital refused to provide treatment
and delay treatment, this also de-motivated the villages as they travel so much and
wouldn‟t get any treatment. So come again without any guarantee of treatment discourage
villagers to use this scheme

47

Chapter 6 Key Findings, Recommendation and
Conclusion

6.1 Key Findings

1. Rashtriya Swasthya Bima Yozna provide the benefit to five member in a family, if there is
more than five member in a family, Head of family has to select five member so only
these members can get benefitted from this scheme. This study reveal that 41.4% of
sample families have more than five members so this is not sufficient to cover all the
family members health insurance
2. This study finds that 57.4% of head of family has education level below primary standard
so illiteracy also plays constrain for awareness spread and utilization of scheme. But the
good sign is that only 9.2% of family have education level up to primary rest of 90.8%
families have at least one member in family is more educated than primary standard. So
overall literacy level is increased so now it is easy for spreading awareness as new
generation is more literate.
3. Beneficiary of this scheme is divided into five category in this study, and result of this
study reveal that major chunk of beneficiary around 48 % are labor those are associated
with agriculture and non agriculture. Second category come of household those major
source of income is agriculture they contribute 33% of population. So if this scheme
implement according to plan the labor class will get more benefit.
4. For 47% of surveyed household the distance of nearest hospital is more than 10 KM from
their village. So accessibility of hospital is major issue for people. Only 24% of household
has empanelled hospital under five kilometer of range.
5. Only 12.6% of household completely understand the procedure involve in this scheme.
Others have only basic knowledge about this scheme, and 5.7% of household only
registered they don‟t know what is this scheme all about. So awareness issue should be
taken into consideration.
6. Loudspeaker announcement is major source for information regarding registration process
and awareness for scheme. Loudspeaker announcement carry 35% chunk in all the source

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Awareness, Accessibility and Barriers in Utilization of Rastriya Swasthya Bima Yozna Services among BPL Families in Puri District, Odisha

Awareness, Accessibility and Barriers in Utilization of Rastriya Swasthya Bima Yozna Services among BPL Families in Puri District, Odisha

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Awareness, Accessibility and Barriers in Utilization of Rastriya Swasthya Bima Yozna Services among BPL Families in Puri District, Odisha