Evidence into Public Health Policy (EPHP-2016), 2rd National conference on bringing Evidence into Public Health Policy (EPHP 2012)

Font Size: 
Challenges in attaining Universal Health Coverage (UHC): Empirical findings from RSBY in Chhattisgarh
Sulakshana Nandi, Dr. Rajib Dasgupta, Kanica Kanungo, Dr. Madhurima Nundy, Dr. Ganapathy Murugan

Last modified: 2012-07-22


Description of the problem

The Rashtriya Swasthya Bima Yojana (RSBY) is aimed at protecting families below poverty line (BPL) against catastrophic health expenses; increasing their access to healthcare and expanding choice of providers[1].

Our recent studies in Chhattisgarh were aimed at examining the implementation and design issues; whether the objectives are being fulfilled particularly in the context of marginalized communities and underserved areas as it is being promoted as the model and vehicle for universal access to health care.


This paper puts together the evidence from three studies undertaken in Chhattisgarh in 2011-12. The studies and their methodologies are as follows:

  1. A quantitative study on RSBY enrolment in 270 villages (18 Districts)[2]. Data was collected through a village level questionnaire.
  2. A qualitative study on the design issues through mapping provider perspectives. Providers were interviewed in three districts (in the second phase of RSBY implementation) and included private for-profit (small 10-20 bedded nursing homes and multi-specialty corporate hospitals), public (medical college, district and sub-district hospitals) and not-for-profit (low-cost and Christian missionary) institutions, as well as interviewed state-level administrators.
  3. A quantitative study on access of Particularly Vulnerable Tribal Groups (PTGs) to health and nutrition services[3]. 1200 families from Baiga, Kamar, Pahari Korwa communities were studied through a household questionnaire.

Main findings

Very low enrolment and usage in remote villages and among vulnerable communities, instances of denial, lack of transparency and sharing of information with beneficiaries and high out of pocket expenditure were common findings of the quantitative studies. Only 32% of the PTG families were enrolled of whom 4% had used the card.

Private empanelled facilities were providing narrow and selective range of services and picking and choosing more profitable conditions/packages, though experiencing an increase in case load.

Public hospitals reported decline in patients, and a shift to the private sector. CHCs and PHCs were unable to compete with private hospitals in better-off areas but reported higher numbers of beneficiaries in tribal blocks. They were mostly treating common medical conditions with few surgical conditions/procedures. Patients were often being admitted for OPD-level conditions.

Package rates were not sufficient for complications requiring long stay or expensive medication; both public and private providers were performing few high-end procedures.

Not-for-profit hospitals, providing a relatively large range of services like medical conditions, surgeries, orthopedic procedures and chemotherapy, reported increase in case loads and some cost-cutting measures, without compromising on quality.

Settlement/rejection of claims seemed ad hoc and providers adopted ‘defensive’ (sometimes corrupt) practices against losses.

Discussion including recommendations

The study shows that RSBY is far from achieving complete coverage and the most vulnerable communities are being left out. There is no guarantee of services for the poor. The poor is not being protected from catastrophic expenditure as high end procedures are very few. There is huge advantage for private nursing homes with increased turnover and incomes as they are ‘cherry picking’ conditions and patients. Not-for-profit hospitals are providing largest range of services. The public health system is unable to compete and is weakening. Costs of care for medical conditions are being artificially inflated.

There is need for a strong monitoring and grievance redressal mechanism, including transparency during empanelment. Time-bound settlement of claims needs to be ensured through penalties for delays. System for referral and complications need to be evolved and cost for high end packages needs to be revised and made realistic.

Emphasis of UHC should be on strengthening of public health system and building its capacity for regulation of private sector. There needs to be a focus on exclusion rather than on inclusion errors and free health services need to be guaranteed. Only then can UHC be achieved.

[1] Swarup A. and Jain N. (Undated). Rashtriya Swasthya Bima Yojana - A Case Study from India


[2] JSA Chhattisgarh and PHRN

[3] http://www.phrnindia.org/our_work/research_advocacy.html