The Socioeconomic and Institutional Determinants of Participation in India’s Health Insurance Scheme for the Poor

Abstract

The Rashtriya Swasthya Bima Yojana (RSBY), which was introduced in 2008 in India, is a social health insurance scheme that aims to improve healthcare access and provide financial risk protection to the poor. In this study, we analyse the determinants of participation and enrolment in the scheme at the level of districts. We used official data on RSBY enrolment, socioeconomic data from the District Level Household Survey 2007–2008, and additional state-level information on fiscal health, political affiliation, and quality of governance. Results from multivariate probit and OLS analyses suggest that political and institutional factors are among the strongest determinants explaining the variation in participation and enrolment in RSBY. In particular, districts in state governments that are politically affiliated with the opposition or neutral parties at the centre are more likely to participate in RSBY, and have higher levels of enrolment. Districts in states with a lower quality of governance, a pre-existing state-level health insurance scheme, or with a lower level of fiscal deficit as compared to GDP, are significantly less likely to participate, or have lower enrolment rates. Among socioeconomic factors, we find some evidence of weak or imprecise targeting. Districts with a higher share of socioeconomically backward castes are less likely to participate, and their enrolment rates are also lower. Finally, districts with more non-poor households may be more likely to participate, although with lower enrolment rates.

Understanding public health insurance in India: A design perspective

“…The first‐generation PHIs (except CGHS) identified beneficiaries though surveys; however, it lacked incentives to enroll them, and therefore, even after five decades, the coverage was limited . The second‐generation PHIs had incentives to enroll beneficiaries, but they relied on poverty registers that had extensive errors, resulting in the well‐off, educated, and politically connected getting enrolled rather than the socially disadvantaged groups from poorly developed areas . The third‐generation PHIs have improved the effectiveness of the targeting mechanisms by using a new poverty register, verification by field‐level workers, and engagement of nonprofit agencies.…”

Towards universal health coverage in India: a historical examination of the genesis of Rashtriya Swasthya Bima Yojana – The health insurance scheme for low-income groups

“…While private sector participation may be helping reduce patient overload at public facilities, studies also reveal a negative impact on public sector revenues as patients are drawn in greater numbers to private providers. 9 Furthermore, RSBY is also proving more popular with smaller providers vis-a-vis multispeciality providers that are better equipped to treat severe illnesses of greater catastrophic impact for patients. 9 In under-resourced settings with scarce regulation of private sector providers, policymakers may hence need to apply innovative tools and various performance incentives to improve private service delivery.…”

“…As arguably the largest publicly funded national health insurance scheme in the world targeting the poor, there is a growing literature evaluating the RSBY's performance in terms of user awareness, enrolment and utilisation patterns, 8,9 service quality assessments, 8,9 and financial protection goals. 10,11 While earlier studies have produced new evidence on the performance of RSBY, there is little research focussing on the RSBY's historical evolution and genesis: 12 evidence which would be useful to policy makers designing similar programmes for poor populations.…”

Improving Health Outcomes and Health Care in India

“…Districts with a higher share of socioeconomically disadvantaged groups are less likely to participate in the RSBY and their enrolment rate is lower (Nandi et al, 2013). Identifying families living below poverty line (BPL) families is also a crude process, an issue affecting a number of social schemes.…”