Uncovering Coverage: Utilisation of the Universal Health Insurance Scheme,Chhattisgarh by Women in Slums of Raipur

Abstract

In 2013, the National Urban Health Mission (NUHM) was rolled out to effectively address health concerns of the urban poor population. In the last decade, there has been a spate of publicly funded insurance schemes, prominent amongst them being the Rashtriya Swasthya Bima Yojana (RSBY). In 2012, the Government of Chhattisgarh expanded the RSBY into a new avatar, the Mukhyamantri Swasthya Bima Yojana (MSBY), thereby universalising health insurance coverage. This study was conducted in the slums of Raipur, the capital and largest city of Chhattisgarh, with the objective of assessing issues of coverage and utilisation in these areas. The specific focus was on issues of women’s medical conditions and the experiences of women beneficiaries during enrolment in these schemes.

Keywords

Urban health publicly funded insurance universal health coverage commercialisation out-of-pocket expenditure

Introduction

A rapidly increasing Indian urban population, specifically the urban poor, struggles for and pays relatively high amounts for basic services, including housing, water, sanitation and health, a phenomenon termed as ‘informal survivalism’ (Davis, 2006). Public investments in health and other social sectors have not been proportionate to rapid urban growth (Technical Resource Group [TRG] for National Urban Health Mission [NUHM], 2014). While the ‘urban advantage’ is seen in better aggregate health indicators for these populations, they are often worse off than the rural poor (NUHM, 2013; TRG for NUHM, 2014). The urban poor and vulnerable groups pay the ‘urban penalty’ (Rice & Rice, 2009). They often incur a relatively higher health care expenditure or are pushed towards untrained and unlicenced providers (Das & Hammer, 2007). Further, women are more likely to consult private providers than public health care providers (Das & Hammer, 2007; TRG for NUHM, 2014). According to the National Sample Survey Organisation (NSSO) 60th Round, in 2004, 5 per cent of total urban households slipped into below the poverty line (henceforth BPL) status as a result of total health care expenditure—1.2 per cent and 3.8 per cent due to expenditure on inpatient care and outpatient care respectively. In terms of income quintiles, the second poorest quintile in urban areas is most affected by expenses on health care (TRG for NUHM, 2014).

The NUHM was launched as part of the National Health Mission (NHM) to effectively address health concerns of the urban poor, particularly slum dwellers, by making available to them essential primary health care services through various measures, of which insurance is one of the preferred and promoted strategies. A number of publicly funded insurance schemes have been introduced in the last decade, the most prominent amongst them being the Rashtriya Swasthya Bima Yojana (RSBY) or the National Health Insurance Scheme, specifically designed for BPL population.

A fair number of studies have examined issues related to implementation of the scheme, beneficiary experiences and gaps at the policy level. Earlier research on the RSBY in Chhattisgarh has focused on design issues, coverage challenges and beneficiary experiences (Chaupal Gramin Vikas Prashikshan Evum Shodh Sansthan [Chaupal], 2013a, 2013b; Dasgupta et al., 2013; Nandi et al., 2012). In the current study, we build upon our methodologies and grounded understanding to assess issues of coverage and utilisation in the urban slums of Raipur, with a specific focus on issues of women’s medical conditions. Simultaneously, it seeks to understand claims of universal health coverage (UHC) through the insurance route. Chhattisgarh offers a ‘natural experiment’ scenario in this context. In addition to RSBY, the state government launched the Mukhyamantri Swasthya Bima Yojana (MSBY) or the Chief Minister’s Health Insurance Scheme in 2012 for non-BPL families with identical provisions as the RSBY,¹ thereby universalising health insurance coverage.

Literature Review

A review of available literature on publicly funded insurance schemes in India was undertaken under the broad themes of enrolment, utilisation and out-of-pocket expenditure (OOPE). An attempt was made to understand these aspects through a gender lens. We found that there is a dearth of relevant literature other than that related to enrolment and inappropriate care (namely, the prominent issue of unnecessary hysterectomies) (Kapilashrami & Venkatachalam, 2013).

Enrolment

The gender bias in enrolment was found to be nuanced. Grover and Palacios (2011) in their study in Delhi found that, overall, females were less likely to enrol than males; however, they also found that as age increases, so does the probability of women enrolling, with a reverse trend for men.

Analysing enrolment figures for Chhattisgarh, Sun (2011) did not find any gender bias in current figures. However, the daughter in a family had a higher likelihood to be included if there was no cap of five members for enrolment; with the cap, sons had a higher chance of being included. Other authors (Das & Leino, 2011; Rajasekhar, Berg, Ghatak, Manjula & Roy, 2011) noted that common reasons for non-enrolment under RSBY included: no prior information; inability to attend enrolment sessions; computer or power failure; disruption at enrolment camps; and problematic BPL lists (erroneous names of household members, head of household missing from the list and if the head of household was ill or deceased, whole households being prevented from enrolment). The official assessment of the enrolment process for RSBY and MSBY in four districts of Chhattisgarh observed that the main reasons for non-enrolment were: potential beneficiaries were not present in the village, did not apply or had long waiting periods (Centre for Tribal and Rural Development [CTRD], 2013). The majority of enrolled families were not given requisite documents with smart cards; only 13 per cent were provided with the list of empanelled facilities. Within the districts, about half the enrolled people received the card on the day of enrolment (as is the rule), while the rest received it later (CTRD, 2013).

Utilisation

In selecting a hospital, an evaluation of RSBY in Chhattisgarh (Ibid.) found that proximity to place of residence (38 per cent), referral by friends, relatives or doctor (37 per cent), familiarity with the facility (10 per cent), and lack of any other empanelled facility nearby (9 per cent) were the principal determinants of choice. Lack of information regarding empanelled hospitals emerged as a major reason for low utilisation (Ibid.).

La Forgia and Nagpal (2012) found a predominance of surgical procedures in inpatient packages (96 per cent). The highest number of packages (60 per cent) was for cardiology, neurosurgery, nephrology, orthopaedics, oncology and general surgery, with the least number of packages (9 per cent) for paediatrics and obstetrics and gynaecology. Significantly, Grover and Palacios (2011) found that in Delhi, where only private hospitals are participating in the RSBY scheme, patients with ‘complicated’ conditions requiring expensive medicines were being ‘actively discouraged’.

In terms of hospitalisation and utilisation of insurance in Chhattisgarh, Jain (2011) found that men had a higher hospitalisation rate (1.17 per cent) under RSBY than women (1.10 per cent). In contrast, Grover and Palacios (2011) noted that more women were hospitalised under RSBY than men in Delhi, an exception compared to most states.

There is emerging evidence showing the push towards hospitalisation for simple conditions and unnecessary surgical procedures, particularly in the private sector (Kapilashrami & Venkatachalam, 2013; La Forgia & Nagpal, 2012). Women are more vulnerable to these processes. La Forgia and Nagpal (2012) highlighted ‘producer-induced demand’ and documented examples of combining hernia with appendectomy or private facilities carrying out unnecessary hysterectomies (Nundy, Dasgupta, Kanungo, Nandi & Murugan, 2013). This trend points towards ‘over-investment in tertiary care and expensive technologies at the expense of investments in ambulatory care, prevention, and coordinated networks’ (La Forgia & Nagpal, 2012, p. 58). Under the Arogyasri scheme, a higher proportion of surgeries was being conducted in the private sector (83 per cent) than in the public sector (17 per cent) (Prasad & Raghavendra, 2012). Further, private hospitals preferentially treated the more ‘financially remunerative’ cases, while the high-risk cases were sent to public hospitals. They also got informal practitioners to refer hysterectomies for poor women who had gynaecological problems. Selvaraj and Karan (2012) cautioned that prevention was being undermined and simple ailments turned into hospitalisation episodes. Palacios (2011) reported non-payment of transportation allowance to the hospitalised RSBY beneficiaries. This highlights issues of transparency and information to the beneficiary; a large number of persons were not aware of the amount deducted from their insurance cards (Nandi et al., 2012).

Studies from Chhattisgarh showed that private facilities selectively admitted more profitable clinical cases under RSBY (Dasgupta et al., 2013). An evaluation of RSBY in Chhattisgarh, commissioned by the state government, noted that private hospitals did not follow mandatory procedures and have ‘commercialized’ the scheme (CTRD, 2012, p. 150).

Financial Risk Protection/Out-of-Pocket Expenditure

A core objective of publicly funded insurance schemes is to ensure cashless hospitalisation care, thereby promoting financial risk protection and avoiding catastrophic OOPE;² there was little positive evidence emerging on this account. Grover and Palacios (2011) noted that a third of the beneficiaries incurred OOPE; about half of them incurred expenditure on medicines. Several studies have shown that beneficiaries incurred OOPE even while accessing these insurance schemes (Grover & Palacios, 2011; La Forgia & Nagpal, 2012; Palacios, 2011). In Karnataka, patients were asked to pay upfront in RSBY empanelled institutions and the hospital reimbursed them once the insurer credited the amount to the hospital (Rajasekhar et al., 2011). Under the Vajpayee Arogyasri insurance scheme in Karnataka, eligible families incurred a high average OOPE, though lower than non-eligible families (Sood et al., 2014). In Durg district, Chhattisgarh, Nandi et al. (2012) found that 58 per cent of the respondents in the private sector and 17 per cent in the public sector incurred OOPE at an average rate of ₹ 1,078 and ₹ 309 respectively. This was corroborated by the state’s evaluation as well (CTRD, 2012). Selvaraj and Karan (2012) found that despite publicly sponsored insurance, expenditure on hospitalisations has increased in rural and urban areas with a rise in catastrophic headcount, confirming findings from other studies (Wagstaff & Lindelow, 2008; Wagstaff, Lindelow, Junc, Ling & Juncheng, 2009).

Study Site

Chhattisgarh ranks second amongst all Indian states in terms of the proportion of urban slum population (31.9 per cent) and Raipur ranks sixth among cities with the highest slum population (nearly 40 per cent) (Raipur Municipal Corporation [RMC], n.d.). There are 282 slums listed in Raipur city, with more than 80,000 households. This study was conducted in slums of 45 urban wards of Raipur, the capital and largest city of Chhattisgarh.

The total number of families enrolled under RSBY and MSBY in the state is 2.14 million and 1.67 million respectively (Department of Health and Family Welfare, Chhattisgarh, 2014a). In Raipur district, enrolment is 57 per cent, this data is not available for Raipur city separately. Raipur has the highest number (136) of empanelled facilities (private and public hospitals) of the total number of empanelled hospitals (628) in Chhattisgarh; 56 per cent of these are in the private sector. Significantly, 93 per cent of the empanelled facilities in Raipur city are in the private sector. According to the available data, private facilities made 62 per cent of the total number of claims, amounting to an average claim amount of ₹ 7,532 (Department of Health and Family Welfare, Chhattisgarh, 2014b). On the other hand, public facilities made an average claim amount of ₹ 4,443. Private facilities in Raipur district accounted for 80 per cent of the claims, with an average claim amount of ₹ 7,291, and the average claim amount by public facilities was ₹ 4,662. Significantly, 72 per cent of the rejected claims in the district were from the public sector.

Study Objectives and Methodology

The aim of this study is to understand the extent to which women in urban slums are able to access the intended benefits of the Universal Health Insurance Scheme (UHIS) for hospitalisation care in public and private health facilities. It includes the following objectives:

assess coverage of women under UHIS in terms of enrolment, medical conditions and utilisation;

estimate the extent to which cashless treatment is available under UHIS and OOPE that is being incurred; and

compare differences in various costs between the public and private health facilities.

Secondary data were collected from the websites of the state health department and national RSBY. Primary data were collected from a sample of individuals who were hospitalised in the last six months prior to the study (recall period). In order to select the sample, 50 (urban) Mitanins or community health workers (CHWs) were selected through simple random sampling out of 1,010 Mitanins in Raipur city. The sampled Mitanins were asked about all hospitalisations in the last six months in the respective populations that they serve and a line list was drawn up. The surveyors interviewed all the listed cases and additionally, the snowball technique was used to expand the sample size.

Under the Mukhyamantri Sheheri Swasthya Karyakram, one Mitanin covers approximately 500 members of a slum population. It was expected that as the rate of hospitalisation/population, as per NSSO 60th Round, is 2.4 per cent in 365 days, that is, 1.2 per cent in six months, the slum population covered by 50 Mitanins (that is, 25,000) would provide at least 300 respondents. The number of families finally sampled was 323. The total number of patients interviewed from these families was 367 (284 females and 83 males). This article documents the experience of women patients. In the current analysis, data on two women patients were removed as they had accessed health facilities outside the state. A three-part structured interview schedule³ was used to capture the data.

Findings

Demographic and Socio-economic Characteristics of the Female Patients

The highest proportion of female patients belonged to the Other Backward Classes (OBCs) (65 per cent), followed by Scheduled Castes (SCs) (17 per cent), general category (13 per cent) and Scheduled Tribes (STs) (4 per cent). The highest percentage (85 per cent) of such patients was in the age group of 18–45 years. Eight per cent were below 18 years of age, while 7 per cent of the women were above 45 years of age. The main sources of income for the families of the women patients were: labour (47 per cent); service (30 per cent), generally in the informal sector; and small business/self-employment (19 per cent). More than half (56 per cent) of the families of the women patients were entitled to receive highly subsidised grain, while 19 per cent did not have a ration card.

Around 54 per cent resided in pucca houses, 26 per cent in semi-kuchha units and 21 per cent in kuchha units. The main source of drinking water was tap connections (85 per cent). While 34 per cent of the families had a private tap, 51 per cent had access to a public drinking water source. Nearly 99 per cent of the families had an electricity connection at home. For 20 per cent of families, there was no toilet facility; 64 per cent had access to a private toilet; and 16 per cent had to use a public toilet. Families mainly used gas (56 per cent) and wood (38 per cent) as cooking fuel. This profile corresponds well with census data and that of the slum population surveyed in the urban baseline survey on health by the State Health Resource Centre (SHRC), Chhattisgarh, thus confirming a fair degree of representativeness (SHRC, 2013).

Enrolment

Sixty-six per cent of the family members of the sampled (323) households were enrolled in the health insurance schemes. The overall enrolment showed the marginal gender differential; a slightly higher percentage of women (68 per cent) was enrolled than men (65 per cent). Disaggregated by age, in the 6–18 years age group, more boys (81 per cent) were enrolled than girls (74 per cent). In the age group above 45 years, a slightly higher percentage of men (90 per cent) was enrolled than women (88 per cent) (Table 1).

Of the 282 women patients in the sample, 57 per cent reported that their families were enrolled. Disaggregated by social categories, enrolment patterns conformed to the expected social gradient: highest among the general category (63 per cent), followed by SCs (57 per cent) and OBCs (57 per cent). Lowest enrolment was reported among the STs (44 per cent). Of the families who were enrolled, enrolment under RSBY (42 per cent) and MSBY (43 per cent) was nearly the same; 15 per cent could not confirm under which particular scheme they had enrolled. They were included in the enrolled category and data on them was analysed, as they were able to answer all the other questions related to enrolment and benefits.

Reasons for non-enrolment were reported to be: not having information regarding the enrolment drive (35 per cent); name missing from the list (16 per cent); certain family members being unavailable at the time of the enrolment drive (13 per cent); and being unaware of the scheme (10 per cent). Eight per cent reported not receiving the card despite enrolment. Other reasons included being refused enrolment, not having an identity card and not interested in enrolling.

Year of Enrolment and Renewal

Among the enrolled families, 57 per cent had enrolled in 2013 for the first time, while 24 per cent had first enrolled in 2011. Of the families who had enrolled in 2013, 69 per cent were MSBY card holders, while 17 per cent were RSBY card holders and the rest were not aware of the type of card. Significantly, of the 65 families enrolled before 2013, only 46 per cent had renewed their card in 2013. Though reasons for non-renewal were not asked in this study, some other studies have investigated this aspect (CTRD, 2012, 2013).

Time Taken for the Smart Card to be Issued

Of those enrolled, 57 per cent received the insurance smart card on the day of enrolment (the norm), 31 per cent between one and five days and another 8 per cent within 15 days. For enrolment, families paid an amount of ₹ 30 and of the enrolled persons, 97 per cent reported paying the requisite amount. It is stipulated that the list of empanelled hospitals has to be given along with the smart card, though only 5 per cent reported receiving it.

Table 1.

Enrolment Status by Gender and Age Groups of the Respondents

Age Group of the Respondents (years)	Female Respondents		Male Respondents		Total
Age Group of the Respondents (years)	Enrolled in Family Card (per cent)	Not Enrolled in Family Card (per cent)	Enrolled in Family Card (per cent)	Not Enrolled in Family Card (per cent)	Enrolled in Family Card (per cent)	Not Enrolled in Family Card (per cent)
0–1	9	91	7	93	8	92
1–6	64	36	59	41	61	39
6–18	74	26	81	19	77	23
18–45	76	24	74	26	75	25
45 and above	88	12	90	10	89	11
Total	68	32	65	35	66	34

Source: Computed by authors on the basis of survey data.

Hospitalisation

Conditions for Which Women Were Hospitalised

Around 78 per cent of women were hospitalised for obstetrics and gynaecological conditions and 22 per cent for non-gynaecological conditions. Out of the total obstetrics and gynaecological conditions, 72 per cent of women were admitted for childbirth. Among men, respiratory conditions and water/food-borne diseases (including jaundice and typhoid) were the most common conditions for hospitalisation. Table 2 details the profile of conditions under which female and male respondents were hospitalised.

Which Facilities Did Women Use?

Around 57 per cent of women accessed public sector facilities for the conditions reported, 37 per cent accessed the private sector and 5 per cent accessed both. A higher proportion of women whose families were not enrolled went to the public sector for all conditions. While women accessed the public sector more for pregnancy (63 per cent) and other gynaecological conditions (76 per cent), the trend was the opposite for non-gynaecological conditions. Fifty-five per cent accessed the private sector.

Facility Type by Condition

A total of 325 visits were made by the sample of 282 women during the recall period. Of the total visits, 234 (72 per cent) visits were to a facility empanelled under UHIS. While most of the public facilities visited were empanelled (90 per cent), just about half (47 per cent) of the private facilities used were empanelled under UHIS. The main reasons for selection of facility were: familiarity with the facility (38 per cent); suggestion or referral by someone (46 per cent); and proximity to place of residence (6 per cent). More than half the women (58 per cent) went to the public sector because somebody had suggested that they should go there, or referred them, and 50 per cent of women going to the private sector reported that they usually accessed that particular facility. ‘Choice’ of a provider,⁴ one of the hallmarks of the insurance schemes, seemed to be a determinant for only 8 per cent of women going to the public facility and for 5 per cent of women going to the private facility. A higher proportion of visits were made to empanelled public facilities than to private facilities. While 58 per cent of the visits to private facilities were to an empanelled one, 42 per cent of the visits were to a non-empanelled facility (Table 3). Out of 325 visits, empanelment status for 12 facilities could not be determined.

Table 2.

Conditions under Which Female and Male Respondents Were Hospitalised

Conditions for Hospitalisation	Hospitalised Respondents
Conditions for Hospitalisation	Female (n)	Female (per cent)	Male (n)	Male (per cent)	Total (n)	Total (per cent)
A. Pregnancy related	205	72	–	–	205	56
Delivery	202	71	–	–	202	55
Miscarriage/ANC	3	1	–	–	3	1
B. Other gynaecological	17	6	–	–	17	5
Uterus problem	3	1	–	–	3	1
Tubectomy	14	5	–	–	14	4
C. Non-gynaecological	62	22	83	100	145	40
Accident	1	0	2	2	3	1
Respiratory diseases	5	2	10	12	15	4
Weakness/anaemia/malnutrition	5	2	3	4	8	2
Cancer	3	1	0	0	3	1
Cataract	5	2	6	7	11	3
Diarrhoea and vomiting	7	2	5	6	12	3
Fever/malaria/dengue	3	1	3	4	6	2
Fracture	6	2	4	5	10	3
Heart related	3	1	5	6	8	2
Gastroenteritis	1	0	6	7	7	2
Mental illnesses	0	0	1	1	1	0
Paralysis/nerve/brain related	1	0	6	7	7	2
Sickle cell disease	3	1	1	1	4	1
Tuberculosis	1	0	4	5	5	1
Jaundice/typhoid	5	2	10	12	15	4
Leprosy	1	0	0	0	1	0
Appendicitis/Appendicectomy	1	0	2	2	3	1
Burns	2	1	0	0	2	1
Hernia	0	0	2	2	2	1
Hydrocele	0	0	2	2	2	1
Kidney problem	3	1	1	1	4	1
Pancreatitis	0	0	1	1	1	0
Others	6	2	9	11	15	4
Total (A + B + C)	284	100	83	100	367	100

Source: Computed by authors on the basis of survey data.

Note: ANC: antenatal care.

Utilisation of the UHIS

About a fifth (21 per cent) of the sampled beneficiaries were able to use the insurance card at least once for treatment during the recall period. Of the women who had insurance cards (161), only about a third (36 per cent) used it for treatment. Of the men who had insurance cards (51), 41 per cent were able to use it for treatment at least once during this period. For women, the card was least used for pregnancy-related conditions (33 per cent) and most for non-gynaecological conditions (44 per cent). In terms of visits to facilities, 18 per cent (59 women) of the total 325 visits to facilities involved usage of insurance cards. On disaggregating the data into utilisation of public and private providers (Table 4), the usage of cards was found to be higher for the private sector (49 per cent) for all conditions when compared to the public sector (24 per cent).

One major reason for no card use was that families did not have cards. For women who had cards, the reasons for not using are given next. Among those who underwent hospitalisation, 50 per cent of them were not enrolled for either scheme and therefore did not have cards. This is significant considering that the ‘universal’ insurance scheme receives considerable commitment and support from the state. Of women accessing the public sector, 16 per cent reported that the hospital did not ask for the card and another 13 per cent reported that the card had not been renewed. The principal reason for non-utilisation of the card for those accessing private institutions was that the hospital was not empanelled. In 7 per cent of cases, the patient was not enrolled on her family’s card. In 2 per cent of cases in public facilities and in 7 per cent of cases in private facilities, the hospital refused treatment under the insurance scheme; the reasons were not shared with the patient and the family (Table 5).

Table 3.

Choice of Empanelled versus Non-empanelled Facilities*

Enrolment Status	Public Health Facilities		Private Health Facilities		Combined
Enrolment Status	Empanelled	Non-empanelled	Empanelled	Non-empanelled	Empanelled	Non-empanelled
Enrolled	97	3	58	42	78	22
Not enrolled	89	11	33	67	70	30

Source: Computed by authors on the basis of survey data.

Note: * Number of women patients.

Table 4.

Utilisation of Insurance Cards in Public and Private Health Institutions*

Conditions for Utilising Health Insurance Cards	Type of Health Facilities
	Public		Private		Went to Both		Combined
	Card Used at least Once by Card Holder	Card Not Used by Card Holder	Card Used at least Once by Card Holder	Card Not Used by Card Holder	Card Used at least Once by Card Holder	Card Not Used by Card Holder	Card Used at least Once by Card Holder	Card Not Used by Card Holder
Pregnancy related	23	77	48	52	33	67	33	67
Other gynaecological	0	100	100	0	0	0	25	75
Non-gynaecological	35	65	48	52	50	50	44	56
Total	24	76	49	51	43	57	36	64

Source: Computed by authors on the basis of survey data.

Note: * Number of women patients.

Table 5.

Reasons for Non-utilisation of the RSBY/MSBY Cards

Reasons for Not Using Card	Type of Health Facilities
Reasons for Not Using Card	Public (%)	Private (%)	Combined (%)
No smart card	55	42	50
Hospital staff did not ask for smart card	16	7	12
Card was not renewed	13	6	10
Services under RSBY/MSBY card not provided there	0	22	9
Patient not registered under smart card	7	7	7
Hospital authority refused to treat under RSBY/MSBY smart card	2	7	4
Others	6	7	6
Don’t know	0	4	1
Total	100	100	100

Source: Computed by authors on the basis of survey data.

Utilisation of UHIS by Card Holders in Empanelled Facilities

Out of the total number of visits to empanelled facilities (234), 61 per cent had cards. Of these card holders who went to an empanelled facility, only 41 per cent could use the card for treatment. Card usage in empanelled private facilities (71 per cent) was higher than in empanelled public facilities (25 per cent). The reasons for non-utilisation of cards in empanelled facilities were that either the card was not renewed or the hospital did not ask for the card. The latter was more so in the case of public facilities. Nearly two-thirds of women with cards were not aware of the toll free number for complaints and grievance redressal; only one woman had filed a complaint. The usage was least for gynaecological conditions and highest for non-gynaecological conditions.

Amount Booked in Smart Card by Facility

Fifty-nine per cent of the women who used cards were informed of the amount booked from the card. For the 35 women who were informed about the booking amount, the average amount booked per hospitalisation for non-gynaecological conditions was the highest—around ₹ 10,500. The amount booked in the private facilities was more than double the amount booked in public facilities for these conditions. Of women who used the card, receipt of the booked amount was given to only one-third (32 per cent). In the private sector, more women received the receipt (39 per cent) than in the public sector (22 per cent). The smart card was returned to 25 per cent of the women the same day, while another 53 per cent received it within five days. Only 10 per cent of the women were paid/reimbursed the entitled conveyance costs (₹ 100).

Out-of-Pocket Expenditure (OOPE)

Significantly, the study found that despite the rollout of UHIS, women were continuing to incur very high expenditure for hospitalisation, an average of ₹ 9,947 per hospitalisation case. Only 4 per cent of women did not incur OOPE, and the rest of the 271 women incurred OOPE. The average OOPE expenditure for non-gynaecological cases was much higher than for gynaecological cases. More than half of the OOPE (52 per cent) was on account of fees charged by the facility. Expenditure incurred on medicines contributed to 18 per cent and investigation and tests contributed to 15 per cent of the expenditure. Of the women who incurred OOPE, 90 per cent had to spend on transportation, followed by medicines (76 per cent). Nearly half the women reported paying money to the doctor/nurse, and also paid for fees charged by the hospital. Disaggregating by clinical conditions, the highest expenditure was incurred for heart-related conditions (₹ 1,22,800), followed by appendicectomy (₹ 52,980), cancer (₹ 52,828), fracture (₹ 44,000) and kidney conditions (₹ 40,780) (Table 6).

When average OOPE is calculated for the total number of visits made (n = 325) to a facility, it works out to an average ₹ 8,624 per visit. The average OOPE for women in the private facility was more than six times higher than in the public facility. It is important that women incurred OOPE despite using the RSBY/MSBY card for treatment. For those who had used the card (for all conditions), average OOPE was ₹ 7,530 per visit. In case of deliveries, the average OOPE, in addition to card usage, was ₹ 5,626 per visit. The average OOPE incurred was much higher for women who used the card in private facilities (₹ 10,733) than in public facilities (₹ 2,518). More than one-third of the women (37 per cent) borrowed money in order to pay for treatment. It was found that around 61 per cent of them met their OOPE from their savings. Four women had to sell jewellery or some other valuable item, while three women had to mortgage valuables in order to pay for treatment.

Table 6.

Average OOPE for Different Clinical Conditions*

Clinical Condition	Average OOPE (in ₹)	n
Pregnancy related	10,352	3
Respiratory diseases	26,794	5
Weakness/anaemia/malnutrition	9,770	5
Cancer	52,828	3
Cataract surgery	8,810	5
Delivery	6,646	200
Diarrhoea and vomiting	3,936	7
Fever/malaria/dengue	5,467	3
Fracture	44,000	6
Heart related	1,22,800	3
Sickle cell disease	15,433	3
Jaundice/typhoid	1,898	5
Burns	22,650	2
Kidney problem	40,780	3
Uterus problem	4,235	3
Tubectomy	480	14
Total	9,947	282

Source: Computed by authors on the basis of survey data.

Note: * The list is indicative and does not include all conditions.

Childbirth

The single-most important cause for hospitalisation of women was childbirth; 200 deliveries were reported from among 282 women users and of them, 145 were normal deliveries, while 55 women (28 per cent) had caesarean section (C-section). Public facilities were accessed by 63 per cent of women for childbirth, principally the District Hospital and Medical College in Raipur. Cards were used in 17 per cent of the total birthing cases; 28 per cent in the private sector and 10 per cent in the public sector. Of the card holders, 73 per cent used it in private empanelled facilities and 23 per cent in public facilities. Among those who had C-section, 42 per cent of women accessed private facilities compared to 19 per cent in public facilities. The utilisation of insurance was higher for C-section than for normal deliveries, with a higher proportion in private facilities (32 per cent) than in public ones (21 per cent). The average amount booked for normal births in private hospitals was twice that of the amount booked for the same in the public sector (₹ 7,607 versus ₹ 3,775). However, for C-section, the average amount booked in the public sector was slightly higher than the average amount booked in the private sector (₹ 13,333 versus ₹ 12,388).

Discussion

Coverage of Women under UHIS in Terms of Enrolment, Medical Conditions and Utilisation

Enrolment Is Not Universal

While the current study finds that there has been an increase in enrolment since the introduction of the MSBY (57 per cent compared to 28 per cent, according to the SHRC baseline report of 2013), 43 per cent of the urban slum population in Raipur city continued to lack coverage under the UHIS. Government data show a similar trend in enrolment for both Raipur district (57 per cent) and for the entire state (59 per cent). Enrolment was not very different for men and women, as well as for different social groups. While 90 per cent of the families were aware of the scheme, many could not enrol due to problems in the enrolment process, as previously discussed in other studies (CTRD, 2013; Das & Leino, 2011; Grover & Palacios, 2011; Rajasekhar et al., 2011).

Low Utilisation of UHIS despite Large Numbers of Empanelled Hospitals

The overall usage of insurance was very low. Of women whose families had insurance, only one-third were able to use it. This is despite the fact that Raipur district has the highest number of empanelled facilities (136 facilities), with a concentration in Raipur city. Data on claims too show that Raipur makes the highest number of claims in the state, and also claims the highest amounts. Even if we consider only visits to empanelled facilities, less than half (41 per cent) of the women whose families had insurance actually used insurance for treatment. The main reasons for non-use included not being asked about the card on admission, facility not being empanelled and card not being renewed.

Determinants of Choice of Facility

One of the stated objectives of this scheme is to provide ‘choice’ to the patient in selection of facilities. We found that choice of the facility was rarely determined on considerations related to insurance. In only 2 per cent of the visits did the respondent report a particular hospital being selected because it gave them the advantage of using UHIS. The critical determinants in choosing the facility were familiarity with the facility and being referred to or sent there by someone. Only 5 per cent of the beneficiaries reported receiving the list of empanelled facilities along with the insurance smart card despite it being mandated. These findings were also corroborated by the evaluation commissioned by the government (CTRD, 2013). There was no significant difference between the proportion of women patients with insurance cards (78 per cent) and those without (70 per cent) going to empanelled facilities. The study found that most of the accessed public facilities were empanelled and only half of the private facilities used were empanelled under UHIS. The pattern of choice of empanelled and non-empanelled providers implies that the patients may not be convinced about the utility or efficacy of UHIS and therefore, other considerations carry more weight. This begs the question: to what extent does UHIS determine choice of facility and thereby actually give a ‘choice’ to the beneficiaries?

UHIS Biased towards Certain Procedures and Conditions

The utilisation of UHIS was highest for non-gynaecological conditions (49 per cent). There seems to be a bias towards surgical procedures; the usage of the cards for C-section was more than twice than that for normal deliveries. This has been a very common finding in most studies (Grover & Palacios, 2011; Kapilashrami & Venkatachalam, 2013; La Forgia & Nagpal, 2012; Narayana, 2010; Selvaraj & Karan, 2012; Shukla, Shatrugna & Srivatsan, 2011). Another disturbing and consistent finding was that women incurred OOPE despite availing of insurance and they had to borrow money in order to pay for the hospitalisation expenses. This finding corroborates those of other studies (CTRD, 2012; Grover & Palacios, 2011; La Forgia & Nagpal, 2012; Nandi et al., 2012; Prasad & Raghavendra, 2012; Rajasekhar et al., 2011; Selvaraj & Karan, 2012; Sood et al., 2014).

Differences between Public and Private Providers

Higher Utilisation of Public Facilities with Higher UHIS Usage in Private Facilities

The study finds that nearly two-thirds of the women went to public facilities for delivery, while the SHRC baseline study had found that an equal number of deliveries took place in public and private facilities (SHRC, 2013). This possible shift in delivery cases from private to public in the last year may have been a result of the urban health programme. However, for non-gynaecological conditions, women accessed private facilities more. This included conditions like respiratory diseases, fracture and heart-related conditions. Additionally, cases related to uterus problems went to the private sector. Though less number of women went to empanelled facilities, the utilisation of UHIS is higher than in private facilities.

Private More Expensive, Irrespective of Card Usage or Medical Condition

The findings on OOPE show that the private sector is more expensive than the public in every situation. Moreover, the average amounts booked through UHIS are also higher in the private sector. The average OOPE for women in the private facility was more than six times higher than in the public facility. This is more evident for C-sections, for which the OOPE in a private facility, when insurance was not used, is more than five times than in the public facility.

Conclusion

Globally, insurance schemes are being promoted as one of the main interventions for UHC. In India and especially in Chhattisgarh, the state-sponsored insurance schemes (RSBY and MSBY) are being equated with UHC and, in fact, the terms are often used interchangeably, even though coverage is not universal on all three dimensions (population, health care services or financial protection). Evidence is emerging, including from the current study, of barriers (in availability, affordability, acceptability and agency) to effective and equitable access to health care under these insurance schemes. Moreover, global evidence on the efficacy of these schemes on financial risk protection and health outcomes is far from encouraging. There is adequate evidence that health insurance schemes for the informal sector in low and middle income sections suffer from several drawbacks: low uptake, and no strong evidence of impact on utilisation, financial protection or health status. Undeniably, few insurance schemes provide protection for high level of OOPE, but this impact is weaker on the poor. The study on utilisation experiences of the RSBY/MSBY in the context of urban poor women is no departure from this trend. In principle, Chhattisgarh provides health insurance to all; achieving ‘universalisation’ is the first challenge. In exploring the experiences of urban poor women, we found that the RSBY/MSBY is neither able to provide coverage to all nor accord sufficient protection, and singularly fails to protect beneficiaries from catastrophic expenditures. Moreover, there is evidence of commercialisation of health care and negative consequences for women, as seen in the cases of unnecessary hysterectomies. In the light of our evidence, serious doubts arise regarding the efficacy of universal insurance in providing financial protection; equitable and effective access to health care for the urban poor comes under question. Universal insurance is clearly no guarantor of and does not automatically translate into universal access. The policymakers should not suffer from this misplaced belief.

Footnotes

Acknowledgements

We are grateful to the respondents who shared their experiences with us. Thanks to the surveyors for undertaking the field survey and to the Mitanins and the Mitanin programme team for facilitating the survey. We thank the Paul Hamlyn Foundation for providing funds to undertake the survey. Thanks are due to Dr. T. Sundararaman, Dr. Vandana Prasad and Dr. Ganapathy Murugan for their inputs in developing the study methodology.

Notes

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