Considering the impact of Rashtriya Swasthya Bima Yojana on women’s healthcare and on their empowerment
In spring 2017, India launched a new national health policy which re-emphasizes the importance of women’s health and the need for gender mainstreaming. At the same time, the country is in the process of changing its public health insurance landscape for poor and vulnerable population groups. But are these measures sufficient to improve women’s access to healthcare?
The lower status of women in India is a root cause for many of the health risks and vulnerabilities to which Indian women and girls are exposed: the prevalence of gender based violence is high; early marriages are still very common in rural areas and result in premature pregnancies and in girls interrupting or ending their education too early; many poor families prefer to invest their scarce resources in their sons rather than in their daughters and this is reflected in women’s and girls’ lower education and health outcomes. Although India has over recent years established a legal framework that should protect women and girls and ensure their rights, a large gap remains between the equality this legislation aims for and the reality on the ground.
Out-of-pocket payments for healthcare cause and aggravate households’ poverty
India’s health system is characterized by large inequalities, huge gaps in the network of public health care providers, poor quality of health services and one of the highest shares globally in private out-of-pocket payments for health services. Today, most developing and developed countries have introduced output-based financing systems, paying providers for services they have delivered, based on stringent accountability mechanisms. In contrast, India continues to provide funding to public health care providers irrespective of the services they deliver and requires them to provide essential health care services for free. In reality, Indians continue to make considerable out-of-pocket payments even in public health care facilities in most states. Often poor people decide to use private health care providers because they believe that the quality of care might be better or because there is simply no acceptable public health facility within their reach.
In India out-of-pocket payments for health services are a major cause of poverty. The situation is particularly bad for workers in India’s informal sector, for their families and here especially for their women and girls. Most informal workers lack access to public mechanisms of social health protection. When they or their family members fall sick and need costly treatments, shortterm survival strategies include taking expensive loans, selling productive assets, interrupting their children’s school education and depending on child labour. In many cases they continue to postpone urgent treatments because they simply cannot afford them.
India’s RSBY: A national health insurance for the poor
In 2008, the Indian government made an important move to address this problem and introduced the national health insurance scheme Rashtriya Swasthya Bima Yojana (RSBY) for Indian families whose income is below the poverty line. RSBY covers hospitalisation costs of up to 30,000 Indian Rupees (EUR 400) per year for up to five members of these families. Their insurance premiums are paid for by the Indian central and state governments. More than 36 million households (approx. 130 million individuals) are currently enrolled in RSBY and they can access healthcare in around 8,500 public and private hospitals across India. To date, RSBY has covered the costs of more than 11 million hospitalisations of members of poor households.
Has RSBY made a difference for poor women and girls?
Given that the available data are incomplete and in many cases not gender-disaggregated, there is no straightforward answer to this question. However, gendered trends in utilisation and enrolment indicate that RSBY has improved poor women’s access to healthcare and empowered them to seek health services independent of their husbands’ approval.
Female enrolment in RSBY has increased from 40% in 2012 to 49% in 2017. This is due, in part, to the requirement for beneficiaries’ spouses to also be enrolled and, in another part, to awareness-raising campaigns which were carried out to specifically target and inform women about RSBY’s advantages. Once women are enrolled in RSBY, they tend to use services more often than men, both for themselves and for their children. Compared to 43% in the first round of RSBY’s implementation, women now account for 52% of the hospitalisations.
Further research is needed to better understand the reasons behind women’s greater utilisation of hospital services. Hypotheses range from the assumption that women tend to take better care of their health needs than men to the fact that men often migrate to other states for work which limits their access to RSBY in their state of origin.
For the time being RSBY covers enrolled women’s deliveries at hospitals and automatically includes their newborn children in the scheme. According to its National Health Policy 2017, however, India aims to assure the “availability of free, comprehensive primary health care services” to its citizens in order to progressively achieve Universal Health Coverage. As part of this, both preventive and curative sexual and reproductive health services for women should be included in the service package covered by RSBY and synergies should be ensured between RSBY and existing programmes, such as the Reproductive, Maternal, Newborn, Child and Adolescent Health programme (RMNCH+A).
But even now RSBY appears to have a positive impact on gender equality in its beneficiaries’ households. In the past, when they paid health expenses out-of-pocket, wives needed their husbands’ approval before they could seek healthcare. With RSBY this is no longer necessary: Women can access RSBY-covered services on their own account. In the state of West Bengal RSBY has even begun to enrol women as heads of households – quite a feat if one considers India’s patriarchal social order.
Exploratory interviews with female RSBY beneficiaries confirm that they feel in many ways empowered by RSBY. If, to what extent and under which circumstances RSBY actually improves women’s social and financial status has yet to be systematically explored and evaluated.
Social health insurance can help to improve the status of India’s women
As part of an ongoing social health insurance reform process, India’s government is currently tackling various of RSBY’s shortcomings and has begun to design a new and improved social health insurance scheme. The possibilities of mainstreaming gender into the new scheme’s design and implementation are manifold.
Since 2011, the Indo-German Social Security Programme (IGSSP), implemented by Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH on behalf of Germany’s Federal Ministry for Economic Cooperation and Development (BMZ), has advised India’s government and a number of federal states regarding RSBY’s design and implementation (see also Health insurance for India’s poor: Meeting the challenge with information technology (German Health Practice Collection, 2016)).
Reducing the disparities between men’s and women’s access to health services and between the quality of the services they receive has been an important focus of IGSSP’s advisory services. If policy makers and implementers pay attention to women’s health needs and their health seeking behaviours, social health insurance can make equal access to health care for men and women a reality and help improve the status of India’s women.
Susanne Elisabeth Ziegler, November 2017