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Evaluation Study of Rashtriya Swasthya Bima Yojana in Shimla & Kangra Districts in
Himachal Pradesh
Amicus Advisory Pvt. Ltd.
16-B, 16th Floor, Atma Ram House
1, Tolstoy Marg, New Delhi-110 001
www.amicusadvisory.com
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CONTENTS
ABBREVIATIONS ................................................................................................................................... 4
EXPLANATION OF TERMS USED ........................................................................................................... 4
EXECUTIVE SUMMARY & SUGGESTIONS ............................................................................................. 5
Chapter-1 ............................................................................................................................................. 9
BACKGROUND OF THE STUDY .......................................................................................................... 9
Rashtriya Swasthya Bima Yojna ....................................................................................................... 9
Chapter-2 ........................................................................................................................................... 12
RESEARCH METHODOLOGY & SAMPLING...................................................................................... 12
Sample Size..................................................................................................................................... 12
Sampling ......................................................................................................................................... 12
Sample source ................................................................................................................................ 13
Research Tools ............................................................................................................................... 13
Field Recruitment and Training ...................................................................................................... 13
Data Entry and Validation .............................................................................................................. 14
Analysis ........................................................................................................................................... 14
Chapter 3............................................................................................................................................ 15
PROFILE OF THE POPULATION ....................................................................................................... 15
Household Head ............................................................................................................................. 15
Households Size and Sex Ratio ....................................................................................................... 15
Age Group Structure ...................................................................................................................... 15
Occupational Status ....................................................................................................................... 16
House type ..................................................................................................................................... 17
Toilet............................................................................................................................................... 17
Drainage Type................................................................................................................................. 17
Land Property ................................................................................................................................. 18
Drinking Water ............................................................................................................................... 18
Water Purification .......................................................................................................................... 19
RBSY Status of the Sampled Households ....................................................................................... 19
Membership with Local Institutions .............................................................................................. 20
Sources of Awareness about Government Schemes ..................................................................... 21
Chapter-4 ........................................................................................................................................... 23
EXTENT OF AWARENESS ABOUT RSBY SCHEME ............................................................................ 23
Awareness about RSBY Scheme ..................................................................................................... 23
Sources of Information................................................................................................................... 23
Perception about Eligible Households ........................................................................................... 24
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Perception about Own Eligibility.................................................................................................... 25
Awareness about Cost to join RSBY and Free Treatment .............................................................. 25
Awareness about benefits under the Scheme ............................................................................... 26
Year of Enrolment and Eligible Members ...................................................................................... 27
Reasons for Non-enrolment in 2008 .............................................................................................. 28
Reasons for Non-enrolment in First Round ................................................................................... 29
Year of enrolment and distance from venue ................................................................................. 29
Source of information about enrolment ........................................................................................ 30
Obtained Rashtriya Swasthya Bima Yojna (RSBY) Card ................................................................. 31
Instruction Given with Card ........................................................................................................... 31
Chapter-5 ........................................................................................................................................... 32
HOSPITALIZATION & ACCESS TO RSBY ........................................................................................... 32
Maternity Cases in last five Years .................................................................................................. 32
Hospitalization Cases in Past 2 Years and Access of RSBY Scheme ............................................... 32
Major Illnesses................................................................................................................................ 33
HOSPITALIZATION AND QUALITY OF CARE PROVIDED .................................................................. 36
Reason for Choosing the Health Facility ........................................................................................ 36
Treatment and Tests Done ............................................................................................................. 36
Helpdesk and Waiting Time ........................................................................................................... 37
Verification and Information on Card’s Balance ............................................................................ 38
Hospitality at the Facility ................................................................................................................ 38
Current Status of Patient’s Health ................................................................................................. 39
Satisfaction from the Services ........................................................................................................ 40
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ABBREVIATIONS
RSBY
NGO
MFI
SHG
BPL
BDO
MLA
CMO
DM
Govt
HH
OBC
OPD
OT
RSBY
SC
TB
HP
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Rashtriya Swasthya Bima Yojana
Non Governmental Organization
Micro-finance Institutions
Self Help Groups
Below poverty line
Block Development Officer
Member of Legislative Assembly
Chief Medical Officer
District Magistrate
Government
Household
Other Backward Caste
Out Patient Department
Operation Theatre
Rashtriya Swasthya Bima Yojna
Scheduled Caste
Tuberculosis
Himachal Pradesh
EXPLANATION OF TERMS USED
1. RSBY Enrolled Households: Those who are enrolled but have not utilized benefits yet. Also
categorized as Category A-1 in this report.
2. RSBY Hospitalized households: Those who are enrolled under RSBY and have also utilized benefits.
Also categorized as Category A-2 in this report.
3. Non-RSBY Households: Those who are eligible but have not enrolled under RSBY for various
reasons. Also categorized as Category B in this report.
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EXECUTIVE SUMMARY & SUGGESTIONS
The districts under study have logged admirably high ratios as regards enrolment of BPL population under
RSBY. It is also noteworthy that these two districts (and the State of HP, most probably) have the highest
conversion ratio in the country.
District
Shimla
Kangra
Total
BPL
Insured
Population Population
(Families)
35,030
25,731
65,517
54,511
1,00,547
80,242
Conversion
ratio
(Families)
73%
83%
80%
As the feed-back indicates, RSBY is a huge success in H.P. among those who have availed of the benefits
under the scheme most of whom not only desire to draw repeat benefits under the scheme but also to
recommend the same to the others.
There are areas for improvements as regards efforts put in by the insurers / TPA in providing usersliterature and creating adequate awareness about RSBY and the benefits afforded there under as also
operational guidelines to be followed by the provider organizations. More endeavours are needed to create
greater awareness, especially among those who are eligible-but-not-enrolled and enrolled-but-not-yetbenefited so as to ensure maximization of enrolments and enhance the level of utilization of benefits.
The ensuing text carries our suggestions also.
Profiling the RSBY population
1.
2.
3.
4.
Overall, 22 % households are headed by women which are more than the national average.
Mean household size is 4.5 which is in line with the national average (4.9, NFHS-3).
Majority (47%) households are engaged in farming, followed by unskilled labourer (31%).
Membership of Cooperatives (25%), SHG (16%) and Political Parties (12%) were observed to be
more popular among those households who had affiliations to some kind of groups.
5. Local Panchayat officials (53% and 65%) and print/visual / audio media (29% and 13%) are the
major sources of information on the government schemes in Shimla and Kangra respectively.
Awareness about RSBY
1. Overall 51% of households surveyed were aware about RSBY. Predictably, the awareness level was
very high (86%) among those households who were enrolled and had availed of the benefits under
the scheme. It is evident that more efforts need to be put in to –
a. Educate enrolled households on the benefits of the scheme and how to obtain the same.
We suggest a state-wide IEC plan is drawn up by insurers in consultation with RSBY Cell for
the districts which have reported high enrolments but have not logged optimal numbers of
hospitalizations. The number of hospitalizations in other, comparable districts can serve as
benchmarks for this exercise. In addition to the targeted interventions by insurers, local
hospitals in such districts can be roped in to enhance the level of awareness among the
masses through small health camps or off-site OPDs. One is reasonably certain that the
costs incurred by hospitals on this activity can be made up through referrals for
hospitalization.
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b. Bring the un-unrolled (but eligible) population in the fold of RSBY. Encouraged by prevailing
high conversion ratios, H.P. can certainly attempt the impossible. Conceding that repeat
visits by the enrolment agencies are not as productive as the first one, and thus adversely
impact the costing of an insurer, a high-impact ( pre-enrolment) campaign is needed
involving the insurers as also the local institutions most relied upon by the eligible
population.
2. Panchayats (61%), friends/neighbours (9%) and media (9%) were the major sources of awareness
about RSBY. The Govt. may discuss with insurers the possibility of engaging panchayat-nominated
local residents for enrolments as also for facilitation of hospitalizations for an appropriate
remuneration. It is worth mentioning that such individuals can also be very useful in keeping a
watch on malpractices which adversely impact the Govt. (who funds premium) and insurers (who
finance hospitalizations).
3.
78% of respondents were correct as regards their perception that BPL status earns them eligibility
for enrolment under RSBY. About 8% respondents cited AAY as the eligibility criterion. IEC
campaigns as suggested above shall help clear misconceptions.
4. Majority (83%) were aware that it costs Rs.30/- to enrol under RSBY. IEC campaigns as suggested
above shall help clear misconceptions.
5. An alarmingly high (75%) respondents were not aware of the maximum spend that RSBY affords
per family per annum. The remaining respondents stated that they could spend Rs. 3,000/- to Rs. 1,
75,000/- .
6. 65 % respondents were aware that free treatment is provided under the scheme. About 29% stated
that there is no provision for free treatment.
7. Over 55% respondents were aware that up to five members are eligible to be covered under the
scheme. Of the remaining, 37 % responded that all members in a family can be covered.
8. A sizeable, over 45 % of respondents were enrolled in 2008. Of the remaining 24% and 16% were
enrolled in 2009 and 2010 respectively.
9. On enquiry as to why didn’t they enrol to the scheme in 2008, most (37%) cited their lack of
understanding of the scheme as the main reason.
10. Local Panchayat officials (62%), AWW (8%) and local officials (8%) were the main sources of
information on enrolment activities.
11. Majority of the households (98%) reported to have received the RSBY cards. Over two-third of the
respondents showed their cards to the interviewers. Though we have no empirical evidence to
back our observations with, but based on the grapevine, this could easily be the best scenario in
the country.
12. Having received the RSBY card, it is imperative that the beneficiaries are also informed as to how to
use the same.
a. About 49% respondents informed that they didn’t receive any instructions / literature
b. Only 15% respondents received the list of empanelled hospitals
c. 28% were given formal instructions on use of the cards
d. Responses were not very encouraging when it came to the beneficiaries’ level of
knowledge as to whom to contact in case of a query (6%) and about district kiosk (1%)
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Notwithstanding the possibility that these responses are that of a sampled population and may
not be fully representative of overall situation, the situation needs to be addressed urgently.
Technology still intimidates some of us. One can fairly estimate the stock response of a
predominantly rural & poor population to a technology-driven initiative like RSBY if its use is
not adequately explained. Whilst recommending a larger evaluation of this aspect of RSBY in
HP, we suggest that the aforementioned details / information is compiled and distributed
across the state through institutions/ functionaries favoured by the cardholders e.g., panchayat
officials / ANMs / local NGOs.
Hospitalization and Access to the Scheme Benefits
1. It is very encouraging to observe that there is an extensive use of RSBY cards. A total of 1,046
respondent households had fallen ill in the last two years and nearly 90% sought hospitalization
using their RSBY cards.
2. ENT, Accidents and Gastro account for nearly 52% of hospitalizations. The health profile of each
geography created by RSBY through the data created for well over two years can be used by the
Govt. for their future interventions for better healthcare management of the local population.
3. There is a reasonably high level of awareness (70%) about Critical Care cover provided by the Govt.
of H.P. About 74% were observed to be in the know as to how to use the facility. But the awareness
levels as regards the diseases covered (28%) and the empanelled hospitals (29%) need to be
addressed. An IEC campaign as suggested above shall help increase the awareness about the
Critical Care.
Hospitalization & Quality of Care provided
1. 89% respondents chose hospitals for treatment based on a hospital’s reputation.
2. About 84% underwent surgeries and confirmed that diagnostic tests were done and medicines
were dispensed.
3. Over 85 % respondents had availed treatment before hospitalization under RSBY which goes on to
prove that even the external referral route is working excellently and most patients are not walking
into hospitals directly. More encouraging is the fact 81% had taken prior treatment at PHCs, SCs
and CHCs which can be strengthened for their capabilities as regards preliminary check-up and can
function as more effective platform for referrals to hospitalization under RSBY.
4. Post-hospitalization, 36% hospitalized respondents took treatment of some kind mostly at PHCs/
SCs/ CHCs (60%) and Public Dispensaries (37%)
5. Bus is the main means of transportation of treatment. But, looking at the expenses involved, it is
suggested that the Govt. considers revising upwards per hospitalization limit in the next round of
bidding by insurers.
6. 43% respondents reported availability of separate RSBY desks at hospitals. Since a separate helpdesk is a prerequisite for empanelment of a hospital under RSBY, a wider scrutiny in other districts
also is recommended so that errant hospitals can be immediately advised to correct the situation.
7. Admirably, over 75% respondents reported that it took them 15 to 30 minutes only to get the
check-up done.
8. Only 19% confirmed that they were informed about the cost of the treatment / hospitalization.
Prima facie it doesn’t concern the beneficiaries (as about 73% had sufficient balances in the cards)
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but in the larger interest of all and the beneficiaries, it should be made a practice that cost of
treatment is made known to all concerned.
9. Entries to hospitals were mainly through OPD (49%) or Emergency (37%).
10. Politeness & helpfulness of the Helpdesk staff was appreciated by over 97% respondents.
11. 88% confirmed that they were provided food by hospitals.
12. Discharge summary was provided to over 84% respondents. Hospitals need to be advised to issue
discharge summary as well as transaction slips in all cases. Discharge summary, needless to say,
shall come in handy for future treatment. Though RSBY card records last 10 transactions on the
chip itself and, should a beneficiary so desire, can go to a district kiosk and find out balance to his/
her credit, usefulness of a physical transaction slip increases in a rural milieu where the beneficiary
shall have a physical evidence of credit balances.
13. Though the awareness as regards 5-days post-hospitalization treatment was low (36%), nearly 96%
reported that medicines were provided and tests were conducted by hospitals after discharge. This
goes on to prove that full benefits of the post-hospitalization facility are being availed of by
beneficiaries and being provided by hospitals.
14. Most respondents (94%) reported that their health has improved as compared to before.
15. Nearly 90% respondents answered that most of their queries were answered during
hospitalization.
16. A very high degree of satisfaction from services – Excellent (26%) and Very Good (70%) – was
reported by the respondents.
17. Over 77% stated that they would recommend others to avail of the facility and near 89% confirmed
that they themselves would again avail the facilities under RSBY
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Chapter-1
__________________________
BACKGROUND OF THE STUDY
India is one of the fastest growing economies of the world, especially after adopting the policy of
liberalization in the 1990s. However, the fruits of liberalization and growth have not been able to reach
millions of the country’s poor particularly in the rural areas. A large percentage of India’s population still
lives below the poverty line which is the cause of malnutrition, illiteracy, inadequate healthcare and low
awareness about the hygiene. Poverty creates ill-health because it forces people to live in an
environment that is characterized by absence of decent shelter, clean water and adequate sanitation. The
demands that the basic requirements of food & shelter make on the meagre monetary resources of the
BPL population, the issue of healthcare invariably takes a backseat. As a result, they either completely
ignore their health or make do with sub-optimal care which in one way or the other impacts their
livelihood. The vicious circle continues.
Rashtriya Swasthya Bima Yojna
The workers in the unorganized sector constitute about 93% of the total work force in India. Though a slew
of welfare schemes have been initiated by the Government for occupational groups, the coverage has
remained limited. Majority of the workers are still without adequate social security.
One of the major insecurities for workers in the unorganized sector is frequent incidences of illness in the
family and need for medical care and hospitalization. Despite the expansion in the health facilities, illness
remains one of the most prevalent causes of human deprivation in India. Appreciating the inadequacy of
public healthcare infrastructure, it is gradually being recognized that health insurance is one of the
effective ways of providing protection to the poor against the risk of otherwise unaffordable health
spending. However, most efforts to provide health insurance in the past have faced difficulties in both
design and implementation. The poor are unable or unwilling to take up health insurance because of
attendant costs or lack of perceived benefits. Organizing and administering health insurance, especially in
rural geographies, has also been a challenge.
Appreciating the need to provide an insurance cover to below poverty line (BPL), Rashtriya Swasthya Bima
Yojna was introduced. It is a health insurance scheme for the Below Poverty Line (BPL) families in the
unorganized sector. Encouraged by the good response from all stakeholders, the Govt has extended the
scheme to various other groups also.
RSBY is a comprehensive, insurance-backed healthcare scheme which provides for coverage of hospitalization
expenses incurred by the Below Poverty Line populace of the country. Main features are as underInsurance Coverage
RSBY provides hospitalization coverage for up to Rs. 30,000/- for a family of five on a floater basis.
Transportation charges are also covered up to a maximum of Rs. 1,000/- with a limit of Rs. 100/- per
hospitalization. The hospital which has provided the treatment will pay the transportation charges at the time
of discharge.
Registration Fees
The beneficiary will have to pay Rs. 30/- at the time of enrolment and at subsequent renewals, as registration
fee.
Eligible beneficiaries
Only those families whose names appear in the list provided by the State Govt. are eligible for enrolment
under RSBY. Up to a maximum of five members of a family can be enrolled which includes husband, spouse
and three dependents. Dependents can be children, parents or any other family member whose name
9
appears in the BPL list. If the family has more than three children, the head of the household will have to
decide which three children are to be insured. There is no age limit in RSBY and anybody can be enrolled if
they are in the BPL list. The head of the household need to be insured at the beginning and dependents’
names can be added later also. All eligible families, enrolled in to the scheme, are issued a RSBY Card for
identification. New born is covered from day one in the scheme.
Hospitalization & Medical coverage
“Hospitalization” shall Mean Admission in hospital upon a written advice of medical practitioner for a
minimum period of 24 hours except in case of specified treatment (Day Care), where the admission in such
hospital may be for a period of less than 24 hours.
Cashless Treatment
RSBY provides that no payment is to be made by an insured person for treatment taken in a network-hospital
up to the limit of sum insured. All medical bills are settled between a hospital and the insurance company. The
insured person only has to produce the RSBY Card (Smart Card) at the hospital and to give the biometric
thumb impression. For treatments in excess of the limit of sum insured and also for treatments excluded
under the scheme, the insured person shall have to bear the expenses. The list of treatment and the cost are
available on the website www.rsby.in.
Network Hospitals
These are the hospitals empanelled by an insurance company in consultation with the State Government to
provide cashless treatment to RSBY beneficiaries. The empanelment is done as per the standard empanelment
guidelines of RSBY. Based on the ground realities, these guidelines may be relaxed by the State Govt. in special
cases.
Package Rates
The charges for medical/ surgical procedures/ interventions under the Benefit package, based on thorough
market research, have been pre-determined. The state governments in consultation with all parties concerned
fix the package charges for that particular year. The same can be amended with mutual consent for the next
year. Provided that the Beneficiary has sufficient insurance cover remaining at the time of seeking treatment,
such listed package will not be subject to pre-authorization by the Insurer.
Smart Card
All eligible families, enrolled under RSBY, are issued a RSBY Card on yearly basis i.e. a fresh card is issued every
year. If required, one family can be issued two such cards, carrying details of two separate sets of insured
persons, but the sums insured available for treatment under both cards shall total up to Rs. 30,000/- only i.e.,
the overall limit per family. Smart Card enables identification of beneficiary through photograph and
fingerprints, besides other information about a patient. The same can be read at the hospital using the card
reader and a computer. More importantly, it enables cashless transactions at empanelled hospitals and
portability of benefits across the country. This card necessarily needs to be shown by an insured person at a
network hospital before seeking treatment. A typical RSBY Card shall be as under.
Pre-existing Diseases
All Pre-existing diseases, unless specifically excluded, are covered under RSBY from the day one itself.
Any disease that was present at any time in the past (including a disease which the insured person may not
have been aware of) is termed as pre-existing.
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Maternity benefits
All expenses related to the delivery of the baby in the hospital are covered. Both normal and caesarean
deliveries are covered under RSBY. A new-born is covered under RSBY since birth automatically for the
remaining period of the health insurance policy even if the new-born is the sixth member. However at the
time of renewal of the policy, the household will have to take a decision whether to include the new born for
the following year. Expenses incurred in connection with voluntary medical termination of pregnancy are not
covered except when induced by an accident or other medical emergencies to save the life of the mother.
Transportation Allowance
Provision for transport allowance (actual with limit of Rs. 100 per hospitalization) subject to an annual ceiling
of Rs. 1,000 shall be a part of the package. This will be paid by hospitals to the beneficiary at the time of
discharge.
Pre and Post Hospitalization
Pre and post hospitalization expenses up to 1 day prior to hospitalization and up to 5 days from the date of
discharge from the hospital shall be part of the package rates.
Food Charges
Food only for the person who is hospitalized is covered in the package rate. Please note that it
to provide food to RSBY patients while admitted in the hospital.
is mandatory
RSBY, though not the first attempt to provide health insurance to low income workers, it is unique in
many ways.
• The program involves insurance companies and hospitals, both in public and private sector, with
sufficient incentives to take part. This ensures expansion of the scheme as well as its long-term
sustainability
• The scheme provides the participating BPL households with the freedom of choice of obtaining
treatment from both public and private hospitals
• It envisages use of technology ,in a very user-friendly manner, in carrying out transactions at frontend and back-end
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Chapter-2
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RESEARCH METHODOLOGY & SAMPLING
The survey was conducted in two districts, namely Shimla and Kangra.
Sample Size
The sample size for the study is as follows
•
•
For every 1,000 household/ RSBY enrolees, 30 household/ enrolees were selected for survey. i.e.
2.5% sample were surveyed out of total enrolees
Apart from that for every 1,000 non enrolees, 1.5% sample was surveyed out of total non enrolees
Enrollee (Category-A)
Sr.
No
1
2
•
District
Name
Shimla
Kangra
Total
Non Enrollee (CategoryB)
No of BPL
Sample
Non
Sample
families
Number
(2.5%)
enrolled
(1.5%)
35,030
25,731
644
9,299
139
65,517
54,511
1,362
11,006
165
1,00,547
80,242
2,006
20,305
304
Out of the total enrolee sample, 60% sample was against the member / household who had utilised
the benefits under the scheme i.e. availed the benefit of cashless hospitalisation and the balance
40% were the member/ household who were enrolled but had not utilised the benefits.
Sr. No
District
Name
Enrollee
sample
(Category-A1) Benefit
utilized (60%)
(Category A2) Benefit
non utilized (40%)
1
Shimla
644
386
258
2
Kangra
1,362
817
545
Total
2,006
1,203
803
Sampling
The sample size discussed above under three different categories i.e. Category-A1, Category-A2, and
Category-B, were distributed equally across the villages. The selection of households was carried out
following a two stage sampling procedure. In the first stage the villages were selected by PPS (Probability
Percentage ate to Size) sampling. For selection of villages a district wise sampling frame was prepared for
both the districts separately. In total 26 villages will be selected from Shimla district and 55 villages from
Kangra district. The Number of households selected from each village and the total number of households
at district level is presented in below table.
Sr. No
1
District
Name
Shimla
No. of
villages
selected
26
2
Kangra
55
Sample Size per Village
(CategoryA1)
Benefits
(Category A2)
utilized
Benefits non
(Category B)
(60%)
utilized (40%)
Non-Enrollee
15
10
5
15
10
3
12
Sr. No
1
2
District
Name
Shimla
No. of
villages
to be
selected
26
Total Sample Size covered at District Level
(CategoryA1)
Benefits
(Category A2)
utilized
Benefits non
(Category B)
(60%)
utilized (40%)
Non-Enrollee
390
260
130
Kangra
55
825
550
165
Total
81
1,215
810
295
In the second stage the household selection was done at village level. Two separate lists of households
were prepared for Category-A1 and Category-A2 households. Using the lists, proposed number of
households was selected through systematic random sampling. Category-B households were selected
randomly representing the entire village in terms of geographical coverage.
The respondents were preferably the head of household and, if not available, the spouse or an available
adult dependent (age 18+), who could provide information about the household and household member,
were selected for the interview.
Sample source
For each category of sample, the source of data is as followsCategory
Category A1
Type of Respondent
Enrolled, benefits utilized
Category A2
Enrolled, benefits not utilized
Category B
Not enrolled, but eligible
Source of sample
Claims data
RSBY enrolment
data
Non enrolled but
otherwise BPL
Research Tools
The questionnaire was developed in consultation with the RSBY Cell of Himachal Pradesh. The
Questionnaire was developed in English originally and later was translated in Hindi language for better
understanding of the field investigators and respondents.
Field Recruitment and Training
Our pre-trained team provided thorough training to the field survey teams on RSBY scheme, the survey tool
and the methodology that was followed. Local field staff was inducted at the state level for smooth
execution of the project and ensure good quality data.
All the recruited interviewers were given training by the researchers and senior field personnel of the
organization including field practice. Besides explaining the study tools, the interviewers were also
informed about the nature of interviews and specific skills required to elicit sensitive data. The entire
training was provided in local language. The training programme aimed at de-sensitising the interviewers
and facilitating open discussion about the study. The training also included introductory session on the
study objectives, target groups, importance of the study and implications of the study findings.
The methods used to impart the training included discussion, role play, demonstration interview, mock
interview, field practice etc. The ultimate objective of the training programme was to ensure uniformity in
data collection and accuracy and validation of the data collected.
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Data Entry and Validation
Data entry was done in the CS pro (Census Survey Processing) data entry package which is very much
authenticated for data entry purpose. Data entered in CS Pro is compatible with all the statistical software/
packages. CS Pro minimise wrong data entries at a great extent.
Analysis
All the statistical analysis has been done by the help of SPSS package. SPSS package provide us a platform
for recoding and computation in data for better statistical analysis. All the required statistical tables are
generated by SPSS only. For the analysis purpose, frequencies, cross-tabulation, transformations etc were
used in the SPSS.
14
Chapter 3
________________________
PROFILE OF THE POPULATION
Household Head
Overall, 22 percent households are headed by women which are more than national average. But in
majority, men are the main decision maker across sampled households. These figures show the dominancy
of men and practices of patriarchy.
Table 1: Population and Sex Ratio
Shimla
Kangra
Total Households
764
1546
Male headship
81.70%
75.90%
Female Headship
18.30%
24.10%
Mean household size
5
4.3
Total population
3808
6702
Male population
50.90%
51.10%
Female Population
49.10%
48.90%
Sex Ratio (female per 1000 male)
964
959
Sex Ratio 0-6 (girls per 1000 boys)
923
844
Overall
2310
77.80%
22.20%
4.5
10510
51.00%
49.00%
961
869
Households Size and Sex Ratio
Mean household size in the targeted households is close to five members per household. It is similar to
national average (4.9) stated in NFHS-3. Data reveals an important finding that the sex ratio among
targeted population is greater than national average. At the district level a variation has been observed that
Kangra district has lower sex ratio than Shimla.
Age Group Structure
Age group and sex pyramid presented below states that though there are greater sex ratio among the
targeted households but there is greater sex ratio imbalances in lower ages. In general, base of the pyramid
should be broad and narrow towards the peak but here base is narrow.
15
Graph 3.2: Age Sex Pyramid
Almost one-third of population is below 15 years of age and 60 year old or more. Remaining population is
in productive age group.
Occupational Status
a. Dependency
More than half of the population in the targeted sample is dependant in nature. Only 38 percent
population is in working state and they bear expenses and other responsibilities of the rest of the
population.
Among dependant population, 39 percent is children (below age of 15 years), 23 percent is currently
enrolled for study, 31 percent are housewives and rest 8 percent is old age population.
About 11 percent of the population is in the productive age group but they are unemployed. They are also
dependent for their economic needs on the earning members of the households.
Table 2: Dependency Status
Dependency Status
Shimla
Kangra
Dependant population
54.30%
49.10%
Children
30.90%
43.30%
Currently Studying
23.10%
23.50%
Housewife
38.00%
25.80%
Old age
7.90%
7.50%
Unemployed population 13.10%
10.30%
Overall
51.00%
38.50%
23.40%
30.50%
7.70%
11.30%
16
b. Employed Population
It is important to mention here that working population includes the working women and old age
population and they are excluded from the dependant category. Overall, 38 percent population is in
working state and they are the source of generating income.
Table 3: Occupation of Employed Population
Working profile
Shimla
Kangra
Overall
Working population
32.60%
40.50%
37.70%
Farming
86.50%
28.70%
46.80%
Livestock Rearing
0.50%
5.90%
4.20%
Salaried Job
2.50%
9.10%
7.00%
Self Employed/ Trader
1.70%
2.50%
2.20%
Employed Skilled Laborer
2.10%
12.30%
9.10%
Employed Unskilled Laborer
6.80%
41.60%
30.60%
House type
Majority (92 percent) of households have their own house while a small percentage (7 percent) of
respondents stated that they are residing in rented house.
Toilet
Two-third of the households has their own toilet or separate toilet. Members of the rest of households
seem to be practicing open defecation which is unhygienic in nature. Open defecation can be a reason for
reproductive morbidity especially among women counterpart.
Drainage Type
Graph 3.6 reveals that availability of systematic covered drainage system is not sufficient across all the
sampled households. Majority of households reported that open “kutcha” drain system is the main drain
system in Kangra while open “pucca” drain system is the main drain system for the households in Shimla
district. One fourth of the households in Shimla have underground drain system. Open and “kuccha” drain
system is not environment friendly and it has an adverse effect on human health. It is a root cause or place
for breed of mosquitoes and flees. In rainy season, open drain system can be an origin for water borne
diseases.
17
Land Property
More than 92 percent of surveyed households in Shimla have ownership of cultivable land while in Kangra
three-fifth of households has their own cultivable land. Land ownership of households in Kangra district
depicts that there are less farming practices in the targeted households in comparison to Shimla. Less
ownership of cultivable land in Kangra reveals the reason for more labourer practices as occupation.
Drinking Water
Piped water (72 percent) is the main drinking water source for the households and hand pump (17 percent)
is the second major source. Rest of the households stated that they use water for drinking purpose from
well, pond, rainwater, surface water etc.
18
Water Purification
One third of the households reported that they purify water before use. Practices of water purification are
more in households of Shimla as compared to households from Kangra districts. Overall, purifying water
before use is a healthy practice and it saves individuals from various water borne diseases.
RBSY Status of the Sampled Households
Graph 3.11 shows the RBSY status of the targeted households. More than half of the households (52
percent) are reported under the RSBY-hospitalized category, 35 percent reported under RSBY-nonhospitalized category while rest of the households are reported under the non-RSBY category.
Graph 3.11: RBSY Status of the Households
19
Membership with Local Institutions
Active membership with any organization, committee, association or group provides us a platform for
knowledge and experience sharing. It is a place where people talk about current scenario and situations.
More than two-fourth of respondents from non-RSBY category stated that they do not have any
membership with any specified category or other category. While among RSBY hospitalized and enrolled
households, 35 percent respondents in each category stated that their household does not have any
membership. Co-operative (26 percent), self help groups (16 percent), and political parties (12 percent) are
more popular among households for any membership. Membership with trade unions (23 percent) is also
popular among RSBY-enrolled household category and among RSBY-hospitalized category membership
with local village level institutions (9 percent) is also popular.
Households with no membership are larger in Shimla district as compared to Kangra district. In Kangra
district majority of households (70 percent) have some type of membership. At district level, SHGs, trade
union, village level institutions (VEC, ICDS), political and religious institutions are more popular in Kangra
district as compared to Shimla district. In Shimla District, co-operative is most popular institution where
membership is the highest.
20
Table 4: Membership
Shimla
Kangra
Type of local
RSBY
RSBY
RSBY
RSBY
membership Enrolled hospitalized Non RSBY
Enrolled hospitalized Non RSBY
HH
household household Total household household household Total
(multiple)
SHG
0.60%
10.40%
3.70%
15.20%
27.90%
10.20%
22.70%
Cooperative 31.50%
27.20%
14.60%
25.50%
51.50%
14.30%
3.10%
25.50%
Trade union
1.90%
2.40%
1.90%
2.10%
36.00%
4.70%
1.00%
14.50%
NGO/MFI
client
0.30%
0.80%
0.40%
7.90%
2.70%
4.20%
Village
committees
(e.g. VEC;
ICDS)
1.60%
3.60%
1.80%
3.20%
10.90%
1.00%
7.80%
Political
party
0.60%
4.40%
1.70%
22.60%
15.70%
4.10%
17.20%
Religious
organization
0.60%
3.20%
1.30%
10.30%
8.40%
8.50%
RWA (urban
areas)
2.00%
0.20%
0.80%
Other
organization
2.90%
1.20%
1.60%
1.60%
2.60%
2.10%
No
Membership 62.00%
50.40%
81.10%
63.40%
18.20%
30.60%
80.60%
29.80%
Not aware
1.30%
0.40%
2.40%
1.30%
1.80%
2.30%
1.00%
2.10%
Sources of Awareness about Government Schemes
On enquiry about the sources of awareness about government schemes, the respondents reported Local
Panchayat workers/ officials as the major source of awareness among all categories of households. The
response reveals the proactive participation of panchayat in local development. Media (print, visual and
audio) and local civil societies (NGOs) have also become a major source of information. NGOs have played
an important role in creating awareness especially among RSBY-enrolled households, in Kangra district.
(Graph 13)
Friends and family members are in more advantageous position in dispersing the awareness about
government schemes. (Graph 13)
In Shimla, other than Panchayat, media has great impact on awareness on all categories except non-RSBY
households as compared to Kangra district. Friends and families play an important role in creating
awareness in Kangra district. (Table 5)
In Kangra district, other than Panchayat, local political leaders and NGOs are also very important in
enhancing awareness level of public about government schemes. The findings state that political leaders
and NGOs are more active in Kangra district. (Table 5)
21
Table 5: Sources of Awareness
Sources of awareness about government schemes
Friends
and
family
Shimla
RSBY
Enrolled HH
RSBY
hospitalized
HH
Non RSBY
HH
Total
Kangra
RSBY
Enrolled HH
RSBY
hospitalized
HH
Non RSBY
HH
Total
Media
(print,
visual
or
audio)
Local
Panchayat
workers Administration Religious
/officials
officials
leaders
MLA
Local
NGO
Other
3.20%
2.60%
0.30%
2.40%
4.40%
0.80%
2.50%
0.40%
19.20% 32.50%
47.40%
21.20% 33.20%
40.80%
2.80%
3.40%
17.50%
77.20%
1.90%
15.60% 28.70%
53.30%
1.40%
0.70%
2.40%
4.40%
6.70%
84.80%
2.60%
6.70%
28.10% 67.30%
15.40% 12.90%
57.00%
8.90%
4.80%
9.50%
2.00%
46.90%
48.00%
1.00%
11.10% 13.10%
65.30%
6.40%
2.00%
1.00%
7.90%
1.30%
4.10%
4.10%
1.00%
5.40%
14.90% 26.60% 0.80%
22
Chapter-4
___________________________________
EXTENT OF AWARENESS ABOUT RSBY SCHEME
Awareness about RSBY Scheme
To measure awareness levels of the respondents a section was developed in the research instrument. Even
the benefited household were asked about scheme awareness, sources of information and understanding
of the provisions under schemes.
Overall, 51 percent respondents reported to be aware about the scheme. None of the respondents from
non-RSBY households’ category was reported to be aware about the scheme even though they belonged to
the BPL category. Majority of respondents (87 percent) from RSBY-hospitalized category are aware about
the finer details of the scheme while only 18 percent respondents from RSBY-enrolled category are
reported to be aware. At the district level there is also a significant difference in awareness level.
In Kangra district, more than 92 percent respondents in RSBY-hospitalized category reported to be aware
about the scheme while in Shimla district the percentage is 62 percent. Among RSBY-enrolled households,
15 percent respondents in Shimla district and 20 percent respondents in Kangra district stated that they are
aware about the scheme.
Sources of Information
Further figures in graphs and tables will reveal the extent of awareness and sources of information among
respondents who reported to be aware about the scheme.
Data reveals that sources of information are not diversified. Concentration of respondents’ answer is
focussing majorly around Panchayat. Friends /neighbours, media and health staff are the other sources
from where respondents become aware about the scheme and percentage of these respondents are 8-9
percent only. Percentages of NGO personnel, area committee members, community educators,
leaflets/brochures, local PDS shopkeepers etc are minimal and these sources have marginal impact on the
respondents’ awareness.
23
From the table 4.1 it can be observed that impact of Panchayat, ration shop, friends/families and
community educators are different in both the district. Panchayat (63 percent), community educators (5
percent), ration shop (4 percent) have more impact in Kangra district as compared to Shimla. At the same
time in Shimla, friends/neighbours and survey people have more impact than in Kangra district.
Overall
RSBY
RSBY
Enrolled hospitalized
HH
HH
Friends /
neighbor
Radio / TV
/ paper
Leaflets/
brochure
Health
Staff
Community
Educators
Panchayat
Ration
shop
NGO
Survey
people
Table 4.1: Sources of RSBY Awareness
Shimla
Both
RSBY
RSBY
Enrolled hospitalized
HH
HH
Both
Kangra
RSBY
RSBY
Enrolled hospitalized
HH
HH
Both
6.30%
9.40%
9.10%
17.40%
18.10%
17.90%
1.00%
7.90%
7.20%
9.80%
8.00%
8.20%
17.40%
6.50%
9.00%
6.20%
8.30%
8.10%
1.60%
1.40%
3.90%
3.00%
1.20%
1.10%
2.10%
8.60%
7.80%
6.50%
7.10%
7.00%
8.80%
8.00%
0.70%
67.80%
4.50%
59.50%
4.10%
60.50%
41.30%
1.30%
51.00%
1.00%
48.80%
1.00%
80.40%
5.10%
61.00%
4.70%
62.90%
7.00%
4.30%
1.30%
3.80%
1.90%
1.30%
2.60%
1.00%
2.00%
10.30%
4.90%
1.00%
4.40%
1.90%
6.30%
2.80%
3.20%
8.40%
10.40%
1.00%
1.80%
1.70%
17.40%
Perception about Eligible Households
More than two-third of the respondents stated that only BPL families are eligible for getting benefits under
RSBY scheme. About 7 percent respondent told that everyone is eligible under the scheme while 9 percent
responded that only AAY families are eligible. Approx 3 percent respondents were unaware about the
eligibility of households whilst they reported that they know about the scheme.
Attributing eligibility for the scheme to everyone, only AAY families or only NREGA card holders etc
suggests inadequate knowledge of the respondents. And, percentage of respondents with inadequate
knowledge is more in Shimla district as compare to Kangra district.
24
Table 4.2: Perception about eligibility
Only
NREGA
card
holders
Don’t know
1.40%
8.60%
2.60%
6.30%
3.80%
77.70%
7.70%
2.30%
4.10%
2.20%
15.50%
84.80%
68.40%
3.20%
3.90%
13.00%
9.00%
Both
Kangra
RSBY Enrolled household
RSBY hospitalized household
12.40%
72.10%
2.50%
3.00%
10.00%
1.00%
8.00%
93.80%
77.30%
2.10%
9.50%
2.40%
3.10%
2.80%
Both
7.30%
78.90%
8.80%
2.10%
2.90%
Everyone
Only
BPL
families
Only
AAY
families
Overall
RSBY Enrolled household
RSBY hospitalized household
1.40%
9.10%
90.90%
75.90%
Both
8.20%
Shimla
RSBY Enrolled household
RSBY hospitalized household
Perception about Own Eligibility
About two-third of the respondents reported that their household/family is eligible under the scheme
while 21 percent stated that they are not eligible for the scheme and the rest respondents (5 percent)
couldn’t state clearly about their eligibility.
Table 4.3: Perception of Respondent's own eligibility
Type of Households
Yes
No
Don’t
Know
Overall
RSBY Enrolled household 93.00% 4.20%
RSBY hospitalized household 72.00% 23.20%
Both 74.50% 20.90%
2.80%
4.80%
4.60%
Shimla
RSBY Enrolled household 91.30% 4.30% 4.30%
RSBY hospitalized household 76.80% 11.60% 11.60%
Both 80.10% 10.00% 10.00%
Kangra
RSBY Enrolled household 93.80% 4.10%
RSBY hospitalized household 71.20% 25.20%
Both 73.40% 23.10%
2.10%
3.60%
3.50%
Awareness about Cost to join RSBY and Free Treatment
Majority of the households (83 percent) reported that Rs. 30 is to be paid for enrolment of households
under the scheme while 10 percent stated that there is no charge for the enrolment. Around 7 percent
respondent could not state any amount for the enrolment. Percentage of respondent is more in Shimla
district as compared to Kangra district who stated that there isn’t any charge for the enrolment. (Table 4.4)
On being asked about the sums assured per year under the scheme, two-third of the respondent couldn’t
state any amount and rest one fourth of the respondent couldn’t come at one response. These
respondents stated that one can spend Rs. 3,000 to Rs 175,000 in year under the scheme. Percentage of
unaware respondents about the amount is higher in Shimla than Kangra district. (Table 4.4)
25
Type of
Households
Overall
RSBY Enrolled
household
RSBY hospitalized
household
Both
Shimla
RSBY Enrolled
household
RSBY hospitalized
household
Total
Kangra
RSBY Enrolled
household
RSBY hospitalized
household
Total
Table 4.4: Awareness about cost and free treatment
Maximum amount
Awareness about cost of
per year that can be Free treatment provided
enrolment
spent
in the hospitals
No cost
Rs 30
Don’t
know
Don’t
know
3,000 to
175,000
4.20%
89.50%
6.30%
94.40%
5.60%
45.50% 42.00%
12.60%
10.60%
9.80%
82.10%
83.00%
7.30%
7.20%
72.90%
75.50%
27.30%
24.70%
67.60% 27.20%
64.90% 29.00%
5.20%
6.10%
4.30%
80.40%
15.20%
97.80%
2.20%
84.80% 10.90%
4.30%
16.80%
13.90%
70.30%
72.60%
12.90%
13.40%
82.60%
86.10%
17.20%
14.00%
69.70% 16.10%
73.10% 14.90%
14.20%
11.90%
4.10%
93.80%
2.10%
92.80%
7.20%
26.80% 56.70%
16.50%
9.50%
9.00%
84.20%
85.10%
6.30%
5.90%
71.20%
73.30%
28.70%
26.60%
67.20% 29.20%
63.20% 31.90%
3.60%
4.90%
Yes
No
Don’t
know
More than three-fifth of the respondents (65 percent) revealed that under the scheme free treatment is
being provided in the hospitals while more than one-fourth from the respondents (29 percent) stated that
there is no provision for free treatment in the hospitals under the scheme. And, rest of the respondents
couldn’t state any answer about the free treatment under RSBY scheme. Response about free treatment in
the hospitals under RSBY scheme is more among respondents from Shimla districts as compared to Kangra
district. At the same time, percentage of respondents is doubled in Kangra district in comparison to Shimla
district who reported that there is no provision for free treatment in the hospitals under the Rashtriya
Swasthya Bima Yojna (RSBY).
Awareness about benefits under the Scheme
About 22 to 28 percent of household stated that under the scheme many services are being provided to the
beneficiaries such as transportation allowances, paid for medical tests, medicine and drugs. At the district
level, there is not much difference in awareness about transportation allowances and payments for
medicine and drugs. But there is a 5 percent difference in awareness about payment for medical tests.
26
Table 4.5: Awareness about services under schemes
Transportation
allowances provided to
the patient
Paid for
medical
test
Paid for
medicine
and drugs
4.20%
24.40%
41.30%
22.40%
49.70%
23.70%
21.90%
24.70%
26.80%
6.50%
24.50%
21.70%
31.00%
26.10%
28.40%
20.40%
28.90%
27.90%
3.10%
24.30%
50.50%
20.90%
60.80%
22.90%
22.20%
23.90%
26.60%
Overall
RSBY Enrolled household
RSBY hospitalized household
Total
Shimla
RSBY Enrolled household
RSBY hospitalized household
Total
Kangra
RSBY Enrolled household
RSBY hospitalized household
Total
Year of Enrolment and Eligible Members
More than half of the respondent told that up to five members per BPL family are eligible under the
scheme while 35 percent stated that all the members of a family are eligible for getting benefits under the
scheme. About one-tenth of the respondents couldn’t state clearly the number of members eligible under
the scheme.
At the district level comparison, (from the table 4.6) it can be found that in Kangra district more people are
aware about the number of members eligible per household under RSBY scheme than in Shimla. It is
important to mention here that in Shimla district one-fourth of the interviewee couldn’t give a clear answer
about the number of eligible members while the same response in Kangra district is minimal. Inadequate
awareness about the number of eligible members in a family is more among respondents from RSBYenrolled households.
Table 4.6: Perception about eligibility
No. of eligible members
Up to 5
All HH
Don’t
members members know
Overall
RSBY Enrolled HH
RSBY hospitalized
HH
Total
Shimla
RSBY Enrolled HH
RSBY hospitalized
HH
Total
Kangra
RSBY Enrolled HH
RSBY hospitalized
HH
Total
Year of enrolment
2008
2009
2010
Don’t
know
73.40%
11.20%
15.40%
41.30%
4.20%
11.90%
42.70%
52.60%
55.10%
37.80%
34.60%
9.60%
10.30%
45.90%
45.30%
26.30%
23.60%
16.60%
16.00%
11.30%
15.10%
52.20%
21.70%
26.10%
80.40%
2.20%
6.50%
10.90%
49.00%
49.80%
26.50%
25.40%
24.50%
24.90%
51.00%
57.70%
20.00%
15.90%
7.70%
7.50%
21.30%
18.90%
83.50%
6.20%
10.30%
22.70%
5.20%
14.40%
57.70%
53.20%
56.20%
39.80%
36.50%
7.00%
7.30%
45.00%
42.80%
27.40%
25.20%
18.10%
17.70%
9.50%
14.30%
27
According to the respondents about half of the households were enrolled in 2008 under RSBY scheme.
One-fourth of the households enrolled in 2009 and 16 percent in 2010. More than one-sixth of respondent
are not aware about the year of enrolment. From the table 4.6 it can be observed that in Kangra district
more than half of the respondents in RSBY-enrolled category are unaware about the year of enrolment as
compared to 11 percent in Shimla district. (Table 4.6)
Reasons for Non-enrolment in 2008
Majority of the respondents who were not enrolled in 2008 answered that they couldn’t understand the
scheme properly (37 percent) and 22 percent had no proper documents to show their eligibility. One-tenth
of respondents stated that the scheme has no relevance or use for them. Some of the responses given by
the respondents are not in alignment with RSBY provisions but have been included here as they represent
the respondents’ understanding of the issue.
In Shimla district more than one-tenth households reported that enrolment booth was far away from their
residence in comparison to 8 percent in Kangra district. Percentage of those who mentioned that they
didn’t understand the scheme is more in Shimla district than in Kangra across all households.
Even after being eligible as a beneficiary under the RSBY scheme in Kangra district a small percentage of
respondents reported that they are not eligible while none of the respondent reported the same in Shimla
district. These findings indicate the improper eligibility knowledge about the scheme across public.
Table 4.7: Reasons for Non-enrolment
Overall
Shimla
RSBY
Enrolle
d HH
Booth too far
away
It’s of no use
Get similar
facilities in
government
hospitals
Didn’t find any
hospital in the
list
Distrust in
scheme
Did not have
proper
documents
Did not feel
comfortable with
the technology
involved
Didn’t
understand the
scheme
Not eligible for
the scheme
10.00%
30.00%
60.00%
RSBY
hospitalize
d HH
Total
8.70%
8.20%
11.80%
RSBY
hospitaliz
ed HH
Total
8.40%
8.00%
11.10%
12.30%
11.70%
7.50%
7.00%
7.80%
7.40%
1.20%
1.80%
1.30%
1.80%
7.50%
7.00%
7.80%
7.40%
21.10%
21.60%
28.60%
25.00%
20.80%
21.50%
2.50%
2.30%
14.30%
12.50%
1.90%
1.80%
42.90%
50.00%
35.70%
36.80%
3.90%
3.70%
36.00%
37.40%
3.70%
3.50%
RSBY
Enrolle
d HH
Kangra
RSBY
hospitali
zed HH
Total
14.30%
12.50%
RSBY
Enrolle
d HH
11.10%
100.00
%
33.30%
55.60%
28
Reasons for Non-enrolment in First Round
Those who could not enrol in first round of enrolment, majority of them stated having no proper
knowledge about the scheme and enrolment procedure during the first round of the enrolment.
Having no proper understanding about the scheme is more frequently reported in Kangra district as
compared to Shimla district. In Shimla, more than two-third respondents in RSBY enrolled category stated
that they did not make application because they did not have proper understanding about the scheme at
the time of first round. The same trend is found in Kangra district. It shows that they made application
when they come to know about the scheme properly. Spreading proper awareness among targeted
beneficiaries can play an important role to enhance access of the scheme. (Table 4.8)
Table 4.8: Reasons for Non-enrolment in first round
Booth too
far away
Didn’t
know
about the
scheme at
that time
Didn’t get
to know
about
enrolments
RSBY
Enrolled
HH
Overall
RSBY
hospitalized
HH
4.90%
6.20%
6.00%
41.50%
37.60%
38.20%
36.60%
38.10%
37.80%
2.70%
Didn’t find
hospital
Did not
have
proper
documents
Didn’t
understand
the
scheme
17.10%
Total
RSBY
Enrolled
HH
Shimla
RSBY
hospitalized
HH
Total
RSBY
Enrolled
HH
Kangra
RSBY
hospitalized
HH
Total
3.60%
3.00%
5.60%
6.60%
6.40%
80.00%
21.40%
30.30%
36.10%
39.90%
39.30%
20.00%
42.90%
39.40%
38.90%
37.40%
37.60%
2.20%
7.10%
6.10%
2.00%
1.70%
4.90%
4.10%
14.30%
12.10%
3.50%
3.00%
10.60%
11.60%
10.70%
9.10%
10.60%
12.00%
19.40%
Year of enrolment and distance from venue
Overall, more than 55 percent households reported that list of eligible households displayed/distributed
publically. In the table 4.9, district level comparison depicts that in Shimla district less percentage of
respondent told to the interviewee about the display of eligible’s list publically as compare to respondents
from Kangra district. Also, table 4.9 shows that mostly households were enrolled in 2008. Same pattern can
be found in both the study districts. About one-third of the respondents could not state about the actual
year of enrolment
Majority of the households who got enrolled under the RSBY scheme reported that the enrolment camp
was within 2 kilometres. While about 40 percent households in both the district are located with 2-8
kilometres from the enrolment place. (Table 4.9)
About 6 percent of respondent couldn’t say about the distance of venue and this figure double in Shimla
district. Percentage of households situated more than 8 kilometres from the enrolment venue is
comparatively less across both the district or overall.
29
Table 4.9: Recent year of enrolment and distance of enrolment venue
Overall
Shimla
RSBY
Enrolled
HH
RSBY
hospital.
HH
Eligible’s List
displayed
publically
25.90%
59.80%
Enrolment year
Don’t know 65.00%
26.50%
2008or Before 28.00%
44.90%
After 2008 7.00%
28.70%
Distance of Enrolment venue (distance)
within 2 kms
2-5 kms
5-8kms
more than 8
kms
Don’t know
Kangra
Total
RSBY
Enrolled
HH
RSBY
hospital.
HH
Total
RSBY
RSBY
Enrolled hospital.
HH
HH
Total
55.70%
19.60%
33.50%
30.30%
28.90%
64.40%
60.90%
31.10%
43.00%
26.00%
43.50%
45.70%
10.90%
29.70%
56.70%
13.60%
32.80%
54.20%
13.00%
75.30%
19.60%
5.20%
25.90%
42.60%
31.30%
30.80%
40.40%
28.70%
27.30%
25.90%
17.50%
47.30%
31.40%
10.30%
44.80%
30.70%
11.20%
41.30%
19.60%
2.20%
41.90%
38.10%
9.00%
41.80%
33.80%
7.50%
20.60%
28.90%
24.70%
48.20%
30.20%
10.50%
45.50%
30.10%
11.90%
1.40%
28.00%
8.10%
3.00%
7.30%
6.00%
2.20%
34.80%
4.50%
6.50%
4.00%
12.90%
1.00%
24.70%
8.70%
2.40%
8.00%
4.60%
Source of information about enrolment
Local panchayat members are major source of information about the enrolment under the RSBY scheme
across all households in both the districts.
Table 4.10: Source of information about enrolment
Overall
Shimla
RSBY
RSBY
Enrolled hospitalized
HH
HH
Total
RSBY
RSBY
Enrolled hospitalized
HH
HH
Total
From Posters
1.40%
6.40%
5.80%
4.30%
11.00%
9.50%
From Word of
mouth
From NGO
7.00%
3.40%
3.80%
19.60%
11.00%
12.90%
8.40%
4.20%
4.70%
3.90%
From Sarpanch
41.30%
44.90%
44.50%
2.10%
0.70%
17.50%
From ANMs
From AWWs
From
Panchayat
Secretary
From local
officials
Announcement
From Wall
writings
Others
RSBY
RSBY
Enrolled hospitalized
HH
HH
Total
5.7%
5.10%
1.00%
2.0%
1.90%
3.00%
12.40%
4.3%
5.10%
47.10%
43.80%
45.40%
44.6%
44.60%
1.90%
1.30%
1.00%
2.3%
2.00%
9.00%
8.00%
8.40%
6.50%
9.2%
8.20%
18.00%
17.90%
4.50%
6.50%
20.4%
20.30%
8.80%
7.70%
3.90%
3.00%
9.6%
8.70%
0.40%
0.30%
0.60%
0.50%
0.3%
0.30%
0.70%
23.10%
Kangra
32.60%
13.00%
0.10%
2.80%
5.20%
19.60%
1.00%
30.40%
8.40%
13.40%
19.60%
0.10%
1.8%
3.60%
30
Obtained Rashtriya Swasthya Bima Yojna (RSBY) Card
Majority of the households (98 percent) reported to have received RSBY cards. Graph 4.3 reveals that
percentage of households that had received RSBY cards is less in Shimla district as compared to Kangra
district.
Few household did not receive card even after enrolment. Death of the head of household, lack of valid
documents, problem at enrolment station and refusal from the authority without telling any reason etc
were reported reasons for the not receiving the RSBY card.
Data reveals that more than two-third of household shown their RSBY card to the interviewees.
Instruction Given with Card
Majority respondents stated that they did not receive any instruction while receiving the RSBY cards. About
one-fourth of the respondent answered that they did receive information about how to use the card. Less
than one-fifth of respondent received information about empanelled hospitals for the treatment. A very
small percentage of respondents received information about whom to contact for any related query and
available district kiosks while it is very important for any household. Previous results show that lack of
proper awareness about the scheme among respondents may lead for less access of the scheme. Providing
information about available kiosks can enhance access among targeted households.
Table 4.11: Instruction given with cards
Overall
Shimla
RSBY
Enroll
HH
Instruction given with card
List of hospitals 2.90%
How to use card 22.90%
Whom to
contact for any
query
About kiosk
Didn’t get any 74.30%
Told for date of
start using cards
7.90%
RSBY
hospital.
HH
Total
17.10%
28.70%
15.40%
28.00%
6.50%
1.60%
46.10%
25.30%
Kangra
RSBY
Enroll
HH
RSBY
hospital.
HH
Total
RSBY
Enroll
HH
RSBY
hospital.
HH
Total
37.80%
15.60%
27.20%
12.00%
29.70%
4.20%
15.80%
17.40%
29.00%
16.10%
27.70%
5.70%
1.40%
49.50%
62.20%
1.40%
1.40%
54.40%
1.00%
1.00%
56.30%
80.00%
7.40%
1.60%
44.60%
6.60%
1.50%
48.10%
23.20%
6.70%
25.90%
21.40%
8.40%
25.20%
23.50%
31
Chapter-5
______________________________
HOSPITALIZATION & ACCESS TO RSBY
Maternity Cases in last five Years
Among hospitalized RSBY category, a total of 124 pregnancy cases were found in the survey in recent past
where 16 were from Shimla district and rest 108 pregnancy cases were from Kangra district. All children
from Shimla district were alive at the time of interview while 4 children died in Kangra before the interview.
Overall, 16 percent childbirths took place at home. In Shimla district none of the child was delivered in
private facilities while few of the deliveries from Kangra district took place in other facilities (includes NGO,
private facility).
Main reason for childbirth at home was the cost factor. In Shimla all the respondents stated cost for not
going to health facilities. In Kangra district other than cost factor, respondents had some other reasons also
for non-health facility delivery. Those reasons were family customs, they did not get permission from family
or facility was closed at the time of delivery etc.
Table 5.1: Current status of Maternity experience and place of delivery
Shimla
Kangra
Overall
N
%
N
%
N
%
Home
3
18.7%
17
15.6%
20
16.1%
Govt/Municipal Hospital
13
81.3%
87
80.6%
100
80.7%
4
3.80%
4
3.20%
Place of Delivery
Other facilities (NGO, Pvt
etc)
Hospitalization Cases in Past 2 Years and Access of RSBY Scheme
Table 5.2 shows that a total of 1,046 respondent households had fallen ill in last two years and visited
hospitals for some kind of treatment. About four types of diseases were dominant in Kangra district as
compared to Shimla.
Table 5.2: Hospitalization cases in past 2 years
Shimla
Kangra
Overall
%
N
%
N
%
N
RSBY Enrolled HH
3.30%
6
2.70%
23
2.80%
29
RSBY hospitalized HH
96.70%
177
97.30%
840
97.20%
1,017
Total (N)
183
863
1,046
32
More than 90 percent of eligible sample households sought hospitalization by using their RSBY card. Only,
three cases did not utilize the card for the stated reason of patient not being in the list of insured persons
or they were not aware that disease was covered under the scheme or due to emergency during which
they did not use the card.
Majority of the respondents were aware that Himachal Government is providing additional Critical Care
cover for the treatment. More than one-fourth of the respondent reported that they are aware about the
empanelled hospitals. Besides, one-fourth of respondent were reported to be aware about the Critical Care
by the Govt. Almost two-third of the households reported that they understand how one can avail the
facilities provided under the scheme. Table 5.3 reveal the findings that households with RSBY-hospitalized
status are reported to be more aware as compared to the households with RSBY-enrolled status.
Table 5.3: Awareness about Government’s Critical Care Cover Initiative
Overall
RSBY
RSBY
Enrolled hospitalized
HH
HH
Aware of H.P. Govt’s Critical Care Cover, in
addition to RSBY
Aware about empanelled hospitals
Aware about diseases under Critical Care
Aware how to utilize the facility
Total
62.10%
89.40%
69.90%
25.70%
30.50%
28.70%
22.00%
29.50%
31.20%
95.40%
28.00%
73.70%
District level analysis indicates that more percentages of households in Kangra district are aware about the
Himachal Government’s initiative and provision of rupees thirty thousand for treatment. But surprisingly
utilization of facility is more in Shimla district as compared to Kangra district.
Table 5.4: Awareness about Government’s Critical Care Initiative at district level
Shimla
Kangra
RSBY
RSBY
Enrolled hospitalized
HH
HH
Total
RSBY
RSBY
Enrolled hospitalized
HH
HH
Total
Aware of Critical Care
Initiative in addition to RSBY
29.20%
78.40%
38.70%
82.60%
92.30%
85.30%
Aware about empanelled
hospitals
6.70%
18.90%
14.50%
29.80%
33.10%
31.80%
Aware about diseases under
Critical Care
Aware how to utilize the
facility
3.30%
23.00%
16.20%
26.20%
33.10%
30.60%
10.00%
94.90%
68.20%
33.70%
95.60%
74.90%
Utilized the facility
55.60%
98.40%
96.00%
18.10%
96.60%
85.00%
Major Illnesses
A total of 1,034 people were fallen ill and visited hospital for any kind of treatment under the scheme.
More than four times of illness cases took place in Kangra district as compared to Shimla.
ENT related problems, accidental cases, gastro related illness were the major illnesses frequently reported
by the respondents. Among patients with RSBY-enrolled status almost one-fourth of the respondents could
not reveal about the actual illness of the patients and their response came as don’t know. (Table 5.5)
33
Table 5.5: Major illness faced by population
Overall
ENT related
Eye related
Accidental
Gynae problems
Gastro related
Ortho problems
Fever/ typhoid/ Pneumonia
Tuberculosis
Dental problem
Cardiac problems
Urinary problems/ stone
RSBY
RSBY
Enrolled hospitalized
HH
HH
Total
3.30%
25.90%
25.30%
6.70%
2.90%
3.00%
20.00%
14.50%
14.60%
6.70%
7.30%
7.50%
20.00%
11.60%
11.70%
6.70%
4.80%
4.80%
3.60%
3.50%
1.70%
1.60%
1.00%
1.20%
4.50%
4.30%
Other
Not Aware
6.70%
6.70%
23.30%
9.80%
8.10%
4.50%
9.60%
8.00%
5.00%
At the district level, analysis reveals that there is not much of a difference in illness faced by population
with RSBY hospitalization. In Shimla, population with RSBY-enrolled status faced either gastro problems (40
percent) or urinary/ stone problems (40 percent) while rest of the population was not aware about the
specific illness faced by the patients. At the same time, in Kangra district among RSBY-enrolled patients,
majority of them visited hospital due to accidental cases or gastro related problems.
Table 5.6: Major illness faced by patients at district level
Shimla
Kangra
RSBY
Enrolled
HH
RSBY
hospitalized
HH
Total
RSBY
Enrolled
HH
RSBY
hospitalized
HH
Total
ENT related
21.10%
21.40%
4.00%
27.00%
26.20%
Eye related
3.20%
3.10%
8.00%
2.80%
3.00%
Accidental
15.70%
14.80%
24.00%
14.30%
14.50%
Gyane problems
5.90%
7.10%
8.00%
7.60%
7.60%
Gastro related
11.40%
11.70%
16.00%
11.60%
11.70%
Ortho problems
4.30%
4.10%
8.00%
4.90%
5.00%
Fever/ typhoid/
Pneumonia
Tuberculosis
6.50%
6.10%
2.90%
2.80%
2.70%
2.60%
1.50%
1.40%
Dental problem
0.50%
0.50%
1.10%
1.40%
Cardiac problems
6.50%
6.10%
4.00%
3.90%
11.90%
12.20%
9.30%
9.00%
8.60%
8.20%
8.00%
7.90%
7.90%
1.60%
2.00%
24.00%
5.10%
5.70%
Urinary problems/ stone
40.00%
40.00%
Other
Not Aware
20.00%
34
Incidences of ENT related illness is the highest among the respondents. Second highest problem faced by
the respondents is accidental incidences.
Table 5.7: Incidence of illness (Overall)
Overall
Illnesses
RSBY hospital HH
One incidence @
ENT related
21 population
Eye related
191 population
Accidental
38 population
Gyane problems
76 population
Gastro related
48 population
Ortho problems
115 population
Fever/ typhoid/ Pneumonia
154 population
Tuberculosis
325 population
Dental problem
553 population
Cardiac problems
123 population
Urinary problems/ stone
56 population
Other
68 population
At the district level analysis presents facts that in Kangra district, incidences of urinary/ stone related illness
are also high.
Table 5.8: Incidence of illness at district level
Shimla
ENT related
Eye related
Accidental
Gyane problems
Gastro related
Ortho problems
Fever/ typhoid/ Pneumonia
Tuberculosis
Dental problem
Cardiac problems
Urinary problems/ stone
Other
Kangra
RSBY hospital HH*
33
212
44
116
61
159
RSBY hospital HH*
19
185
36
69
45
106
106
255
1273
106
58
80
177
355
473
129
56
65
*Incidence of illness @ respondents
35
Chapter-6
__________________________________________
HOSPITALIZATION AND QUALITY OF CARE PROVIDED
Reason for Choosing the Health Facility
Major reasons to opt health facility for hospitalization were good reputation and closeness to home among
respondents.
Table 6.1: Reasons for choosing the facility
Overall
Reason for choosing the facility
Close to home
Reputation is good
Suggested by the relative/ friends, Referred
by doctors, Always go to this hospital
RSBY hospitalized HH
8.80%
89.00%
2.20%
Shimla
Kangra
RSBY
RSBY
hospitalized hospitalized
HH
HH
9.30%
8.70%
86.00%
89.60%
4.70%
1.70%
Treatment and Tests Done
Majority of the patients had surgery/operation during the hospitalization in both the districts. More than
80 percent patients had surgery in RSBY-hospitalized category in Kangra while in Shimla it is 60 percent
patients.
Ninety percent patients had to take medicines during treatment. The same trend observed for various
diagnostic tests done in treatment. Major diagnostic tests were x-ray, ECG tests etc.
Table 6.2: Treatment and tests done
Overall
Had surgery
Medicines given
X-ray/ECG etc Diagnostic tests
conducted
RSBY hospitalized HH
83.80%
90.20%
89.70%
Shimla
Kangra
RSBY
RSBY
hospitalized hospitalized
HH
HH
59.70%
88.10%
93.80%
89.60%
89.10%
89.80%
Majority of the respondents reported that patients were availing treatment before hospitalization. The
main health facility for treatment before hospitalization was government facility while 17 percent reported
that patient was taking treatment from public dispensaries.
Table 6.3: Treatment before hospitalization and place of treatment
Overall
Shimla
Kangra
RSBY
hospitalized HH
RSBY
hospitalized HH
RSBY
hospitalized HH
treatment availed before hospitalization
85.20%
55.00%
90.50%
Source of treatment
PHC/ sub-centres/CHC
Public dispensary
Private facility
81.40%
16.70%
1.90%
63.40%
26.80%
9.80%
83.40%
15.60%
1.00%
36
More than one-third of patients continued treatment after getting discharged from the health facility. And,
majority of them availed government facility for continuing their treatment followed by treatment at public
dispensary including CGHS, ESI etc. A small percentage of patients took treatment after their discharge at
private facilities.
Table 6.4: Place for treatment after discharge
Overall
Shimla
Treatment after discharge
Source of treatment
PHC/ sub-centres/CHC
Public dispensary
Private facility
RSBY hospitalized HH
35.70%
Kangra
RSBY
RSBY
hospitalized hospitalized
HH
HH
36.40%
35.50%
59.50%
37.20%
3.20%
85.10%
14.90%
55.00%
41.20%
1.90%
Bus was the major source of transportation to reach the health facility. About one-fourth of patients in
Shimla reached health facility by other source of transportation also. Other sources were private vehicle,
taxi, tempo etc. At the same time a marginal percentage of patients received their travel reimbursement
from the facility.
Table 6.5: Transportation and reimbursement
Overall
Shimla
Source of transportation
Bus
Other
Hospital reimburse travel
cost
Kangra
RSBY
hospitalized
HH
RSBY
hospitalized
HH
RSBY hospitalized
HH
91.50%
8.50%
75.20%
24.90%
94.30%
5.60%
4.40%
7.80%
3.80%
Mean expenditure on transportation was observed to be Rs. 220/Helpdesk and Waiting Time
More than two-fifth of respondents reported that a separate RSBY helpdesk was available at the health
facility. In Shimla majority of respondents reported the availability of separate helpdesks.
Majority of the patients had to wait up to 30 minutes before their check-up at the health facility. While
more than one-tenth of patients had to wait for more than 30 minutes for the treatment.
Table 6.6: Helpdesk availability and waiting time
Overall
Shimla
RSBY
hospitalized
HH
Separate RSBY
helpdesk at hospital
42.60%
Waiting time before checkups
Less than 15 minute
11.00%
Kangra
RSBY hospitalized
HH
RSBY
hospitalized
HH
67.40%
38.30%
14.00%
10.40%
37
15 to 30 minutes
75.20%
69.80%
76.10%
30 to 60 minutes
6.50%
10.10%
5.80%
More than 60 minutes
7.40%
6.20%
7.60%
Verification and Information on Card’s Balance
All patients completed their fingerprint verification before the treatment for availing the facility.
About one-fifth patients were told about the cost involved in their treatment. About same percentage of
patients were told about balance remaining in their card for usage. Two third patients had sufficient
amount in their card to pay for the treatment cost.
Table 6.7: Verification and information received
Overall
Shimla
Fingerprint
verification done
Told about cost
involved in
treatment
Told about money
left in Smart Card
Had sufficient
amount in Card
Kangra
RSBY
hospitalized
HH
RSBY hospitalized
HH
RSBY
hospitalized
HH
100%
100%
100%
18.60%
27.10%
17.10%
18.20%
32.60%
15.70%
72.80%
76.20%
71.60%
Hospitality at the Facility
Almost half of the patients visited health facility in OPD while about two-fifth of patients admitted in the
health facility through emergency category. Remaining patients went to hospital through referral or other
means.
A vast majority of the respondents stated that the helpdesk staffs were very helpful and polite. Also,
majority of patients received food on their stay at the health facility.
Table 6.8: Entry in the facility and hospitality received
Overall
Shimla
Kangra
RSBY
RSBY
RSBY
hospitalized hospitalized hospitalized
HH
HH
HH
Means of entry in hospital
Emergency
OPD
Referral
Other
Staff at helpdesk was polite/helpful
Provided food to patient during stay
37.20%
48.80%
7.00%
7.00%
97.30%
88.00%
30.00%
50.00%
20.00%
95.40%
79.80%
39.40%
48.50%
3.00%
9.10%
97.90%
89.40%
More than 84 percent of respondents stated that they were provided summary at the time of discharge.
Majority of the beneficiaries received their health card back after admission or at the time of discharge
while few beneficiaries received their cards later. Main reason for the delay in returning the health card
was stated that staffs wanted to keep card till insurance claim was settled.
38
Post-hospitalization, fifty percent of the patients in Kangra were told that they still have some amount in
their cards while none of the card holder received the same information in Shimla district.
Table 6.9: Information provided at the time of discharge
Overall
Shimla
Kangra
RSBY hospitalized
HH
RSBY hospitalized
HH
RSBY
hospitalized
HH
84.40%
69.00%
87.10%
73.60%
Time when received RSBY card back
After admission
48.70%
On discharge
50.70%
Next day
0.10%
two days later
0.50%
Told for money left in
card
50.00%
76.00%
73.10%
55.80%
43.40%
47.50%
52.00%
0.10%
0.40%
On discharge summary
provided
Verification done
before discharge
0.80%
50.00%
As regards 5-days post hospitalization cost, only 36 percent of respondents with RSBY-hospitalized status
mentioned that they are aware about the same.
From the Table 6.10 it can be observed that same pattern is present for medicine provided by the hospital,
test prescribed after discharge and prescribed test was organized by the hospital only. At the district level
there is not much variation in prescription provided at the time of discharge.
Table 6.10: Prescription at discharge
Overall
RSBY
hospitalized HH
Aware that 5 day post
hospitalization cost is covered
Medicine prescribed while discharge
Medicine provided by hospital
Tests prescribed after discharge
Test done by hospital
36.00%
90.00%
96.00%
95.60%
94.70%
Shimla
Kangra
RSBY
RSBY
hospitalized hospitalized
HH
HH
40.30%
86.80%
86.60%
86.80%
86.80%
35.30%
90.50%
97.60%
97.20%
96.10%
Current Status of Patient’s Health
Except negligible number of patients, all the patients reported that their health has improved as compared
to the health status before hospitalization. But percentage of completely improved status is very marginal
and the same pattern can be found in Table 6.11 across all households categories in both the study
districts.
Table 6.11: Current health status of the patient
Has died
Overall
Shimla
RSBY
RSBY
hospitalized hospitalized
HH
HH
0.20%
Kangra
RSBY
hospitalized
HH
0.30%
39
Improvement
Partially improved
Completely improved
94.00%
2.80%
3.00%
83.70%
10.10%
6.20%
95.80%
1.50%
2.40%
Satisfaction from the Services
Majority of respondents answered that all of their queries were answered during hospitalization in both
the districts. About one-fourth responses were in favour of excellent service provided, while majority (more
than 70 percent) of responses stated that very good services were provided and they are satisfied.
Table 6.12: Satisfaction from the services
Overall
Shimla
RSBY
RSBY
hospital
hospital
HH
HH
All queries answered
90.30%
81.40%
Rating of satisfaction
Excellent
25.70%
24.00%
Very good
70.40%
64.30%
Good
1.50%
3.10%
Average
1.50%
7.80%
Poor
0.90%
0.80%
Kangra
RSBY
hospital
HH
91.80%
26.00%
71.40%
1.20%
0.40%
1.00%
Few responses came against the hospital staff stating that there was a demand for money from the
patients.
However, majority of the responses came in favour of the facility and they were satisfied from the services
provided. That’s why majority of the respondents (77 percent) stated that they will refer others to come to
the facility for treatment. Besides, they will come again to the current facility for the treatment in future.
Table 6.13: Bribery and referring others to come at current health facility
Overall
Shimla
Kangra
RSBY
RSBY
RSBY
hospitalized
hospitalized hospitalized
HH
HH
HH
Money demanded
1.90%
2.30%
1.80%
Recommend others for treatment
77.10%
83.70%
75.90%
Return to the facility in future if needed
88.90%
71.40%
91.00%
Overall, it can be noted that majority of the hospitalized households were satisfied from the services and
interested to avail the facility again in future. These findings indicate towards excellent healthcare delivery
under RSBY in the state.
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