Increasing Awareness among RSBY Beneficiaries:

Results from a Pilot in Karnataka

Raghav Puri and Changqing Sun

May 2014

1. Introduction

The Rashtriya Swasthiya Bima Yojna, Government of India’s national health insurance

scheme, was launched in April 2008 with the objective of protecting poor households

from the financial burden arising due to health shocks. Under RSBY, each household can

enrol up to five members and get inpatient health insurance coverage of INR 30,000

(USD 510) annually. The average household premium that ranges from INR 400-600

(USD 6-10) is fully subsidized by the government and the household only pays a

registration fee of INR 30 (USD 0.5). RSBY covers all pre-existing diseases and allows

beneficiaries to avail inpatient healthcare at RSBY-empanelled hospitals (both, public

and private) across the country. Today, six years later, approximately 37.2 million

households are enrolled under RSBY1.

At the state level, the rolling out of RSBY begins with a competitive bidding process for

the selection of Insurance Companies (IC) that will implement the scheme in specific

districts (more than one IC can be selected in each state). Once selected, the ICs along

with a Third Party Administrator (TPA) and a Smart Card Service Provider (SCSP) start

enrolling households according to the list of eligible households provided by the state

government. As the ICs receive premium payments based on the total numbers of

households enrolled, they have an incentive to enrol all eligible households. When an

eligible household visits the enrolment station, they pay INR 30 as a registration fee and

the enrolment team captures biometric thumb impressions and photographs of all

members present. The IC then prints and activates a RSBY smart card, updated with the

photographs and biometric information, and hands it over to the household. The IC also

provides each family with an information pamphlet that has a list of all RSBY-

empanelled hospitals in the district.

1 Figures from rsby.gov.in (as on 30 April 2014)

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Once the household has their RSBY card, they can avail inpatient treatment at any of the

RSBY empanelled hospitals across the country. When RSBY cardholders are admitted to

an empanelled hospital, the hospital blocks the required package depending on what

treatment the patient requires. This package has a fixed rate and covers the cost of

treatment, accommodation, medicines and food. As RSBY is a cashless health insurance

scheme, the hospital is required to settle the claim with the IC. This process of availing

benefits under RSBY is referred to as utilisation. The RSBY backend data management

system (RSBY-MIS) captures all enrolment and utilisation data and serves as an

important tool for monitoring the implementation of the scheme.

Early evidence of RSBY suggests that while most people, especially those who are

enrolled in RSBY, are aware that a program called RSBY exists, they are not aware of

what they are entitled to under RSBY. This lack of awareness has been cited as an

important reason for the high enrolment rates but low utilisation in some districts (Jain

2012). A study by GIZ (2013) in three states – Bihar, Karnataka and Uttarakhand –

found that 55, 45 and 65 per cent of enrolled beneficiaries interviewed had ‘very poor

knowledge of RSBY’ in the respective states. According to Rajashekhar et al (2011),

many beneficiaries who had enrolled in Karnataka did not receive the RSBY information

pamphlet during enrolment. The study also revealed that many households that had

enrolled in the scheme did not receive their RSBY smart cards. The gap in educating

beneficiaries about health insurance benefits has been observed in other programs as

well. Based on over 18 years’ experience of VimoSEWA, a micro insurance programme

implemented by the Self-Employed Women’s Association, Desai (2009) suggests that

constant education and community involvement – in both implementation and

monitoring – are key to ensuring that benefits actually reach the poor.

A common theme that emerges from these studies is the important role of information

in the effective implementation of a health insurance program such as RSBY. The lack of

information and the inability of intended beneficiaries to absorb the information that is

being provided are important hurdles in reducing health expenses and increasing

access to healthcare among poor households through RSBY.

2. RSBY in Karnataka

RSBY was first rolled out in five districts of Karnataka in February 2010. The

Department of Labour and Employment is responsible for implementing the scheme in

the state. During the first phase of implementation, 179 hospitals were empanelled and

1.5 million BPL households enrolled under RSBY. The coverage of the scheme was

further expanded to all thirty districts of Karnataka in the second phase of

implementation which started in October 2011. Table 1 provides key performance

indicators (enrolment and utilisation rates) for RSBY in Karnataka. The enrolment rate

is only 42% while the national average is about 50%. While the state utilization rate is

2.1%, again below the national average, there seems a large variation across districts.

Among the three districts where the IEC intervention was carried out, Kolar district’s

utilization rate is three times that of Chamarajanagara.

Table 1: Performance2 of RSBY in Karnataka

Karnataka Chamarajanagara Chitradurga Kolar

Eligible Households

4,145,164 97,870 130,695 126,232

Enrolled Households

1,745,461 40,319 65,913 48,325

Enrolment Rate (%)

42.1 41.2 50.4 38.3

Hospitalisation Cases

36,268 484 1,402 1,841

Utilisation Rate (%)

2.1 1.2 2.1 3.8

Empanelled Hospitals (Private)

874 (546) 12 (8) 15 (9) 20 (14)

Note: Figures above are for the financial year 2012-13 (1 April-31 March)

3. Literature Review

There is very limited literature available on RSBY information, education and

communication (IEC) activities. Das and Leino (2011) and Johnson and Kumar (2011)

provide some interesting insights from field experiments of RSBY IEC activities in Delhi

and Jharkhand, respectively. While the former used RSBY information pamphlets to

increase RSBY enrolment among eligible households, the latter conducted health camps

with the aim of reaching out to eligible households about the scheme. The studies are

important as information pamphlets and health camps are the most widely used IEC

2 Source: Figures from RSBY Connect (April 2013 Edition) and Karnataka Labour Department

activities by state governments and ICs in increasing awareness about RSBY among

eligible households.

While both studies did not find any considerable change in either enrolment or

utilisation rates due to the interventions, Das and Leino (2011) observed that

households visited by the survey team, as part of a survey being conducted

simultaneously with the experimental IEC campaign, were 60 per cent more likely to

enrol in RSBY. This suggests that IEC tools that are more targeted and involve direct

interaction with beneficiaries might work better. This finding is further corroborated by

the GIZ (2013) study that shows how enrolled beneficiaries listed village-level

functionaries, NGOs and community-based organizations (CBOs) as their main source of

information about RSBY.

A more recent study by Platteau and Ontiveros (2013) aims to understand the factors

responsible for low uptake and contract renewal of health insurance programs in poor

countries. The study presents findings from a household survey of eligible beneficiaries

of a micro insurance program in India. The study found that “deficient information

about the insurance product and the functioning of the scheme, poor understanding of

the insurance concept and the resulting low use of the insurance product by eligible

households” were the main factors for low rates of renewal. It concluded by identifying

“understanding failure” as the key issue in providing health insurance to poor

households. It is important to note that this micro insurance program required

beneficiaries to pay the premium amount whereas under RSBY the government

subsidies the premium and beneficiaries are only expected to pay a minimal

registration fee. However, its emphasis on the importance of the role of information in a

health insurance program is relevant to this study.

As the coverage of RSBY increases across the country, state governments will require

innovative IEC methods to reach out to RSBY beneficiaries. While a consensus is

emerging on directly reaching out to beneficiaries and moving beyond the conventional

IEC methods, such as information pamphlets, there is a need to further identify cost-

effective IEC methods that are successful in informing RSBY beneficiaries about the

various benefits of the scheme, which leads to better utilization.

To address this gap in evidence of effecting IEC methods that directly engage with

beneficiaries of RSBY, two field experiments were conducted in three districts of

Karnataka between September 2012 and February 2013 to test different IEC methods

that use NGOs as facilitators in increasing awareness. The interventions and the

methodology used to evaluate the impact of these interventions have been discussed in

the next two sections. The sixth section presents the results from this experiment and

the last section discusses both IEC methods.

4. Interventions

The IEC interventions were implemented in 353 villages, spread across three districts of

Karnataka, by MYRADA, the partner NGO for this study. The first intervention was

rolled out in two districts of Karnataka (Chitradurga and Kolar) in September 2012. The

two districts were selected based on the following factors: among the ten districts

where MYRADA has strong ground level presence already; has relatively high

proportion of Scheduled Caste and Scheduled Tribe population; and the RSBY program

performance in terms of enrolment and utilisation rates was lower or at most similar to

than that of Karnataka as a whole. This intervention involved Self-Help-Group (SHG)

Federations as a medium for dissemination of information to households eligible for

RSBY. MYRADA, like most NGOs working with SHGs, is organised at four levels – district

office, Community Managed Resource Center (CMRC) that functions as a block-level

office, SHG Federation, and SHG. The NGO has field staff (also referred to as CRPs or

Community Resource Persons).

The SHG Federation centred trainings involved trainings at three different levels (see

also Graph 1):

1. Training of Trainers – This day-long event includes a training session on RSBY and

the IEC intervention. It was attended by all CMRC managers and CRPs in the district.

The training started with the screening of the RSBY video (in local language

Kannada) and a presentation about the scheme by representatives from the

insurance company and the Department of Labour and Employment. This was

followed by a detailed discussion on how to conduct SHG Federation trainings and

preparation of field implementation plans (dates and timings of SHG Federation

trainings) by all CMRCs. These trainings were attended by 40-50 NGO staff.

2. Federation Training – Federation trainings were organised a week after the

district-level training as this gave the CMRCs time to inform SHG federations about

the training dates. On average, each Federation has 12 to 15 SHGs, and each SHG

usually sends 1 or 2 member representative to attend the trainings. While the

majority of the SHG Federation trainings took place at the CMRC, in some cases the

trainings were held in a village public venue such as anganwadi center or

government school. In the trainings, the RSBY video was screened and followed by a

reading of the RSBY pamphlet, the primary IEC tool for the trainings3. This

pamphlet was important as it would ensure that the same message was conveyed in

all trainings. After the training was over, each participant was provided RSBY

pamphlets for distribution to their peer SHG members (and non-SHG RSBY

beneficiaries) in their respective villages.

3. SHG Meeting – On their return to the village, the trained SHG members distributed

the RSBY pamphlets to other SHG members (and non-SHG RSBY cardholders in

their village) and discussed the important points listed on the pamphlet. As CRPs

visit each SHG once every month (to collect payments, check the accounts register

and provide information on new programs), it is their responsibility to follow-up on

whether the SHG members had received the RSBY pamphlets. During this visit, the

CRP would answer any questions that members from the SHG (or non-SHG RSBY

cardholders, invited to the meeting by SHG members) might have about RSBY.

3 See Appendix I for an example of the training material.

One major advantage of this approach is its scalability as SHGs across the country are

organised under federations and a member of each SHG attends monthly federation

meetings. However, a challenge that emerged during the implementation of federation

trainings was that SHG members and RSBY beneficiaries may not overlap as much and

do not overlap at all in some SHGs. If SHGs did not have any member who was eligible

for RSBY, then there would not be much interest in understanding RSBY during the

training. In such cases, the likelihood of SHG members to further disseminate

information at the village level would be less than the ideal situation when SHG

members were expected to reach out to households that were eligible for RSBY but not

linked to SHGs.

Based on the experience of rolling out this intervention in the first two districts, the

intervention was modified and implemented in the third district (Chamarajanagara) in

December 2012 at the request of the Department of Labour and Employment. The

district was specifically selected because it has the second lowest utilization rate among

30 districts. To address the abovementioned concern, the IEC intervention was modified

to streamline the training structure by dropping SHG federation trainings and instead

having the NGO trainer visit each village and train all RSBY beneficiaries (SHG and non-

SHG) directly. In SHG federation trainings, SHG members from 3-4 different villages

would attend a typical training, while in this case trainings had to be organised in each

village. Though this approach translated into more number of trainings, it ensured that

all RSBY beneficiaries were directly trained by the NGO field staff. This intervention, if

successful, would also be easier to implement in areas where the NGO does not have

SHG networks.

5. Methodology

To assess the impact of the IEC intervention, the intervention was rolled out in two

phases by dividing the target villages in two groups4. In Chitradurga and Kolar Districts,

federations from Group 1 villages were trained in the first week of September while the

remaining federations from Group 2 villages were trained in the last week of October,

with a lag of 50 days.

4 See Appendix III for a detailed map illustrating the rollout of IEC intervention in Kolar District.

As the two groups were selected randomly, the difference in the utilization rates of the

two groups during the 50 days window is the expected impact due to the IEC

intervention (see Graph 2 below). Furthermore, the changes in the utilization rates of

the two groups in the 50 days following the training of Group 2 villages would confirm

the measurement of the impact as well as the sustainability of such impact. Because the

SHG-Federation-CMRC partnership does not cover all villages in the same blocks, there

are a good number of villages that did not receive the same intervention. Although these

villages may not be similar to the target villages, the change in the utilization rate for

these no-intervention villages could serve as a reference measure of change over time in

general.

In this study, the utilisation rate is calculated as the percentage of RSBY households

having enrolled members hospitalised under RSBY during the specified period. The data

source is the enrolment and transaction database provided by the Ministry of Labour

and Employment which is the Nodal Ministry responsible for RSBY program

implementation at the central government level. This definition is used almost

exclusively by the Nodal Ministry and the State Nodal Departments when measuring the

RSBY utilization performance.

Similarly, in Chamarajanagara, village-trainings were implemented in two phases.

Trainings were held in group 1 and group 2 villages in late December and late February,

respectively. Table 2 provides basic information about the two groups in all three

districts.

Table 2: Sample Characteristics

District Chamarajanagar Chitradurga Kolar Round 1 2 1 2 1 2 # of GPs/villages 32 34 41 41 93 92 Average # of households

194 137 178 82 24 31

Average distance to district headquarter (km)

53.2 49.2 27.0 38.2 13.5 18.3

Average distance to block headquarter (km)

32.4 26.4 9.1 21.3 6.2 7.8

Average distance to nearest PHC (km)

8.1 4.5 2.4 5.6 18.5 26.3

Average distance to nearest private RSBY hospital (km)

25.4 22.1 8.8 21.2 44.8 42.9

The two groups are not exactly similar in terms of accessibility to urban amenities

including health care service providers. The Group 2 villages in the first two districts,

particularly in Chitradurga, are located further away from the district headquarters

where most prominent RSBY hospitals are located. Similarly the average distances to

the block headquarters, the nearest PHC, and the nearest private RSBY hospital are also

larger, except for the nearest private RSBY hospital in Kolar. Apparently, when villages

were randomly assigned to the two groups, the NGO staff did not follow through the

strict rule and a number of exceptions were made to put villages located very close to

CMRCs (where the training of SHG federations took place) into Group 1. The exception

decisions were made because it is impractical to stop the villages randomly assigned to

Group 2 attend the IEC intervention for the Group 1 villages as SHG members living in

villages very close to the CMRC often drop by. This difficulty also motivated the

modification to the IED approach taken in the third district.

6. Results

Table 3 and Table 4 show the results for Chitradurga and Kolar Districts, respectively.

The Group 1 villages received the IEC intervention in the first week of September. By

the last week of October or within 50 days after receiving the IEC intervention, the

utilisation rate (i.e. the percentage of RSBY households using their RSBY cards for

hospitalisation) for Group 1 villages in Chitradurga and Kolar had increased by 0.53 and

0.22 than the previous 50 days, respectively. So indeed the SHG trainings have had a

strong positive impact on the utilisation rate. During the same time period, the

utilisation rate in Group 2 villages that were yet to receive the same IEC intervention

saw only minor changes (a decrease of 0.05 in Chitradurga but an increase of 0.03 in

Kolar). So were the changes observed for the “control” villages. Then in the last week of

October, Group 2 villages received the intervention. By mid-December, the utilisation

rate in Group 2 villages had only increased by 0.07 and 0.05, respectively while the

corresponding change in the utilisation rate of the control group was -0.02 and -0.14.

Another standing out change is of Group 1 villages. While the utilization rate of Group 1

villages continued to increase (though less than that of the first 50 days) in Chitradurga ,

the utilization rate of Group 1 villages decreased in Kolar and incidentally was back to

the same level before the intervention.

Table 35: Chitradurga District

# of RSBY households

U0 U1 U2 U1-U0 U2- U1

group1 8855 0.44 0.97 1.23 0.53 0.26 group2 4081 0.81 0.76 0.83 -0.05 0.07 “control” 39260 0.30 0.35 0.33 0.05 -0.02

Table 4: Kolar District

# of RSBY households

U0 U1 U2 U1-U0 U2- U1

group1 4164 0.14 0.36 0.14 0.22 -0.22 group2 3950 0.15 0.18 0.23 0.03 0.05 “control” 19192 0.31 0.32 0.18 0.01 -0.14

It is evident that the IEC intervention had a strong impact for Group 1 villages, but much

smaller impact for Group 2 villages. One likely explanation could be that the two villages

are actually not exactly the same in some aspects that were not controlled properly

when randomly selecting villages into the two groups. As shown in Table 2, on average

the two groups are different in terms of accessibility to urban amenities including

5 See Appendix II for explanation of results

health care service providers. The Group 2 villages in both districts, more so in

Chitradurga than in Kolar, are located further away from the district headquarters

where most prominent RSBY hospitals are located. Similarly the average distances to

the block headquarters, the nearest PHC, and the nearest private RSBY hospital are also

larger, except for the nearest private RSBY hospital in Kolar. Apparently, when villages

were randomly assigned to the two groups, the NGO staff did not follow through the

strict rule and a number of exceptions were made to put villages located very close to

CMRCs (where the training of SHG federations took place) into the Group 1. The

exceptions were made to avoid the situation that the villages randomly assigned to

Group 2 may attend the IEC intervention for the Group 1 villages since SHG members

living in villages very close to the CMRC often drop by.

Another important observation is that the increase in utilisation rate in Group 1 during

the first 50 days after the IEC intervention seems not sustained in the following period.

As households in these two districts were receiving RSBY cards for the first time, the

sudden rise and fall in utilization could be partially due to beneficiary households’

unmet demand for hospitalization treatment, which was addressed relatively quickly

once they received the required information to use RSBY.

In the third district Chamarajanagara, village trainings were organized at Gram

Panchayat (GP) level, in the last week of December for Group 1 and in the last week of

February for Group 2 (Table 5). The utilisation rate for Group 1 GPs had increased by

0.89 by mid-February or 50 days after receiving the IEC intervention, more than ten

times than the previous rate. The results also confirm that the strong impact of the IEC

intervention would decrease subsequently; therefore it is unlikely that one-time

intervention would permanently increase the utilization rate to a higher level.

Table 5: Chamarajanagara District

# of RSBY

households U0 U1 U2 U1-U0 U2- U1

group1 5952 0.07 0.96 0.54 0.89 -0.42 group2 4999 0.28 0.24 0.82 -0.04 0.58 control 11591 0.28 0.20 0.10 -0.09 -0.09

One more important determinant for any state government to choose between the two

IEC interventions would be the cost of implementing each. In this experiment, the

approximate cost per training at federation level and at village level was INR 1600 and

INR 1250, respectively. If the number of people that received RSBY information through

these trainings is taken into consideration, then the ‘cost per person informed’ is INR 5

and INR 24, respectively. Although the ‘cost per person informed’ for village trainings is

high, this IEC method provides a lot of flexibility in how it is rolled out.

7. Conclusion

The important role of information in the successful implementation of a health

insurance program for the poor was explored through the experiment with RSBY IEC

interventions in Karnataka. While the IEC intervention clearly was shown to have a

strong impact on the utilization rate subsequently, the impact would be neither

sustained over time nor uniform across different conditions, which play a role in the

health care seeking decision of RSBY beneficiaries. Furthermore, even though the village

level training in Chamarajanagar clearly was more effective in increasing utilization

among RSBY beneficiaries than the SHG federation trainings in the other two districts,

the former is also more expensive.

The Chamarajanagar approach has an advantage in terms of targeting to RSBY-eligible

households as trainers visit each village and train households that have enrolled in

RSBY. With the Chitradurga than in Kolar approach, there is a possibility that the

representative sent by SHGs for the federation meeting may not be RSBY beneficiary

and, therefore, not be interested in learning about RSBY. Another limitation of SHG

federation trainings is that they rely on the SHG members trained at the federation

meeting to return to their villages and disseminate the information to other SHG

members and, more importantly, non-SHG members eligible for RSBY. However, as

states consider expanding RSBY to more groups (for instance, Karnataka has decided to

provide a RSBY card to state BPL households), the SHG federation approach may work

better because more SHG members will become eligible for RSBY.

The cost consideration is also an important factor. If the state government has limited

financial resources, then it can identify villages with low RSBY utilization and ask the

partner NGO to carry out trainings in the selected villages. This flexibility is not always

available with SHG federation trainings as SHG members are very aware of the activities

being conducted in their networks and would not appreciate if only some SHGs in

selected villages are receiving training. This was an important learning in this study as

the partner NGO insisted that a ‘phase-in’ randomisation design is adopted because all

SHGs in their network should get the treatment.

Even though SHG federation trainings are easier and less expensive to implement, they

require high RSBY coverage among SHG members to be as effective as village trainings.

As RSBY coverage expands across the country and more districts come under its ambit,

village trainings should be viewed as an essential one-time investment to ensure that

beneficiaries are aware of their entitlements under RSBY.

References

Council for Tribal and Rural Development (CTRD). “Final Report on Evaluation of

Rashtriya Swasthiya Bima Yojana in Chhattisgarh” Accessed January 25, 2013.

http://rsbychhattisgarh.in/WebSite/UploadDoc/70.pdf

Das, Jishnu and Leino, Jessica. “Evaluating the RSBY: Lessons from an Experimental

Information Campaign.” Economic and Political Weekly, 46, no.32 (2011): 85-93

Desai, Sapna. “Keeping Health in Health Insurance” Economic and Political Weekly, XLIV,

no.38 (2009): 19-21

Gesellschaft für Internationale Zusammenarbeit (GIZ). Evaluating the Implementation

Process of Rashtriya Swasthiya Bima Yojana in Bihar, Uttarakhand and Karnataka.

Presentation on January 21, 2013 at GIZ Office, Delhi, India.

Jain, Nishant. 2012. (Add Title) RSBY National Workshop at Ranchi (May 2012)

Johnson, Doug and Kumar, Sushil. “Do Health Camps Make People Healthier? Evidence

from an RCT of Health Camps on Usage of RSBY” (2011). Accessed on January 25, 2013.

http://ssrn.com/abstract=1873269

Platteau, Jean-Phillipe and Ontiveros, Darwin Ugarte. 2013. Understanding and

Information Failures: Lessons from a Health Microinsurance Program in India. Research

Paper No. 29. Microinsurance Innovation Facility. International Labour Organisation.

Geneva

Rajasekhar et al. “Implementing Health Insurance: The Rollout of Rashtriya Swasthya

Bima Yojana in Karnataka” Economic and Political Weekly, 46, no.20 (2011): 56-63.

Krishnaswamy, Karuna and Ruchismita, Rupalee. 2011. Performance Trends and Policy

Recommendations - An Evaluation of the Mass Health Insurance Scheme of Government

of India, RSBY Working Paper, Ministry of Labour and Employment, GoI

Appendix I

Training material

1. RSBY Training Video produced by Karnataka RSBY team (http://youtu.be/jIbypmLdZqQ)

2. RSBY Pamphlet

3.

3. Village Training in progress at a government school in Kothlavadi Village,

Chamarajanagara District by MYRADA field staff on 18 February 2013.

Appendix II

Notes on Time Line

Chitradurga and Kolar

Villages 1 IEC in early Sep, 2012 Utilisation rates under RSBY: U0 Jul-Aug, 2012 U1 Sep-Oct, 2012 U2 Nov-Dec, 2012

Villages 2 IEC in early Nov, 2012

Other Villages No IEC

Chamarajanagara

GPs 1 IEC in late Dec, 2012 Utilisation rates under RSBY: U0 Nov-Dec, 2012 U1 Jan-Feb, 2013 U2 Mar-Apr, 2013

GPs 2 IEC in late Feb, 2013

Other GPs No IEC

Note: Ui is calculated as percentage of total RSBY households having enrolled members hospitalized in period i.

Appendix III

Rollout of IEC intervention in Kolar District