Background
The government of India has sought to protect poor households from high out-of-pocket expenses for hospital care through a National Health Insurance Scheme (RSBY). Launched in 2008, it provides a ‘smart card’ to all those on the Below Poverty Line (BPL) list and who are willing to pay Rs 30 per family per year. In return, these families can avail of ‘free’ hospital services in empaneled hospitals (government as well as private) upto a maximum of Rs 30,000 per family per year. The Health Inc study in Karnataka sought to assess whether the RSBY protected the poor or not?

This study was financed by the European Commission from May 2011 to Dec 2014.  Other partners in this study were

• London School of Economics – London, UK
• Institute of Tropical Medicine – Antwerp, Belgium
• Tata Institute of Social Sciences – Mumbai, India
• CREPOS – Dakar, Senegal
• ISSER – Accra, Ghana

Aims and objectives of the study
The main objectives of the study in Karnataka were to:

• Document the inclusionary effect of RSBY
• To understand how and why it includes / excludes the vulnerable using a social / political / economic and cultural lens.

Methods
We used a mixed methods to study the extent of inclusion of the poor in RSBY. We surveyed 6,040 households across Karnataka. We also conducted in-depth interviews with key stakeholders, including community members to understand the reasons for the findings.

Results
We found that

• Nearly 50% of the eligible were not aware of the RSBY programme
• Of those aware, only 77% could enroll in the scheme, the others were not enrolled due to various exclusionary factors
• Finally among those who were enrolled, a very small number benefited from the scheme in terms of cashless hospitalisation services. The rest had to pay for their services because of various reasons.

Discussion
We found that exclusionary processes operate at all steps of implementation of the RSBY scheme. These exclusions are driven by social factors (age, gender, language, literacy), political factors (having political contacts), economic factors (being a daily wage earner, subsistence living, migrant labourers, inability to pay bribes), and cultural factors (religion, caste, tribal). Moreover, each step is intrinsically linked with the others so that exclusions in one stage have repercussions on others and vice versa. RSBY itself is not capable of addressing the existing exclusionary processes in society, with implementation often succumbing to these exclusions.