Case studies

Seeking affordable healthcare

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By registering for a Rashtriya Swasthya Bima Yojana (RSBY) smart card, Ranglal Bharti and his pregnant wife Urmila Devi, hoped to receive good-quality healthcare at reduced cost, under the Indian health insurance scheme for below-the-poverty-line families. However, the treatment they received was disappointing and humiliating. With support from PACS and partner SKEVS, they persisted in demanding their rights, and their faith in the card eventually paid off.  Meanwhile, PACS and SKEVS used outreach and advocacy to remind local organisations of their responsibilities and local people of their entitlements.

Urmila shows her RSBY card.

The right to healthcare

Even in fine weather, the Dalit basti (settlement) is usually the most difficult to access in any village; when it’s raining, only agility and desperation are likely to get you there.

Bhadurpur Village, in the Seorati block of the Kushinagar district of Uttar Pradesh in northern India, is no different. What stands out is the enthusiasm of the women – gathered together out of the rain, in a small, half-constructed room, piled high with construction material and other debris – to share their stories. These include the experiences of 30 year-old Urmila Devi and her 35 year-old husband Ranglal Barti, whose faith in their RSBY health insurance card – and in their own entitlement to good healthcare – eventually paid off, despite frustrating and humiliating treatment at the hands of local hospitals.

Benefits of the RSBY smart card

Ranglal Bharti runs his own electrical repair shop in Bhadurpur village; he also goes house-to-house repairing gadgets or trouble-shooting electrical problems and works as a private linesman with the UP State Electricity Board, repairing faults and maintaining transformers in the village that are fed by the massive 11kV high-tension line nearby. However, there are 16 private linesmen in the area since the government implemented a recruitment freeze on linesman, so competition is fierce. Ranglal also risks his life for his work, since he receives no safety equipment from the Electricity Board for working on the high-tension lines.

Ranglal attended the capacity-building and awareness-generating activities organised by CSO Samudayik Kalyan Evam Vikas Sansthan (SKEVS), the PACS partner working in the village, and it was at one of these that he first heard of the RSBY smart card, entitling below-the-poverty line families to cheaper healthcare. Not one to miss an opportunity to help his family and community, he immediately met up with PACS Block Coordinator, Prabhu Nath Prasad, who outlined the benefits of the RSBY smart card. 

Prasad explains: ‘When we facilitated the formation of women’s self-help groups (SHG) here, meetings were often attended by both men and women, and we did not mind it at all. In all our meetings, we spoke of how, and why, women should form SHGs in the village, and how it would help enhance their personal and socio-economic development, inculcate a habit of regular savings and lead to their awareness of credit, as well as issues related to equity and gender. During these meetings, we also introduced government schemes and programmes the community could benefit from.

'RSBY was one such focus of our discussion. We explained the objectives of the RSBY scheme, like financial protection from healthcare expenses on hospitalisation, improved access to quality health care and providing beneficiaries with the power of choice to select a healthcare provider. As a result, many people in the village came forward during the card registration process, one of whom was Urmila and her husband, Ranglal.’

Barriers and challenges

In August 2013, pregnant Urmila woke Ranglal to tell him that her labour pains had started. Holding their newly minted RSBY card, Ranglal immediately checked the booklet that came with it and located the nearest hospital to the village. Urmila was not yet in discomfort and the auxiliary nurse midwife (ANM) had told him that it would take a day or so for the delivery, so he realised he had time do his research and find the best option for his wife.

‘I wanted to be sure, when the moment came, where to go and how far it would be. I did not want to run from hospital to hospital with my pregnant wife, putting her and the baby at great risk. So I took out my motorcycle and, as the booklet said, went to the Buddha Hospital in Fajil Nagar, 27km away. When I spoke to the health staff there, they said she could deliver at the hospital, but we could not use the card to pay for the expenses, since they did not accept the RSBY card. So I came back home, deciding to go to another hospital the next day.

‘The next day, I went to the Government Primary Health Centre (PHC) at Tamkoi Raj, 10km away. The sarkari (government) nurse looked at the papers and said my wife had another two days to go for the delivery, so the hospital could not admit her now. “Come after two days, we’ll see then,” she said. I was now both disappointed and worried – the two hospitals the RSBY booklet had mentioned had turned out to be disappointments, and I was worried because I was not sure what was in store the next day. Would a hospital accept her tomorrow, or would we have to go to a far-away city for the delivery? What about the expenses? I went to sleep with only an assurance – soon to be proved wrong – that we still had time on our hands.’

Urmila went into labour at 10am the following day. Ranglal immediately called the toll-free ambulance number (108), but the driver told him there had been a big accident on the highway and he was busy ferrying the injured to hospital. ‘Wait for one-and-half-hours; I’ll not be able to come before then,’ he said. 

Desperate, Ranglal hailed an auto rickshaw and rushed his wife to the Government Primary Health Centre at Tamkoi Raj. The ride set him back Rs. 700, but it was not the time to haggle! However, all was not resolved. In the evening, Urmila was referred from the health centre to the District Hospital in Kushinagar; since it was getting late, Ranglal stopped at the Al Sifa Life Care hospital at 7pm.

Staff there said they could supervise the delivery, but refused to accept the RSBY card. ‘So I asked “will you accept money?” and they said they would,’ explains Ranglal. ‘Ironically, while the receptionist told me bluntly that they did not accept RSBY cards, there was a banner about the RSBY card on display near the entrance!' 

Ranglal paid Rs. 300 as admission fee and the hospital demanded Rs. 6,000 as a deposit. He informed staff his wife wanted a natural delivery because there were no known complications, but they stated that they would perform a C-Section. He insisted on a normal delivery because he did not have the money to pay for a C-Section. Despite this, they  gave him a long list of medicines to purchase, which he gave to the hospital.

Urmila delivered normally and their daughter, Nandini, was born at 11pm. ‘The next day, the hospital slapped a bill of Rs. 12,000 on me,’ continues Ranglal. ‘Taken aback, I didn’t  know what to do. Then I called the only person who could help me: the PACS Block Coordinator, Prabhu Nath Prasad. In despair, I told him my problem. He said: “have faith… I will help you immediately”.’

Third-party support

Prasad gave Ranglal the RSBY toll-free number and told him to speak to the operator. ‘The operator said “let me talk to the hospital”, but the staff refused. Instead, they began to taunt me – “just pay and go. Why did you not bring money?” When I told the operator I was not getting any help from the hospital staff, he assured me he was on the job and asked for a few minutes. He also gave me the Swasthya helpline toll-free number (1800 180 5145) and told me to speak to them.

‘It was already 10am, and I was facing relentless pressure from the hospital staff. I immediately called the Swasthya helpline and told them my problem. The operator called the chief medical officer (CMO), Kushinagar; the CMO, in turn, called me and said, “let me talk to the hospital staff”. But no one from the hospital was willing to speak to the CMO either, so after some time, he sent some one from his staff to the hospital to get the details.

‘Hungry and tired, I went to a nearby hotel to find something to eat. It was here that I got a conference call from the Swasthya Helpline operator, who told me this was a call between me, the CMO and the operator. After a long discussion, they told me to go to the hospital. When I reached it, the receptionist told me that the hospital had agreed and that I could use the RSBY card to pay the medical bill.

‘Following the conference call, there was absolute panic in the hospital. They began accusing me of trying to be a neta (politician) and were very rude and angry. Then they threw another technicality at me: the hospital refused to accept the card unless my wife was admitted for 24-hours, as per the rules of RSBY. It was already evening by now and my family members were confused; they kept on pleading with me to pay the hospital so everyone could leave. But I was adamant.

Prasad tals to women from the community about their rights.

‘I went to the hospital biometric machine and swapped the card to pay, and the payment was accepted. But because my wife had to remain in the hospital for 24-hours, the hospital did their best to make our stay as uncomfortable as possible: they did not give a single tablet without asking for money, and every time someone came, they were sure to say something rude to me or my family.’

Ranglal’s belief in Prasad and the RSBY card finally paid off: he only paid the Rs. 2,500 charge mandated by the government for normal deliveries, instead of the Rs. 12,000 the hospital had demanded. But the hospital did not give him the medical file, the legally mandated birth certificate or discharge slip. As soon as he left hospital, Ranglal called the RSBY toll-free number and the operator put in another conference call to the hospital. Ranglal told the operator that the hospital had charged him Rs. 300 as an admission fee and had not given him the return fare of Rs. 100, as mandated under RSBY. The operator demanded the hospital make an immediate refund of the entire backlog, and the hospital was forced to pay back Rs. 400 they had charged Ranglal.

‘Ultimately, I paid only Rs. 2,500 instead of Rs. 12,000,’ says Ranglal. ‘I met many patients in the hospital who had been admitted but were not allowed to use their card. But I was sure I was not wrong. And my faith in Prasad was complete. How can someone from such a large programme give me wrong information? I was depending on him.’

Raising awareness

Prasad reports that, later, he and staff from the NGO, had a detailed discussion with Dr Shaumsul, the proprietor of Al Sifa hospital, and other health staff involved in this episode, to talk through issues and clarify rules around RSBY. He discovered that many RSBY ‘beneficiaries’ had poor understanding of their entitlements under the scheme in the community, so still incurred out-of-pocket expenses, and that there was poor coordination of the initiative at district level.

‘One told me: “I took my RSBY card with me when my father suffered from stomach pain but it was not accepted, as the hospital said they only provide free treatment on hospitalisation and I would have to spend from my pocket,”’ recalls Prasad. ‘Another said: “I went to hospital for fever which was empanelled but they didn’t accept the card, saying this can be utilised only for hospitalisation.” These people were not aware that RSBY doesn’t cover out-patient facilities.

‘With PACS support, we took on the challenge of information dissemination. We worked to comprehensively improve information and awareness generation by providing adequate information to the community using various communication media. We also advocated with the state health department to work as problem solvers for clients and to keep a check on insurance and third-party administrator companies. We asked them to disseminate to beneficiaries – and also disseminated ourselves – the toll-free helpline numbers, list of eligible hospitals with addresses, and benefits of scheme in the form of pamphlets in local languages. This has increased the utilisation of the card and decreased unnecessary harassment of both medical staff and patients.’
 
Today, Al Sifa hospital offers exposure visits to women RSBY card-holders to show them how to use the card and the facilities that the hospital offers. So far, two exposure visits with 20 women card-holders have  taken place as a result of our outreach and advocacy effort.

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