Ayushman Bharat holds the promise to advance equity both within households as well as across social groups. However, the geographical inequities characteristic of India’s healthcare provisioning need to be overhauled first for the scheme to be more equitable. 

The National Health Protection Scheme was the largest publicly funded health insurance scheme in the world, it intends to offer financial risk protection to the poorest and the vulnerable. Each identified household has to be insured for an annual sum of Rs 5 lakhs for a variety of ailments needing secondary and tertiary healthcare.

Equity in health is defined as “the absence of systematic disparities in health (or in the major social determinants of health) between groups with different levels of underlying social advantage/ disadvantage—that is, wealth, power, or prestige.”

The study is located in villages of predominantly rural blocks in five backward districts of West Bengal. The districts are: Murshidabad, Malda, Dakshin Dinajpur, Uttar Dinajpur and (undivided) Jalpaiguri. Information was collected from 449 households through quantitative face-to-face interviews.

Household as a Site of Inequity

The household is a site of unequal distribution of power and resources. It has been seen that the overall hospitalisation rate is the lowest for the poorest households. Further, the rate of hospitalisation of females in these households is relatively higher than the males. The study showed that the access to healthcare is likely to improve for conventionally disadvantaged members in those households that have active RSBY cards.

The hospitalisation rates improve for persons with disability in the households with active RSBY cards. In such households, 20% of the differently abled were hospitalised in the past one year prior to the study. The hospitalisation rate is lower than the national average.

From among households without RSBY cards or lapsed cards, Muslims were most likely to be hospitalised. This is primarily because the Muslim-dominated districts of Murshidabad and Malda also had the highest number of empanelled hospitals. This study showed that 53.1% of the households preferred the nearest hospital for hospitalisation.

Implications for National Health Protection Mission

Malpractices such as admitting more patients than the bed strength in the hospital can be detected and flagged by the system software. There is no limit on the number of household members who can be enrolled under the scheme. Such corrections will undoubtedly help to advance the goal of universal health coverage in an ethical and equitable manner.

The design of the RSBY scheme also offers lessons in what may be done to avoid perpetuating inequities. Health insurance schemes can counter both intra- household and inter-household inequities. The unevenness and urban bias in India’s health infrastructure restrict all three dimensions of access to healthcare, limiting as they do physical accessibility, financial affordability and acceptability of health services.

While health insurance schemes such as the RSBY may have countered some of the inequities operational within and across the households. With such a compromise on equity, the goal of universal health coverage is unlikely to be reached in the near future.