When state-funded health insurance schemes fail to provide financial protection: An in-depth exploration of the experiences of patients from urban slums of Chhattisgarh, India

ABSTRACT

This paper explores the dynamics of access under the state-funded universal health insurance scheme in Chhattisgarh, India, and specifically the relationship between choice, affordability and acceptability. A qualitative case study of patients from the slums of Raipur City incurring significant heath expenditure despite using insurance, was conducted, examining the way patients and their families sought to navigate and negotiate hospitalisation under the scheme. Eight purposefully selected (‘revelatory’) instances of patients (and their families) utilising private hospitals are presented. Patients and their family exercised their agency to the extent that they could. Negotiations on payments took place at every stage, from admission to post-hospitalisation. Once admitted, however, families rapidly lost the initiative, and faced mounting costs, and increasingly harsh interactions with providers. The paper analyses how these outcomes were produced by a combination of failures of key regulatory mechanisms (notably the ‘smart card’), dominant norms of care as a market transaction (rather than a right), and wider cultural acceptance of illegal informal healthcare payments. The unfavourable normative and cultural context of (especially) private sector provisioning in India needs to be recognised by policy makers seeking to ensure financial risk protection through publicly financed health insurance.

KEYWORDS:

• Publicly funded health insurance
• financial protection
• regulation
• qualitative study
• India

Acknowledgements

The Authors are grateful to the respondents and Mitanins for sharing their stories.

Disclosure statement

No potential conflict of interest was reported by the authors.

Data availability statement

The authors confirm that the data supporting the findings of this study are available within the article.

ORCID

Sulakshana Nandi http://orcid.org/0000-0002-4366-4566

Notes

1 The proportion of Below Poverty Line (BPL) households in the population is calculated state-wise by the government based on per capita consumption expenditure survey data. The identification of BPL families is done through a socio-economic census by government. At the time RSBY was launched, around one-third of households in India were categorised as BPL.

Additional information

Funding

This paper is part of the PhD of the first author for which a part fellowship was provided by the Belgian Development Cooperation (Belgisch Ontwikkelingsagentschap) (DGD) through the Institute of Tropical Medicine, Antwerp.