T Seshadri* 1 , G Ganesh 1 , MH Anil 1, MK Pati 1 , M Kadammanavar 1, N Devadasan 1

1. Of old exclusions &new barriersTracing the experience of vulnerable groups in Karnataka using RSBY T Seshadri*1, G Ganesh1, MH Anil1, MK Pati1, M Kadammanavar1, N Devadasan1 1Institute of Public Health Bangalore, India with the Health Inc consortium Health Systems in Asia Singapore 14th Dec 2013

2. National Health Insurance Scheme (RSBY) Source: Devadasan N, Swarup A. Rashtriya Swasthya Bima Yojana: an overview. IRDA Journal. 2008;6(4):33 – 36.

3. Health Inc project • How social exclusion influences access to health services despite health financing reforms to ultimately help make these reforms inclusive • Four sites – Ghana, Senegal, Maharashtra and Karnataka, India • In Karnataka • 6040 households across four districts • Mixed methods, longitudinal approach • Ongoing stakeholder interaction, wrap up in coming year Source: generated from baseman from Wikimedia Commons/User:Planemad

4. Available at URL: http://www.lab-initio.com/screen_res/nz045.jpg 1865 Kekule moments before his brilliant insight into the structure of benzene

5. Experience has shown that simply bestowing equal rights based on some universalist notion of citizenship does not guarantee equal agency, opportunity, influence or outcome. Kabeer N (2002) Social exclusion, poverty and discrimination: Towards an analytical framework. IDS Bulletin 31(4), 83–97 Gender Scheduled caste Scheduled tribe & RSBY

6. Scheduled caste Karnataka They will make us sit outside and not enter the office. We will be waiting for so long to get any information about these schemes but they are not bothered about helping us. They want us to be kept down. (Resident_Mysore Rural)

7. 23% study population (16% Karnataka*) – 39%urban • One-fourth of households did not know their social category • Higher illiteracy rate Awareness of RSBY: 1.4 times more likely to be aware than general category (1.1-1.6,95% CI) Enrolment in RSBY: Comparable to general category (39%) *Census 2001

8. Tightly knit communities with high sense of solidarity • Exclusion mainly reported in villages where minority • Geographical isolation and differential development visible • Vocal about instances of active discrimination • Participation in local politics a key factor (less frequent 20%, 1.3 times more likely to access) - Politics ‘disrupts’ traditional roles • Who heads the household matters - elderly or daily wage labourer 2 times less likely to enroll • Internalised sense of inferiority

9. Scheduled Tribes Karnataka

10. 9.5% study population (6.6% KarnatakaCensus2001) • forest dwelling, hilly areas (nearly two-third) in Karnataka • Active exclusion from accessing information on RSBY • Rural enrolment rates significantly low at 29% only (4 times less likely than others) • Urban enrolment rates high at 48% • Geographical clustering, history of chronic exclusion from accessing basic public services • RSBY exclusion at more macro level • Relative geographical, social isolation, sparsely populated • RSBY enrolment less attractive

11. Solidarity highest at local level, limited across tribes • Political participation low • Mainly daily wage earners • Significant non-agricultural means of livelihood - migration for work significant • Limited access to other services – relational exclusion due to lower education levels, occupation opportunities, etc • Female-headed households 5 times more likely to be excluded • Not owning house, illiterate head associations

12. Gender

13. Gender wise education • Female-headed households: • 1 in 6 households • 45% elderly • 87% illiterate • 61% of all women above 14yr not earning (18% men) • Lower rates of awareness and enrolment in rural Karnataka comparable to ST households • If enroll, often do not received cards

14. Who is she? elderly or ST increases possibility of exclusion by 5 times, being Muslim increases it by 10 times • Within households – more likely not be included except if spouse, not part of decision-making though • Long queues at camps, added responsibilities in household and frailty of elderly • Less likely to be involved in local politics or social networks, male administrators, passive exclusion, internalised process

15. What does this all mean? • Some exclusion due to administrative failures, some passive, others enforced • Consistent exclusion at every stage of programme implementation • RSBY in theory and on the ground • Drive for universal health coverage • A more complicated set of challenges for policy makers • Need to adopt a social exclusion perspective when looking at performance of a social health protection scheme 'If the misery of the poor be caused not by the laws of nature, but by our institutions great is our sin.' CharlesDarwin

16. Acknowledgements FUNDING The Health Inc Project is funded by the European Commission’s Seventh Framework Programme FP7/2007 under grant agreement No. 261440. The views and conclusions presented in this presentation are the sole responsibility of the author and do not necessarily reflect the views of the Commission. All images used in this PowerPoint have been taken from Wikimedia Commons. HEALTH INC PARTNERS