Bengal's Swasthya Sathi Scheme Achieves High Coverage, But Reveals Cost Disparities in Healthcare
Kolkata: A groundbreaking research report released in Kolkata on Friday highlights that West Bengal's Swasthya Sathi health insurance scheme now covers an impressive 74.5% of the state's residents. This places it among the highest coverage rates for publicly-funded health insurance programs across India, showcasing significant progress in healthcare accessibility.
Stark Contrast in Out-of-Pocket Expenses Between Public and Private Facilities
The report, however, uncovers a critical issue: beneficiaries of Swasthya Sathi incur substantially higher out-of-pocket expenses (OOPE) when utilizing the scheme at private healthcare facilities compared to government institutions. Specifically, the data indicates that OOPE for drugs and diagnostics is four times greater in private hospitals.
According to the findings, a Swasthya Sathi beneficiary spends an average of Rs 4,000 as OOPE in government hospitals, while this figure skyrockets to Rs 16,300 at private hospitals. This disparity raises concerns about the financial burden on patients despite insurance coverage.
Research Methodology and Key Findings
The excerpts were presented at a workshop organized by Pratichi at the Amartya Sen Research Centre in Salt Lake. They form part of a collaborative project titled "Health Financing Fragmentation and Universal Health Coverage," conducted by Imperial College, London, and O.P. Jindal Global University, with funding from the UK-based National Institute for Health and Care Research.
The Bengal segment of the study involved a comprehensive survey of 2,525 households, encompassing 10,235 individuals across four districts: Murshidabad, West Burdwan, Jalpaiguri, and North 24 Parganas. The survey was conducted between June and September 2024.
Among the surveyed population, 16.6% had utilized the Swasthya Sathi scheme. The report further details that 70% of these users accessed the scheme in private hospitals, while only 30% did so in government hospitals.
"We find that among Swasthya Sathi users, OOPE was incurred particularly for drugs (mean Rs 6,700) and diagnostics (Rs 6,800)," the report stated, emphasizing the specific areas where costs accumulate.
Reasons for Non-Usage and Additional Financial Burdens
The study also sheds light on why 83.4% of Swasthya Sathi beneficiaries did not use the scheme during hospitalizations. It notes that non-usage is not typically a matter of choice. Key reasons include:
- Hospitals denying service under the scheme
- Hospitals not being empanelled with Swasthya Sathi
- Specific services not being covered by the insurance
- Long waiting periods for treatment
Of those who did not use the scheme, 70% sought treatment in government hospitals, and 30% in private hospitals. The financial impact was severe: individuals who opted out of using Swasthya Sathi in private hospitals faced an average OOPE of Rs 2.9 lakh, while those in government facilities paid Rs 3,400.
Outpatient Care and Coverage Gaps
The report further analyzes outpatient (OP) care, which constitutes approximately 90% of all out-of-pocket expenses in Bengal. Out of 1,067 OP episodes studied, only 43% involved seeking medical care, with the majority turning to private providers.
Notably, 12% received no treatment at all, and nearly 50% resorted to self-treatment. This trend is often driven by the perceived mildness of ailments or financial constraints, highlighting gaps in healthcare utilization.
For the 13.2% of individuals not covered by Swasthya Sathi, the divide between government and private hospitals is even more pronounced. The study suggests that government hospitals are the most viable option for this group, with an average OOPE of Rs 3,000. In contrast, if these uncovered individuals seek care at private hospitals, they end up paying an average OOPE of Rs 3.1 lakh.
The report concludes by identifying high out-of-pocket expenses as a pervasive nationwide problem, underscoring the need for systemic reforms to enhance healthcare affordability and access under public insurance schemes like Swasthya Sathi.
