COMMENTARY

Economic & Political Weekly EPW JANUARY 11, 2014 vol xlIX no 2 25

Sujata Gothoskar (sujatagothoskar@gmail.com) is an independent researcher and an activist. She has been a part of the women’s movement and the labour movement for many years.

Too Little, Too LateRashtriya Swasthya Bima Yojana in Maharashtra

Sujata Gothoskar

While the union government announced its plan to extend the Rashtriya Swasthya Bima Yojana to the unorganised working class poor like rickshaw-pullers, ragpickers, mineworkers, sanitation workers, etc, the Government of Maharashtra has decided to scrap RSBY and replace it with the Rajiv Gandhi Jeevandayee Arogya Yojana. This article analyses the conditions of waste pickers and argues not to pit one type of healthcare against another and not to scrap schemes like the RSBY that have come anyway too late.

On 4 June 2013, the union cabinet approved the extension of the Rashtriya Swasthya Bima Yojana

(RSBY) to rickshaw-pullers, ragpickers (waste pickers), mineworkers, sanitation workers, autorickshaw drivers and taxi drivers. It was hoped that this would facilitate health insurance cover to these sections of the workforce.1

RSBY is a health insurance scheme that is implemented by the Ministry of Labour and Employment, Government of Maharashtra. The scheme provides for smart card-based cashless health insurance cover of Rs 30,000 per annum to below the poverty line (BPL) families (a unit of fi ve persons) in the unorganised sector. The scheme became operational from 1 April 2008 and is implemented in 25 of the 28 states and seven union ter-ritories. This could be termed as the fi rst serious effort at health insurance for in-formal workers and those living below the poverty line.

In the three years since its launch, the RSBY has helped provide access to hospital-based care to a large number of poor, informal sector workers. According to the website of RSBY, by 30 November 2013, over 37 million smart cards had been issued, and these covered 100 million people with health insurance. It has been claimed, an IT- enabled network of hospitals and insu rance companies has ensured effi cient and cashless delivery of healthcare.2

Some aspects of the scheme’s design have been well-considered and are applicable to the needs of the poor, for instance, the RSBY’s coverage for a family of fi ve matches with India’s average family size of 5.3. Overall, although there have been issues in the conceptualisa-tion and implementation of the RSBY, it is an entitlement that holds promise for enabling cashless access to hospitalisation

for extremely poor people. Several lacunae have been pointed out, like exclusion of sections of workers, high out-of-pocket expenses, lesser proportion of women availing of the benefi ts, inadequate in-formation dissemination, lack of regula-tions and accountability among others.3

During the course of implementation, RSBY has been extended to street ven-dors, beedi workers, domestic workers, building and other construction workers, and Mahatma Gandhi National Rural Employment Guarantee Act (MGNREGA) workers, who have worked for more than 15 days during the previous year.4 It is common knowledge that the sections covered under the RSBY are sections that are one of the most hard-working and yet the poorest sections in our society.

Unorganised Workers and Healthcare

According to the National Commission for Enterprises in the Unorganised Sec-tor, about 836 million or 77% of the pop-ulation constitutes most of India’s infor-mal economy. These sections live below the $0.4 a day.5 They are India’s working poor, with long working hours, arduous work, no rest, no holidays and no proper nutrition. Little wonder then that their health is extremely precarious. This is all the more true of women workers within these sections and communities.

It is important for the state to adopt universal healthcare system and it is crucial for all working people to be able to access good, rational and affordable healthcare. However, until there is such a systemic change, arrangements have to be made to ensure at least the most vulner-able get access to basic services. Good, adequate and cheap healthcare is an urgent need and a really great challenge for these sections of workers. Several studies have shown how healthcare is one of the main reasons for indebtedness among poor working class households. This also has a specifi c name called medical debt.6 The share of out-of-pocket spending on private healthcare is very high in India compared to most other developing countries (Berman et al 2010). About 39 million additional people fall into poverty each year as a result of this expenditure (Balarajan et al 2011).

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JANUARY 11, 2014 vol xlIX no 2 EPW Economic & Political Weekly26

The unorganised sector workers, the working poor have always been deprived of adequate healthcare. The Employees State Insurance Scheme has not inclu ded these sections despite repeated demands by unions and pious declarations by governments. This major lacuna was sought to be addressed by several health insurance schemes at the state as well as the central level. Several unions and non-governmental organisations have also attempted to deal with this very glaring gap in the lives of the working people, especially women workers. For example, the Self-Employed Women’s Association (SEWA), a union of over 1.1 million women workers in the informal economy as a VimoSEWA scheme.7

One such major initiative has been the RSBY. The scheme is largely funded by the central government with the centre fi nancing 75% and the state government contributing 25% of the expenses. The scheme covers hospitalisation charges up to Rs 30,000 for up to fi ve members of a family for a year. A family is required to pay Rs 30 as registration fee. The scheme also provides for Rs 1,000 per year as transportation costs. It, however, does not provide for outpatient care or the cost of medicines. Each household is provided with a smart card that stores the names, age, photographs and thumb impressions of the family members.

However, despite the announcement of the extension of the scheme to more sections of workers, there is talk that the Government of Maharashtra has scrapped the scheme from February 2013. There have been news reports indicating this withdrawal. There is also the reality that tenders have not been invited from insurers this year. This has been a big disappointment for sections that were looking forward to be included in the scheme and have just been included.

Hence in mid-June 2013, several repre-sentatives of the alliance of Indian waste pickers (AIW), Maharashtra, met to discuss the inclusion of waste pickers in the RSBY. The move was supposed to benefi t around two lakh waste pickers across the state.

Work of Waste Pickers

Waste collection is socially relevant, eco-nomically productive and environmentally

benefi cial “work”. In fact, India has one of the highest recycling rates in the world. According to the World Bank, 1% of the urban population in developing countries earns a living through waste picking and recycling. The International Labour Organisation (ILO) estimates that there are between 15 and 25 million waste pickers in the world.8 An estimated two million of these are in India (Burke 2012). Most observations as well as studies have pointed to the fact that the majority of these are women.

A study of the municipal corporations of Pune and Pimpri-Chinchwad con-ducted by the Kagad Kach Patra Kashta Kari Panchayat (KKPKP), a union of waste pickers in Pune and Pimpri-Chinchwad region has shown how these waste pickers have saved several crores of rupees of the corporation’s money in waste handling costs. A rough estimate puts the annual savings of the corporation to above Rs 12 crore. The formal study commis-sioned by the ILO and undertaken by a team of researchers from the Shreemati Nathibai Damodar Thackersey women’s university in 2000-01 found that collec-tively, scrap collectors salvaged 144 tonnes of recyclable scrap prior to its transpor-tation, thereby saving the municipal cor-porations of Pune and Pimpri-Chinchwad about Rs 16 million per annum in trans-portation costs alone! By implication,

each waste picker contributed Rs 246 worth of unpaid labour per month to the municipality. The study also found that the annual contribution of the scrap trade to the total income generated in Pune was about Rs 185 million.9

Unfortunately, despite their very signi-fi cant function in society, these self-employed women occupy the lowest rung in the informal economy and are generally treated with contempt. Despite collectively cleaning the country, scrap collection is neither recognised as a work, nor scrap collectors as workers. Consequently, waste pickers receive no employment guarantee, regular wage or state benefi ts. Given the dangerous and insecure nature of the work, it is a fragile existence. But India’s waste pickers are not recognised in offi cial statistics.

Health Issues of Waste Pickers

Most of the women come from not just very poor families and class, but also from castes that are low down in the caste hierarchy. These are people who have been historically discriminated against for centuries and systematically denied any opportunity for looking for any alternatives.

The work they do is called 3-D work, i e, dirty, dangerous and demeaning (often dirty, dangerous and demanding or dirty, dangerous and diffi cult). 3-D is

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Economic & Political Weekly EPW JANUARY 11, 2014 vol xlIX no 2 27

an American neologism derived from a Japanese expression referring particularly to diffi cult work done that involves high risk and is low status.10

As the name indicates, dirty, dangerous and demanding work can impose severe physical and mental costs on workers. There is often a risk of not being able to work for a long time due to injuries or general depletion of health or mental fatigue. After experiencing themselves and witnessing the constant physical and mental injury to co-workers or even death, the stress can cause mental fatigue and post-traumatic disorder.

Several studies have pointed out the occupational health and safety issues the waste pickers experience. The Shram Shakti report brought out by the gov-ernment in 1988 has noted some of these issues.11

Waste pickers work from sunrise to sunset sifting through garbage. They work erratic hours and often eat very lit-tle and infrequently as there is no space for them to have their meals during work time. This is often said to give rise to problems like hyperacidity and other stomach-related ailments. They are in addition subject to the elements much more than most other occupations. They walk several miles every day and carry huge and heavy loads on their heads. This also gives rise to serious musculo-skeletal problems.

While sifting through the garbage, very often their hands get wounded by shards of broken glass thrown in the rubbish. Needles, metal shards, glass frag ments cause serious physical injuries, while cuts and pricks are an everyday phenomenon. No protective equipment like gloves are provided as these women are not even considered workers.12

Bottles, containers with chemical res-idues, contaminated needles, heavy met-als from used battery cells, for example, are things that they have to contend with daily.13 Unprotected exposure to contam-inants, hazardous materials is a daily reality. So is contact with fecal matter, toxic fumes, decomposed waste. Also almost daily is their brush with rod ents, vermin as well as stray dogs and cats.

They work among unstable landfi lls, where mountains of waste sporadically

collapse, trapping those inside. There have been several instances of waste pickers being run over by trucks and similar accidents as also becoming vic-tims of fi res and landslides even in cities like Mumbai. Harassment by the police is said to be a part of their daily routine. Apart from injuries and bites and dizzi-ness, nausea, back pain are common.14

The abysmal working conditions reinforce their equally unsatisfactory living conditions, especially in cities, where steep real estate prices and constant evictions make life even more diffi cult and seriously affect their health. All these conditions give rise to severe stress and cause mental stress and disorders. Low life expectancy is said to be a common phenomenon among waste pickers.

It is well known that women are the last to seek healthcare and when they have to pay for it, her health takes the last priority. Sexual assault and violence are not uncommon as the women are vulnerable when out very early or late and on the streets doing work that is not recognised as legitimate.

According to a report of ILO in April 2012, “Promoting health and safety in a green economy”, new recycling techno-logies may introduce new risks. Also, new materials and products, when being collected as waste, may present a variety of occupational risks from nanomaterials and new types of chemicals to the con-tinuous growth in electronic waste. In addition, waste disposal is turning into a new branch of the energy sector where waste-to-energy processes can generate hazards from impure gas production, explosions, dangerous substances and gases in confi ned spaces. Future landfi ll mining for valuable resources will in-crease exposures to harmful material.15 Waste management strategies need to shift from considering waste as an un-wanted burden to viewing it as a valued resource, or to prevent its generation in the fi rst place.

The ILO study states that recycling work can be dirty, polluting, undesirable, even dangerous, and it is often poorly paid, even in developed countries. A study of working conditions in recycling centres in Sweden, for example, identifi ed several risks and found a high frequency of

injuries. The fi rst step towards changing this scenario is to protect the people in-volved in this work by protecting their livelihood, their remuneration, their housing, their nutrition and their health.16

Confusion between Schemes

It is reported that the Government of Maharashtra17 intends to extend its Rajiv Gandhi Jeevandayee Arogya Yojana (RGJAY) launched in eight districts of Maharashtra to the rest of the state.

Domestic workers who were included in RSBY in the earlier year have also not gone very far ahead in getting the benefi ts of this scheme. One of the reasons why this is the case and why the Maharashtra government has decided not to imple-ment the RSBY in the state may be because there is another scheme, i e, RGJAY that has more coverage in terms of proce-dures as well as fi nances.18 That the cov-erage under the RGJAY is Rs 1,50,000, much more than the RSBY. The RGJAY also covers all the members in the family within the limit of Rs 1,50,000.

It is important to understand how-ever that the two schemes are very dif-ferent in nature and cover very different aspects of healthcare. RGJAY is a scheme that provides for 972 surgeries/therapies/procedures along with 121 follow-up packages in 30 identifi ed specialised categories. These include general, ENT, ophthalmology, gynaecological and obstet-rics, gastroenterology, cardiac, paediatric, etc, surgeries in a cashless manner. The detailed list is provided and is very clear. While it is important that the working poor have access to these pro-cedures, these constitute tertiary health-care and cannot replace the benefi ts the RSBY scheme affords to workers. The RSBY includes expenses of hospitalisation as well as day-care treatments and sur-geries that are not part of the procedures included in the RGJAY. For example, nor-mal deliveries are covered by RSBY but not by RGJAY.

The latest media reports seem to in-dicate that the Government of Mahar-ashtra has withdrawn from the RSBY and launched the RGJAY in the entire state, when Sonia Gandhi inaugurated RGJAY in November 2013. It is indeed strange that even a Congress-ruled state

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JANUARY 11, 2014 vol xlIX no 2 EPW Economic & Political Weekly28

like Maharashtra is refusing to implement the centre’s fl agship schemes.

There are defi nite advantages of RGJAY. One is that it includes more people – anyone earning up to Rs 1 lakh annually is covered by the RGJAY, while RSBY cov-ered only BPL families. Second, people are entitled to much larger amounts under the RGJAY – Rs 1.5 lakh, while under the RSBY the amount is only Rs 30,000. The problem, however is that, it excludes general illnesses and covers those proce-dures like neurosurgery, cardiac surgery, etc, that affect a much smaller propor-tion of the population.

Tertiary and specialised healthcare is important for workers and their families as one such procedure can completely wipe out their entire savings and meagre assets. However, the working people need primary and secondary healthcare more often due to their work and the stress and strain of the work. It is well known that the poor avoid seeking medical care as they cannot afford to pay for it nor can they seek medical care when they have to work to be able to provide for food for the family. This is even truer of women workers. Hence providing primary, secondary and terti-ary healthcare to sections of the unor-ganised working class is urgent. It is equally important not to pit one type of healthcare against another and not scrap schemes like the RSBY that have come anyway too late.

There have been several studied cri-tiques of the RSBY and its implementa-tion. There are critiques of the RSBY also from the point of view of the concept of Universal Health Care as a right.

As put forward by Anant Phadke, a health activist, there are some deeper, basic problems with RSBY.19

Some of these are that there are no standard treatment guidelines. Thus a case of fever can be conveniently labelled by the doctor as dengue fever and the patient gets admitted under fear psycho-sis; the patient is given unnecessarily IV fl uids, undergoes unnecessary investi-gations and the government pays bills in hundreds for a case which could have cost Rs 20. In such cases, primary care patients become secondary care, and patients are burdened with irrational

and excessive medication. Another thing, insurance companies have a vested inter est in getting higher premium amounts and less number of people getting benefi t. Also, a great deal of government money is spent on paying the insurance compa-ny. It has also been observed that the most vulnerable, the migrant workers, street-children, deserted women, etc, do not get cards and are excluded from the benefi ts. What is important is to im-prove the secondary care in public health services and not rout the cases that genuinely require secondary care to private hospitals.

There have been several studies which indicate that in Maharashtra, for exam-ple, the RSBY has not been functioning in a proper manner. Several aspects of the functioning of the scheme have been critiqued (Thakur and Ghosh 2013; Narayana 2010).

According to the Recommendation 3.1.9 of High Level Expert Group (HLEG) on Universal Health Coverage (UHC), con-stituted by the Planning Commission of India in October 2010, with the mandate of developing a framework for providing easily accessible and affordable health-care to all Indians, insurance companies should not be involved in the UHC system. It prohibits the use of insurance compa-nies or any other independent agents to purchase healthcare benefi ts on behalf of the government.20

According to Anant Phadke,21 while RSBY should not be scrapped, it is important that all such state-funded so-called insurance schemes must be merged in a stepwise manner into public health system.

Notes

1 Cabinet, 4 June 2013, 20:40 IST, “Extension of Rashtriya Swasthya Bima Yojana to other Occupational Groups”, available at: http://pib.nic.in/newsite/erelease.aspx?relid=96411

2 Jain Kalpana, “Health Insurance in India: The Rashtriya Swasthya Bima Yojana”, Assessing Access for Informal Workers, WIEGO Policy Brief (Social Protection) No 10, September 2012, http://wiego.org/sites/wiego.org/fi les/publi-cations/fi les/Jain-Health-Insurance-Informal-Economy-India-WIEGO-PB10.pdf

3 Ibid. 4 See Note 1. 5 National Commission on Enterprises in Unor-

ganised Sector (NCEUS), 2009. 6 Wikipedia, Medical debt, http://en.wikipedia.

org/wiki/Medical_debt 7 Jain (2012), op cit.

8 “Promoting Health and Safety in a Green Eco-nomy”, ILO, April 2012, http://www.ilo.org/wc-msp5/groups/public/@ed_protect/@protrav/ @safework/documents/publication wcms_ 175 600.pdf

9 Ujwala Samarth, “Occupational Health of Waste Pickers in Pune: KKPKP and SWaCH Members Push for Health Rights”, undated, http://www.mfcindia.org/main/bgpapers/bgpapers2013/am/bgpap2013Vv.pdf

10 Wikipedia, Dirty, Dangerous and Demeaning, http://en.wikipedia.org/wiki/Dirty,_Danger-ous_and_Demeaning

11 Shram Shakti: Report of the National Commis-sion on Self-employed Women and Women in the Informal Sector, 1988.

12 Samarth, Ujwala undated, op cit, http://www.mfcindia.org/main/bgpapers/bgpapers2013/am/bgpap2013 Vv.pdf

13 “Women in Informal Economy Globalising and Organising (WIEGO), Waste Pickers, 2013”, http://wiego.org/informal-economy/occupati onal-groups/waste-pickers

14 WIEGO (2013), op cit.15 “Promoting Health and Safety in a Green Econ-

omy”, ILO, April 2012, http://www.ilo.org/wc-msp5/groups/public/@ed_protect/@protrav/@safework/documents/publication/s_175600.pdf

16 ILO (2012), op cit. 17 Asian Age, 3 July 2013.18 Conversations with several domestic workers’

unions. 19 Phadke, Anant, “Insourcing of Some Private

Providers in the Proposed UHC System in Maharashtra”, unpublished.

20 High Level Expert Group Report on Universal Health Coverage for India, New Delhi, Novem-ber 2011, p 12.

21 Personal communication with Anant Phadke dated 1 December 2013.

References

Balarajan, Y, S Selvaraj and S V Subramanian (2011): “Healthcare and Equity in India”, The Lancet, Vol 377, Issue 9764, February, pp 505-15.

Berman, P, R Ahuja and L Bhandari (2010): “The Impoverishing Effects of Healthcare Payments in India: New Methodology and Findings”, Economic & Political Weekly, 17 April, Vol XIV, No 16.

Burke, Jason (2012): “Cleaning Up India’s Waste: But What Is the Future for Army of Tip Pick-ers?”, The Guardian, London, 2 July.

Narayana, D (2010): “Review of the Rashtriya Swasthya Bima Yojana”, Economic & Political Weekly, Vol XLV, No 29, pp 13-18.

Thakur, Harshad and Soumitra Ghosh (2013): Case Study Report On “Social Exclusion and Rashtriya Swasthya Bima Yojana (RSBY) in Maharashtra”, School of Health Services Studies, Tata Institute of Social Sciences, Mumbai, May.

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