A process evaluation of Rashtriya Swasthya Bima Yojana (RSBY) enrolment process: Lens of accountability

Abstract

Increased accountability (through increased efficiency, cost reduction and expertise of private actors) has been used as one of the primary justifications for encouraging private sector participation in the public health programmes in developing countries like India (Brinkerhoff, 2004; Blanchett & Tolley, 2001). However, the literature suggests that the assumption of increasing accountability has not only received little empirical verification but also remains conceptually under-developed (Mulgan, 2000; Bovens, Goodin & Schillemans, 2014). The term accountability has been referred to as ‘a complex and chameleon like term’ for being used synonymously with other terms like responsibility, transparency, answerability, responsiveness, control etc. (Mulgan, 2000). Accountability being described as an ‘icon’, as a ‘social relation’ and as a ‘liability’, it remains an elusive and much contested concept (Bovens et al. 2014). Pointing to limited empirical evidence, Rein & Scott (2009) argue that benefits of PPPs are unlikely to reach intended beneficiaries without appropriate accountability mechanisms. Moreover, partnership based programs, like Rashtriya Swasthya Bima Yojana (RSBY), involve multiple actors (public as well as private) with networked linkages that makes it a complex and multi-level phenomenon to study from an accountability perspective (Frink et al., 2008; Mulgan, 2002). Thus, to understand the functioning of accountability mechanisms in the implementation of RSBY, we carried out a theory based process evaluation of the scheme’s enrolment process using qualitative methods (including document review, instrument-based as well as field observations, formal and informal interviews) along with some RTIs (Steckler & Linnan, 2002). While the enrolment process is important for the success of any program, it is particularly salient for schemes targeting the disadvantaged (Forgia & Nagpal, 2012). The findings from the study point towards significant gaps in the ability of eligible citizens to be able to benefit from the scheme. Many of these gaps arise from not only implementation failures but can also be traced to the program design. Issues of information asymmetry, accountability overload, ambiguity in understanding of roles and responsibilities amongst the actors, especially the street-level bureaucrats (ASHA workers, field key officers, enrolment operators etc.) were found to weaken the functioning of accountability mechanisms in the field. Also, the capacity building exercises and few formally stated accountability mechanisms were found to largely play a symbolic role instead of necessarily contributing to improved implementation. Our study contributes to the understanding of implementation issues from the lens of accountability in programs like RSBY which are targeted in nature (not universal) and involve complex networked linkages amongst actors across organizations and institutions. Through this, the study raises questions about the feasibility of involving private actors in being able to substitute for weaknesses in state capacities and scarce public resources and creating more accountable public health institutions.