The public-health discourse must move beyond a top-down approach and listen to people to formulate best insurance practices.
Much ink has been spilled in documenting the inadequacy of budgetary allocations for public health insurance, specifically for the Rashtriya Swasthya Bima Yojana (RSBY), the world’s largest publicly-funded health insurance (PFHI) scheme. Though the 2017-18 budget allocation has marginally increased from last year’s revised estimates, it has declined relative to last year’s budgeted amount by about ₹500 crore. However, higher budgetary allocation can only constitute a small part of the solution to the scheme’s mixed, if not lacklustre, performance.
Under the scheme, a Below Poverty Line (BPL) family of five is entitled to more than 700 treatments and procedures at government-set prices, for an annual enrolment fee of ₹30. However, even nine years after its implementation, it has failed to cover a large number of targeted families — almost three-fifths of them. Their exclusion has been due to factors like the prevalent discrimination against disadvantaged groups; a lack of mandate on insurance companies to achieve higher enrollment rates; and an absence of oversight by government agencies.
Increase in hospitalisation
True, there has been a substantial increase in hospitalisation rates. However, it is unclear if it has enabled people to access the genuinely needed, and hitherto unaffordable, inpatient care. Often, doctors and hospitals have colluded in performing unnecessary surgical procedures on patients to claim insurance money. For instance, hospitals have claimed reimbursements worth millions of rupees for conducting hysterectomies on thousands of unsuspecting, poor women. Indeed, in the absence of regulations and standards, perverse incentives are created for empanelled hospitals to conduct surgeries. It is thus not surprising that there is no robust evidence of an improvement in health outcomes.
Evidence on the financial protection front is conflicting as well. One study revealed that poorer households in districts exposed to the RSBY and other PFHIs recorded an increase in out-of-pocket (OOP) expenditures for hospital care, and a corresponding rise in incidence of catastrophic expenditure. There is near-consensus that the RSBY has resulted in higher OOP expenditures. Though it is a cashless scheme, many users are exploited by unscrupulous hospital staff.
So, what is the solution? There is a need to bring the ‘public’ back into the discourse on public health to highlight its present culture. The conversation needs to move beyond a top-down approach specifying budget allocation and administrative and technical efficiency. It needs to involve listening to the real public to deliberate on various health practices and policies.
My ethnographic study of the RSBY in Kalaburagi and Mysuru districts between 2014 and 2016 brought to light that a top-down approach on allocation and coverage was important but, by itself, did not translate to expected outcomes. What mattered more was the existing culture of health insurance — how it was perceived, practised and experienced in the everyday, local worlds of the enrolled households. Though they valued aspects like the money available and the number of illnesses covered, they were more deeply affected by how other actors — doctors, local officials, neighbours and even relatives — related to health insurance.
Card not accepted
The disillusionment of Savitri, one of the beneficiaries, after obtaining the plastic card said it all: “If public officials only give us the card without telling us how to use it, the card is just plastic material. Sometimes information is also not correct, making us feel that the card is of no real value if we do not know how to use it.” Further, many hospitals refused to acknowledge the card’s value. Shivakumar’s observation summed it well: “We went to the hospital with the card. Not only could it not be used but also the doctors did not even acknowledge us as patients… We just brought the card home and tossed it to the shelf.” Many bemoaned the absence of public debate on health issues and the RSBY card. Deva’s pithy response was illustrative: “If it is not talked about and debated, we can only think that there is no big value that we should pay attention to.”
Households clearly separated the economic value from social ones. A section saw health insurance as a bad omen, one that announced arrival of illness. Ramesh Kumar, among those in his neighbourhood who refused to enrol, explained: “This card is not a solution for illness, it is a cause of it. You see, when you people knock on our doors to give us the card, it feels like an illness is knocking on our doors. The farther away we are from the card, the further we are from health problems.”
Overall, while the discourse on a greater allocation to RSBY and enhancement of cost-effectiveness are important, a shift of emphasis is needed, bringing the ‘public’ back into the sphere of public health.
Vani S. Kulkarni teaches Sociology at University of Pennsylvania, Philadelphia.