“Humans are humans because of their person. The rich have a body and so do I. Why, then, should I have to suffer without treatment when they enjoy all possible facilities? Why should our healthcare expenditure be only Rs 30,000?” asked Manju, one of the participants in a study I conducted for my master’s thesis at the Department of Global Health and Social Medicine, Harvard Medical School.
The study was on the Rashtriya Swasthya Bima Yojana (RSBY), a health insurance scheme for the poor launched by the government of India in 2008. It entitled ‘targeted’ families to hospitalised care up to Rs 30,000 annually in an institution of their choice, to be selected from a list of accredited hospitals and health centers – private and public.
As a member of a below poverty line (BPL) household, Manju was entitled to the “benefits” of RSBY. That the scheme did not work well is a public knowledge. Indeed, informed agencies have consistently been asserting that the Indian health system requires a thorough overhauling – no cosmetic change can improve its state of affairs. Yet, the lessons of RSBY and other ornamental health schemes has not had any impact on public policy. The RSBY is back, in an albeit amplified version and with a new name: the Pradhan Mantri Jan Arogya Yojana (PMJAY) under the Ayushman Bharat National Health Protection Scheme (ABNPHS).
The ABNPHS and the PMJAY look quite ambitious. They claim to ‘build a new India by 2022’ with “two far-reaching initiatives under Ayushman Bharat”. It will be implemented at an “unprecedented scale”, and will help India capitalise its demographic dividend, ensure enhanced productivity, well-being and avert wage loss and impoverishment, the government claims.
The first of the two initiatives pertains to creation of 150,000 health and wellness centres, which will bring health care “closer to the homes of the people”. The second is the PMJAY, which provides health protection cover to poor and vulnerable families.
Has the government discovered a treasure of resources?
How does one perceive this miraculous claim? In India, the distance between the proclamation of policies and their implementation is vast and pervasive. The claim of reversing the seven decades of health failure in less than half a decade, thus, ‘dictates’ us to believe that the Union government has discovered a treasure house of resources to bring about this change and will make India free of poor and ill health, stop impoverishment owing to health expenditures and enhance productivity manifold with enhanced health ability.
Although it is claimed that the wellness centres “will provide Comprehensive Primary Health Care (CPHC), covering both maternal and child health services and non-communicable diseases, including free essential drugs and diagnostic services”, no information has been made available as to how this goal will be met.
First, no roadmap has been given regarding the creation of 150,000 wellness centers for primary care. Will they be newly created or will the existing primary care system (sub-centers), Primary Health Centers (PHCs) and Community Health Centers (CHCs) be converted to serve the purpose? If it is the first, what necessitated the creation of a new entity and how will this be different from the existing centers?
- First, no roadmap has been given regarding the creation of 150,000 wellness centers for primary care.
If it is the second, how does the government plan to accommodate the existing system with adequate staff, facilities and space? The gap between required and existing numbers of SCs, PHCs, and CHCs are 19%, 22% and 30% respectively. There are huge vacancies for grassroots-level workers and doctors at PHCs: 8% of the PHCs are operating without doctors. The shortage was particularly acute at the CHC level: 82% of the posts of doctors (surgeon, obstetrician gynecologists, pediatricians, and physicians) at the CHC level are vacant.
The ABNHPS claims that “the government of India is committed to ensuring that its population has universal access to good quality health care services without anyone having to face financial hardship as a consequence”. The measure taken is the PMJAY, a health insurance scheme which, “will provide financial protection (Swasthya Suraksha) to 10.74 crore poor, deprived rural families and identified occupational categories of urban workers’ families as per the latest Socio–Economic Caste Census (SECC) data (approx. 50 crore beneficiaries). It will offer a benefit cover of Rs. 500,000 per family per year (on a family floater basis).”
Declared measures are neither practical nor adequate
Yet, the declared measures seem hardly practical or adequate. While it identifies that 62.58% of the population “are not covered through any form of health protection”, the population covered under PMJAY is only 38% (50 crore of the current total population, i.e, 132.42 crore). There still remains 32.87 crore of the population (or 25%) uncovered by any health protection scheme.
Health, finance minister Arun Jaitley in his budget speech asks us to believe, is an issue of economic growth and poverty alleviation. Tellingly, the speech did not dedicate a separate paragraph on health; rather, it appeared under the sub-head ‘poverty alleviation’. Even if we force ourselves into tandem with the prevailing fashion and keep the intrinsic value of health aside, fitting it into the narrow box of instrumental priorities of health and well-being, we cannot escape the question of what happens to those whose annual catastrophic health expenditure (PMJAY covers only hospitalised care) exceed Rs 5 lakh, the upper cap of the health insurance to be provided to the poor and vulnerable?
- There still remains 32.87 crore of the population (or 25%) uncovered by any health protection scheme.
In September 2018, I returned to Manju and said, “You must be happy now. The government has raised the treatment cost coverage to Rs 5 lakh. It’s no more a paltry Rs 30,000.” She wasn’t happy. She was angry. “We will be happy only when we die. You say, more money, that means more loot by the [private] hospitals. Go away, and give this news to the hospitals,” she said. Almost all studies on RSBY, including the RSBY’s own evaluation, have pointed out the gross medical abuse, plunder by private hospitals and people’s exclusion from the scheme owing to non-availability of any health facility in their vicinity.
Aside from corruption, the RSBY experience showed that the utilisation of health insurance is contingent to the robustness of publicly delivered health facilities. For example, while the average number of hospitalisations under RSBY in Kerala is 0.15 per household, the corresponding figure for Jharkhand is a meager 0.03 per household. Interestingly, the average value per hospitalisation (cost realized under RSBY) is much higher in Jharkhand (Rs 5,919) than in Kerala (Rs 3,731).
In Jharkhand, a substantial number of public facilities, including the PHCs without indoor facilities have been accredited under RSBY. People in those areas, thus, have no facility to resort to, whether public or private. The limited number of private nursing homes tend to enjoy monopoly of treatment. Conversely, in Kerala, public delivery of healthcare and a regulatory mechanism work in tandem to act as a check for the private health market.
Likelihood of health insurance abuse
Economist Kenneth Arrow warned in his famous paper ‘Uncertainty and the Welfare Economics of Medical Care’ that the very term ‘profit’ denies trust relations and “…hospitalization and surgery [which only are covered under PM-JAY, as also in its earlier incarnation RSBY] are more under the casual inspection of other”. This implies that the likelihood of health insurance abuse through plundering of the public exchequer and also by encouraging many other unethical practices, is much higher in states with poorer health delivery mechanisms, which lead to an unregulated health market.
The possible fertile ground for profit making through insurance schemes, feeble – if not impossible – public supervision of the actual medical treatment [given especially in the private hospitals] and denial of trust relationship made Arrow argue for redistribution by government of direct health services, instead of redistribution of purchasing power by the government. This possibility is particularly high in states with fragile publicly delivered health care system.
In contrast, states with better public delivery of healthcare and other social services are better equipped to bring the medical practices under public inspection. This also creates a check for the private market in two ways: (1) by offering the population a substantial competitive choice and (2) through a strong social service network that enhances the capability of the people to choose.
Since people are already socialised to access health services in these states, the increased socio-economic status of the population may lead to their utilisation of the private market as well, as has been the case in Kerala.
Alas, the government of India is stubbornly resistant to learning from experience, either from home or from away.
Kumar Rana works with the Pratichi Institute of the Pratichi India Trust, founded by Amartya Sen. He lives in Kolkata.