Thirty-year-old Aarti Devi (name changed) stared incredulously as I prescribed analgesics for her back pain. No, she wasn’t unhappy with the treatment, but was troubled because I had prescribed analgesics three times a day after meals, on a full stomach. I realised that buying analgesics was not an issue. Getting three square meals a day, however, was.
In India, the ruptures within the healthcare delivery system do not pertain merely to issues of infrastructure or want of capital, they go far beyond. Thus, it is imperative to analyse the government’s flagship programme – Ayushman Bharat – within the context of the unique combination of India’s staggering poverty and vulgar capitalism.
In his interaction at the Express Idea Exchange, the CEO of Ayushman Bharat, Dr Indu Bhushan, asked what was wrong with providing resources to the private sector to ensure services for the poor. He meant that besides public healthcare facilities, this was the first opportunity in the country’s 71 years of sovereign existence that the poor will have access to private healthcare as well. There is significant optimism, if not inanity, in this assertion, because our brush with private players over a broad spectrum of involvements in the past has been far from pleasant.
From privatisation of roads to water bodies, to the killer Blueline buses of Delhi, most private ventures of the government have resoundingly failed. How, then, can we assume that the private healthcare providers in the country will behave differently? It’s an open secret that most private hospitals in Delhi fail to provide free treatment and beds to poor patients, despite this being a legal requirement in lieu of the land given at the time of their construction. If this can happen in the country’s capital, we can only imagine the situation in smaller towns and cities.
The government is none the wiser following the lessons learnt from the Rashtriya Swasth Bima Yojna (RSBY), a programme not very different from Ayushman Bharat, started by the previous regime. It entitled poor families for treatment of up to Rs 30,000 per year. In 2016, RSBY data revealed that 80% of reimbursements under the scheme were made to private enterprises. It might not be wrong to label these reimbursements as a legitimate loot of public money.
Unfortunately, post neo-liberalisation there have been persistent efforts to blur the boundaries between public and private funded healthcare, resulting in perilous repercussions in a developing country like ours. More than 80% of healthcare in India is provided by private facilities. Poor medical regulation, ethical concerns, issues of class and caste differentiations and non-availability of adequate facilities in the hinterlands of the country, remain major obstacles to the adequate delivery of healthcare through such private players.
Patients like Aarti would never be able to seek treatment in a posh corporate hospital of Delhi, despite Ayushman Bharat. Too many socio-economic barriers will either restrict her entry or limit her persistence with treatment in one of these ‘luxury’ hospitals. Thus, opening private healthcare setups to insurance capitals without taking care of the said obstacles would have disastrous results.
A better, yet more tedious option would have been to iron-out the rules governing the interface between the two treatment sectors even before thinking of launching a scheme like Ayushman Bharat. An even better approach would have been to restructure the regulation of healthcare delivery so that more robust outcomes could be ensured through the scheme. Depending less on the insurance model within Ayushman Bharat would have been equally effective in providing a more comprehensive healthcare delivery system.
An equally intriguing aspect of the scheme is its inattention to the primary healthcare setup. The main focus, it seems, is on secondary and tertiary health care facilities. Having said this, the scheme plans to create 1,50,000 Health and Wellness Centres (HWC), which are essentially uplifted extant Primary Health Centres (PHC). Economic experts like Prabhat Patnaik, have carefully evaluated the scheme and showed that the money allocated in the 2018-19 union budget for the creation of these HWCs is merely Rs 80,000 per centre.
This meagre allocation is not only insufficient for an effective upliftment, but also a blow to the very concept of Universal Health Care (UHC), as described by the World Health Organisation (WHO). The essence of UHC appears to have been lost in the din of the scheme. For an effective UHC, the starting point should have been the PHCs – with an emphasis on prophylactic aspects of healthcare. The insurance model of the scheme is an incentive-based model which will promote the therapeutic aspect of healthcare in the country, leading to extra diagnostics and superfluous treatment strategies.
The complexities of healthcare delivery in India are many. With the pursuit of neoliberal policies, the divide between the ‘haves’ and the ‘have-nots’ is at an unprecedented level. We rank poorly in the world hunger index, the malnutrition index and on other parameters of health. What we needed were small-scale, community-based health insurance programmes, as it has been shown throughout the world that such schemes raise healthcare utilisation and lower the household financial burden.
An even better idea would have been to increase the spending on health for the simple reason that it is the sole responsibility of the state. The political leadership of the country should realise that our experiments with insurance-based models of healthcare have failed in the past. In the words of Karl Marx, history repeats itself, first as tragedy, second as farce.
Shah Alam Khan is a professor of orthopaedics, AIIMS, New Delhi, and the author of Man With the White Beard. The views expressed are personal.