It has been described as “a scheme to provide health insurance coverage” for the people of Goa. A reincarnation of the defunct ‘mediclaim scheme’, it ignores the extensive debate on whether privatizing health programs in developing countries leads to economically efficient outcomes. Insurance as an alternative source of healthcare funding has been resurrected by the NITI Aayog report. It claims that for an expenditure of 0.76% of GDP “the government can provide modest healthcare for the bottom half of the population”; and after this “there does not remain a case for additionally free provision of the service by the government”. Ergo: – the remaining population can go fly a kite. This is extremely irresponsible, considering that the New National Health Policy 2015 recommends an allocation of 2.5% of GDP by 2020. The government cannot even cope with the current allocation of 1.1%; the global recommendation being at least 5-6% of GDP of which the major share should come from the government. The resultant out of pocket expenditure, drives an additional 55 million Indians into poverty as it gets financed by sale of assets and loans.
The latest National Sample Survey Organization has only 13% covered by government funded schemes. The centre spends Rs 25000 crores on healthcare. Insurance, even restricted to the low income groups would cost an additional Rs 15000 crores. The disease burden in India has changed so that 60% of deaths in 2014 were due to preventable non-communicable (NCD’s) and lifestyle diseases which have token allocations in healthcare budgets and none at all in insurance. Would these additional funds not be better spent on improving basic facilities like clean drinking water, sanitation and basic primary care rather than insurance? Excessive reliance on health insurance as a means of health-care delivery has been shown to be neither prudent, nor cost-effective.
The Goa government has opted for the DDSSY scheme with a Rs 120 crore premium paid to United India. Families will be enrolled on the basis of residency alone, for a premium of Rs 200 or 300 depending on the number of family members; providing a cover of Rs 2.5 or 4 lakhs respectively. Any expenditure over and above this amount will be borne by the patient. As CGHS rates are applicable, this situation will apply to most of the 447 procedures listed. Interestingly, beneficiaries of CGHS facilities themselves incur out of pocket expenditure of about 42%. At the time of writing 1.38 lakh families have been enrolled bringing in a premium between Rs 2.76 to 4.14 crores. Again the question that arises: would this financial outlay of nearly Rs 116 crores not have been better spent in improving the basic amenities at public sector institutions? How much would it cost to provide regular water, cleaner toilets, more regular power, cleaner linen, filling vacant posts and even increasing staff? Was a feasibility study done or a cost-benefit analysis carried out? Lack of basic amenities, long queues and waiting lists are issues that damage healthcare delivery in the public sector; clinical outcomes in fact improve with increased volumes. Such schemes are doomed because they do not tackle the core deficiencies in the public healthcare system. The government is abdicating its responsibilities and passing the buck onto the public sector, which operates on a for-profit basis.
There are issues with implementation. The DDSSY as described has guidelines for empanelment for private hospitals which merely state that the hospital and operating theatre should be “fully equipped”; the term is not defined. Likewise the hospital “should have fully qualified doctors and nursing staff”. It is well known that many private allopathic hospitals have “qualified” homeopaths and ayurveds as RMO’s. Does the term “fully qualified” cover these as well, “normalizing” such illegalities? Interestingly the scheme also covers “ayurvedic procedures”, “yoga and naturopathy”. It is left up to the insurer to establish the credentials of the hospital being empanelled.
Vociferous objections to the scheme have been raised on the grounds that medical education at the GMC will be hit because patients will opt for empanelled private hospitals which have been permitted to handle a list of 447 procedures. The drop in attendance at GMC it is claimed will put MCI recognition at risk. Recognition is based on a bed strength rule of thumb of one bed for every student; the current GMC bed strength is more than adequate and no cause for concern. The second stipulation is that the bed occupancy should be 75%. Which begs the question: why do patients opt for treatment in private hospitals at all? Most often it is for better basic amenities, less crowded OPD’s and non-existent waiting times. In a few cases, it would be to avoid travelling long distances. The cardiac surgery unit has demonstrated conclusively that when you deliver efficient service at the GMC, the private sector cannot compete and their expensive equipment lies collecting dust.
Now the conundrum: is it fair to ask a patient to put up with dirty toilets, lack of water and electricity, dirty linen, and erratic operating theatre schedules because the students need the experience? It is certainly unreasonable to demand such “loyalty” from patients; and therefore objections on the grounds of upsetting MCI recognition are untenable. This raises serious issues, because it is for the government to establish such basic amenities as a norm and not expect the patient to be tolerant, and suffer inconvenience in deference to students’ welfare.
Universal insurance costs more than the single payer system and just doesn’t work, often because procedures of doubtful benefit like mammograms and robotic surgery and unnecessary investigations are advocated. The time taken for failure to manifest may vary; but fail it will. It must be made available only to the low income groups with strict compliance enforced to prevent abuse; and that too after attempting to reduce the disease burden by attending to basic primary care. Otherwise it becomes just another gimmick.
(Dr Gladstone D’Costa is the Chairman, Accreditation Committee and member, Executive Committee, Goa Medical Council.)
