One of the many schemes the government claims as its banner achievement is the Ayushman Bharat insurance scheme. Purported to be the “world’s largest initiative to cover 50 crore villages”, the scheme hopes to insure ten crore families below poverty line for a cover of Rs 5 lakh each, with a budgetary allocation of Rs 2000 crores. Even by conservative estimates the cost is estimated at Rs 26000 crores for premiums alone. This does not include administrative costs. The scheme hopes to tackle the reality that of the world’s 100 million people pushed into poverty by out of pocket health care costs, 49% are Indian. The National Health Protection Mission which spawned the scheme proposes to empanel private hospitals and lays down permitted limits of charges for various procedures. Cesarean section was pegged at Rs 9000, Laparoscopic gall bladder surgery Rs 15000 and so on. Complications and unforeseen events were not catered for.
Apart from the obvious issue of budgetary under-provisioning, the scheme has many fundamental flaws. The price caps are unrealistic and predicted to result in manipulation of bills leaving the patient out of pocket and back to square one. Already there are reports from various States’ hospitals being struck off the empanelled list because of billing irregularities. This was a result of rates being decided without any consultations with the very private sector that is expected to provide these services. Two recent and exhaustive reports, “A Critical Assessment of the Existing Health Insurance Models in India” by the Public Health Foundation of India, and a World Bank report “Government-Sponsored Health Insurance in India; Are You Covered?” by Gerard La Forgia and Somil Nagpal have dissected every aspect of healthcare insurance in a manner not often seen in this country. Both reports predicted instances of frauds making this yet another “jumla”.
Fraud comes in various shades and colours. The World Bank has already warned that as more people are able to afford healthcare and the government ramps up insurance coverage, the risk of excessive care may increase. This may take the form of over investigation, over diagnosis and indeed unnecessary treatment. Added to this is “defensive medicine” and aggressive marketing by hospitals. The World Bank warns that these are emerging as serious problems in India. “Individuals in India with private voluntary health insurance are two to three times more likely to be hospitalised than the national average.” There has in fact been an attempt to launch a “Society for Less Investigative Medicine”, at AIIMS to increase both doctor and patient awareness of the issue. The “leakage” in India is estimated to be around 20%, and the most common perpetrators of Healthcare Insurance fraud are healthcare providers. Often this takes the form of excessive billing, claiming for services not actually rendered, or claiming to have rendered treatment for a “covered” illness whilst actually treating an illness not covered.
Experience tells us that there is no short-cut to universal health coverage. Countries like Thailand and Mexico have achieved it through significant provisioning to public health infrastructure. In Thailand, all sub-districts have health centres, serving 3,000-5,000 people, and all districts have a district hospital, serving 30,000-50,000 people. Unless similar targets are adopted in this country, the dismal state of health care will continue. PHCs remain the key.
This was underlined by the recently tabled report “Tribal Health in India – Bridging the gap and a Roadmap for the future” by an expert committee jointly constituted by the MoHFW and Ministry of Tribal Affairs (MoTA) under Dr Abhay Bhang. The report took four and a half years instead of the projected six months because there was a total lack of baseline information. It established that the division of the population into rural and urban segments was flawed. The 10.4 crore tribals who make up 8.6% of the population were included in the “rural” but not accounted for in any healthcare planning. These forgotten Indians who do not figure in any statistics, often reside in villages 30 km from the nearest road, forget about health services, and are bypassed by most population surveys because of inaccessibility, language difficulties or simple neglect.
The country claims a reduction in maternal mortality figures; but this report discovers that the tribals were not included in any research hence the figures are not known. 40.6% live below the poverty line; illiteracy rates are 41% and 90% have no access to tap water. Funds allocated for tribal welfare disappear into “black holes”, and as a result, they will remain untouched by such grand insurance schemes as there is no designated provision for accommodating them. They urgently require primary health centres to provide basic health care.
In the face of such inequity and schemes doomed to failure because inadequate planning and funding, we indulge in grandiose projects like mammoth 182-metre statues costing Rs2989 crores. It took 1700 tonnes of bronze imported from China; 70,000 tonnes of cement and 24000 tonnes of steel. One can’t help wondering how many primary healthcare units could have been built with this: or how many additional hospital beds could have been created to reduce the huge deficit. In spite of a water shortage in the area, water was diverted for the project. Tribal lands were used without any compensation till date. Central Public Sector Enterprises were arm twisted into contributing Rs 146.83 crores as CSR. The CAG objected as the project did not qualify under CSR as it is not a heritage asset.
Faced with a dearth of funds for its ambitious welfare schemes, the government, obsessed with the coming elections was obliged to call upon the Reserve Bank to part with Rs1000,000 crores from its reserve funds; over and above the dividend already paid. A refusal triggered off a faceoff and public spat.
The moot question is: is this in the genuine interests of the people of India? Surely not; our people certainly deserve better.
(The writer is a founder member of the Voluntary Health Association of India)
