Thinking Allowed: Baffling Budget - Public health for private wealth?
Picture this. You have to go up and down a rickety old staircase every day and ask that the stairs be repaired and have railings to keep you safe. “Don’t worry!” smiles the owner of the staircase expansively. “You won’t fall! I’ll employ a catcher to catch you. I’ll pay him to catch you and pay him to look after you while you are in his catching net, recovering from the tumble. It’s my dream to see you happy!” Mystified, you mumble your thanks, but point out that all you need is the railing, and some repairs. Then the catcher on the pry would not be necessary. He waves your suggestions aside. “Don’t worry — I’ll fix a sum for every catch!” he says magnanimously. “Just make sure that you tumble within that amount. And that only one person in your family tumbles in a year.” You return to the rickety staircase. Now it is surrounded by enthusiastic catchers brandishing their nets and waiting for you to fall. “He’s mine!” hisses one. “No, I’ll get him...” snarls another. Unsettled by such sudden, intense attention, you trip. Thankfully, it’s only the second step — you land on your feet. But the catchers are upon you. Quick as a flash one throws a net on you and drags you down.
“Oh look, you’re hurt!” says the Catcher. “No, no, I’m fine,” you say. “I’ll just get back on the stairs…” “But you mustn’t!” says the Catcher. “Here, lie down and rest while we get you some hot carrot and parsley soup and a nice grilled chicken sandwich to get your strength back.” “I’m not hungry,” you say, confused. “Maybe a glass of water?” “No water. How about California orange juice?” “I must get back to work...” “Quiet! You’ve had a great fall. You are traumatised. You need care. Lie still. You may have broken a bone. Or had a head injury. We must do some tests. Can you sign? Never mind, give me your right thumb…” You lie enmeshed in the catcher’s net and realise that you have just ruined the chances of everyone in your family of getting any assistance for the rest of the year. Now there would be nobody to catch your old mother if she stumbles on these shaky stairs, or if your toddler topples off them. Nobody except you. As always.
The health insurance scheme for the poorest Indians in this year’s Budget is a bit like this. It is unlikely to be of substantial benefit to the 100 million poor and vulnerable families that it professes to help. Instead, it will benefit private hospitals and insurance companies. And specially since we have no proper regulation of health providers. The catchers on the pry. In any case, there is no alternative to strengthening our public healthcare system. Most of the poor and vulnerable people do not even have physical access to bigger urban hospitals. They need good primary health centres for everyday health issues. Most of them are woefully inadequate, and many dysfunctional. Some don’t have electricity, or water, or basic equipment, or even health workers, the first rung on the ladder of healthcare. PHCs are the lifeline of a country battling infant and maternal mortality, stunted physical and mental growth, tuberculosis, malaria, diarrhoea, and chronic and lifestyle disorders. Instead of using public money to strengthen public healthcare, this Budget is helping private hospitals grab public funds. Across India, most health insurance is claimed by private hospitals.
Everything costs more in private hospitals, where the emphasis is on profit, not the patient’s needs. So you have a battery of tests, many unnecessary, and often have procedures, including surgeries, you do not need. It is so much worse for the poor and the vulnerable. The biggest disadvantage of the beneficiaries of this scheme is that they are poor, possibly illiterate, forever obeying orders they don’t even try to understand, hugely out of their depth in a hospital and unaware of their rights as citizens and patients. We have seen how our sarkari insurance schemes do more harm than good to the poor and vulnerable. The Rashtriya Swasthya Bima Yojana (RSBY), which offers Rs 30,000 insurance cover to those below the poverty line — and may be replaced by this new National Health Protection Scheme (NHPS) offering Rs 5 lakhs per family — has triggered several health tragedies among the unlettered poor. For example, thousands of unsuspecting young women across India, particularly in Bihar, Chhattisgarh and Andhra Pradesh, have had their uteruses removed by unethical medical practitioners seeking to maximise insurance claims. So very often the insurance increases the patient’s suffering and the money she pays. Because instead of treating, say, a small stomach infection that she had come for, she is now paying for an unnecessary hysterectomy and its paraphernalia and her bill exceeds the insurance amount.
Also, private caregivers pick and choose more profitable cases, which does nothing to improve general healthcare. Studies have shown that the RSBY has not increased access to healthcare for the poor, nor significantly reduced their out-of-pocket spending. Rather, it has somewhat increased it. And, of course, this grand talk of introducing the “world’s largest healthcare programme” is doubtful. First, this NHPS was announced in the 2016 Budget offering '1 lakh per family, then quickly vanished from sight. Second, it will not reach the 500 million people per year as it implies — it can only reach 100 million each year, one person per family. Even this would be a big step, but it has constraints. Third, the insurance is only for secondary and tertiary in-patient care. It won’t pay for doctors’ fees, medicines and tests if you are not hospitalised. So if you have a chronic ailment that doesn’t need hospitalisation, you must continue to pay out of your own pocket for treatment at home. The toiling poor often prefer outpatient healthcare, since they can’t afford to miss work and lose wages. And finally — could the government put our money where its mouth is? When you allocate less than 1.5 per cent of our GDP for health, can you actually be serious about National Health Protection? Why not recognise this for what it is — helping the private sector with public funds and misleading the poor and vulnerable, to build an election plank for next year?
