By Archit Jain
Over half of the female citizens in India are anaemic. A quarter of pregnant women never receive prenatal care, and less than 1 hospital bed is available for every 1,000 people. A long period of robust economic growth notwithstanding, the state of Indias health sector is far from satisfactory. An important reason why people are unable to improve their health outcomes is the burgeoning medical costs. A study at the Tata institute of Social Sciences in 2011 concluded that the medical expenses account for more than 15% of the nations poverty burden.
[su_pullquote]An important reason why people are unable to improve their health outcomes is the burgeoning medical costs.[/su_pullquote]
With regards to this, the de-emphasis on universal healthcare provision in the Union Budget 2017-18 is disturbing. Though the allocation for the health sector has increased from Rs 39,879 crores in 2016-17 to Rs 48,878 this year, most of it will be spent on upgrading district hospitals and improving medical education. While these are welcome initiatives, they should not be allowed to replace a comprehensive health insurance programme.
A new programme or the old scheme?
The National Health Protection Scheme (NHPS) aims to provide poor families with a health cover of upto Rs 1 lakh to shield them from health-related financial shocks. It was one of the highlights of last years budget. The intention was to expand the Rashtriya Swasthya Bima Yojana (RSBY), the Indian National Congress flagship health insurance plan catering to families below the poverty line. RSBY provided an insurance cover of only Rs 30,000 for a family of five and included only primary and secondary healthcare.
The new priority will also include tertiary healthcare and is planned to be fully IT-enabled.
It was expected that this years budget would build upon the proposed NHPS, perhaps even include families with an annual income upto Rs 2 lakhs, instead of the current Rs 1 lakh criterion. Unfortunately, that did not happen. Budget notes suggest that last years proposals on the scheme still await cabinet approval. Hence, expansion is not possible.
Analysing NHPS: Weighing the merits
[su_pullquote]Another advantage of the proposal lies in its conceptualisation as a single scheme intended to converge all existing state-backed health programmes.[/su_pullquote]
Beneficiaries under the Health Protection Scheme will not merely be listed on the basis of income. They will also be listed based on deprivation and identified occupational categories. These categories will be as defined in the recently released Socio-Economic Caste Census. This is important because it expands the beneficiary base. This will not merely include the BPL population, but will also cover families based on socio-economic strata, who are in as much need of state support to improve their health outcomes. Another advantage of the proposal lies in its conceptualisation as a single scheme intended to converge all existing state-backed health programmes. This will enable families covered under other health insurance schemes to be eligible under NHPS.
NHPS: A ‘new’ RSBY?
Despite these merits, NHPS remains the version 2.0 of a programme whose effectiveness is little known to the public. By all standards, RSBY has been shrouded in mystery. Publicly available information about the magnitude of its achievements is rare. This is problematic because opacity in a government programme can quickly turn it into a breeding ground for corruption. It impedes academic work that can evaluate the impact of the programme.
RSBY scheme to promote healthcare was shrouded in mystery | Photo Courtesy: Eklavya.comA few researchers have managed to study the impact of RSBY and similar state level schemes. They have argued that it is clear that such initiatives reduce the financial burden of the poor. However, the evidence of their impact on quality and accessibility of hospitals is ambiguous. This implies is that households don’t necessarily receive better medical treatment. They end up merely saving cash that would have earlier been spent on healthcare.
RSBY: A flawed programme and a bad model
Whatever little data is available to the public points towards a flawed programme. This scheme was primarily supposed to benefit the poor households. However, about 25% of its beneficiaries are people who do not own a BPL ration card. Enrolment remains extremely poor. Even in the districts in which RSBY was launched before 2010, as many as 30% of the targeted households are still not enrolled. Enrollment into the programme is maximum in states such as Kerala and Himachal Pradesh, where public healthcare expenditure is already high. The scheme hasnt had a similar impact in the Indo-Gangetic plain, where it is needed the most.
RSBY is also notorious for the skewed incentives it created for hospitals. Ethically, doctors should suggest hysterectomies (partial or total removals of the uterus) only in extreme medical conditions, when all other treatment options fail. Between April and October 2010, a total of 385 operations reported by 3 private hospitals in Dausa, Rajasthan. Out of these, 286 were hysterectomies. Private hospitals advised hysterectomies to young women even for ordinary issues like fibroids or bleeding. Covered by RSBY, these surgeries were completely free to them. Hence, the women were not unwilling to go under the knife. The result was a flagrant abuse of public money and a lifetime of health-related side effects for these women.
NHPS: An improvement, but not the solution
[su_pullquote align=”right”]NHPS, at its core, is the familiar public-private partnership model, only fancier and more ambitious.[/su_pullquote]
NHPS, at its core, is the familiar public-private partnership model, only fancier and more ambitious. It is premised on the belief that putting purchasing power in the hands of consumers will drive the private sector to open more hospitals in these underserved areas. However, this is a market that has information asymmetry between the patients and hospitals. Hence, policies like these render uninformed consumers susceptible to exploitation.
The governments willingness to collude with the private sector in bridging this healthcare gap is commendable. However, it also cannot shirk its responsibility as the primary service provider and regulator in this sector.
It would be unfair to admonish the programme given that it has never been formally implemented.
There is also no reason to believe that the new scheme would be a panacea for Indias health woes. It is clear that NHPS in its original form wouldnt best serve the intention of universal health coverage either. But it comes closer to that than anything else the country has seen, and improving its structure is a better idea than abandoning this exercise.