My writing on Yashaswini, the "Health" Insurance Scheme
The whole issue of Health Insurance
Some clarification:
1. In the first place let us get this clear. What has to be brought into focus is the clarity that we are not talking of “Health” Insurance but of “Health care” insurance or Medical insurance. So let us all bear this in mind before we get carried away by this whole concept. I also hope that this group is in a position to understand and appreciate that Health is much bigger and Health care is not Health and comprises only a very small portion of the overall struggle for health. With this basic intro I would now be intermixing “health” and “health care” words.
2. Also this runs as an anti-thesis to the whole struggle of “Health as a Human Right”. This also runs contrary to the concepts of mainstreaming public health, that health is a public good and not a private property and that governments should take increasing responsibility for public health. This is not an empty rhetoric anymore. Increasingly research evidence is showing that countries which are having bigger health budgets and taking responsibility for the same (Sri Lanka, Scandinavian countries like Denmark, Norway, Sweden etc.,) have much better health indicators (Infant Mortality rate IMR, Maternal Mortality Rate MMR etc., which are listed in the Millenium Development goals (MDGs) as targets) than in countries where health care is privately financed like India, USA etc., Read also Kalpana Sharma’s article about the same http://www.hindu.com/mag/2005/09/18/stories/2005091800080300.htm
I was till yesterday in Mumbai attending a Global Researchers conference called as “Global Forum for Health Research” (www.globalforumhealth.org) an offshoot of WHO, which was formed again as the counter current in which the main objective is to overcome the “10/90 gap” as they call it in which they want to reverse the whole phenomena of 90% of the research money being spent on 10% of the problems and vice-versa. During this forum presentation after presentation presented this fact about public spending
3. As rightly pointed out by Dr. Sujit, there is a sort of “Fait Accompli” about the whole issue of public spending in health. There is an element of fatality about this whole issue. That the government has failed to deliver (Government’s health system delivery has got cold) and hence let us at least get an insurance which is privatisation by other means. Since the governments these days as well are very happy to grab hold of such “innovative” schemes which can deviate the public from its own failure. Most of these private insurance schemes anyways cover the privatised hospitals and none of them even talk about public health system, this suits the “Payment for health” dominant paradigm of the globalised health care providers. This again denigrates the whole argument of “Health for All” to “Health for those who can pay”.
4. The Globalised Governments is also giving into these arguments in the name of Public-private partnerships (PPP). The globalised medical fraternity (not the health fraternity) of India which promotes the whole concept of “Medical tourism” and tele-medicine in which India can become the sweat-shop for the world’s outsourced medical care so that a patient from the US can come to Narayana Hrudayalaya (whose director, Devi Shetty is incidentally responsible for bringing in the Yeshaswini scheme) for a cardiac operation for very little cost and Narayana Hrudyalaya can claim to have 100% bed ocupancy where beds of heart patients are arranged like a conveyor belt production (not joking, this has been one of the PR press conferences in which Devi Shetty has claimed to bring in this concept of conveyor belt heart operations). It really does not matter that 3000 children die of preventable diarrhea in India and UNDP says India is having the worst IMR and MMR indicators and that Bangladesh has fared better in its recently released Human Development Report of 2005. The Medical fraternity says the government health system has failed to deliver, so let us have a public private partnership in which the delivery systems would be taken care of by the private. The governments gleefully fall for this bait. So what does the government do? I will give you 2 examples of PPPs in India in which it is like “Kaam mera, naam tumhara”. The Government builds a multi crore hospital in Chattisgarh spends public money to build the same and then hands it over to a private fellow “Escorts” asking it to “maintain” the same. It is also entitled to collect maintenance costs from the patients. So it runs away with the profits at no extra sweat on its part. One more classical example of PPP is the privatisation of water in Delhi. In the name of PPP the Delhi government (the “performing” government of Shiela Dikshit) spent and built up all the distribution channels for the private French water company, Suisse, to “maintain” the same by charging user fees and run away with profits.
5. I know there is already a question arising in some of your minds. Some of you might have this question of “what is wrong with Privatisation and user fees if it can deliver?” The whole question is “Do they deliver?” I have mentioned many times that Private by its very nature is profit oriented (I am not telling profit is wrong). But because it is profit oriented its services would also be only where profits are there. So if you listen to Suisse story further you would come to know that the company stopped the distribution of water to some of the lower income places (for those who could not pay) and hence “Whither water and in the larger context Health as a Human Right”! So just like an Airtel does not serve the public beyond 10 kms from the city, Jet Airways does not fly from Manali to Delhi, Suisse will not deliver water to the public who need it most or an Escorts will not give medical care to those who fall ill the most, as it does not “pay” to deliver to such population and do not have a “return of Investment” and a problem further aggravated with PPP is that the private fellow has not even put in his Investment to begin with for it to think of an ROI! So profit orientation for Jet Airways or for an Airtel is still justified as we have still not come to a stage of asking for “Telecommunication is a Human Right or Air transport is a Human Right”. We can still categorise them as luxuries but can the same be said about air, water, food and the same yardstick applied to the same?
6. Some more problems with the privatisation and in this case insurance are the accountability mechanisms. Who is the private mechanism accountable to? Is there any entitlement concept in this? The only mechanism is the payment mechanism and historically and research wise (again some of the presentations in the Research Forum showed that, it might be good for you people to look at some of the abstracts of the Forum 9 which throws some light on these issues) is that the poor will not seek health care till the time it becomes catastrophal as the poor apply the same logic of buying the grains in which case buying is inversely proportional to the cost of the grain and hence poor tend to buy less and less of grain ( Sainath in one article quotes that since globalisation and privatisation of India, India’s per capita grain consumption has fallen from 161 kgs to 147 kgs per year) and by the same logic since the poor have to “buy” medical care, they would do so lesser and lesser till it becomes very critical or catastrophal
7. Health insurance not only justifies privatisation of health care, it does not create enough pressure mechanisms on the public sector to deliver. So the public system can be more and more undermined and finally abandoned leaving the health care of the poor to the sharks of the globalised medical fraternity who would be the products of the privatised medical colleges (logical conclusion of the recent SC ruling on private professional education). So the government would be made to wriggle away from one Human Right after another.
8. Of course, since most of you are in the US, you are also exposed to the over medicalisation or the lack of rational medicalisation that happens as a result of insurance. Today in India we are getting into a concept of financing the Sex selective Abortions where loans are given to doctors by medical devices companies to have an untrasound machine and recover costs and sine there is no Moral pressure or ethics involved in making profit, at some point of time insurance could be used to cover these! As Dr. Sujit says there is the issue of “Moral Hazard”.
Having said all these let us look at the situation of the poor and those who do not have access to health care at all
1. I have said these many times and reiterated by Dr. Sujit. The dreaded 80:20 ratio. 80% private and 20% public
2. More and more people driven to BPL because of Catastrophal Health care Expenditure(CHE). Second most cause of rural indebtedness.
But look at these other facts.
a) The doctors per capita ( both private and public included) is the highest in India
b) The bed capacity is also according to the WHO mentioned norms
So what needs to be done?
1. I met Deva in Mumbai and was having a discussion on the same. He says a well meaning public health person like him have to think in terms of health insurance, as sitting in the grass-roots he cant wait endlessly for the public system to deliver. He wants that to happen but till that time he would want to evolve a community based health financing scheme. This is again a “Fait Accompli” system. This also comes from an NGO sort of thinking But as explained above, the community with a community based health insurance (CBHIS) would not come anywhere near the public facilities to put pressure on the health care systems and hence the public systems would be further undermined. What about the community without any NGO to take the initiative. What about the communities which do not have any PPPs? Should they wait for an NGO to come by to get them health care? Even if this was to be mainstreamed what is the guarantee that the government-run CBHIS would deliver like the famed Yashaswini scheme?
2. The other problems with the CBHIS as of now is that they are dependent on the conditionalities of the market placed medical insurance people (like the Cholamandalam or the Sundaram etc.,) like Dr. Sujit mentions, the line between the lines. So again it needs an NGO, like ACCORD, to negotiate which understands the nuances and the fine print of the insurance people to get the maximum leverage
3. One more problem with CBHIS is that most of them cannot be organic or endemic. What I mean is that it can’t be run like SHGs in which there is an inherent homogenous risk sharing. People can’t just save some money per month or per year and then share the risk of the costs of health care by running their own insurance schemes (like the SHG cooperatives or federations which can run a diary). There is a minimum threshold level of risk pooling and cross subsidy that needs to happen if an insurance has to work and this makes them dependent on the market placed insurance companies which cross subsidize from the risk pooling of the so called “rich”. This makes the communities exposed to the market driven insurance companies.
4. There is also talk that once a sufficient critical mass of people begin accessing the services they begin to ask for better services (does it sound similar to the percolation theory of the globalisation which resulted in the crisis of Argentina, South Korea and even Singapore?), but what we all forget when it comes to medical services, is that the consumer-product relationship does not work in this case
5. Most of the private people offering the insurance schemes are offering the justification of the low bed occupancy in the private sector for giving insurance! Hence there is no concept of utilisation of the public services and building pressure on this to get better services.
Now Yashaswini scheme:
1. The great Ankaleshwar aiyer praised it as “Miracles at Rs. 7.50”. He must have been talking about the miracle PR that Devi Shetty (Director of Narayana Hrudayalaya) did with the help of having this scheme launched at Rs. 7.50 per month with everyone talking about this scheme and how this was the best thing under the sun!
2. First let me explain the scheme and then will comment further on this. Please give particular attention to the words within quotes
3. The scheme was started with the help of the then Krishna government. The broad contours of the scheme are as follows:
· This scheme is for farmers.
· Enrolment through the cooperative sector. All the people who are part of the cooperative will become beneficiaries
· The beneficiaries have to contribute Rs.60 per year and the government would contribute a further Rs. 30 towards the same
· Cooperative department would be in charge of operationalising the same.
· List of accredited private hospitals
· The scheme is valid for surgeries
· No reimbursement for diagnostic costs or instrument costs etc.,
4. It is true that this scheme costs the “farmer” only Rs. 7.50 per month!
5. Aiyer has been truthful in telling that “heart operations” cost lakhs. Aiyer has also been partly true in telling that “heart operations” can be costing only Rs. 7.50 per month.
6. He is also true in telling about the government also paying Rs. 2.50 per month (sadly true that a government has gullibly been made part of this).
7. I hope people are observing the quoted words. Actually what this scheme does is only to cover the surgeries and for that they take a premium of Rs. 60 per year from the farmer and then a further Rs. 30 from the government making it Rs. 90 per year. How was this done? How many of us still are observing the word surgeries or operations? If you have been observant, you can see the fallacy behind this. For most of the people, the PR bulldozing of Devi Shetty and his agents (like Aiyer) does not tell that most of the people who are paying up do not epidemiologically seek medical services for surgeries? Most of them spend money on non-surgical visits to the medical facilities. So what they need is not surgery but coverage of general medical conditions. Most of them poverty related (like TB, Malaria, HIV/AIDS etc., ) which anyways is surely excluded but heart operation, definitely yes! Most of the insurance schemes have delivery and pregnancy related costs also excluded (I don’t know for sure about Yashaswini) which in fact are the most common health care costs incurred by these people.
8. The brochure of the Yashaswini scheme reveals a very interesting statistic. In the list of objectives mentioned for the scheme, it quotes a study which says that the existing private bed occupancy in Karnataka is not fully utilised to its full potential and this scheme aims to improve upon the same! Hence to increase the private bed occupancy of the private sector (which includes his own conveyor belt heart operating hospital) this scheme was introduced. He also did not have to use too much of his great convincing capacity with the previous chief minister, who incidentally was thrown out by popular vote in the elections, because he was wanting to make Bangalore, the Singapore of India and sold to the globalised “medical tourism” concept.
9. If you people are still in the “so what? “mode, then let us talk about the other quoted words. I have put in quotes the word “Farmer”. If you look at Aiyer’s article he says “The numbers must be large (preferably lakhs), spreading risks”. So how was this achieved? The scheme simply, by getting the government in its bag, could convince it to help the scheme with the farmer’s cooperative that was 12 lakhs strong at that time. It was a different matter that neither the farmer was educated nor was he asked whether he needed it. In the Focus Group Discussions that my friend during the study did, she observed that most of them did not know what the card that was given to them meant, or why was Rs. 60 collected from them by the cooperative society at the time of their membership renewal. So there was no endemic or organic relationship here.
10. Further the concept of “Farmer” itself needs to be looked at. Who can be members of the cooperative? According to the rules of the cooperative, those who own certain acreage of land are eligible to become members of the cooperative! So is anyone able to understand the implications of this? So in one shot this was made “property-centric” or middle level and rich farmer – centric and hence reaching the same population which anyways had some access to health care. But who needs health care services more? Do we fight often that we need to reach health services to the poor, marginalised landless labourers, carpenters, gardeners, taxi drivers (not owning the taxi), garment workers etc.,?
11. Even accepting that farmers also need health care and there are poor people even among them, let us examine whether this has reached them. Let us come to the hospitals selected for the scheme. They are all again city-centric, again defeating the same purpose for which this scheme is supposed to reach. One of the main reasons for lack of access to the health facility or access to TB drugs is the perceived loss of opportunity costs to the people (loss of the wage for the day, the transport costs, the travel time etc.,) and if the clinics selected are all city-centric then who is this scheme reaching? There is some problem with the non-transparent selection of such clinics / nursing homes. Some clinics have come out openly with grievance that their clinic is not selected. There are cases where they had been selected but then removed from the list without giving any reason.
12. Let us examine why Clinics are crying hoarse on getting into the list of accredited hospitals. There is an incentive for the clinics to be enrolled in this! Actually what has happened is that there is a standard list of surgeries and their costs listed out for the patients and the rates allotted for these surgeries are quoted at Narayana Hrudayala prices which in turn would be much higher than the normal nursing homes. So they have everything to gain! So there is a coterie of people who make the decisions for the scheme in the most intransparent manner. Also this is a government scheme, so in this age of “Right to Information” and all that, the whole scheme is shrouded in mystery with nobody knowing how many people used this. What has been the expenditure on this etc., Efforts by many people and even ILO to get some basic information on this scheme has been met with little success. Nobody has as yet been able to get an appointment with the Secretary of the Cooperative department. So all the information that we get is only through the PR channels.
13. So then, is this scheme not at all reaching the people? Yes, it reaches some. In Insurance parlance there is a term called as “Adverse Selection”. What this means is that people pay the premium when they get a feeling that they are going to have health care costs (like for example pregnancy etc., or if you are detected to have a bigger operation). As I said before none of them know that such a scheme exists and the ones who know are the ones who always have the access to information (the literate, village heads, the big farmers etc.,). In the study conducted it was again revealed that these people were the ones who were making the adverse selection. Actually if you look at it from the health care point of view, the adverse selection is actually the normal selection but then we are talking about market-driven health care here and not the “Health for All”.
14. Of course, this scheme also has its usual exclusions. Medical / clinical tests done before the surgery are not covered! The instruments and devices needed like stents needed for heart surgeries (angioplasty) are all extra cost and such other exclusions for an apparently “poor” population and all this at Rs. 7.50 only!
15. The last point is purely commercial. We made a rough calculation of the money involved. If you were to take a rough estimate of 20 lakhs farmers included (I wouldn’t say enrolled) in the beneficiaries list and each of them paying Rs. 90 (including government contribution) then the money collected is Rs. 18 crores (Rs. 180 Million) and when we calculated this money against the number of operations conducted with an average cost of each operation is around Rs. 45000 (from Rs. 65000 being the upper limit for Heart operation) it was found out that the Yashaswini trust would be still left with lots of money per year Sorry, I have forgotten the exact number of surgeries. But by their very nature of being secretive how much they have actually spent on what operations is not known for any outsider to check out the viability or replicability of such an option. But even after this Devi Shetty is unhappy with the whole thing and then he is devising ways to part with the Government by starting his own pilot project with Rs. 120 as the premium and with ICICI as his partner in a Taluk called Anekal near Bangalore. We have not heard the last word yet.
So is there an alternative?
1. One alternative is that the government starts a social insurance scheme (like earlier ESI) which also includes the health care expenditure tagged to the public health system and there are estimates that this can come about at a reasonable cost
2. Or we fight for “Health as a Human Right” without giving into the temptations of easier options of looking at the black box model of inputs and outputs. So much money given (input), so many people insured (output) types. Without getting into the fatalistic situation like “at least these many people have been saved from catastrophal situations”. These could be like the “cure is worse than the disease” or into a situation like if we don’t do it some other organisation can do a bad job.
3. Invest in people / bottom – up movements who can be change agents or counter currents to the dominant paradigm and hence bring about change in the society than simplistically an NGO
4. Work towards value addition in the Health Sector with people based movements in such a way that the work puts pressure on the public system to deliver a comprehensive primary health care ( like NAPM did with CEHAT in Maharashtra with support from an AID chapter by mainstreaming the whole concept of Community Health Worker in the tribal district of Maharashtra)
5. Have a proper media and communications strategy (cultivating the media) again as counter currents to the globalised media ( particularly Times of India type of newspapers) so that the general public are also not carried away by the media blitz.
6. Bring pressure on the governments to think about the 70% marginalised which vote for them and not the 30% globalised who run the system of parallel governance (the Devi Shetties) with no accountability mechanisms. This is as much needed in countries like USA which can suffer because of Katrina as for us in India. Read Articlehttp://www.hindu.com/mag/2005/09/18/stories/2005091800100300.htm Maybe if we started working there to identify and mitigate the causes of Katrina we could also be saved from these dominant paradigms and we could work towards Health as a Human Right and not a lesser Fait Accompli.
Coincidentally just as I finished writing this article yesterday night to send it to you people, today in the Hindu we have an informal interview between Devi Shetty and Sudershan http://www.hindu.com/mp/2005/09/20/stories/2005092000960100.htm which exactly reinforces what all I have tried to convey through this article.
The question now would be can we in AID work towards creation of these processes than being happy with the “Black Box” models?
Some clarification:
1. In the first place let us get this clear. What has to be brought into focus is the clarity that we are not talking of “Health” Insurance but of “Health care” insurance or Medical insurance. So let us all bear this in mind before we get carried away by this whole concept. I also hope that this group is in a position to understand and appreciate that Health is much bigger and Health care is not Health and comprises only a very small portion of the overall struggle for health. With this basic intro I would now be intermixing “health” and “health care” words.
2. Also this runs as an anti-thesis to the whole struggle of “Health as a Human Right”. This also runs contrary to the concepts of mainstreaming public health, that health is a public good and not a private property and that governments should take increasing responsibility for public health. This is not an empty rhetoric anymore. Increasingly research evidence is showing that countries which are having bigger health budgets and taking responsibility for the same (Sri Lanka, Scandinavian countries like Denmark, Norway, Sweden etc.,) have much better health indicators (Infant Mortality rate IMR, Maternal Mortality Rate MMR etc., which are listed in the Millenium Development goals (MDGs) as targets) than in countries where health care is privately financed like India, USA etc., Read also Kalpana Sharma’s article about the same http://www.hindu.com/mag/2005/09/18/stories/2005091800080300.htm
I was till yesterday in Mumbai attending a Global Researchers conference called as “Global Forum for Health Research” (www.globalforumhealth.org) an offshoot of WHO, which was formed again as the counter current in which the main objective is to overcome the “10/90 gap” as they call it in which they want to reverse the whole phenomena of 90% of the research money being spent on 10% of the problems and vice-versa. During this forum presentation after presentation presented this fact about public spending
3. As rightly pointed out by Dr. Sujit, there is a sort of “Fait Accompli” about the whole issue of public spending in health. There is an element of fatality about this whole issue. That the government has failed to deliver (Government’s health system delivery has got cold) and hence let us at least get an insurance which is privatisation by other means. Since the governments these days as well are very happy to grab hold of such “innovative” schemes which can deviate the public from its own failure. Most of these private insurance schemes anyways cover the privatised hospitals and none of them even talk about public health system, this suits the “Payment for health” dominant paradigm of the globalised health care providers. This again denigrates the whole argument of “Health for All” to “Health for those who can pay”.
4. The Globalised Governments is also giving into these arguments in the name of Public-private partnerships (PPP). The globalised medical fraternity (not the health fraternity) of India which promotes the whole concept of “Medical tourism” and tele-medicine in which India can become the sweat-shop for the world’s outsourced medical care so that a patient from the US can come to Narayana Hrudayalaya (whose director, Devi Shetty is incidentally responsible for bringing in the Yeshaswini scheme) for a cardiac operation for very little cost and Narayana Hrudyalaya can claim to have 100% bed ocupancy where beds of heart patients are arranged like a conveyor belt production (not joking, this has been one of the PR press conferences in which Devi Shetty has claimed to bring in this concept of conveyor belt heart operations). It really does not matter that 3000 children die of preventable diarrhea in India and UNDP says India is having the worst IMR and MMR indicators and that Bangladesh has fared better in its recently released Human Development Report of 2005. The Medical fraternity says the government health system has failed to deliver, so let us have a public private partnership in which the delivery systems would be taken care of by the private. The governments gleefully fall for this bait. So what does the government do? I will give you 2 examples of PPPs in India in which it is like “Kaam mera, naam tumhara”. The Government builds a multi crore hospital in Chattisgarh spends public money to build the same and then hands it over to a private fellow “Escorts” asking it to “maintain” the same. It is also entitled to collect maintenance costs from the patients. So it runs away with the profits at no extra sweat on its part. One more classical example of PPP is the privatisation of water in Delhi. In the name of PPP the Delhi government (the “performing” government of Shiela Dikshit) spent and built up all the distribution channels for the private French water company, Suisse, to “maintain” the same by charging user fees and run away with profits.
5. I know there is already a question arising in some of your minds. Some of you might have this question of “what is wrong with Privatisation and user fees if it can deliver?” The whole question is “Do they deliver?” I have mentioned many times that Private by its very nature is profit oriented (I am not telling profit is wrong). But because it is profit oriented its services would also be only where profits are there. So if you listen to Suisse story further you would come to know that the company stopped the distribution of water to some of the lower income places (for those who could not pay) and hence “Whither water and in the larger context Health as a Human Right”! So just like an Airtel does not serve the public beyond 10 kms from the city, Jet Airways does not fly from Manali to Delhi, Suisse will not deliver water to the public who need it most or an Escorts will not give medical care to those who fall ill the most, as it does not “pay” to deliver to such population and do not have a “return of Investment” and a problem further aggravated with PPP is that the private fellow has not even put in his Investment to begin with for it to think of an ROI! So profit orientation for Jet Airways or for an Airtel is still justified as we have still not come to a stage of asking for “Telecommunication is a Human Right or Air transport is a Human Right”. We can still categorise them as luxuries but can the same be said about air, water, food and the same yardstick applied to the same?
6. Some more problems with the privatisation and in this case insurance are the accountability mechanisms. Who is the private mechanism accountable to? Is there any entitlement concept in this? The only mechanism is the payment mechanism and historically and research wise (again some of the presentations in the Research Forum showed that, it might be good for you people to look at some of the abstracts of the Forum 9 which throws some light on these issues) is that the poor will not seek health care till the time it becomes catastrophal as the poor apply the same logic of buying the grains in which case buying is inversely proportional to the cost of the grain and hence poor tend to buy less and less of grain ( Sainath in one article quotes that since globalisation and privatisation of India, India’s per capita grain consumption has fallen from 161 kgs to 147 kgs per year) and by the same logic since the poor have to “buy” medical care, they would do so lesser and lesser till it becomes very critical or catastrophal
7. Health insurance not only justifies privatisation of health care, it does not create enough pressure mechanisms on the public sector to deliver. So the public system can be more and more undermined and finally abandoned leaving the health care of the poor to the sharks of the globalised medical fraternity who would be the products of the privatised medical colleges (logical conclusion of the recent SC ruling on private professional education). So the government would be made to wriggle away from one Human Right after another.
8. Of course, since most of you are in the US, you are also exposed to the over medicalisation or the lack of rational medicalisation that happens as a result of insurance. Today in India we are getting into a concept of financing the Sex selective Abortions where loans are given to doctors by medical devices companies to have an untrasound machine and recover costs and sine there is no Moral pressure or ethics involved in making profit, at some point of time insurance could be used to cover these! As Dr. Sujit says there is the issue of “Moral Hazard”.
Having said all these let us look at the situation of the poor and those who do not have access to health care at all
1. I have said these many times and reiterated by Dr. Sujit. The dreaded 80:20 ratio. 80% private and 20% public
2. More and more people driven to BPL because of Catastrophal Health care Expenditure(CHE). Second most cause of rural indebtedness.
But look at these other facts.
a) The doctors per capita ( both private and public included) is the highest in India
b) The bed capacity is also according to the WHO mentioned norms
So what needs to be done?
1. I met Deva in Mumbai and was having a discussion on the same. He says a well meaning public health person like him have to think in terms of health insurance, as sitting in the grass-roots he cant wait endlessly for the public system to deliver. He wants that to happen but till that time he would want to evolve a community based health financing scheme. This is again a “Fait Accompli” system. This also comes from an NGO sort of thinking But as explained above, the community with a community based health insurance (CBHIS) would not come anywhere near the public facilities to put pressure on the health care systems and hence the public systems would be further undermined. What about the community without any NGO to take the initiative. What about the communities which do not have any PPPs? Should they wait for an NGO to come by to get them health care? Even if this was to be mainstreamed what is the guarantee that the government-run CBHIS would deliver like the famed Yashaswini scheme?
2. The other problems with the CBHIS as of now is that they are dependent on the conditionalities of the market placed medical insurance people (like the Cholamandalam or the Sundaram etc.,) like Dr. Sujit mentions, the line between the lines. So again it needs an NGO, like ACCORD, to negotiate which understands the nuances and the fine print of the insurance people to get the maximum leverage
3. One more problem with CBHIS is that most of them cannot be organic or endemic. What I mean is that it can’t be run like SHGs in which there is an inherent homogenous risk sharing. People can’t just save some money per month or per year and then share the risk of the costs of health care by running their own insurance schemes (like the SHG cooperatives or federations which can run a diary). There is a minimum threshold level of risk pooling and cross subsidy that needs to happen if an insurance has to work and this makes them dependent on the market placed insurance companies which cross subsidize from the risk pooling of the so called “rich”. This makes the communities exposed to the market driven insurance companies.
4. There is also talk that once a sufficient critical mass of people begin accessing the services they begin to ask for better services (does it sound similar to the percolation theory of the globalisation which resulted in the crisis of Argentina, South Korea and even Singapore?), but what we all forget when it comes to medical services, is that the consumer-product relationship does not work in this case
5. Most of the private people offering the insurance schemes are offering the justification of the low bed occupancy in the private sector for giving insurance! Hence there is no concept of utilisation of the public services and building pressure on this to get better services.
Now Yashaswini scheme:
1. The great Ankaleshwar aiyer praised it as “Miracles at Rs. 7.50”. He must have been talking about the miracle PR that Devi Shetty (Director of Narayana Hrudayalaya) did with the help of having this scheme launched at Rs. 7.50 per month with everyone talking about this scheme and how this was the best thing under the sun!
2. First let me explain the scheme and then will comment further on this. Please give particular attention to the words within quotes
3. The scheme was started with the help of the then Krishna government. The broad contours of the scheme are as follows:
· This scheme is for farmers.
· Enrolment through the cooperative sector. All the people who are part of the cooperative will become beneficiaries
· The beneficiaries have to contribute Rs.60 per year and the government would contribute a further Rs. 30 towards the same
· Cooperative department would be in charge of operationalising the same.
· List of accredited private hospitals
· The scheme is valid for surgeries
· No reimbursement for diagnostic costs or instrument costs etc.,
4. It is true that this scheme costs the “farmer” only Rs. 7.50 per month!
5. Aiyer has been truthful in telling that “heart operations” cost lakhs. Aiyer has also been partly true in telling that “heart operations” can be costing only Rs. 7.50 per month.
6. He is also true in telling about the government also paying Rs. 2.50 per month (sadly true that a government has gullibly been made part of this).
7. I hope people are observing the quoted words. Actually what this scheme does is only to cover the surgeries and for that they take a premium of Rs. 60 per year from the farmer and then a further Rs. 30 from the government making it Rs. 90 per year. How was this done? How many of us still are observing the word surgeries or operations? If you have been observant, you can see the fallacy behind this. For most of the people, the PR bulldozing of Devi Shetty and his agents (like Aiyer) does not tell that most of the people who are paying up do not epidemiologically seek medical services for surgeries? Most of them spend money on non-surgical visits to the medical facilities. So what they need is not surgery but coverage of general medical conditions. Most of them poverty related (like TB, Malaria, HIV/AIDS etc., ) which anyways is surely excluded but heart operation, definitely yes! Most of the insurance schemes have delivery and pregnancy related costs also excluded (I don’t know for sure about Yashaswini) which in fact are the most common health care costs incurred by these people.
8. The brochure of the Yashaswini scheme reveals a very interesting statistic. In the list of objectives mentioned for the scheme, it quotes a study which says that the existing private bed occupancy in Karnataka is not fully utilised to its full potential and this scheme aims to improve upon the same! Hence to increase the private bed occupancy of the private sector (which includes his own conveyor belt heart operating hospital) this scheme was introduced. He also did not have to use too much of his great convincing capacity with the previous chief minister, who incidentally was thrown out by popular vote in the elections, because he was wanting to make Bangalore, the Singapore of India and sold to the globalised “medical tourism” concept.
9. If you people are still in the “so what? “mode, then let us talk about the other quoted words. I have put in quotes the word “Farmer”. If you look at Aiyer’s article he says “The numbers must be large (preferably lakhs), spreading risks”. So how was this achieved? The scheme simply, by getting the government in its bag, could convince it to help the scheme with the farmer’s cooperative that was 12 lakhs strong at that time. It was a different matter that neither the farmer was educated nor was he asked whether he needed it. In the Focus Group Discussions that my friend during the study did, she observed that most of them did not know what the card that was given to them meant, or why was Rs. 60 collected from them by the cooperative society at the time of their membership renewal. So there was no endemic or organic relationship here.
10. Further the concept of “Farmer” itself needs to be looked at. Who can be members of the cooperative? According to the rules of the cooperative, those who own certain acreage of land are eligible to become members of the cooperative! So is anyone able to understand the implications of this? So in one shot this was made “property-centric” or middle level and rich farmer – centric and hence reaching the same population which anyways had some access to health care. But who needs health care services more? Do we fight often that we need to reach health services to the poor, marginalised landless labourers, carpenters, gardeners, taxi drivers (not owning the taxi), garment workers etc.,?
11. Even accepting that farmers also need health care and there are poor people even among them, let us examine whether this has reached them. Let us come to the hospitals selected for the scheme. They are all again city-centric, again defeating the same purpose for which this scheme is supposed to reach. One of the main reasons for lack of access to the health facility or access to TB drugs is the perceived loss of opportunity costs to the people (loss of the wage for the day, the transport costs, the travel time etc.,) and if the clinics selected are all city-centric then who is this scheme reaching? There is some problem with the non-transparent selection of such clinics / nursing homes. Some clinics have come out openly with grievance that their clinic is not selected. There are cases where they had been selected but then removed from the list without giving any reason.
12. Let us examine why Clinics are crying hoarse on getting into the list of accredited hospitals. There is an incentive for the clinics to be enrolled in this! Actually what has happened is that there is a standard list of surgeries and their costs listed out for the patients and the rates allotted for these surgeries are quoted at Narayana Hrudayala prices which in turn would be much higher than the normal nursing homes. So they have everything to gain! So there is a coterie of people who make the decisions for the scheme in the most intransparent manner. Also this is a government scheme, so in this age of “Right to Information” and all that, the whole scheme is shrouded in mystery with nobody knowing how many people used this. What has been the expenditure on this etc., Efforts by many people and even ILO to get some basic information on this scheme has been met with little success. Nobody has as yet been able to get an appointment with the Secretary of the Cooperative department. So all the information that we get is only through the PR channels.
13. So then, is this scheme not at all reaching the people? Yes, it reaches some. In Insurance parlance there is a term called as “Adverse Selection”. What this means is that people pay the premium when they get a feeling that they are going to have health care costs (like for example pregnancy etc., or if you are detected to have a bigger operation). As I said before none of them know that such a scheme exists and the ones who know are the ones who always have the access to information (the literate, village heads, the big farmers etc.,). In the study conducted it was again revealed that these people were the ones who were making the adverse selection. Actually if you look at it from the health care point of view, the adverse selection is actually the normal selection but then we are talking about market-driven health care here and not the “Health for All”.
14. Of course, this scheme also has its usual exclusions. Medical / clinical tests done before the surgery are not covered! The instruments and devices needed like stents needed for heart surgeries (angioplasty) are all extra cost and such other exclusions for an apparently “poor” population and all this at Rs. 7.50 only!
15. The last point is purely commercial. We made a rough calculation of the money involved. If you were to take a rough estimate of 20 lakhs farmers included (I wouldn’t say enrolled) in the beneficiaries list and each of them paying Rs. 90 (including government contribution) then the money collected is Rs. 18 crores (Rs. 180 Million) and when we calculated this money against the number of operations conducted with an average cost of each operation is around Rs. 45000 (from Rs. 65000 being the upper limit for Heart operation) it was found out that the Yashaswini trust would be still left with lots of money per year Sorry, I have forgotten the exact number of surgeries. But by their very nature of being secretive how much they have actually spent on what operations is not known for any outsider to check out the viability or replicability of such an option. But even after this Devi Shetty is unhappy with the whole thing and then he is devising ways to part with the Government by starting his own pilot project with Rs. 120 as the premium and with ICICI as his partner in a Taluk called Anekal near Bangalore. We have not heard the last word yet.
So is there an alternative?
1. One alternative is that the government starts a social insurance scheme (like earlier ESI) which also includes the health care expenditure tagged to the public health system and there are estimates that this can come about at a reasonable cost
2. Or we fight for “Health as a Human Right” without giving into the temptations of easier options of looking at the black box model of inputs and outputs. So much money given (input), so many people insured (output) types. Without getting into the fatalistic situation like “at least these many people have been saved from catastrophal situations”. These could be like the “cure is worse than the disease” or into a situation like if we don’t do it some other organisation can do a bad job.
3. Invest in people / bottom – up movements who can be change agents or counter currents to the dominant paradigm and hence bring about change in the society than simplistically an NGO
4. Work towards value addition in the Health Sector with people based movements in such a way that the work puts pressure on the public system to deliver a comprehensive primary health care ( like NAPM did with CEHAT in Maharashtra with support from an AID chapter by mainstreaming the whole concept of Community Health Worker in the tribal district of Maharashtra)
5. Have a proper media and communications strategy (cultivating the media) again as counter currents to the globalised media ( particularly Times of India type of newspapers) so that the general public are also not carried away by the media blitz.
6. Bring pressure on the governments to think about the 70% marginalised which vote for them and not the 30% globalised who run the system of parallel governance (the Devi Shetties) with no accountability mechanisms. This is as much needed in countries like USA which can suffer because of Katrina as for us in India. Read Articlehttp://www.hindu.com/mag/2005/09/18/stories/2005091800100300.htm Maybe if we started working there to identify and mitigate the causes of Katrina we could also be saved from these dominant paradigms and we could work towards Health as a Human Right and not a lesser Fait Accompli.
Coincidentally just as I finished writing this article yesterday night to send it to you people, today in the Hindu we have an informal interview between Devi Shetty and Sudershan http://www.hindu.com/mp/2005/09/20/stories/2005092000960100.htm which exactly reinforces what all I have tried to convey through this article.
The question now would be can we in AID work towards creation of these processes than being happy with the “Black Box” models?
posted by Prasanna Saligram @ 11:27 PM
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