Indian Govt Must Realise That Insurance Can’t Replace Healthcare

On 29 May, the prime minister invoked Ayushman Bharat-PM-JAY after a long time. He announced that children orphaned by COVID-19 would be made beneficiaries, and therefore eligible for a Rs 5 lakh health insurance cover per annum. PM-JAY is the centrepiece of India’s public health push, currently. With the global pandemic, and especially the ferocity of the second wave of COVID-19 in India, we must examine what India means when it says public health.

The Immediate Background

In 2008, the UPA, inspired by the success and popular support for then Andhra Pradesh Chief Minister YSR Reddy’s Aarogyasri schemem — of public money subsidising secondary and tertiary private hospitalisations — started its Rashtriya Swasthya Bima Yojana. This targeted poor families and covered secondary and tertiary treatment for up to Rs 30,000. Subsequently, several state governments launched their own state-specific health scheme versions.

This remained an insurance scheme that covered 1000 treatments as well as a cashless component; the costs of certain treatments was fixed. The Modi government regarded this as a flagship scheme before the 2019 general elections and it aimed to cover the bottom 40 percent, and 10.74 crore of the 24.88 crore households in India (as per Census 2011) were identified as beneficiaries. Ayushman Bharat also claimed to take care of primary health through wellness centres, but mainly, it remained a way to offer money in order to fund hospitalisations.

How We Look at Healthcare: Let’s Do Away With the ‘Insurance Lens’

But here is the rub. An insurance lens on public health does grave injustice to the people. Just making sure that people can have some ‘cashless’ service at public and mostly private hospitals and projecting that as India’s ‘public health programme’ is creating more problems than solving it, for our 1.3 billion.

COVID-19 has surely nailed the importance of public health to mean a network of effective local healthcare workers and good local health infrastructure. The conundrum at the start of the pandemic, of high-income countries falling victim to the ravages of the virus, but medium-income countries doing better, was resolved soon. So, countries like Vietnam, South Korea, Thailand beat the US hands down. Countries with a healthcare system primarily centred around insurance, lost out.

Thailand’s Successful Implementation of Universal Health Coverage

The WHO noted earlier this year in its bulletin, that Thailand’s successful implementation of universal health coverage (UHC), which began in 2002, “demonstrated the value of long-term investment in health systems and primary healthcare. To accommodate the rapid increase in service utilisation required for the implementation of UHC, the Thai government more than doubled the number of qualified nurses and midwives from 84,683 (13.2 per 10,000 population) to 191,575 (27.6 per 10,000 population; 94.8 percent women) between 2002 and 2018.

Oxygen fell short, as did ventilators and medicines and access to doctors; it did not matter if you had all the money and insurance, lives could just not be saved because something far more fundamental — healthcare facilities and personnel — was inadequate; the system was broken.

Evidence of Complete Collapse of India’s Primary Healthcare

The Indian government’s own figures, in its annual report ‘Rural Health Statistics’, published by the Health Ministry’s National Health Mission for 2019-20, vouches for this complete collapse of primary healthcare other than in a few states like Kerala, Tamil Nadu and Himachal Pradesh. The three-tiered centres, the sub-centres, primary health centres (PHCs) and community health centres (CHCs) have failed people woefully, with both crumbling infrastructure and inadequate personnel.

Consider this; just about 4 percent of sub-centres, 13 percent PHCs and 9 percent CHCs conform to Indian Public Health Standards (IPHS) (these are a set of uniform standards published in January/February 2007, envisaged to improve the quality of healthcare delivery in the country). Or look at what the state of specialists in states which should have been more alert to their health status reveals — Gujarat needed 1,392 specialists, but the report records that only 13 specialists were in place. Uttar Pradesh needed 2,844 specialists but had just 816; Madhya Pradesh needed 1,236 but had a mere 46. Rajasthan needed 2,192 but had 438.

An insurance push alone, thus, is no remedy for the disease. All in all, the issues at play here are closely tied in with our democracy.

Why Public Health Is An Index of the State of Our Democracy

Firstly, does good health for everyone rank as a priority for the ruling party? It is only when there is a genuine commitment to all lives being equal that public health as a goal can be pursued. Public health is an index of the state of our democracy, how much those in power care. As so cruelly brought into focus during the pandemic, in states run by the ruling party for decades, Bihar (15 years), Gujarat (for quarter of a century) and Madhya Pradesh (15 years), the visible absence and absolute neglect of primary healthcare is a cause for alarm.

As Amartya Sen and Jean Drèze point out in Uncertain Glory, of 300 articles published in a leading newspaper between January and June 2000 that they analysed, not one was about health. The authors “repeated the exercise between January and June in 2003,” and they found one.

How Big Healthcare Innovations Have Often Followed In the Wake of Crises

The pandemic has forced the conversation on health. The PM, on 30 April, in his Cabinet meeting, referred to the pandemic as a “once in a century crisis”. A crisis of such proportions must be used as an opportunity to effect big shifts. Globally, big healthcare innovations have often followed in the wake of such crises. The Spanish flu and the world wars led to the UK developing its signature National Health Service (NHS), epidemics like smallpox led to unthinkable things like the US’s Center for Disease Control (CDC) and the Soviet Union’s Institute of Virus Preparations, cooperating at a time of an intense cold war to distribute the smallpox vaccine to developing countries.

In India, the Bhore Committee in 1946, the High Level Expert Group on Universal Health Care in 2011 and the high level group which submitted its report to the 15th Finance Commission in 2019, have spoken eloquently on what public healthcare in India must mean.

We have seen how public health mismanagement has had unintended consequences. It has impacted our reputation for making vaccines for the world, and consequently has hurt India’s influence in the region. Its reputation is at grave risk, so if not the lives of millions, perhaps just the pragmatism of it should lead India’s government to evolve a roadmap and follow it through with a commitment to preventive, primary healthcare — for all.

Source: The Quint