The new National Health Protection Scheme (NHPS) which is considered to be the world’s largest government-funded health programme, announced in the 2018-19 Union Budget can be seen as a ray of hope that can break the ideological blockage which states that public health system is good and not corrupt. Or it could also be just another way of socialist health system which has been failing miserably since 70 years. Considering that it will benefit the society and improve healthcare in the country, it will encourage India to be digital in its healthcare system as well.
The NHPS’s basic proposal is to help 500 million poor Indians to get quality healthcare which is a fundamental right as per the Constitution. Under this scheme, the Central Government and the various state governments will collectively pay premiums, for each of the family included in the scheme, to insurance companies. The token amount of money currently allocated for this scheme is Rs. 2,000 crore, while the premium that will be paid per annum for each family by the Centre (60 per cent) and State (40 per cent) will be Rs. 1,100. On this premium, each family will get coverage of up to Rs. 5 Lakh per family per annum.
This scheme seems quite ideal for those who do not have access to good health care. Also, the patients get a free hand to choose between public and private healthcare centers in order to get the required treatment. Apart from this, it encourages the idea of ‘cashless India’ as all the transactions that the authorized insurance company carries out will be mostly cashless which is much better than reimbursing the money.
Although, there are some issues which are a bit worrisome. For example, this scheme concentrates majorly on secondary and tertiary healthcare. Also the cost allocated is not sufficient according to many experts. “The token amount of Rs. 2,000 crore is not sufficient. For about 10 crore families we at least require roughly about Rs. 5,500 to 6,000 crore as the token amount,” said Amitabh Kant, CEO, NITI Aayog while addressing to media after the launch of NHPS in the 2018-19 budget. Vinod Paul, a member of NITI Aayog had, in an interaction with the media, said that the government needs an investment of Rs. 10,000 crore to Rs. 12,000 crore for an insurance cover of Rs.5 Lakh for each family each year.
But the bigger issue is less about insurance and more about the doctors, rather the lack of them. “We have tried to increase the number of doctors through various methods like National Health Mission. Apart from this we also tried a new method of ‘online bidding,’ under which a doctor can register on our website and demand for a salary he/she thinks is fit for his/her respective job. Sadly, somehow nothing has worked out satisfactorily,” said Hanumanthappa, District Health Officer, Shimoga.
To find out how many doctors are required and how many exist, we did a survey in one of the taluks in Shimoga district of Karnataka. This may not capture the nub of the issue but goes to show that a survey done randomly can sometimes indicate how big the problem is.
Here are the results of the survey:
Apart from lack of doctors, the government hospitals in Hosanagara lack basic facilities leading to deaths. There are total of 11 government hospitals in Hosanagara taluk. These government hospitals are understaffed and underfinanced. It also lacks basic facilities such as medical equipments, skilled labour and lack or delay in supply of medicines. The primary necessities like aprons, injections, sterilizers, gloves and many more are not provided as well. The medicines provided are either insufficient or not the right ones to treat the patients. The Taluk General Hospital has vacancies for doctors since five years, The Ripponpete PHC has since 13 years, The Combined Dispensary, Nagara has vacancies since six years; and similarly rest of the eight hospitals have vacancies since many years.Other near-by taluks, Shikaripur and Soraba also face the same problem. Not only the adjacent taluks in Shimoga district but also Shiggaon (Haveri district), Basavan Bagewadi (Bijapur district) and Honahalli (Davangere district) face the problem of lack of doctors.
Dr. Anil Kumar of Ripponpete Community Health Care said that it is common to see pregnant women or their new born die as there are not enough medical equipment to perform caesarean operations.
Another doctor, Dr. B. T. Tejaswi of The Combined Dispensary, Nagara said that a patient named Ramaiyya died two years ago, due to lack of ambulance facility. Such issues have had an impact on the mental health of the doctors themselves as they are at the receiving end of the relatives or the patients’ anger. They also feel extremely guilty for not being able to save the lives of their patients though it is none of their fault, but such is their commitment that they own up the responsibility. Some of the doctors do shy away from working in government hospitals due to various reasons such as low salaries, pressure from patient and their relatives, and political pressures as well.
The government provides just Rs.120 per patient for Laparoscopy which is insufficient as the initial treatment itself requires a minimum of Rs. 1000 per patient, the doctors point out. As mentioned earlier, hospitals lack equipment as well as trained nurses to perform caesarean operations. The nurses or the D-group employees (ward boys or sweepers) are unskilled and do not have proper medical knowledge. Thus, they do not know the correct use of equipments and other facilities.
Even though the officials say that there is a fluctuation in the number of deaths, there has not been a single year for the past five years that somebody has not died in Hosanagara taluk. Also there are several instances of families suffering from various financial problems because the sole earning member in the family has fallen sick and does not get treated well in time. Even to get admitted to a government hospital in Shimoga city is a strain on their meagre resources.
The Karnataka state government says that they have allocated and disbursed funds to district hospitals but officials at the Primary Health Centers claim they haven’t seen any money yet.
There are other issues too. The doctors are sometimes asked to fabricate the forensic records by the police who they fear can land them in big trouble. The young doctors complain that they do not get enough opportunities to grow in their profession as they are handicapped by lack of medical equipment.
There is some ray of hope though. Of late, the government hospitals have gradually started getting the infrastructural facilities in the hospitals which is a good sign but still due to unavailability of doctors, the question prevails as to who will make use of these facilities.
“This hospital became a 100 bedded hospital in January. Now I have all the required equipments to treat the patients but still the work pressure is high as we are just two doctors available here. We do not have any specialists apart from one dentist and me. It becomes really difficult for me to handle so much pressure as the average footfall of patients per day is 75 to 80,” said Dr. Lingaraj G B, M.B.B.S, at Hosanagara Taluk General Hospital.
Doctors who are not eligible to treat patients, like dentists, are forced to treat them.
In Hosanagara taluk, the Vajpayee Aarogya Scheme that has been launched for the Below Poverty Line (BPL) card holders cannot be availed by many of the beneficiaries as they are yet to receive cards since almost two to three years. “My father had filled the form to get a BPL card in 2016 and still we have not got it. We have done all the necessary procedures and given all the documents for it, but the Gram Panchayat has not done anything. Last year I badly needed the help of the Vajpayee scheme to treat my mother for Cancer but I had to shell out all money from my savings and had to sell gold ornaments for paying the bills of her treatment as I did not have the BPL card,” said Harsha Siquera , who drives auto rickshaw to earn for livelihood.
However, doctors in private clinics earn decently, at least much more than their counterparts in government hospitals. “Even we face problems in terms of getting medicines and maintain hygiene all by our own. The biggest problem we face is that people come to us for getting treated and then say that they will make the payments in a few days as they do not have money,” said Dr. Aruna U who runs her private homeopathic clinic, Chaitra Clinic, in Hosanagara.
Another Ayurvedic private doctor, Dr, Raghavendra Rao said that they also had faced the problem of not getting good opportunities when they were young. “But if all think in this way then the health conditions of rural India will worsen even further. So instead of sitting and crying why cannot we try and help in whatever we have,” he added.
The private and public doctors have welcomed the NHPS as they believe that it will help the patients enormously as long as it is put into practice and does not remain on paper.
Private doctor Dr. Chaitanya, who runs Suvarnashree Clinic right opposite to the Primary Health Care Centre in Nagara, Hosanagara added, they can provide even better services if given some honorary help by the government.
Further the public doctors also agree with the views of private doctors.
Dr. B T Tejaswi, The Combined Dispensary, Nagara.
The government doctors have one issue with the latest health scheme. They believe that if the government health care system has to grow then private doctors should be kept away from it. The patients however believe that as long as they get the right treatment, it does not really matter whether the government doctors treat them or the private doctors. “We are only bothered about getting treatment at a cheaper or reasonable rate or for free. Till today the government has only announced 10,000 schemes but still we struggle to avail them as there is very poor or sometimes no implementation of those schemes,” said Alex Fernandes, who lives in Hosanagara.
After looking at all these arguments, one thing that strikes the most is that ‘there is no point in just introducing more and more schemes if there are no doctors available at the ground level to treat the patients’. From the history of the subsidies and schemes launched by the government, we can infer that out of the total number of schemes that are introduced, more number of schemes either do not work completely or lack proper implementation.
The very first public health insurance scheme was launched in Andhra Pradesh in April 2007. The name of the scheme is Rajiv Gandhi Aarogyashri Community Health Insurance (RACHI) scheme and it helps the BPL card holders to avail the benefit of free healthcare. Under this scheme, the government pays Rs. 210 premium for each family, to the insurance companies, on which each family gets a cover of up to Rs. 1.5 lakh plus Rs. 50,000 as buffer amount. The State government of Andhra Pradesh took successful efforts to provide BPL cards on the basis of White Rations Cards immediately so that each of the beneficiary could avail the above mentioned benefits. But the question of RACHI’s sustainability still prevails as many private hospitals in Andhra Pradesh had demanded to increase the tariffs by 30% and had threatened that they will not treat the poor under the said scheme if their demands are not fulfilled. As a result the AP government had to hike the tariff. Also, any scheme helping the poor has to be cashless as it becomes easy for the poor because he/she does not have to look after it and does not have to wait for cash reimbursement, along with reducing the scope for corruption. Apart from that, in cash based system, hospitals have to provide facilities without the assurance of getting repaid by the government. On the other, still many more small villages like Hosanagara where due to the prevailing loop holes in the system people have not even got the BPL cards, availing subsidies on its basis is way too far!
Thus, we can conclude that a well-designed and properly funded public health insurance system like the new National Health Protection Scheme will hopefully incentivise private and public health services to create facilities which have been lacking since ages. Also, it is not enough to throw money at the problem but the government has to ensure healthcare services are expanded and correspond to needs.
