Monday, March 14, 2016

The Universal Health Coverage Numbers Game

Some years ago, during a sojourn in Sitapur, we began discussing Rashtriya Swasthya Bima Yojana (RSBY), the National Health Insurance Scheme which provides 'cashless care' for hospitalisation at 'empanelled' private hospitals. The RSBY coverage limit is Rs. 30,000 per year for a family of five. I was already involved in the research of government-supported insurance schemes in Karnataka, and knew that while they gave poor families 'access' to private hospitals (there are denials as well), the devil was in the out-of-pocket expenditure that followed.

Here the tale was different:
"हमने उनको भगा दिया", "किन को ?”  "अरे, कार्ड छापने वालों को!"
which roughly translates to: “We chased them away”, “Who?”, “The card printers!”
Every year, the RSBY card has to be re-issued, so Third Party Administrators (TPAs) go to these villages to enrol people in the scheme at a cost of Rs. 30. But my friends in SKMS (Sangtin Kisan Mazdoor Sangathan) were fed up of getting a useless card - “We go to Sitapur city with this card to all the private hospitals, but no one gives us free treatment”. So they refused to get enrolled and asked the TPA to leave. One year, the District Collector got involved – he went to some villages and requested the villagers to cooperate! But as far as I know, some are still holdouts.

And they should continue to hold out and encourage more to do the same. Why? Because the concerted efforts to equate 'health insurance' with 'access to health care' are beginning to impact how we measure the latter. In the Sustainable Development Goals (SDGs), Target 3.8 is to “achieve universal health coverage (UHC), including financial risk protection, access to quality essential health care services, and access to safe, effective, quality, and affordable essential medicines and vaccines for all”. The indicators to measure this target are under discussion, and a sudden move has been made to change Indicator 27 from:

“Fraction of the population protected against catastrophic/impoverishing out-of-pocket health expenditure”
“Number of people covered by health insurance or a public health system per 1000 population” 
A detailed analysis of what this means can be found here but to put it very simply – 'Here's your card. Now you have health care – good luck!'

The state of health care in our country is disgraceful. In the public sector, there is a shortage of staff, medicines and services coupled with abuse and corruption; in the private sector there are irrational and unnecessary treatments and huge medical bills. Private hospitals have kept patients in ICUs when there was no hope of survival, refused to hand over their body until bills are paid, even held on to babies until they received payment for the delivery. They are hiring bouncers (to protect their staff) and bill collectors (to hound their 'debtors'). There are definitely good doctors and providers, but they are hard to find. 

And the insurance system impacts even good hospitals negatively. Recently, I was at a meeting where doctors from some hospitals that provide quality, low cost care in remote areas were talking about their claims rejection ratio. About 25% of their claims submitted to RSBY are rejected, and they said that this was true across the board and with private insurance as well (unless they have good contacts with the Insurance company). These hospitals are socially motivated and do not turn away patients – others either don't care or cannot afford to treat patients free of cost. 

So while we are protesting cuts in health budgets, gathering evidence on the problems with insurance schemes, documenting denials of health care and advocating for a comprehensive health system, the rules are being changed. People across the world will one day wake up to discover that they had Universal Health Coverage after all – they just didn't know it!

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