By Dr Arun Mitra
Like other slogans much expectations have been raised from the highly advertised National Health Protection Scheme (NHPS) – the Ayushman Bharat rolled out by the Prime Minister on 23rd September at Ranchi. It is said to be the biggest health insurance scheme in the world. It is therefore important that the scheme is reviewed to see whether it will provide universal comprehensive healthcare to the citizens of our country.
The scheme will cover 10 crore families that is 50 crore people with a coverage of Rs. five lakh for secondary and tertiary hospitalization care. With India’s population hovering around 130 crores, this means nearly 80 crore people will be left out of any coverage benefit. Very few of this uncovered 80 crore population has resources enough to effectively support their healthcare needs. The income limit for households for qualifying as a beneficiary under the BPL (below poverty line) list is at about Rs. 27,000 per annum. A household with an annual earnings of more than Rs. 27,000 will stand excluded from the BPL list. The upper limit has been arrived at by allowing five earning persons in a household with a per capita monthly income of about Rs. 447/- per month in the rural areas, which works out roughly to Rs. 2,250 per month per household. This is too meager an income to meet basic needs for a healthy life. Large number of our population are thus little above this level who are unable to support their basic healthcare needs who would be devoid of any benefit of the Ayshman Bharat.
Since the scheme will cover only the hospitalized patients and not the outpatient care or the preventive healthcare, it does nowhere meet the criteria of comprehensive universal health care. Nearly eighty per cent of the time, the out-of-pocket expenditure of patients is on outpatient care which is not covered under NHPS. It is also not clear whether post hospitalization expenses will be met with by the insurance companies or by the patient. In many diseases, post hospitalization care is very expensive and lifelong.
Senior citizens are the most vulnerable population who need continuous care and empathy. Most of the diseases that occur at this age are chronic in nature, which demand repeated visits to doctors. At a time when the earnings have come down substantially or have become nil, it becomes difficult for the senior citizens to bear with. In the absence of coverage of OPD care, even those who will be enrolled in the NHPS, will not benefit much. Elderly have special nutritional needs which need to be fulfilled. In the Ayushman Bharat there is no such mention of these requirements.
The social determinants of health like supply of clean drinking water, adequate sanitation system, proper housing, nutrition and sufficient wages to meet these day to day needs and health education are the primary factors related to healthcare. However these determinants are not integrated in government’s policy making in practice.
Making of toilet sounds good but it has to be monitored. Since in most of the cases the toilets are not connected to the sewer lines in the rural areas, there have to be dug holes to collect the excreta. This needs proper maintenance in a scientific manner. Just putting one time seat may not serve the purpose. In ‘kucha’ dug holes there is seepage of soiled water causing pollution of the drinking water in the nearby vicinity. Many such toilets are not being put to the desired use; some are being used as store houses. Government gives Rs. 4000/- for construction of such toilet. In fact this amount is too low. Minimum cost to build a toilet of the size of 5 x 5 feet will not be less than Rs. 12000. To construct this size of toilet minimum of 800 bricks are needed @ Rs.5/- per brick. If Rs. 8000/- has to be contributed by the person himself then it is unlikely that each and every family will build toilets.
Nutrition plays the most important part in health. That a well-nourished person is less likely to be taken ill compared to the one with poor nourishment needs no explanation. For proper nourishment we need a balanced intake of proteins, carbohydrates, fats, vitamins and minerals etc. All this comes from daily intake of staple food like wheat/rice, vegetables, meat, eggs, milk, fruits etc. As per calculation for a daily intake of 2100 calories through balanced diet for an adult, the cost comes to around Rs.90/- per day at the present rate of prices. For a family of 5 persons it requires Rs. 13500/- per month for food only. With falling wages, insecure jobs, and contractualization of employment all this is a pipe dream for vast majority. Thus most of our population remains undernourished.
Housing is another issue which is an important determinant of health of a person. One’s longevity much depends on the environmental conditions one lives in. With large number of our population living in shanty houses, it would be naïve to expect them to be healthy.
It is well known that the insurance companies’ primary motive is to earn profit. It is presumed that since the number of insured in the NHPS will be very large and as at any given time very few people are hospitalized, this will give enough scope to the companies to reap profits. But if at any stage the companies find it to be unviable, they would not hesitate to pull out on one excuse or the other. If the premium is low then many of them may not join the scheme at all.
Those not covered under the scheme will be left to the mercy of insurance companies whose coverage is premium based. More the premium, more the coverage! The premiums have become very high and out of reach of most of our population. For example a family of five with three senior citizens has to shelve around one lakh rupees annually as premium to get a coverage of 5 Lakh rupees even in the public sector insurance companies. This is impossible for most of those uncovered under NHPS.
The concept of universal comprehensive health care was first of all realized by the former Soviet Union who in the Soviet constitution 1936 guaranteed that the Citizens of the USSR have the right to health protection. According to the Article 42 of the Soviet constitution 1936 “This right is ensured by free, qualified medical care provided by state health institutions; by extension of the network of therapeutic and health-building institutions; by the development and improvement of safety and hygiene in industry; by carrying out broad prophylactic measures; by measures to improve the environment; by special care for the health of the rising generation, including prohibition of child labour, excluding the work done by children as part of the school curriculum; and by developing research to prevent and reduce the incidence of disease and ensure citizens a long and active life.” (Soviet Constitution, 1936).
Likewise Healthcare in Britain is mainly provided by its public health service, the National Health Service, that provides healthcare to all permanent residents of the United Kingdom that is free at the point of use and paid for from general taxation.
Much needs to be done to ensure healthcare for all. The social determinants have to be taken care of while talking of health care. For this public spending on health which is meagre 1.04 % of the GDP at present has to be increased to at least 5% of the GDP. Sufficient funds have to be released towards the schemes to meet the requirements for nutrition, housing, water supply, sanitation and health education, otherwise the Ayushman Bharat will also meet the same fate as Swachh Bharat Abhiyan. (IPA Service)
The picture is taken from the Internet.