Commercialisation of medical care and Public Medical Insurance Schemes in India: Who Benefits?

1. Commercialisation of medical care and Public Medical Insurance Schemes in India: Who Benefits? Rama V. BaruProfessor Centre of Social Medicine and Community Health Jawaharlal Nehru University New Delhi

2. The framing and core arguments that I propose to build in this paper is that the expansion of public insurance schemes is a continuum of commercialisation of medical care. It is also a response to the pressures from civil society regarding rising inequities in accessibility and affordability to health services. • Empirical evidence of rising Out of Pocket Expenditures and its adverse impact on the poor and the highly differentiated middle class highlighted the crisis in medical care. • Targeted public medical insurance schemes was a policy response by some States.

3. Brief history of public medical insurance schemes • The Bhore Committee discussed the desirability of health insurance and concluded that India first needs to build a strong, universal public health services. • It was of the opinion that having insurance schemes for the organised sector would break social solidarity. • Soon after independence two medical insurance schemes were introduced- the ESI and the CGHS. • Both the schemes together cover only around 10 percent of the population • The remaining population incurred out of pocket payment for medical care in the public and private sector

4. Continuum of Commercialisation and inequities in access to medical care • Poorly funded public services provided spaces for the growth of the private sector • In several southern and western states there was a steady growth of the private sector at the secondary level by the late 1970s • Variation in the distribution- largely urban centric; economically prosperous districts; promoted by doctor entrepreneurs

5. Analysis of 42nd Round of the NSS on utilisation showed a high dependence on the private sector for out patient care. • For hospitalisation there was a variation across states and income quintiles. • States with a larger presence of the private sector also had a higher level of utilisation largely in the middle and upper quintiles • With the introduction of health sector reforms in the 1990s, the public sector was commercialised • The distinction between the ‘public’ and ‘private’ was blurred

6. Analysis of survey data in the 1990s and 2000s showed the increased dependence on the private sector across income quintiles for hospitalisation. • As a result the burden of expenditure for out patient and in patient care was highest for the poorest • It was also fairly high for middle income quintiles • A social gradient of burden was observed for a large percentage of the population

7. The question of rising inequities in access to health services gained visibility globally and nationally through social networks of health activists and their allies • There was growing concern of rising out of pocket expenditures and indebtedness due to medical care in India • In the 1980s, several Non Government organisations initiated Community Based Health Insurance schemes inorderto improve access to medical care. Partnerships were formed between risk pooling in the community and the locally available public and private services. • These initiatives influenced the design of some of the government led medical insurance programmes

8. By the 1990s the private sector had expanded across states and was facing a crisis with the uncontrolled expansion of the middle and corporate sector • Resulted in competition within the private sector leading to corruption, kickbacks and unhealthy practices inorder to maintain patient supply • Constant demand by the private sector for government subsidies

9. Corporate sector was able to wrest more than the middle private sector • This led to a great deal of antagonism and fracture of interests within the the private sector • The lobbying power of the private sector with the government was influential in shaping targeted public medical insurance schemes

10. The State and Centre led targeted public medical insurance programmes are initiated in the 2000s • The first such programme is Yeshsvani in Karnataka in 2003 • For institutional deliveries the Chiranjivi and JananiSurakshaYojana • Partnership between public financing and mixed provisioning • It gave a boost to the private sector and simultaneously gave political mileage as a populist programme for the poor.

11. Based on a synthesis of the evidence there are some key concerns: • All these schemes focus only on curative care at the secondary and tertiary levels . • Therefore the hospital becomes the centre of the working of these scheme. • The schemes are public-private arrangements wherein the financing is by the government while the provisioning is by the public and private sectors. • Given the weak state of public services, the ‘for profit’ segment of the private sector plays an important role in provisioning. • The spread of the private sector is uneven marked by inter and intra state variations in the availability and accessibility of health services. They tend to be concentrated in urban areas and in developed states.

12. The heterogeneous character of the private sector that it is largely unregulated has implications for price and quality of services. • Given the anarchy of the market in medical care there is a danger of inflation of cost to the government. • There is also a fiscal risk to those who are covered by this scheme since the private hospitals recover costs beyond what has been set from the patient.

13. Characteristics of Public medical Insurance Schemes • The common characteristics that emerge from the synthesis of evidence are: • Most of the state led schemes cover pre decided disease conditions. • Some cover pre-existing conditions and others do not • Prasad (2015) in his analysis of the Rajiv Arogyasri shows that initially only 163 procedures were covered but with growing pressure from hospitals and users it rose to 938 in 2011. • It was observed that there was a mismatch between the disease burden and the diseases treated by the scheme.

14. Majority of the surgeries wereperformed in private hospitals and according to an estimate in 2008, the total number of surgeries in private hospitals under Arogyasri was 59,846 for which they were paid Rs 2,252 million (Reddy: 2008:21). • The proportion of hospitals empanelled was overwhelmingly skewed to the private sector. 80 percent of the empanelled hospitals were in the private sector, located mostly in urban areas and in the developed districts of erstwhile Andhra Pradesh.

15. In Maharashtra nearly 84 percent of empanelled hospitals were in the private sector. It observed that it is the middle private sector with a bed strength ranging from 30 to 50 that has the highest participation (Wagle et Shah (2017). • Hospitals with more than 100 beds are reluctant to participate in the State led insurance programme whereas would prefer the CGHS where the pricing is higher for the super specialities. • Some of these tendencies are also observed in the Vajpayee Arogyasri in Karnataka.

16. The centrally sponsored RSBY showed the inter state variations in the empanelment of hospitals • Proportion of empanelled government hospital varies from 45.86% in Kerala to as low as 4.95% in Haryana (Narayana: 2010). • In States where the private sector growth is less, the proportion of empanelled public hospitals is higher. In Chattisgarh nearly 60 percent of the empanelled hospitals in the RSBY programme were public. • It was also observed that poorer districts in Chattisgarh faced the problem of a weak public sector and a small private sector (Nandi et al:2015).

17. Several studies have also shown that these targeted insurance schemes that do not adequately cover the population living below the Below Poverty Line. • There are three forms of inclusion and exclusion- the social, diseases covered and the type of provisioning. • The social dimensions of inclusion and exclusion can be defined by the multiple axes of caste, gender, tribe and ethnic identities. • Studies from Maharashtra, Andhra Pradesh and Chattisgarh have shown that men tend to use the scheme more than women. Tribal and Muslims have less access than others. • All this points to the fact that while those Below Poverty Line maybe eligible, the poorest have difficulty in enrolling, accessing and utilizing the services.

18. Most of these schemes privilege non communicable and chronic diseases over others. • Conditions requiring super specialist intervention are taken up by tertiary private hospitals while those requiring secondary level care are relegated to government hospitals and the middle private sector. • Qualitative studies have shown that complicated cases are usually diverted by the private sector to government hospitals.

19. The evidence is showing that the public insurance schemes have definitely helped to further consolidate the middle private sector. • It is also the case that the private sector has been unhappy with the pricing structure and the corporate sector has found ways to engage with the schemes which benefits them. • They have also been able to define the diseases for which they will offer treatment for and re-negotiate the pricing with the respective state governments.

20. The administrative and governance demands of the insurance schemes is a complex partnership between a society or trust created by the government, a third party intermediary and the empanelled hospitals. • The link within this structure and with the beneficiaries from the stage of enrolment and utilisation is weak. • Some of these schemes have link workers to facilitate access for beneficiaries but it is still remains weak. • The impact of these schemes on OOPs are few and show a mixed picture. • In some states it has declined while in others it has not changed much. • Other concerns are of corruption in empanelment, charging beneficiaries for treatment and denying treatment when required.

21. The recent initiatives in health policy has given rise to several contradictions. • The idea of a comprehensive approach to public health has lost its relevance • Targeted public insurance schemes have privileged curative medical care in an unregulated market • Weak initiatives for regulation to address market failures • The public insurance schemes have little or no link with primary level care

22. Most of the studies are focused on the fiscal, design and implementational aspects of the programme. • Sociologists and anthropologists are now engaging beyond the negative and positive evaluation of these schemes. • They are critically engaging with the interaction between various insurance interventions, the people, institutions and providers in the schemes (Ahlin et al:2016). • A few important questions that are not adequately answered by the available studies are to do with the power dynamics between those who frame the policy; those who implement the policy and the recepients of the policy and those who frame and fund research (Ahlin et al: 2016)

23. There are several questions that have not been adequately explored in evaluations of insurance schemes. The following are a few. • How does the public perceive and understand health insurance? • Do targeted programmes create tensions between those who are entitled and those who are not? • Does it alter perceptions of the understanding of health? • Does it lead to a medicalised understanding of health?

24. Differences in behaviour between cashless and cash insurance schemes? • How do insurance schemes influence provider behaviour? • Experience of health insurance coverage for chronic illness, elderly care and disability • Impact of insurance on quality of medical care • The systems for consumer protection and accountability and public scrutiny of the insurance schemes

25. Thank you