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Understanding the Legality of Healthcare Systems Across India

Dr. Nupur Tiwary – Health Care Performance Systems in Tribal areas

8.6 per cent of India’s population (which is more than half of the Tribal population in the World) constitutes the Tribal.

The dynamics of health issues are related to left wing extremism. The ‘left wing’ considers providing one basic medicine (such as Disprin) as medical assistance. They assign doctors that are not very well trained, and the only reason they bother is because they always want to take something away from the Tribal. They don’t fight for the Tribal rights anymore. To understand the Tribal issues, Dr. Tiwary also gave a brief background about the left-wing extremism. She also mentioned the governance technique that Naxalites use to control the Tribal.

One of the major problems with regard to healthcare is the accessibility issue. The government (including the Police) has never been able to successfully reach the Tribal. This is not only because of the remoteness of their location, but because of the constant terror created by the Naxalites in these area by their system of ‘Janatana Sarkar.’

Obviously, there are various health (including reproductive) issues that they face. Malnutrition, communicable disease (especially STDs), high risk sickle cell amnesia, child mortality (most prevalent in children under 5), undernutrition and amnesia in pregnant women, lack of pre or post-natal care are the most prominent ones.

But the question is, who takes care of them? NRHM, which is supposed to support these primitive tribes, is not functioning as it’s supposed to. There is lack of transport, reluctant doctors, failure of PDS which adds on to the existing problems. The issue is that someone in need cannot reach the doctors in time. But they are very reluctant because they believe that it’s unethical to take these government aided medicine.

Based on personal interaction, Dr. Tiwary informed that most of the tribal population has its own intrinsic, traditional cures. For them health is a personal issue, not a community one. Pregnancy has never been a medical issue, but a natural process where nothing artificial must be done. Their indigenous practices, which are very inherent to their way of life, has been patented by others multiple times, without any accreditation being given to them. Now the problem has become more acute because their indigenous medicine is getting extinct due to deforestation. Moreover, the traditional doctors/ practitioners are not getting sufficient money, so they have started doing minimal work for their survival.

It’s not that the governent is not concerned. The problem is with the approach used. Acts, dances, nuke nates, radio transmissions are methods that make a genuine impact on these tribal. What is your reach, how do you take it forward, is very important. Even though there are various challenges (lack of emergency transportation, discriminatory behavior of health care providers, financial constrains), there is significant scope for expansion.

Dr. Tiwary is hopeful that the new Ayushman Bharat Yojana will be successful in providing better medical facilities to these remotest of tribes, that are getting extinct.


Dr. Indranil Mukopadhyay – Ayushman Bharat: Health insurance

Dr. Mukopadhyay gave a brief introduction about how Health Insurance is like any other insurance, where there is an element of pre-payment in the form of the tax funded program of India ad it protects individuals from the risk of falling in. The idea is to bring people with various risks in a pool.

Ayushman Bharat is like any traditional insurance where there is risk pooling and pre-payment involved. What is new is the access and expenditure that the Government aims to bring in.

Ideally, if there is a good public funded insurance system, the citizens should not be making any payments at the time of falling ill. If not, then access to health care depends on the money a person has, which inevitably leads to the inequality which is very much prevalent in the country.

If Rs. 100 is spent on health, then more than 2/3rd of it comes from a person’s pocket (money only given when a person falls ill). India has one of the lowest public-spending on health, and consequentially high out-of-pocket expenditure.

Dr. Mukopadhyay provided statistical data on the current health care schemes related to insurance and their impact on people. There are several state-sponsored schemes as well, which have come about. Now there is a need to integrate all the schemes, hence this Ayushman Bharat.

A huge part of population is covered under these schemes. If these schemes had been actually effective, huge out-of-pocket expenditures would have reduced, particularly for hospitalization. Around 50.5 million people fall below poverty line, who are the ones that have the maximum out of pocket expenditure. Around 84.4 per cent people don’t have any insurance. What is surprising is that out of the total population, the poorest and the poor have the least insurance coverage, for whom the schemes were allegedly started in the first place.

It is seen that those who are a part of the insurance are seeking hospitalization and care more than the ones who are not, especially the urban poor. So basically, if one has insurance then they seek more health care benefits.

Since the government claims that a person can use this public-funded insurance in private sector as well, the people end up paying more money as compared to how much they would have spent in a public hospital without insurance. Most insurance schemes are there in the public hospitals. These hospitals provide a better financial protection than private ones. The median expenditure is lesser. 3/100 get free care, and majority of those get it in the public sector. Therefore, a good insurance scheme is only successful if there is good public-sector service. So, in states like Tamil Nadu, where public sector is better, the statistics are better than the rest.

Ideally the growth in hospitalization expenditure for poorest of poor should be the least, but even after insurance schemes, this growth has been the highest. So, the people who need it the most are neither covered, nor do they get free care. Dr. Mukopadhyay believes that this entire model really needs to be thought about.

When talking about different types of ailments, it is seen that catastrophic health expenditure is barely covered by these schemes. There has been only 1 per cent decline in this expenditure for the poor.

Dr. Mukopadhyay believes that one of the crucial problems has been the rapid expansion in the private hospital business. It is an industry with increasing return to scale. Because of this, there are various cases of merger and acquisitions.

But at the same time, there is very little accountability on these types of insurance schemes. Barely any grievance mechanism in these schemes. Even Ayushman Bharat does not really give much consideration to it. The lack of legal backing needs more scrutinization.

There is a dire need to expand to expand public sector to preventive and primary health care. If the primary care is strengthened, then the cost of health care automatically comes down. This is seen from the experience of countries like Thailand, Sri Lanka, or even from states like Tamil Nadu.

Another way is of expand the provisions for free medicine through the public sector.