‘MODICARE’ TO THE RESCUE
Thai-inspired health coverage in India
Sunita Devi, 45, has been losing hope for her niece, 13-year-old Soni Kumari. The housewife from Bihar state has been camped on the pavement outside the All India Institute of Medical Sciences (AIIMS), India’s premier healthcare institute in New Delhi, since May 16.
Soni, whose mother is missing and whose father died of alcoholism, has not been able to stand on her own since last December. Doctors at the AIIMS say she is suffering from spinal cord tuberculosis and will need an operation, but it could be a year before the overburdened hospital can schedule one. Meanwhile, medicines to stabilise her condition will cost 70,000 rupees (33,350 baht).
Ms Devi, a blacksmith, made the 19-hour train journey to Delhi with high hopes. Her brother, who is being treated for fistula at the AIIMS, brought them to the capital. When they heard about the long delay in Soni’s operation, they asked Pappu Yadav, a lawmaker from their district, to intercede with the doctors, but to no avail.
The doctors instead referred Soni to Safdarjung, another government hospital across the road. The physicians there rejected the AIIMS diagnosis, admitted the child for a day and then discharged her after prescribing medicines.
Ms Devi still has more faith in the AIIMS diagnosis but seems resigned to her fate. She does not visualise Soni walking again and is planning to return to Bihar soon.
“I will wait for another two or three days. If I do not get a date for early operation I will take Soni back. I have neither the money nor the will to wait for one year. Soni will never be able to walk again,” she told Asia Focus, sitting next to her niece on the pavement and massaging her feet.
Sad stories like Soni’s are innumerable in India, where the government has struggled to deliver quality healthcare in a timely and affordable way to hundreds of millions of poor families. That could change, though not overnight, under a sweeping new insurance programme.
Not far from where Ms Devi was camped out, Beer Kunwar Baitha, a welder from Sitamarhi in Bihar, related a similar tale of anguish and helplessness. He has yet to learn the reason for the stunted growth of his daughter Puja Kumari.
“Puja has not grown at all in the last four years. She was 11 when she first started getting headaches and fever. She has been treated for tuberculosis several times. But look at her — she weighs only 18 kilogrammes,” he says, holding the 15-year -old in his lap.
Treatments for his daughter have left Mr Baitha with a debt of 150,000 rupees (71,500 baht), a huge sum for a family that lives below the poverty line.
The AIIMS sees hundreds of poor patients from across India every month. Many are forced to camp out with their families on the pavements because the hospital does not have enough beds and doctors are so overworked.
The government has set up AIIMS centres in several state capitals. But secondary and tertiary care in tier II and tier III cities is woefully inadequate, and private hospitals charge huge amounts for quality care, forcing poor people to flock to government hospitals in the national capital.
With a view to providing affordable healthcare to poor Indians, the government of Prime Minister Narendra Modi will officially introduce the world’s most ambitious public health insurance programme on Aug 15.
Announced by Finance Minister Arun Jaitely in his February budget speech, the programme is officially known as Ayushman Bharat (Blessed with long life India) or the National Health Protection Scheme (NHPS). Not surprisingly, it has become known as “Modicare”.
“It’s a historic step and a bold decision. It will be the largest public funded health protection scheme in the world,” Health Minister JP Nadda has said.
India spends only about one percent of its gross domestic product on public health, among the world’s lowest, and the health ministry estimates such funding leads to “catastrophic” expenses that push 7% of the population into poverty each year.
Beneficiaries of the new programme will be entitled to healthcare both in public hospitals and participating private facilities. The central government will pay 60% and the states 40% of the cost of covering 100 million poor households with a combined 500 million people.
Each household will pay an annual fee of no more than 1,100 rupees (525 baht) for cover extending up to 500,000 rupees (240,000 baht).
Patterned on Thailand’s Universal Coverage (UC) or 30-baht programme, Ayushman Bharat has been described as “bold, ambitious and courageous” by World Health Organization (WHO) director-general Tedros Adhanom Ghebreyesus.
Forecast to cost 100 billion rupees over the next two fiscal years, it will be overseen by the National Health Protection Mission Agency, headed by a CEO. That model also mirrors the Thailand approach, where the UC programme was separated from the Public Health Ministry in order to reduce red tape, and is overseen by the independent National Health Security Office.
The NHPS will replace existing but limited central government insurance programmes for unorganised workers and senior citizens. The former make up 93% of the workforce in India.
The agency overseeing the programme has already fixed rates for 1,354 medical services to be covered under the NHPS. The rates will be between 15% and 20% lower than those approved under the Central Government Health Scheme (CGHS) for civil servants, pensioners and their dependents.
Private healthcare facilities, particularly those providing five-star care to Indian and foreign patients, say the NHPS rates will not be viable for them. The central government has said that state governments have the option of topping up payments to private providers by 10%, but whether this will happen in practice remains to be seen.
In a bid to bring more states on board, Delhi will allow them to increase rates
paid for some procedures beyond the 10% top-up limit if needed, to match those under existing schemes, the Times of India reported last week.
Uttar Pradesh state, where at least 60 million people are expected to benefit from Ayushman Bharat, has already set aside 4 billion rupees for the programme. It is setting up an agency to facilitate communication between the targeted beneficiaries and designated hospitals and insurance companies.
West Bengal, a state ruled by Trinamool Congress, a regional party, has said it will not join the NHPS but its officials have been attending meetings on the introduction of the scheme.
The National Institution for Transforming India (NITI) Commission, which advises the central government on policy, is working on a plan to help private companies set up 100 hospitals in tier II and III cities, where they would offer treatment under Modicare.
The Modi-led Bharatiya Janata Party (BJP) hopes the NHPS will help it win another term in office next year by wooing back poor Indians who have drifted toward opposition parties.
However, sceptics say that without strong oversight and governance, the programme could be abused by private insurance companies and drain away public money.
Meanwhile, Mr Modi was reported last week to be preparing to further enhance his government’s appeal to voters by providing three more programmes — old age pension, life insurance and maternity benefits — to most working citizens.
The programmes are expected to be introduced soon on a trial basis in selected districts and gradually expanded until next May, when the election is scheduled.
As in Thailand, the new Indian health insurance programme will be run by an independent agency to reduce the risk of it being strangled by government red tape