The Telegraph
Wednesday , January 9 , 2013
Since 1st March, 1999
CIMA Gallary


- The lack of universal healthcare is basically anti-democratic

The live-in maid who cooks in a friend’s house complained one afternoon of acute lower abdominal pain. She was writhing in agony. It was obviously something serious, which a GP could not fix; so the friend took her to the nearest hospital, which was a private hospital. He had no choice in the matter: there were no government hospitals in the vicinity, and the woman’s pain was so intense that even when his car went over a pebble she would shriek in agony. At the hospital, she had to undergo a battery of tests to eliminate all sorts of esoteric possibilities, like ectopic pregnancy, before the obvious conclusion was reached that it was a case of acute appendicitis. She had to spend several days at the hospital before and after the surgery, which itself was quite minor. The cost of her stay, together with the cost of surgery and tests, came to Rs 62,000, and that too after the hospital had generously charged her only for an ordinary bed, even for the night when she was lodged in the ICU, because of the non-availability of such an ordinary bed.

Her family obviously could not have afforded this sum, and even the friend who paid the bill could ill afford it, being a retired academic living on the interest earning on his provident fund. Some would find fault with him for not having insured the maid’s family for medical emergencies. That may be so, but one shudders to think what would have happened to her if instead of being a live-in maid, she had been a daily-wage worker.

In fact, the other day three construction workers were walking down the road near where I live, when a speeding car coming on the wrong side of the road struck one of them and threw her several feet. The car, predictably, sped away, leaving her on the road. Her injuries fortunately were minor. The local GP attended to them and no hospitalization was necessary. But what if it had been necessary? Once again one shudders to think.

It is a shame and a disgrace that after 65 years of independence we still do not have in this country a free and comprehensive health-care scheme covering the entire population. Indeed, ours must be among the most uncaring societies in the world. Britain has the National Health Service, the Scandinavian countries have excellent health-care programmes, and even the United States of America, though its federal government spends much on health to little effect, has at least a scheme in some states, whereby accident victims, and emergency patients requiring “non-elective” medical attention, get free treatment at any hospital they are taken to, even when they are not covered by any insurance policy. The hospital is obliged to provide such treatment.

There is no point in saying that we are a poor country that cannot afford the luxury of free and universal healthcare. Britain built up its NHS when it was war-ravaged; and tiny Cuba, which does not boast of being a high-flier in terms of growth rate, has built up the finest health-care system in the contemporary world in the midst of an economically crippling encirclement organized by the US. (This irrelevance of the growth rate to the institution of schemes for the people’s benefit is one reason why the official obsession with the growth rate in India leaves one completely cold.) The absence of affordable health-care for the poor in India, therefore, is not because the country is poor, but because the rulers are uncaring towards the poor.

Such Central government schemes as have been introduced lately are appallingly paltry. The most notable of them is the Rashtriya Swasthya Bima Yojana. It covers only the population officially declared to be below poverty line, and entitles a family to the reimbursement of medical expenses up to a ceiling of Rs 30,000 per year, if treated at hospitals which are enrolled under the scheme and which ipso facto accept rates prescribed by the Central government for different medical procedures. The premium is borne by the Central and state governments in the ratio of 75:25, though the Centre has put a ceiling on the absolute amount it will pay.

There are certain obvious problems with this scheme. First, those officially considered poor are only a small fraction of the actual poor. Second, the rates for the various procedures have to be pitched quite high to attract hospitals to enroll themselves; and at those rates Rs 30,000 per family per year does not go very far. Third, any critical illness afflicting the heart or the liver or the kidneys entails expenditure per person that is far above the annual family ceiling. Fourth, if even the officially defined poor actually access the scheme in large numbers, then, by the very logic of insurance, the premium demanded will go up, and since the Centre has placed a limit upon its own contribution in absolute terms, the burden on cash-strapped state governments will be too heavy for them to bear. This Central scheme, in other words, is almost designed to be ineffective. And fifth, once state governments bear the burden of the premium payment, even partially, they tend to effect comparable cuts in their normal expenditure on the health sector. As a result, state government money that would have gone into strengthening the public health system, gets wholly or partially diverted, via premium payments, to private heathcare facilities. This not only amounts to a privatization of heathcare at the cost of the exchequer, but also to a net reduction, rather than a net expansion, in healthcare availability to the poor.

In addition to these obvious problems, however, there is an additional major problem in getting people to enroll under this scheme. “Smart cards” for this scheme are issued in particular localities on particular days, and whoever does not turn up at the appointed time and place, whether out of lack of information or some other compulsion, simply does not get enrolled.

While the Central scheme therefore, is dismally inadequate, some individual state governments, especially in south India, have introduced their own schemes. Kerala under the Left Democratic Front government used the RSBY to build up its own programme, the Comprehensive Health Insurance Scheme, under which almost half the households in the state were covered, with the state government paying the full premium for all those not recognized as BPL by the Centre. It also revamped government hospitals and made it mandatory for them to enroll under CHIS. And since insurance premium payment entailed no cuts in the government’s health budget, public health facilities, far from languishing as in other states, came to be better funded: in fact, they got funded from two sources, from the health budget and from insurance premiums. In addition, the state provided CHIS beneficiary families a sum of Rs 70,000 per year over and above the Rs 30,000, for the treatment of critical illnesses at specified government health facilities.

Andhra Pradesh has rejected the RSBY and has its own Arogyasri programme which reportedly provides significant succour to poor households. Tamil Nadu likewise has a health programme of substantial benefit to the poor, which provides financial assistance from the state government for critical illnesses and under which medicines are made available at low prices at government health facilities, through centralized purchases by a government-owned corporation. All these state government efforts are still a long way, however, from the provision of free and universal health-care. And, of course, in most other states, especially the northern states, the situation is quite pathetic.

The need for a universal as opposed to a targeted programme of the sort that even the most advanced state governments have arises from the fact that it represents a right that a citizen enjoys as a member of a fraternity, and not a form of State-sponsored charity. A democratic society based on egalitarian principles must make healthcare available to all as a matter of right, though some may voluntarily opt out of using the facilities through which this right is to be realized. By contrast, any targeted programme seems like a mere distribution of largesse, and therefore smacks of condescension and charity; it is offensive to the democratic ethos. The fact that to this day, healthcare has not been provided to all as a matter of right speaks volumes about the fundamentally anti-democratic ethos underlying Indian democracy.

The recent incident of the gangrape and subsequent death of a young girl in Delhi has held a mirror up to our society, exposing its utter sickness. But this sickness is not confined only to the persistent victimization and persecution of women. It also extends to an unbelievable degree of callousness towards the poor in general. And in this, the middle class is as complicit as anybody else.