There is hardly any country in the world which relied on commercial insurance companies for implementation of UHC

In a recently published paper, titled  ‘Understanding the “Cash-Less” Nature of Government-Sponsored Health Insurance Schemes: Evidence From Rajiv Gandhi Jeevandayee Aarogya Yojana in Mumbai‘, the authors attempt to assess the extent to which the scheme protects families from making out-of-pocket (OOP) expenditure while availing tertiary care from RGJAY accredited facilities. They conclude that despite enrollment in RGJAY, OOP remained high. More than three fifths (63 per cent) of the beneficiaries still incurred OOP payments for services when admitted in the hospital, and more worryingly, it was found that a significantly higher proportion of persons from Below Poverty Line (BPL) families (88.23 per cent) reported paying for diagnostics, medications, or consumables. Viveka Roychowdhury gets one of the authors, Prof Soumitra Ghosh, Tata Institute of Social Sciences, to share some recommendations based on these observations

The authors conclude that universal health assurance is better than publicly funded health insurance schemes like RGJAY. What are the steps they would like the Maharashtra Government and public health policy makers at the Centre to take, to ensure that such ‘leakages’ are reduced?

Since 2005, publicly funded private health insurance (PFPHI) schemes have become popular in the policy circles. However, most of the studies that examined the effects of these programmes point to several serious issues with this kind of health care financing and provisioning arrangements.

The following major issues have been documented by the existing studies on the said insurance programmes: exclusions of eligible beneficiaries, low level of knowledge about the programme amongst the eligible people, inadequate administrative support for programme implementation, high administrative cost of the programme (insurance companies are given as high as 20% of the premium revenues), lack of accountability at all levels, denial of services, fraudulent practices by health care providers (private hospitals), cherry picking of more profitable interventions and extraction of money from the beneficiaries.

More importantly, there is a consensus on this fact that the PFPHI schemes made limited impact on utilisation of services and financial risk protection. People still continue to pay from out-of-pocket despite being covered by PFPHI.

In view of these emerging evidences, the government must think through about the choice of how to finance and deliver healthcare needs. It is important to note that there is hardly any country in the world which relied on commercial insurance companies for the implementation of Universal Health Care (UHC). In order to make UHC a reality, the government must fulfill its commitment of raising the public investment in health from the current level of 1.28 per cent to at least 2.5 per cent of GDP. And these additional financial resources need to be spent on strengthening the public healthcare infrastructure of the country so that people could receive quality healthcare without the fear of financial hardship. Since the services would be provided to all citizens irrespective of their level of income, caste and religion through the public healthcare facilities, the issues of leakages wont arise.

Should private hospitals be dropped from such schemes?

In India, the private sector remains largely unregulated and since it looks at health care as a commodity and not as a right for the people (or as a public good), it would continue to make as much profits as possible by resorting to all kinds of tricks. Even a country like US with its highly sophisticated health management and information system has not been able to check the moral hazard behaviour of the private sector.

Another example from the developing countries is Philippines where a social health insurance (SHI) system is in operation since 1995 and private sector has been the dominant provider. However, this has actually led to supply-driven medical care, unethical practices and the cherry-picking of more profitable interventions by the private sector.

Several studies point that increased funds made available under SHI went to the private sector hospitals at the expense of public hospitals. The effect on financial protection was also very limited as the incidence of out-of-pocket expenditure on health has not declined. It would be therefore desirable not to rely on private hospitals for healthcare provision under any scheme or programme that is tax-funded.

Since the sample size is small, is this study being expanded?

This study has already been published in a highly reputed international journal. However, we are currently carrying out another study covering more than 7000 households in the state. This study will assess the impacts of the programme in terms of access to health care and financial protection.

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