Health Insurance for the Poor - Is it the best solution??
Happen to just read an article at Healthcare as a broad public challenge Sri. Jayaprakash Narayan of Loksatta, Hyderabad is one of our people constantly reminding us about the issue of health expenditure and the implications of the same. In this article he has addressed the proposal of the Government to introduce a subsidized healthcare system for the rural poor. He says that the obvious solution may not be the best and the government needs to consider the solution from different angles.
I have had the opportunity to recently study the health expenditure of some of the poor and not so poor rural communities in a few pockets of TN, Andhra and Karnataka and I tend to agree with Jayaprakashji on this. I found it encouraging that in most of our villages still healthcare is translated as 'an overall feeling of goodness' that encompassed both physical and mental health and not merely absence of diseases. There is certainly a large awareness on hygiene practices prevalent.
I have had the opportunity to recently study the health expenditure of some of the poor and not so poor rural communities in a few pockets of TN, Andhra and Karnataka and I tend to agree with Jayaprakashji on this. I found it encouraging that in most of our villages still healthcare is translated as 'an overall feeling of goodness' that encompassed both physical and mental health and not merely absence of diseases. There is certainly a large awareness on hygiene practices prevalent.
However, I also was a witness to many dangerous practices creeping in rural areas in terms of modern medical quacks and irregulated drug stores. Across Tamilnadu it was common a few months back to find cases of drug stores providing over the counter medicine 'pack' containing among other things, steroid medicine for cases of Chi-gun! Similarly I learnt the the poorer patients in government hospital in Tamilnadu (though aware of its dangers) have to go through the treatment of the same needle being used to inject for 10-15 patients.
With the traditional system of healthcare almost completely uprooted in rural areas (ironically, at a time when they are resurfacing as a fad in the urban centers), the native wisdom and free herbal remedies from the kitchen gardens for even simple illnesses are slowly disappearing from the collective village minds (though I found the same can be easily revitalized through a few simple interventions NGOs have tried out). In a meeting with a group of women belonging to Self-Help Groups(SHGs) in Andhra Pradesh, with an average age of about 40, none of the women knew how to prepare a 'kashayam'!
Mutual insurance has been introduced by NGOs among such women's groups and I feel that this is a good alternative to larger subsidized insurance programmes. But, there cannot be an alternative for a thorough inspection and increase in efficiency of the PHCs, increase in the risk-pooling mechanisms and also a tough regulation on the sale and administering of drugs - both over the counter and through clinics. At the cost of sounding outdated, I think it is still not late to also encourage a kitchen garden based self-medication for at least simple illnesses that can help the poor by saving their medical expense. A dry land farmer in Ramnad mentioned that each outing to a hospital costs him Rs. 350 to 400/- and at times he has to visit the doctors twice every month. Most poor in villages spend on health only if they are pushed to it and then it costs them almost half their wage (if not more, the national average is 60%). They are dependent on their little savings and lending from local villagers and money lenders (and increasingly from SHGs). Hospitalization can mean repayment of loan for the next few decades, unless another member in the family gets a really high paying job, which means migration to either urban or abroad centers as labourer.
Private clinics abound in the rural landscape all over south India today and most villages have at least one quack. A politically well connected local leader in Kuppam in AP mentioned how it some of the quacks are directly connected to medical companies which in turn are owned by corrupt officials and politicians. And it is not just the danger of quacks, even practicing physicians in rural areas happily take advantage of the fact that people don't understand the science and are willing to blindly follow the physician. In Thiruvallur district in TN, I have been told by Panchayat leaders that there are private clinics that inject drips to anyone who comes in as they have been set target by drug companies. In one of my travels, a co-passenger in a train, who happened to be wife of a drug company marketing manager mentioned that her husband is often planning foreign trips for doctors who 'perform' well in their target achievements as a bonus!!
We need to really understand the impact of globalized healthcare system (with its aggressive marketing practices) and its cost implications on the poorest. Why are per visit costs to clinics getting costlier? Why do the number of prescribed tests for the same symptoms seem to be going up with times? are some of the critical questions. Indiscriminate prescription is another major illness that ails our medical system. A friend recently quoted Dr. Arjun Rajagopal of Sundaram Medical Foundation, Chennai as saying that,
"...we are sitting on a volcano as far as misuse of antibiotics is concerned - an epidemic far worse than AIDS". When I further enquired with Dr. Rajagopal, he provided another insights saying, "...the problem that you are referring to, is one symptom of a larger disease - the faulty prescribing habits and ethics of the medical profession. Change, if it is possible at all, can come only from within practicing physicians and not from attitudes of confrontation and censure from outside. This has to start early - from the days of medical college education. And this is where I run into a wall of despair. The present trends and policies with regards to the licensing and certification of medical schools and teaching hospitals has degenerated to one of a crass and unhealthy form of commercialism that does not forebode good for us all". This is another dimension that the general public is unaware of.
A subsidized hospitalization (through the proposed government insurance programme) for the poor in India will be to the human health as bad as a chemical pesticide subsidy to the crops and soil health. It will make the companies rich, the poor, poorer and the overall health worse and whatever self-reliance is there will be wiped out. And worse, it cannot guarantee a quality physician or healthy life. All this at the cost of public funds!!
