The ‘public’ in public health

The discourse must move beyond a top-down approach to listen to the people 

and formulate best insurance practices

Much ink has been spilled in documenting the inadequacy of budgetary allocations 

for public health insurance, specifically for the Rashtriya Swasthya Bima Yojana 

(RSBY), the world’s largest publicly-funded health insurance (PFHI) scheme. Though 

the 2017-18 budget allocation has marginally increased from last year’s revised 

estimates, it has declined relative to last year’s budgeted amount by about ₹ 500 crore. 

However, higher budgetary allocation can only constitute a small part of the solution to 

the scheme’s mixed, if not lacklustre, performance.

Under the scheme, a Below Poverty Line (BPL) family of five is entitled to more

than 700 treatments and procedures at government-set prices, for an annual enrolment 

fee of ₹ 30. However, even nine years after its implementation, it has failed to cover a 

large number of targeted families — almost three-fifths of them. Their exclusion has 

been due to factors like the prevalent discrimination against disadvantaged groups; a 

lack of mandate on insurance companies to achieve higher enrolment rates; and an absence 

of oversight by government agencies

Increase in hospitalisation

True, there has been a substantial increase in hospitalisation rates. However, it is 

unclear if it has enabled people to access the genuinely needed, and hitherto unaffordable, 

inpatient care. Often, doctors and hospitals have colluded in performing unnecessary 

surgical procedures on patients to claim insurance money. For instance, hospitals have 

claimed reimbursements worth millions of rupees for conducting hysterectomies on 

thousands of unsuspecting, poor women. Indeed, in the absence of regulations and 

standards, perverse incentives are created for empanelled hospitals to conduct surgeries. 

It is thus not surprising that there is no robust evidence of an improvement in health outcomes.

Evidence on the financial protection front is conflicting as well. One study revealed that

poorer households in districts exposed to the RSBY and other PFHIs recorded an increase in

out-of-pocket (OOP) expenditures for hospital care, and a corresponding rise in incidence of

catastrophic expenditure. There is near-consensus that the RSBY has resulted in higher OOP

expenditures. Though it is a cashless scheme, many users are exploited by unscrupulous

hospital staff.

So, what is the solution? There is a need to bring the ‘public’ back into the discourse on

public health to highlight its present culture. The conversation needs to move beyond a topdown

approach specifying budget allocation and administrative and technical efficiency. It

needs to involve listening to the real public to deliberate on various health practices and

policies.

My ethnographic study of the RSBY in Kalaburagi and Mysuru districts between 2014 and

2016 brought to light that a top-down approach on allocation and coverage was important

but, by itself, did not translate to expected outcomes. What mattered more was the existing

culture of health insurance — how it was perceived, practised and experienced in the

everyday, local worlds of the enrolled households. Though they valued aspects like the

money available and the number of illnesses covered, they were more deeply affected by how

other actors — doctors, local officials, neighbours and even relatives — related to health

insurance.

Card not accepted

The disillusionment of Savitri, one of the beneficiaries, after obtaining the plastic card said it

all: “If public officials only give us the card without telling us how to use it, the card is just

plastic material. Sometimes information is also not correct, making us feel that the card is of

no real value if we do not know how to use it.” Further, many hospitals refused to

acknowledge the card’s value. Shivakumar’s observation summed it well: “We went to the

hospital with the card. Not only could it not be used but also the doctors did not even

acknowledge us as patients... We just brought the card home and tossed it to the shelf.” Many

bemoaned the absence of public debate on health issues and the RSBY card. Deva’s pithy

response was illustrative: “If it is not talked about and debated, we can only think that there is

no big value that we should pay attention to.”

Households clearly separated the economic value from social ones. A section saw health

insurance as a bad omen, one that announced arrival of illness. Ramesh Kumar, among those

in his neighbourhood who refused to enrol, explained: “This card is not a solution for illness,

it is a cause of it. You see, when you people knock on our doors to give us the card, it feels

like an illness is knocking on our doors. The farther away we are from the card, the further

we are from health problems.”

Overall, while the discourse on a greater allocation to RSBY and enhancement of cost 
effectiveness are important, a shift of emphasis is needed, bringing the ‘public’ back into the 
sphere of public health.

Source : The Hindu