Dr. Nupur Tiwary – Health Care Performance Systems in Tribal areas

8.6 per cent of India’s population, which is more than half of the Tribal population in the world, constitutes the Tribal. The dynamics of health issues are related to left wing extremism. The ‘left wing’ considers providing one basic medicine, such as Disprin, as medical assistance and they assign doctors that are not very well trained. They don’t fight for the Tribal rights anymore. To understand the Tribal issues, Dr. Tiwary  gave a brief background about the left-wing extremism. She also mentioned about the governance technique that Naxalites use to control the Tribal.

One of the major problems with regard to healthcare is the accessibility. The government and as well as the police  has never been able to successfully reach the Tribal. This is not only because of the remoteness of their location, but because of the constant terror created by the Naxalites in these areas by their system of ‘Janatana Sarkar.’

Obviously, there are various health (including reproductive) issues that they face. Malnutrition, communicable disease especially STDs, high risk sickle cell anemia, child mortality, under nutrition and amnesia in pregnant women, lack of pre or post-natal care are the most prominent ones.

But the question is, who takes care of them? NRHM, which is supposed to support these primitive tribes, is not functioning as it should. Lack of transport, reluctant doctors, and the failure of Public Distribution System (PDS)  adds on to the existing problems. The issue is that someone in need cannot reach the doctors in time. Additionally, they are very reluctant do reach out to the doctors because they believe that it’s unethical to take these government aided medicines.

Based on personal interaction, Dr. Tiwary informed that most of the tribal population has its own intrinsic traditional cures. For them health is a personal issue, not a community one. Pregnancy has never been a medical issue, but a natural process where nothing artificial must be done. Their indigenous practices, which are very inherent to their way of life, have been patented by others multiple times, without any accreditation being given to them. Now the problem has become more acute because their indigenous medicine is getting extinct due to deforestation. Moreover, the traditional doctors/practitioners are not getting sufficient money, so they have started doing minimal work for their survival.

It’s not that the government is not concerned. The problem is with the approach used. Acts, dances, nukkad nataks, radio transmissions are methods that make a genuine impact on these tribes. What is your reach and how you take it forward is very important. Even though there are various challenges like lack of emergency transportation, discriminatory behavior of healthcare providers, financial constraints, there is a significant scope for expansion.

Dr. Tiwary is hopeful that the new Ayushman Bharat Yojana will be successful in providing better medical facilities to these remotest of tribes, that are getting extinct.

Dr. Indranil Mukopadhyay – Ayushman Bharat: Health insurance

Dr. Mukopadhyay gave a brief introduction about how health insurance is like any other insurance, where there is an element of pre-payment in the form of the tax funded program of India, and it protects individuals from the risk of falling in. The idea is to bring people with various risks in a pool.

Ayushman Bharat is like any traditional insurance where there is risk pooling and pre-payment involved. What is new is the access and expenditure that the Government aims to bring in.

Ideally, if there is a good public funded insurance system, the citizens should not be making any payments at the time of falling ill. If not, then access to healthcare depends on the money a person has, which inevitably leads to the inequality which is very much prevalent in the country.

If Rs. 100 is spent on health, then more than 2/3rd of it comes from a person’s pocket (money only given when a person falls ill). India has one of the lowest public-spending on health, and consequently high out-of-pocket expenditure.

Dr. Mukopadhyay provided statistical data on the current health care schemes related to insurance and their impact on people. There are several state sponsored schemes as well, which have come about. Now there is a need to integrate all the schemes, hence this Ayushman Bharat.

A huge part of population is covered under these schemes. If the schemes had been actually effective, huge out-of-pocket expenditures would have reduced, particularly for hospitalization. Around 50.5 million people fall below poverty line, who are the ones that have the maximum out of pocket expenditure. Around 84.4 percent people don’t have any insurance. What is surprising is that out of the total population, the poorest of the poor have the least insurance coverage, for whom the schemes were allegedly started in the first place.

It is seen that those who are apart of the insurance are seeking hospitalization and care more than the ones who are not, especially the urban poor. So basically, if one has insurance then they seek more health care benefits.

Since the government claims that a person can use this public funded insurance in private sector as well, the people end up paying more money as compared to how much they would have spent in a public hospital without insurance. Most insurance schemes are there in the public hospitals. These hospitals provide a better financial protection than private ones. The median expenditure is lesser. 3/100 get free care, and majority of those get it in the public sector. Therefore, a good insurance scheme is only successful if there is good public sector service. So, in states like Tamil Nadu, where public sector is better, the statistics are better than the rest.

Ideally, the growth in hospitalization expenditure for poorest of the poor should be the least, but even after insurance schemes, this growth has been the highest. So, the people who need it the most are neither covered, nor do they get free care. Dr. Mukopadhyay believes that this entire model really needs to be thought about.

When talking about different types of ailments, it is seen that catastrophic health expenditure is barely covered by these schemes. There has been only 1 percent decline in this expenditure for the poor.

Dr. Mukopadhyay believes that one of the crucial problems has been the rapid expansion in the private hospital business. It is an industry with increasing return to scale. Because of this, there are various cases of merger and acquisitions.

But at the same time, there is very little accountability on these types of insurance schemes. Barely any grievance redressal mechanism is in place. Even Ayushman Bharat does not really give much consideration to it. The lack of legal backing needs more scrutinization.

There is a dire need to expand  public sector in preventive and primary health care. If the primary care is strengthened, then the cost of healthcare automatically comes down. This is seen from the experience of countries like Thailand, Sri Lanka, or even from states like Tamil Nadu. Another way could be through expanding  the provisions of providing free medicine through the public sector.

Dr. Nupur Tiwary is a faculty member at the Indian Institute of Public Administration. She has around 14 years of teaching and research experience. She has been a member of the Thematic group on Panchayati Raj and Local self government, Ministry of Development of North east Region and also a member of research committee of the Ministry of Human Resource Development.

Dr. Indranil Mukopadhyay is an Assistant Professor at Jindal School of Government and Public Policy. He has 11 years of research and teaching  experience in the area of health economics and healthcare financing. Earlier he has worked as a Research Scientist and Assistant Professor and also as Welcome Trust Postdoctoral Fellow at Health Economics and Financing unit at Public Health Foundation of India, New Delhi.

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