Times of India
05 April 2010
By Dipankar Gupta

India needs a radical rethink on its existing system of healthcare for the needy
Poverty attracts two kinds of policy interventions. The first hopes to eradicate it and the second wants to keep the poor alive. In India, our prime effort has always been, right from the days of antodaya, to somehow keep the poor ticking, even at the lowest levels of subsistence. The NREGA scheme saves the impoverished from starvation on a six–monthly basis. We see the same mindset at work in the way the national health insurance policy, the Rashtra Swasthya Bima Yojana (RSBY), has been devised. Here again the target group is below poverty line (BPL) families and the relief given is inadequate.

To make sense of RSBY’s drawbacks, we need to compare it with the health insurance Bill that Obama recently introduced in America. Of course, the easy way out is to say India is not America and can you compare apples with oranges, or an Apollo with an orangutan? But in both instances, we are talking about human beings and, in both continents, the aim is to help the poor. The trick lies here: do we want to eliminate poverty, or just alleviate it?
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The American health policy exemplifies the drive to eradicate poverty. It gives comprehensive coverage to all, thus allowing the poor equal access as the rich to medical facilities. There is no upper limit in terms of health expenses for claiming insurance benefits in America.

In India, on the contrary, as RSBY is designed only to keep the very poor alive, its cap is at Rs 30,000 per annum for a family of five. You have a sixth member, say, your aged parent, and you wish he were dead. Also, can one legislate that the poor should only have ailments that cost no more than Rs 30,000 a year? In other words, are there diseases of the rich and those of the poor? Can we categorise heart and cancer as status markers that separate the well–to–do from the rest?

This is not a tactic in scaremongering but national figures suggest that, in the realm of non–communicable diseases, after heart ailments, most adults die of cancer. So if a BPL family member gets any of these two illnesses, will RSBY shut its door on that person? Or take a simpler case. If there are complications arising out of child delivery, what happens then? Interestingly, the American health Bill will cover maternity and new–born cases by 2014, maybe earlier. It already takes care of preventive health, for which there are no deductibles, no co–payment.

Incidentally, in India, all expenses arising out of OPD consultations are not covered by RSBY. OPD consultations are free, but a cancer patient’s pathology tests and blood work have to be done frequently. They alone add up to thousands of rupees and we have not come to the medicines yet. Further, our RSBY only allows for hospital procedure “which can be provided on a day care basis”. What then happens to those who need prolonged hospitalisation? Once Rs 30,000 is up, the meter stops and out they go.

The American health Bill does not limit itself to the very poor, or near–starvation families. The governing assumption of the Obama plan is that the rich and the poor suffer similar ailments requiring more or less identical treatments. Its scope is truly universal for it plans to assist families who earn up to $88,000 per annum with their insurance premiums. To get a perspective: most university professors in the US would be happy if they got $88,000 as their yearly pay packet.

In India, it is just the six crore BPL families that are eligible for RSBY. Is this category a satisfying one? If one exceeds the BPL line by a few rupees, does that make the person “not poor”? The Arjun Sengupta–headed National Commission for Enterprises in the Unorganised Sector argues that 44 per cent of the country is poor and about 77 per cent are vulnerable.

Before somebody raises objections to these numbers, note that this commission used National Sample Survey figures which are uniformly accorded academic and state respect. RSBY’s rationale then is to help those in extreme poverty, eliminating millions of others who fall outside the BPL net even by a whisker. This is truly frightening, given the fact that after agricultural inputs the next major reason for rural indebtedness is health.

If RSBY is a stop–gap measure, pending a more comprehensive policy, one could find excuses for its inadequacies. But there is very little chance that it will grow up to look like Obama’s health plan one day. With RSBY, India could have deviated from its past approaches towards poverty, but our administrators are not even aware of this need. As long as the poor are alive and can drag themselves to the voting booth periodically, all is well with the state.

Had RSBY made the rich and the poor indistinguishable, at least in the field of health, that would have amounted to a policy breakthrough. In the same vein, the right to education should eliminate the distinction, at least the egregious ones, between schools facilities for the rich and the poor. Can we look that far ahead?

The writer is a former professor, JNU.