Public health insurance takes ill

Last year, the govt made an ambitious announcement — of covering over 40 lakh families under the first phase of its health insurance scheme. But abysmally low distribution of health cards and hospitals’ hesitation to join in has stopped the project in its tracks. Did the state bite off more than it can chew? Maitri Porecha takes a look

When the state government announced its ambitious free health insurance scheme for the poor, worth Rs1,000 crore — the Rajiv Gandhi Jeevandayee Arogya Yojana (RGJAY) — last October, Rajashree Welawkar hoped that she would soon be able to get rid of the pains that had taken hold of her body. The 54-year-old Malad resident had been battling arthritis for too long. A fall in her house two years ago, which led to fractures in her hips and knees, had aggravated the condition, confining her to a bed.

When the pains became unbearable, she was admitted in the KEM Hospital four months ago. All her hopes are now pinned on hip and knee replacement surgeries. But here’s the glitch: KEM Hospital doctors say she requires four surgeries over a period of two to three years, which will cost Rs5 lakh. The first hip replacement surgery itself would run up a bill of Rs1.5 lakh, as orthopaedic transplants are expensive and have to be procured from private companies.

The Welawkars received their free health insurance cards two months ago. But they have been of little help; the RGJAY’s pilot project, which aimed to cover 40 lakh families, is yet to take off. Blame the delay on the slow distribution of health cards as well as leading private and charitable hospitals’ reluctance to climb on the bandwagon.

Moving at a snail’s pace
The first phase of the RGJAY, which is largely based on Karnataka’s Vajpayee Aarogyasri scheme, will cover families earning less that Rs1 lakh a year in eight districts — Mumbai and its suburbs, Raigad, Solapur, Dhule, Amravati, Nanded and Gadchiroli. Health cardholders will be able to receive free treatment amounting to up to Rs1.5 lakh at empanelled public, private and charitable hospitals.

RGJAY authorities had assured in March this year that the project
will roll out after 50% of the pegged 40 lakh cards are distributed. But, eight months since the scheme was announced, the state health department is nowhere close to meeting its target — only 17.34 lakh cards have been handed out to date. And topping the shame list are Mumbai and its suburbs, where just 4.5 lakh of the 16.24 lakh beneficiaries have received their health cards. Other districts, except Solapur, have performed much better, covering 50% to 90% of the target population.

“We receive close to 600 calls every day on our toll free number 1800-233 2200 enquiring about the scheme. Close to 60% of the distribution is pending,” shrugs Dr K Venkatesh, chief executive officer of the RGJAY.

The holdup
Welawkar’s son, Vishal, is ready to throw up his hands. His hope that the scheme would begin before his mother’s first surgery has been waning by the day. “What’s the use of receiving health cards when the scheme does not help us out in the time of need?” asks the exasperated 33-year-old, even as he admits to making enquiries at the RGJAY kiosk at KEM Hospital daily. Vishal lost his job at a courier company, which paid him Rs5,000 a month, recently. He is at his wit’s end trying to collect funds for the surgery. “I am now scrounging for aid from charitable trusts and other sources.”

Jayesh, a resident of Mazgaon, took the government at its word when he went to the ration shop closest to his house to collect his health card. The state has been repeatedly directing yellow-card holders (those below the poverty line with an annual income below Rs20,000) and orange-card holders (those above the poverty line with a yearly income less than Rs1 lakh) to approach the nearest ration shop to collect their health cards. “I was told at the ration shop that my card had not arrived from the central ration office,” says Jayesh, whose income is less than Rs1 lakh a year.

The 23-year-old commerce graduate is forced to look for a new job every six months as each workplace draws up only a short-term contract with him. With elderly parents and a sister to take care of, Jayesh says he needs the RGJAY card to secure his family in case of an illness or hospitalisation.

“In 2009, all yellow and orange ration cardholders’ details were archived by the ration office. We are using this data to make the health cards,” says Dr K Venkatesh. For Mumbai’s dismal distribution rate, he points the finger at ration inspectors, who, he claims, have refused to co-operate with RGJAY authorities.

But, sources argue that ration inspectors weren’t just rebels without a cause. They say 40% of the posts of ration inspectors in the city are lying vacant. The others’ refusal to shoulder the extra burden led to the roping in of 5,500 anganwadi workers for the distribution work. However, when these anganwadi workers refused to work during the summer holidays, card distribution hit the wall. “We did co-operate in the distribution of health cards in April. But, we have refused to start any such work before June 15. We will not work during the summer holidays,” clarifies an anganwadi worker from Dharavi.

Hospitals play hookey
But even if all beneficiaries receive their cards, the project will continue to be stuck in a rut as long as leading private and charitable hospitals refuse to implement the scheme.

Last Friday, chief secretary JK Banthia held a closed-door meeting with the city’s charity commissioner as well as leading private and charitable hospitals to convince them to be part of the scheme.
Sources at the health department say a solution is being worked out between the state and leading charitable hospitals to club the charity commissioner’s 10% bed reservation scheme for the poor with the RGJAY. But, a report of a sample survey, released by the department this May, of Jaslok Hospital, Breach Candy Hospital and Bombay Hospital revealed that they were using only 4-4.5% of such beds for the poor.

While authorities of these three hospitals were not available for their comments, Dr Sudhir Dagaonkar, spokesperson of the Lilavati Hospital at Bandra, also a leading charitable hospital, says, “We treated 757 poor patients last year. However, whether to be a part of the RGJAY or not is currently being debated by the management. We have already implementing the charity commissioner’s free bed scheme.”

Dr Ravindra Gupta, spokesperson of the SevenHills Hospital at Andheri, which is one of the eight private hospitals empanelled to implement the RGJAY, says over 800 patients have already registered for free surgeries under the scheme’s 972 enlisted procedures. “The hospital’s infrastructure is ready. We are now waiting for the state to give us the green light to start performing such surgeries.”

Health activists are opposing the idea of merging the charity commissioner’s scheme with the RGJAY. “It has been mandated under the scheme design of the RGJAY that in case of charitable hospitals, 10% beds should be reserved for the indigent and 10% for economically-weaker sections. Of the remaining, 25% should be reserved for RGJAY beneficiaries. There is no room for confusion,” explains Oommen Kurian of the Centre for Enquiry into Health and Allied Themes, Mumbai.

Asked to put a deadline to the RGJAY’s launch, health minister Suresh Shetty says, “There have been impediments in distributing health cards. We are in negotiations with leading charitable hospitals to convince them to get empanelled on the scheme. We will start the scheme anytime now.”

Thousands of beneficiaries, though, will find that assurance hard to believe.