Private health care has catastrophic costs that shave off hard-earned savings of patients. The repercussions have spillover consequences, resulting in less money being available to households for food, education, housing and other necessities.
A health emergency is a bigger risk to farmers than an unsuccessful crop. Once they sell their land/livestock, they become indentured labourers and that takes a generation or more to fix.
PUBLIC HEALTH
Care at India’s public hospitals is technically free. However, in reality the poor quality of care, lack of human resources and equipment has impeded them from coping with overwhelming patient loads. As a result, many underprivileged Indians are forced to seek treatment in costly private hospitals they cannot afford, or, simply go without care.
Not only are there steep medical costs involved in a health episode, but there are also incidental expenses. This is further compounded by the loss of income during the period an individual is ill, injured or caring for an ailing loved one.
INSURANCE
Without insurance, people often turn to informal means to manage these risks, but such strategies provide inadequate protection. So when misfortune strikes, many get drawn into debt traps as they borrow beyond their means. This can lead them to sell productive assets, take children out of school or put them to work, compromise on food, or leave other illnesses untreated. Due to this dynamic, a health issue can easily become a financial sinkhole. Health insurance serves two primary functions for individuals. First, it secures financial access to healthcare, both for preventive services and/or treatment. Second, it evens the costs of those services, protecting against potentially devastating economic shocks.
Health insurance policies in India typically don’t cover outpatient or domiciliary treatment, where the major expenses involve pharmacy bills, diagnostic and pathological tests. Several health insurance programmes cover wage loss on account of illness or other health-related issues, but many don’t. Due to these coverage gaps, even insured beneficiaries could incur high indirect costs, especially in cases that require hospitalisation.
AYUSHMAN BHARAT
For instance, India’s flagship public health insurance scheme, Ayushman Bharat, fails to recognise and compensate the indirect costs associated with hospitalisation — and these are quite significant for the poor. These include expenses on travelling to the hospital and back. Additionally, staying in a hospital or at home, after hospitalisation, implies a loss of wages. Often, attending caregivers from the family also have to forgo wages for several days and arrange for their lodging in case the treatment is being undertaken away from their native town.
Poor households may take on debt, selling productive assets or even their homes. This risks a negative feedback loop. Poverty leads to bad health, which generates further poverty. They may be forced to avoid or delay treatment, as they cannot afford to lose their wages. Similarly, those who need longer-term hospitalisation may go back to work even if they have not fully recovered. Lost income, often one of the largest components of a financial shock, is far lower among the insured, because it allows them to seek care sooner.
Since many of the concerns of women are not easily insurable, e.g., maternity costs, a more relevant product would be one that combines insurance and savings. In this way, for example, a woman could use her savings to cover the cost of normal delivery, and insurance to cover the cost of unexpected complications. In evaluating the success of Ayushman Bharat, what matters, even more than the beneficiaries count, is whether it removes the need in the target population to prioritise livelihood over their daily needs. This is normally the case for most poor families who lack income support during the treatment.
It can also consider including primary, day-to-day healthcare instead of just secondary and tertiary care. This is because poorly-delivered primary care inevitably increases the burden on health and finance at the secondary and tertiary levels down the line. Nurses and practitioners of traditional medicine will have to take “Bridge Courses” to keep abreast of the bewildering forms of new diseases. Diseases are not static things. Pathogens change, hosts change and environments change. Our immune systems change as well, as a result of fending off infections. And, of course, our lifestyles change, as also social standards, medical systems and public-health programmes.
Thus, it is necessary to enlarge the benefits to include loss of wages and incidental expenses during hospitalisation. This is already the prevailing practice of specific comparable schemes. Such plans provide a “Hospital Cash” or “Wage Loss” benefit, which is a fixed amount for transportation and wage loss for each day of hospitalisation.
(Dr Naresh Purohit is a Medical Expert and Advisor National Communicable Disease Control Programme. He is also Advisor to six other National Health Programmes and visiting Professor in five Medical Universities of Southern India including Thrissur based Kerala University of Health Sciences. (The views and opinion expressed in this article are those of the author)
