Abstract
Various models are being tried out under Public–Private Partnerships in health care. Community health insurance is one of the models for providing health security for the people Below Poverty Line (BPL). Various states are experimenting on community health insurance with largely state financing, private provisioning of health care, especially curative care. When the partnership is with the for-profit private/corporate sector, where the underlining principle is profit making, the core principal of partnerships of beneficence and equity is undermined. The Aarogyasri scheme started in 2007 as a political move is continuing and praised as one of the most effective ways of treating tertiary, curative, largely surgeries and therapies for BPL population and is completely sponsored by the state. This article critically analyses the procedures and the cost incurred in private and public hospitals and finds that Aarogyasri is skewed towards curative tertiary care and is a big drain on the state exchequer with questions of sustainability. Further, this kind of partnership undermines the existence of large public sector, which is underutilised. The way forward for sustainable and comprehensive health care for people of Andhra Pradesh to ensure ‘Arogyandhra’ is to promote and strengthen public sector.
Introduction
India is one of the few countries which have public health spending of less than 1 per cent of GDP resulting in three quarters of the expense being met from out of pocket spending by individual households. The National Commission on Macroeconomics and Health has pointed out that 3.3 per cent of India’s population is impoverished every year on account of health distress (GOI, 2005: 23). India’s meagre health budget is a cause of and an exacerbating factor in the challenges of health inequity, inadequate availability and reach, unequal access, poor quality and costly health care services. The Government of India has made a commitment to increase public spending on health which includes water, sanitation and other public health facilities from less than 1 per cent to 2.5 per cent of the GDP during the next five years (GOI, 2012). Financial protection against medical expenditure is far from universal in coverage with only 10 per cent of the population having medical insurance. As Out-of-Pocket Expenses (OOPE) cause significant economic burden on the households, the government advocates implementing health financing mechanisms that will protect the citizens from financially catastrophic effect of illness (GOI, 2006).
Is Public–Private Partnership in Health Care Desirable?
Under health sector reforms, one has to collaborate with the private sector through Public–Private Partnership (PPP). There are various definitions for partnerships in health. According to the WHO (1999), it means to bring together a set of actors for the common goal of improving the health of a population based on the mutually agreed roles and principles (WHO, 1999). Core elements of a viable partnership are identified as: beneficence (joint gains), autonomy (of each partner), jointness (shared decision-making and accountability) and equity (fair returns in proportion to investment and effort). 1 The powerful political forces unleashed by the Structural Adjustment Programme (SAP) and Health Sector Reforms (Pollock et al., 2001; Sen, 2001) commodify illness. The biomedical view of health promotes technology-based strategies and the resultant expansion of health markets. For the private sector, profitability is the bottom line ignoring equity and rationality.
The private health sector in India has grown 2 remarkably over the years (Baru, 1999). There has been a substantial increase in the number of hospitals under the private sector during the 1990s (GOI, 2002: 94). Health services in India have been tilted towards private sector from the very beginning. However, from the 1980s onwards, trend has been towards establishing mammoth tertiary sector, multi-specialty and super specialty hospitals. They were started initially by professionals who, after having worked in the USA or UK, realised the potential of ‘health care’ as an industry with profitable margins. The success of this experiment was followed by scores of businessmen investing in the health sector. These big hospitals have been set up with huge public investments and subsidies by the state in the forms of tax exemptions, land subsidies, buying back services like CGHS and other insurances paying to the private sector for their services (Qadeer & Reddy, 2006). Other important issues relate to domestic brain drain where the doctors trained in government colleges and the mid-career reputed doctors, wooed by the corporate hospitals to serve in their hospitals with huge pay packets, found the offers hard to resist (Reddy & Qadeer, 2010).
Given the overwhelming presence of the private sector in health, various state governments have been exploring the option of involving the private sector in order to meet the growing health care needs of the population. At the central level, the 10th Five-year Plan (2002–07) first formalised the need for private sector participation for the health care delivery system. At the same time, various state governments have been experimenting with partnerships with the private sector to reach the poor. Bennet et al. (1994) identified five main problems associated with private-for-profit provision of health services. They are related to the use of illegitimate or unethical means to maximise profit, less concern towards public health goals, lack of interest in sharing clinical information, creating brain drain among public sector health staff and lack of regulatory control over their practices. The 10th Plan document (GOI, 2002: 98) recognised that private super speciality tertiary/secondary care hospitals should be given land, water, electricity, etc., at concessional rates and permission for duty-free import of equipment with the understanding that they will provide in-patient and out-patient services to poor patients free of charge. The experiences in this have been varied and several problems have been reported. Justice Qureshi’s High Level Committee report on Private Hospitals (2001) describes the violation of social commitment of the private hospitals as their focus was more concerned about making profit. None of the corporate hospitals, who received land at throwaway prices and tax exemptions, followed the conditions put forth by the government. Qureshi’s report clearly points out how these corporate hospitals act like ‘money minting machines’. The report labels the private sector ‘is interested in making profit and least interested in the needs of epidemiological investigation of the large number of population’ (Qureshi, 2001; Qadeer & Reddy, 2006).
In the current debate on health security for the poor, health insurance has emerged as an important financing tool for all the ills facing the poor. At the national level, the Rashtriya Swasthya Bima Yojana (RSBY) was launched. Among the states, the Yeshasvini scheme in Karnataka, Kudumbasree in Kerala and Aarogyasri in Andhra Pradesh were launched to extend coverage to workers in the informal sector. However, most of these schemes are still in the experimental phase (Kumar et al., 2011).
A study by Acharya and Ranson (2005) on four community-based health insurance schemes in Gujarat shows that they are sustained by a pooling of resources as well as regular pre-payment of received small medical expenses. Moreover, these schemes are sustained only due to some form of external support without which they could not have survived on their own. Further, community based health insurance covers very small population so has a limited impact from a public health point of view. A critical scrutiny of Aarogyasri by Prasad and Raghavendra (2012) also shows that this scheme is politically driven while, at the same time, it promotes the interest of tertiary corporate hospitals and tertiary public hospitals, further intensifying medicalisation of society.
Objectives of the Article
This article critically looks at the case study of the Aarogyasri health insurance scheme also called Rajiv Gandhi Aarogyasri Community Health Insurance (RACHI) in Andhra Pradesh. Tracing the evolution and motive behind for implementation of the RACHI scheme in 23 districts in Andhra Pradesh, the article probes the role of key players at different levels: public sector, private sector; and is being done from a patient/beneficiary perspective. Further, the significant features and the process of implementation of the scheme are discussed. The basic argument in the article is that the Aarogyasri scheme is skewed towards tertiary care with limited coverage and is run solely on state subsidies, which is unsustainable. The article analyses how the budgetary flow into the treatment of the surgeries can be alternatively used to strengthen the public health system which is more comprehensive in nature and also sustainable. This is a review with information having been gathered from the secondary literature available from the Aarogyasri website, published government reports, newspaper articles, relevant case study reports and published studies. In addition, national and international level health development reports were also reviewed.
Evolution of the RACHI Scheme
The Government of Andhra Pradesh has taken several measures to improve access to health care and to cut down OOPE through PPP projects. In this, notable are the Emergency Management and Referral Institute (EMRI) implemented 108 Ambulance Service and Health Management Research Institute (HMRI) which provide a round-the-clock helpline for medical advice and rural outreach health services. The RACHI scheme is one of the outreach strategies of the Government of Andhra Pradesh (Mallipeddi et al., 2009). It is the flagship scheme for all health initiatives of the state government with a mission to provide quality health care to the poor. The aim of the government is to achieve ‘health for all’ in ‘Aarogyandhra Pradesh’ (Healthy Andhra Pradesh State). 3 To facilitate the effective implementation of the scheme, the state government has set up the Aarogyasri Health Care Trust, under the chairmanship of the Chief Minister.
The Aarogyasri scheme aims to ensure health care for the BPL population at the time of critical and catastrophic illness, through health insurance. Surgeries and therapies are done through an identified network of health care providers under the PPP model. Before setting up of RACHI, the Chief Minister’s Relief Fund (CMRF) supported the poorest segment at the time of serious health crises. Part of the funds was utilised for the hospitalisation and medical assistance as per individual needs and demands.
The Aarogyasri scheme currently covers nearly eight crore BPL population in 23 districts of Andhra Pradesh (Aarogyasri Health Care Trust, 2011a). This scheme provides coverage up to 2 lakhs per family per year subject to limits, in any of the network hospitals (Babu, 2009). The government earmarked ₹925 crores in the financial year (2009–10) which is almost 25 per cent of the total health budget (details are given in Table 1). The state government is the sole funding agency for this health insurance scheme. The government takes care of the entire premium on behalf of the beneficiary.
Allocation of Budget for Rajiv Aarogyasri Community Health Insurance (2007–10)
Implementation Process of the Aarogyasri Scheme
The key stakeholders in RACHI scheme are the state government, a private insurance company (Chennai based Star Health and Allied Insurance) and Tata Consultancy Services (TCS) for ICT solutions (Arogyasri Health Care Trust, 2011b). One hundred and fifty one (151) government and 275 private sector tertiary hospitals across the state have been involved in implementing the scheme. The hospitals have to get empanelled 4 to provide treatment for Aarogyasri patients based on the fulfilment of certain criteria 5 set by the trust and insurance company and all those empanelled hospitals, both private and public, are called network hospitals.
The TCS Programme Director oversees the IT solution 6 and ensures that all the IT needs of the scheme are being addressed on time. The RACHI scheme has ensured a key link person , Aarogyamithra (Health Coordinator), to connect people and the programme at the grass root level. The insurance company has appointed Aarogyamithras at all network hospitals to facilitate admission, treatment and cashless transaction of patients around the clock. The Aarogyamithras have a key role to play. 7
The beneficiaries for the RACHI scheme are identified through the white ration cards provided as part of Annapoorna and Anthyodaya Anna Yojana Scheme for BPL families. It is estimated that about 80 per cent of the population has BPL ration cards and are considered eligible to utilise the benefits provided by the RACHI Scheme. The families, who were covered for specified diseases by other insurance schemes such as CGHS, ESIS, RTC, etc., are not considered eligible for any benefits provided in the RACHI scheme. The RACHI scheme has attempted to incorporate the philosophy of social inclusion in terms of the number people covered without age limit as well as covering pre-existing illness. 8
Beneficiaries can approach through a referral from nearby PHC/Area Hospitals/District Hospital/network hospital. Aarogyamithras placed in the above hospitals facilitate the contact with the beneficiary. The beneficiary may also attend the health camps being conducted by the network hospital in the villages and can get the referral card based on the diagnosis. The Aarogyamithras at the network hospital examine the referral card brought by the beneficiary and also verify the details of the ration card, based on the diagnosis results, admits the patient. After that they send preauthorisation request to the insurance company and the Aarogyasri Health Care Trust.
Specialists of the insurance company and the trust examine the preauthorisation request and approve it if all the conditions are satisfied. The network hospital extends cashless treatment and surgery to the beneficiary. Network hospital, after discharge of the beneficiary/patient, forwards the original bill, discharge summary with signature of the patient and other relevant documents to insurance company for settlement of the claim. The insurance company scrutinises the bills and approves the same for sanction. The network hospitals also provide follow-up services. The entire scheme is cashless for the beneficiary/patients for 121 procedures which are pre-identified (Arogyasri Health Care Trust, 2011c). The scheme provides insurance for specific catastrophic illness 9 that can have serious financial repercussion in the lives of the poor. There are specific diseases that are not covered under this scheme. 10 Till 20 January 2013, a total of 17 lakh surgeries and therapies had been covered. 11 The cost of treatment for every medical and surgical procedure is fixed by the panel of doctors that has to be uniformly followed by all the network hospitals who implement Aarogyasri scheme.
The government is playing the key regulator. It has streamlined the cost of private care through fixed protocols. The government also makes sure of timely reimbursement to the health care providers. It is claimed that continuous monitoring ensures accountability of the private health care providers.
The programme is designed in such a way that there is continuous monitoring at the grassroots level through Self Help Group (SHG) federation and key district level officials carrying out periodic reviews of the progress of the scheme. The other members in the trust are also involved in direct monitoring. The Internet web based solution enables a common monitoring and evaluation framework of the RACHI scheme from any part of the State.
Achievements
The RACHI scheme has achieved its intended objective to improve access to health care by the poor. It is important to look at the progress of the programme in terms of quantitative indicators, which are presented as follows.
Statistical figures mentioned in Table 2, 12 since the inception of the programme on 1 April 2007 till 20 January 2013 indicates that 35,718 health camps had been held at villages in 23 districts. A total of 6,579,658 people have been screened and of those 4,236,191 treated as outpatients and 1,962,531 treated as inpatients. Till date, 14 lakh surgeries/therapies have been conducted for the patients. In this only 441,591 underwent surgeries in government hospitals and 1,314,519 underwent surgeries in private hospital. The preauthorised amount is ₹4,729 crore so far with an annual budget of around 1,000 crore.
Vital Statistics under the Aarogyasri Scheme
Recognition and Replication
The RACHI Scheme has been recognised as one of the largest health social security schemes implemented in India. The scheme was also acclaimed by Planning commission and Ministry of Health, Government of India and by the 13th finance commission. This scheme has won the Manthan Award, South Asia 2009 and eIndia award for 2010. 13
Critical View of the Aarogyasri Scheme
Though the RACHI Scheme has been well appreciated and has significant features, it is important to understand the implications of the scheme in the long run in the context of providing quality and sustained health care for the poor. The analysis should be done in the context of the present canvassing for Universal Health Coverage, where every citizen should be entitled for free health care. In Andhra Pradesh, 80 per cent of the population has white cards though it is also called the BPL card, to access Aarogyasri especially in the private sector, for which government pays. The question is how far is it sustainable? In November 2009, the media highlighted how the health providers, the private health hospitals, have violated the norms by collecting consultation fees, not providing medicines and performing unwanted operations like hysterectomy for the women (Mallikarjun, 2009; Vinjamuri & Vinjamuri, 2011), clear violation against the MoU they signed with the Aarogyasri trust.
It was found that the hospitals discharged the patients who underwent surgeries earlier than the stipulated time required for recovery. Some of the hospitals collected deposit amount prior to the admission and failed to reimburse the amount, yet collected the bill. Around 22 hospitals were suspended from their service for Aarogyasri patients for faking medical bills (Kakinada News, 2009). However, the government has been keenly tracking and monitoring the network hospitals and around 116 hospitals, who were indulging in malpractices or flouted rules, were de-listed. 14
Skewed Towards Tertiary Sector
RACHI is skewed towards tertiary care and for a smaller population at the cost of majority and focused on certain chronic diseases at the cost of communicable diseases. It has, no doubt, created access for the rural poor for specialised health services. But there is a clear shift in focus in terms of setting priorities for providing health care for the poor. The scheme completely prioritises tertiary level super specialty health care that requires surgery and hospitalisation (refer to Table 3). It is important to note that no health insurance scheme focuses on curative care that is not dependent on over medicalisation and high medical technology.
Category-wise Surgeries/Therapies (as on 12 January 2012)
There are pressing concerns as the primary health care delivery system for the poor in rural areas that need to be strengthened as the majority of the poor continue to suffer frequently from infectious illness, malaria fever, gastrointestinal disorders and anaemia. Moreover it may not cover all kinds of frequent illnesses afflicting the poor that lead to impoverishment, disability and premature mortality. Mahapatra (2001) analysed the leading causes of premature mortality and disability in rural and urban areas in Andhra Pradesh. He found that the leading causes of overall disease burden and mortality are lower respiratory infections, diarrhoeal diseases, low birth weight (malnutrition), tuberculosis, ischemic heart diseases and malaria. Among the main causes of disability are accidents due to fall and fire, depression, epilepsy, schizophrenia and protein energy malnutrition among children. These are the illnesses which hamper the daily life of the poor and have a significant impact on their economic condition. Many premature deaths and morbidity faced by the vulnerable sections in the rural areas are merely because of deficient public primary health care and a referral system with an apparent lack of qualified health care providers. Hence, the majority of the rural and urban poor may require basic primary health care services and access to facilities for proper referral services to reduce their disease burden and financial consequences. Further, Aarogyasri in AP shows that the corporate hospitals handle the biggest share of the catastrophic illness cases (as shown in the Table 4) and there is no provision for out-patient treatment of everyday illnesses that affect the working capacity of the patient. The focus on tertiary health care to the exclusion of all other forms of medical assistance leads to an inefficient medical care model with a low level of real impact on meeting the needs of health care and the health of the population (Shukla et al., 2011).
Hospital—Surgeries/Therapies (12 January 2012)
State-sponsored Private Health Systems
The Director, 15 Nizam Institute of Health Sciences (NIMS), Hyderabad, has held that while the public health care system was ‘limping’ because of governmental neglect, the private health care industry was thriving. He cited the soaring number of surgeries conducted in private hospitals as compared to the government hospitals. He was of the opinion that the health sector is ‘going through major crisis in the state’ due to ‘misplaced priorities of the government’; the Tertiary Government Hospitals like Osmania have been neglected (The Hindu, 2008b).
After 18 months of implementation of the RACHI scheme, it was noted that ₹274 crores went to private hospitals and the share of the government hospital in the scheme was only ₹34 crores. Of the ₹274 crores spent on the scheme, ₹135 crores went to cardiac surgeries alone (The Hindu, 2008a). Whereas a total of 59,000 surgeries were performed with the ₹274 crores Aarogyasri budget (mostly in the corporate sector), the Gandhi Hospital could conduct 2.56 lakh operations with a meagre budget of ₹12 crores (The Hindu, 2008b; The Hindu Business Line, 2008). The trend of more number of patients getting admitted in the corporate sector for treatment compared to government hospitals continued (The details have been presented in Table 4). From this data, we can state that till date the corporate or private sector hospital catered to almost 75 per cent of patients whereas the government hospitals catered to 25 per cent. Of the total ₹4,729 crores claimed, the corporate/private hospitals have the highest share of almost 77.3 per cent, that is, ₹3,656 crores and the share of the government hospitals is only ₹1,073 crores.
Underutilisation of Public Health Care System
It was observed that the cardiology wing of the Gandhi Hospital (a government hospital) was inaugurated in October 2008 with a capacity to perform 1,000 surgeries in a year. Nevertheless, between January and May 2009, the department had done only 85 surgeries (Babu, 2009b). In spite of world class operation theatre facilities, the hospital is still not being able to function to its full capacity for want of the required pool of specialist doctors to conduct critical surgeries. The situation is similar at the level of PHCs and CHCs in rural areas and many operation theatres in government facilities remain underutilised due to lack of skilled manpower. Correction of these systemic deficiencies is essential in order to reach large number of the poor in the long term as the private/corporate health care institutions will extend their facilities to the poor only so long as the government support continues because of their necessity to calculate maximum monetary benefits.
Sustainability of Aarogyasri: A Big Question
The purpose of the RACHI scheme is to cut down OOPE for the BPL population and to provide financial protection for catastrophic illness. Though this intention is achieved, it has serious implications and consequences. The former Chief Minister, K. Rosaiah mentioned that the average amount claimed by the Aarogyasri beneficiaries per day is about ₹3.5 crores. As on 20 January 2013, the total amount claimed from its inception was about ₹4,729 crores. According to the Aarogyasri scheme CEO, the state government spent a quarter of the health budget towards the scheme and wanted to approach the central government for support (GoAP, 2009). In the fiscal year 2010–2011, the government allocated ₹925 crores only. The state government approached the centre for sharing the funding of Aarogyasri and extend financial support on 70:30 cost sharing basis on the ground that the burden of the scheme has put enormous pressure on the state exchequer. However, the central government turned down the proposal on the advice of the Planning Commission that recommended against partnering with states for funding any community health insurance scheme. The Planning Commission rejected because they observed that these insurance schemes are turning out to be a ‘cash cow’ for the corporate hospitals. Even though this scheme helped poor families to undergo surgeries, the fact is that the private hospitals were making money through reimbursement by the state government (Times of India, 2011).
In the project implementation plan of NRHM (2008–09) document prepared by state government for the central government, the health insurance premium for BPL families was estimated as ₹279 (GoAP, 2008). However, the premium amount for these families until March, 2009 was ₹330. From 5 April 2009, the premium worked out to be ₹439 per family. There is a likelihood that the premium amount will increase in the coming years. Since the premium insurance cost is fully borne by the state government, there is no direct financial burden on the poor. However, if the prices grow faster than the delivery capacity, the cost escalation might burden the government to sustain the scheme. It’s a huge ‘burden’ on the health care systems of Andhra Pradesh (Ghosh, 2012). This is more so in the light of the central government denying cost sharing to support the state government in implementing this insurance scheme. This may also affect the sustainability of the scheme in the long run.
While the government is continuing the process of strengthening the public health institutions for basic health care, under NRHM, the lack of an adequate number of specialist doctors, appropriate infrastructure and requisite equipments for treatment of serious diseases has created a wide gap between the disease load and the capacity of the government hospitals to serve the poor. In Andhra Pradesh, 74.3 per cent households do not generally use government health facilities. The reasons are: there is no nearby facility (49.2 per cent), the facility timing is not convenient (18 per cent), health personnel often absent (12.8 per cent), waiting time is too long (23.4 per cent) and poor quality care (53.3 per cent) (IIPS and Macro International, 2007).
As on 20 January 2013, statistical data provided on the Aarogyasri website showed that 17 lakh patients underwent surgery and therapy. Numerically, these figures might look attractive. However, if we analyse the figures to assess the extent of outreach of the care received under this scheme since its inception, the total number of beneficiaries appears to be very limited as compared to the overall figure of those insured. The baseline figure for total number of population covered in each phase is taken only as per the NRHM–AP state Project Implementation Plan document submitted to central government in 2008. As per the details mentioned in that PIP, the total number of families covered was 1.84 crore. However, according to the Aarogyasri trust estimates as on 5 April 2009, insurance had been provided to 2.03 crore families. If we analyse these figures, the outreach of the scheme remains very limited. In every phase, we could see that not more than 5 per cent of the people were screened and less than 1 per cent actually got hospitalised and treated for the diseases for the huge amount paid from public sector to private sector (Mani, 2009).
Health insurance works best when services are available in the remote corners and poor households can actually exercise choice (MoHFW, 2005: 5). If 80 per cent have white cards, then it is very likely that those who can afford treatment are also covered under RACHI. Under Universal Health Coverage, this is a welcome step. However, the concern is its financial sustainability given the huge expenditure in private sector, paid by the state and the present reality of under-utilisation of the public sector even when it is functional.
As per the observations made by the National Commission on Macroeconomic and Health, increase in health spending, especially if states subsidise and buys from private/corporate sector, will not yield commensurate results unless equal levels of investment are made in the sectors that has a defining impact on health outcomes. It advocates that poverty alleviation measures and assurance for regular employment and minimum threshold of income as a critical prerequisite of health. What is required is developing an integrated public health system that strengthens the primary, secondary and tertiary level care with due emphasis on inter-sectoral linkages: improving nutrition by ensuring food availability (by strengthening the public distribution system) ensuring safe drinking water supply, creating adequate shelter and sanitation facilities, creation of public transport facilities and road connectivity in interior and remote areas to improve access for mobility of patients, strengthening primary education (GOI, 2005). These are the primary social determinants of health that need to be given focus to improve health and reduce inequalities. Until these needs are addressed for the large number of poor who are living in rural areas, there is little chance for improving their health and getting them out of poverty.
Thus, it can be concluded that the curative services have been given priority at the cost of preventive, promotive and rehabilitative services. Neglect of public hospitals is comparable only to private sector which are thriving and flourishing at state expense. Public hospitals, which have good infrastructure and medical expertise, are being underutilised. There is no mechanism to see the household health care expenditure at all levels, primary, secondary and tertiary and for catastrophic illnesses.
Contrary to the core ethical principles for the partnerships, beneficence (joint gains), in this case state is bearing the whole cost, and equity is defeated, where there are no fair returns in proportion to investment, instead over-medicalisation and unnecessary surgeries are being carried out. Control is in the hands of corporate/private hospitals which lobby for the schemes continuation and inclusion of maximum number of surgeries. This has only served the corporate/private hospitals and resulted in complete neglect of primary and secondary care. Though, Andhra Pradesh is an economically forward state, still only 46 per cent of the population has received basic immunisation. Close to 449 persons per lakh are suffering from TB which is more than Rajasthan and Orissa. AP is the second higher in HIV prevalence rate (0.97 per cent) followed by Manipur. There is an urgent need for an empirical research at household level to assess OOPE on primary, secondary and tertiary level and for catastrophic illnesses after the experience with the Aarogyasri scheme. Its benefits and problems need to be captured. To have a sustainable health care model, there is a need to strengthen the public health service systems and also use them to their optimum level and upgrade them and reduce the state subsidies to the private sector. Till then the ‘Arogyandhra’ dream cannot be achieved.