public health

Rajasthan's ambitious health insurance scheme excludes many poor patients

It requires too many documents, has no checks on hospitals and takes no action on denial of treatment.

Last December, the Rajasthan government launched an ambitious health insurance scheme, the Bhamashah Swasthya Bima Yojana. It ensures cashless cover of up to Rs 3 lakhs for people both below and above the poverty line, under the National Food Security Act.

Like all existing health insurance schemes, this one too was launched with an aim to provide cashless healthcare services to the poor, to reduce out-of-pocket expenditure on treatment and, more importantly, shift some of the patient load on government health facilities to private healthcare providers. The scheme upholds one of the agendas of the government – to privatise essential services, including health and education.

However, the end result is a scheme that excludes many because of its requirement for multiple documents, which are not always available to patients, especially during medical emergencies. There are virtually no mechanisms in place to check malpractices. And it has created new barriers for the poor in their access to treatment, leading to denial of healthcare in both government and private facilities.

While the Rajasthan government has projected the scheme as a major accomplishment, it has turned a blind eye to cases where patients were denied treatment or were exploited. And such cases are piling up by the day.

Criteria that excludes

The scheme includes both secondary (specialised) and tertiary (a more advanced specialised care) healthcare services, providing a cover of Rs 30,000 for not so critical illnesses and Rs 3 lakhs for critical illnesses from a list of 1,715 diseases. The services are available through 475 public health facilities and 568 empanelled private hospitals across the state.

However, the stringent criteria that must be followed to avail of the scheme’s benefits has resulted in many patients being excluded, while some of its features create confusion not just among patients but also among other health service providers.

One of the scheme’s major flaws is that it requires patients to establish their eligibility by furnishing documents, several of which the poor most often do not possess. First, one must have a government-issued Bhamashah Card, which is more or less a state version of Aadhaar but comes with a bank account number registered in the name of the female head of the family. This card has to be seeded under the state direct benefits transfer programme under the National Food Security Act, using the technical infrastructure created for Aadhaar. Apart from this, a patient is required to produce a document of personal identification with a photograph, such as a voter identity card, Aadhaar number, driving licence or PAN card.

Patients who merely provide a ration card at a healthcare facility cannot avail the benefits of this insurance scheme.

Bhamashah Health Insurance Scheme poster
Bhamashah Health Insurance Scheme poster

What’s more, there is very little awareness about these rigid conditions.

One cannot possibly expect patients or their attendants to carry all these documents while leaving for the hospital in a hurry. A large number of the state’s populace also live in kutcha houses, where it is difficult for them to keep these documents secure. The end result is denial of health services to those who need it most.

No accountability

The other challenge patients face under the Bhamashah Swasthya Bima Yojana is searching for the right hospital, especially among the private empanelled hospitals. These only provide select packages under the scheme. Thus, arriving at such a hospital is no guarantee that one will get the required treatment.

Also, even if a hospital has opted to provide a particular package to patients under the scheme, it can still deny treatment on grounds of non-availability of a specialist or other technical reasons. And it can do so without the liability of assisting the patient in reaching the right healthcare facility that can provide the required service.

This often leads to delays in treatment, which can have serious consequences for patients who may require immediate medical attention. However, under the scheme, private empanelled hospitals will not be held accountable for any serious complications or loss of life as a result of their inefficiency or incompetence.

In January, healthcare activists came across Ramesh Garg, a resident of a village near Chittorgarh city, who was seeking treatment for numbness and inflammation in his lower limbs and was denied surgery by a tertiary-level hospital under the government’s insurance scheme. The hospital authorities told Garg that the scheme did not cover his treatment. But after he filed a telephonic complaint with the Bhamashah Swasthya Bima Yojana unit in Jaipur, the hospital agreed to treat him.

There are no systems in place to ascertain the credibility of an empanelled hospital or the quality of services being delivered to patients under the scheme. There have also been incidents where beneficiaries have been made to pay for services despite being eligible for them. In August, Soorat Pyari, a resident of Bharatpur district, went to an empanelled hospital for delivery and was asked to deposit an advance of Rs 9,000. The hospital claimed, falsely, that this deposit was mandatory under the scheme and that it would be returned on her discharge. Since she was in labour, she paid the amount. After she went through a normal delivery, she was given back Rs 4,000 and was told that the rest had gone into taking care of other charges.

Healthcare, not coverage

Claims made by hospitals under the scheme have also caused suspicion. According to a report in the Rajasthan Patrika on October 12, two prominent government hospitals in Karauli district registered claims of just Rs 20 lakhs while the eight private empanelled hospitals in the region registered claims of Rs 80 lakhs for the same period, despite the fact that the patient load at the government facilities was almost 10 times that of the private facilities.

Public health experts have for long condemned government-run health insurance schemes in different states for diverting enormous amounts of public money to serve private sector interests without bringing about much difference in overall health outcomes. There is enough evidence to show that these schemes paved the way for patient exploitation and denial of health rights. Weak monitoring systems coupled with an unregulated private healthcare sector puts patients in extremely vulnerable situations.

There are valuable lessons the Rajasthan government can learn from states where insurance schemes have proven costly affairs and had limited outcomes. Instead of promoting public-private partnership models, the government could instead strengthen its crumbling public health system by introducing schemes for free medicines and diagnostics, which endorse elements of universal healthcare.

The writer is a public health activist associated with the Rajasthan-based organisation Prayas and Jan Swasthya Abhiyan.

We welcome your comments at letters@scroll.in.
Sponsored Content BY 

How sustainable farming practices can secure India's food for the future

India is home to 15% of the world’s undernourished population.

Food security is a pressing problem in India and in the world. According to the Food and Agriculture Organization of the UN (FAO), it is estimated that over 190 million people go hungry every day in the country.

Evidence for India’s food challenge can be found in the fact that the yield per hectare of rice, one of India’s principal crops, is 2177 kgs per hectare, lagging behind countries such as China and Brazil that have yield rates of 4263 kgs/hectare and 3265 kgs/hectare respectively. The cereal yield per hectare in the country is also 2,981 kgs per hectare, lagging far behind countries such as China, Japan and the US.

The slow growth of agricultural production in India can be attributed to an inefficient rural transport system, lack of awareness about the treatment of crops, limited access to modern farming technology and the shrinking agricultural land due to urbanization. Add to that, an irregular monsoon and the fact that 63% of agricultural land is dependent on rainfall further increase the difficulties we face.

Despite these odds, there is huge potential for India to increase its agricultural productivity to meet the food requirements of its growing population.

The good news is that experience in India and other countries shows that the adoption of sustainable farming practices can increase both productivity and reduce ecological harm.

Sustainable agriculture techniques enable higher resource efficiency – they help produce greater agricultural output while using lesser land, water and energy, ensuring profitability for the farmer. These essentially include methods that, among other things, protect and enhance the crops and the soil, improve water absorption and use efficient seed treatments. While Indian farmers have traditionally followed these principles, new technology now makes them more effective.

For example, for soil enhancement, certified biodegradable mulch films are now available. A mulch film is a layer of protective material applied to soil to conserve moisture and fertility. Most mulch films used in agriculture today are made of polyethylene (PE), which has the unwanted overhead of disposal. It is a labour intensive and time-consuming process to remove the PE mulch film after usage. If not done, it affects soil quality and hence, crop yield. An independently certified biodegradable mulch film, on the other hand, is directly absorbed by the microorganisms in the soil. It conserves the soil properties, eliminates soil contamination, and saves the labor cost that comes with PE mulch films.

The other perpetual challenge for India’s farms is the availability of water. Many food crops like rice and sugarcane have a high-water requirement. In a country like India, where majority of the agricultural land is rain-fed, low rainfall years can wreak havoc for crops and cause a slew of other problems - a surge in crop prices and a reduction in access to essential food items. Again, Indian farmers have long experience in water conservation that can now be enhanced through technology.

Seeds can now be treated with enhancements that help them improve their root systems. This leads to more efficient water absorption.

In addition to soil and water management, the third big factor, better seed treatment, can also significantly improve crop health and boost productivity. These solutions include application of fungicides and insecticides that protect the seed from unwanted fungi and parasites that can damage crops or hinder growth, and increase productivity.

While sustainable agriculture through soil, water and seed management can increase crop yields, an efficient warehousing and distribution system is also necessary to ensure that the output reaches the consumers. According to a study by CIPHET, Indian government’s harvest-research body, up to 67 million tons of food get wasted every year — a quantity equivalent to that consumed by the entire state of Bihar in a year. Perishables, such as fruits and vegetables, end up rotting in store houses or during transportation due to pests, erratic weather and the lack of modern storage facilities. In fact, simply bringing down food wastage and increasing the efficiency in distribution alone can significantly help improve food security. Innovations such as special tarpaulins, that keep perishables cool during transit, and more efficient insulation solutions can reduce rotting and reduce energy usage in cold storage.

Thus, all three aspects — production, storage, and distribution — need to be optimized if India is to feed its ever-growing population.

One company working to drive increased sustainability down the entire agriculture value chain is BASF. For example, the company offers cutting edge seed treatments that protect crops from disease and provide plant health benefits such as enhanced vitality and better tolerance for stress and cold. In addition, BASF has developed a biodegradable mulch film from its ecovio® bioplastic that is certified compostable – meaning farmers can reap the benefits of better soil without risk of contamination or increased labor costs. These and more of the company’s innovations are helping farmers in India achieve higher and more sustainable yields.

Of course, products are only one part of the solution. The company also recognizes the importance of training farmers in sustainable farming practices and in the safe use of its products. To this end, BASF engaged in a widespread farmer outreach program called Samruddhi from 2007 to 2014. Their ‘Suraksha Hamesha’ (safety always) program reached over 23,000 farmers and 4,000 spray men across India in 2016 alone. In addition to training, the company also offers a ‘Sanrakshan® Kit’ to farmers that includes personal protection tools and equipment. All these efforts serve to spread awareness about the sustainable and responsible use of crop protection products – ensuring that farmers stay safe while producing good quality food.

Interested in learning more about BASF’s work in sustainable agriculture? See here.

This article was produced by the Scroll marketing team on behalf of BASF and not by the Scroll editorial team.