Budget 2018

With all its weight behind Modicare, Budget 2018 offers little for public health system

The health insurance plan promising Rs 5 lakhs per family per year is an ambitious version of a 2016 scheme that never took off.

Finance Minister Arun Jaitley’s announcement of health insurance cover for 40% of Indians, especially poor families, was one of the major takeaways from the Union Budget 2018-2019 presented on Thursday. The minister hailed the National Health Protection Scheme – promising Rs 5 lakhs a year for each of the targeted 10 crore families, or 50 crore beneficiaries, for secondary and tertiary care hospitalisation – as “the world’s largest government-funded healthcare programme”.

Thursday’s announcement is not exactly new though. The scheme is a more ambitious version of a health insurance plan the Bharatiya Janata Party-led government had announced two years ago but never launched. In his 2016 Budget speech, Jaitley had promised a scheme that would provide health cover of up to Rs 1 lakh a year per family.

To be sure, India needs programmes to protect its poor from health emergencies that push lakhs of households below the poverty line every year. The National Health Protection Scheme – dubbed Modicare – promises 17 times the cover the government now offers under the Rashtriya Swasthya Bima Yojana, its flagship health insurance scheme since 2008. The existing scheme provides insurance up to Rs 30,000 per family per year – woefully inadequate at a time of escalating healthcare costs in India.

While the new insurance plan indicates the government’s seriousness about affordable healthcare for the poor, one question arises: where will the money come from? Former finance minister P Chidambaram raised this question in his statement about the Budget on Thursday.

Allocations to national health insurance schemes – referred to in Budget documents over the years as the Rashtriya Swasthya Bima Yojana, Rashtriya Swasthya Suraksha Yojana or National Health Protection Scheme – have gone up since 2016. On Thursday, the government allocated Rs 2,000 crores to the Rashtriya Swasthya Bima Yojana. But the amount is not enough to fund the government’s ambitious plan.

(BE: Budget estimate; RE: Revised estimate)
(BE: Budget estimate; RE: Revised estimate)

In such a scenario, part of the expense is expected to be met by a 4% health and education cess that will replace the existing 3% education cess. The government estimates this will raise an additional Rs 11,000 crores. Jaitley said this will fund programmes for the education and health of Below Poverty Line – those living on less than Rs 32 a day in villages and less than Rs 47 a day in urban areas – families and rural households.

Other health programmes

Among other healthcare initiatives, Jaitley announced the creation of health and wellness centres at the grassroots level at a cost of Rs 1,200 crores. These centres will essentially be upgraded primary health centres and sub-centres.

For senior citizens, the Budget raised the limit of deduction on health insurance premiums and general medical expenses from Rs 30,000 to Rs 50,000. The limit of deduction for medical expenditure for certain critical illnesses was raised from Rs 60,000 to Rs 1 lakh.

The Budget also allocated an additional Rs 600 crores for nutritional support to tuberculosis patients.

While these provisions are welcome, the Budget has done little to strengthen the larger public health system. Overall allocation to the department of health and family welfare rose by a meagre Rs 1,250 crores from the revised Budget estimate for 2017-2018. In last year’s Budget, the finance minister had not made any major healthcare announcements but still increased the allocation from the previous year by Rs 9,681 crores.

(BE: Budget estimate; RE: Revised estimate)
(BE: Budget estimate; RE: Revised estimate)

Funds for the National Health Mission remained have decreased at Rs 30,130 crores in comparison to Rs 30,800 crores in the revised estimates for 2017-2018.

The budget for the National Rural Health Mission fell slightly to Rs 24,280 crores from Rs 25,459 crores. Programmes under the Rural Health Mission, for immunisation and the control of communicable diseases, for instance, also fell.

Tall order

Among all the provisions in the Budget for the health sector, the insurance scheme for 10 crore families remained the subject of much debate and speculation all through Thursday.

Getting the ambitious National Health Protection Scheme off the ground will not be easy. The fact that the health insurance scheme announced in 2016 is yet to receive cabinet approval seems to point to this. As recently as December, the health ministry said the contours of that scheme were still being finalised.

What makes the 2018 version even more difficult to implement is the fact that it covers treatment at the secondary and tertiary level, which makes it all the more important for primary care at the health and wellness centres to be robust.

There are many other questions the government needs to address. If the scheme is only for hospitalisation, what is the cover for people availing of out-patient department services but still incurring massive medical bills? How much premium will one have to pay to get health insurance cover of Rs 5 lakhs?

Health policy specialists said the premium for the Rs 30,000 cover offered by the Rashtriya Swasthya Bima Yojana is around Rs 750 – which means the premium for coverage of Rs 5 lakhs will be a lot higher.

Then there is the risk that higher insurance benefits will raise the cost of healthcare overall. “Higher benefit package, although always good for beneficiaries, is usually fraught with moral hazard,” said Anup Karan, a health economist with the Indian Institute of Public Health, Public Health Foundation of India. “Price of healthcare will increase, which may be a problem for the uninsured.”

Larger insurance payouts may also lead to a rise in unethical practices with hospitals prescribing unnecessary procedures to avail of the benefits.

“Clear evidence is available that there is a range of malpraxis and moral hazards involved in private provision of care where the costs are reimbursed,” said Amit Sengupta, national convenor of the Jan Swasthya Abhiyan, a network of activists, academics, health professionals, civil society and non-government groups. “Mainly, these involve over-consumption – unnecessary procedures, for example the huge rise in hysterectomy operations, usually totally unnecessary.”

This leads to the subject of regulation. Former Union health secretary Sujatha Rao said, “It will certainly require a very huge effort by the ministries of health at the Centre and state levels to ensure appropriate regulatory systems are in place so that the providers [hospitals and doctors] do not enhance current costs and game the situation. An National Health Assurance Authority must be established to roll out this huge insurance programme with a programme to make adequate investments to build the health service delivery systems in the large swathes of north India where there is neither the public nor the private sector providing health service of reasonable quality.”

The government will have to learn from the shortcomings of the Rashtriya Swasthya Bima Yojana. Around 3.6 crore million families are enrolled under this scheme, which is only about 15% of poor families in the country. This is largely because of inaccurate lists of Below Poverty Line families and lack of awareness about the programme.

“Poor families do not know how to register, where to go, what services are covered and which hospitals are obliged to provide these services,” said Anup Karan. “We need very strong awareness generation to take full advantage of the scheme.”

The National Health Protection Scheme must, therefore, be more efficient in its outreach.

For the government's ambitious National Health Protection Scheme to work well, primary health centres in India must be strengthened. (Credit: Menaka Rao)
For the government's ambitious National Health Protection Scheme to work well, primary health centres in India must be strengthened. (Credit: Menaka Rao)

The government’s emphasis on insurance schemes and the lack of a deep commitment to strengthening India’s public health institutions and infrastructure also signals a larger role for private players in healthcare at the cost of the public health system.

“These schemes essentially involve actual provision of care in private facilities,” said Amit Sengupta. “They involve a transfer of public money to private facilities. Public facilities slide further back vis-a-vis a strengthened private sector. The government’s choice of not strengthening public facilities and instead promoting partnerships with private facilities is an ideological position against public services.”

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Swara Bhasker: Sharp objects has to be on the radar of every woman who is tired of being “nice”

The actress weighs in on what she loves about the show.

This article has been written by award-winning actor Swara Bhasker.

All women growing up in India, South Asia, or anywhere in the world frankly; will remember in some form or the other that gentle girlhood admonishing, “Nice girls don’t do that.” I kept recalling that gently reasoned reproach as I watched Sharp Objects (you can catch it on Hotstar Premium). Adapted from the author of Gone Girl, Gillian Flynn’s debut novel Sharp Objects has been directed by Jean-Marc Vallée, who has my heart since he gave us Big Little Lies. It stars the multiple-Oscar nominee Amy Adams, who delivers a searing performance as Camille Preaker; and Patricia Clarkson, who is magnetic as the dominating and dark Adora Crellin. As an actress myself, it felt great to watch a show driven by its female performers.

The series is woven around a troubled, alcohol-dependent, self-harming, female journalist Camille (single and in her thirties incidentally) who returns to the small town of her birth and childhood, Wind Gap, Missouri, to report on two similarly gruesome murders of teenage girls. While the series is a murder mystery, it equally delves into the psychology, not just of the principal characters, but also of the town, and thus a culture as a whole.

There is a lot that impresses in Sharp Objects — the manner in which the storytelling gently unwraps a plot that is dark, disturbing and shocking, the stellar and crafty control that Jean-Marc Vallée exercises on his narrative, the cinematography that is fluid and still manages to suggest that something sinister lurks within Wind Gap, the editing which keeps this narrative languid yet sharp and consistently evokes a haunting sensation.

Sharp Objects is also liberating (apart from its positive performance on Bechdel parameters) as content — for female actors and for audiences in giving us female centric and female driven shows that do not bear the burden of providing either role-models or even uplifting messages. 

Instead, it presents a world where women are dangerous and dysfunctional but very real — a world where women are neither pure victims, nor pure aggressors. A world where they occupy the grey areas, complex and contradictory as agents in a power play, in which they control some reigns too.

But to me personally, and perhaps to many young women viewers across the world, what makes Sharp Objects particularly impactful, perhaps almost poignant, is the manner in which it unravels the whole idea, the culture, the entire psychology of that childhood admonishment “Nice girls don’t do that.” Sharp Objects explores the sinister and dark possibilities of what the corollary of that thinking could be.

“Nice girls don’t do that.”

“Who does?”

“Bad girls.”

“So I’m a bad girl.”

“You shouldn’t be a bad girl.”

“Why not?”

“Bad girls get in trouble.”

“What trouble? What happens to bad girls?”

“Bad things.”

“What bad things?”

“Very bad things.”

“How bad?”

“Terrible!!!”

“Like what?”

“Like….”

A point the show makes early on is that both the victims of the introductory brutal murders were not your typically nice girly-girls. Camille, the traumatised protagonist carrying a burden from her past was herself not a nice girl. Amma, her deceptive half-sister manipulates the nice girl act to defy her controlling mother. But perhaps the most incisive critique on the whole ‘Be a nice girl’ culture, in fact the whole ‘nice’ culture — nice folks, nice manners, nice homes, nice towns — comes in the form of Adora’s character and the manner in which beneath the whole veneer of nice, a whole town is complicit in damning secrets and not-so-nice acts. At one point early on in the show, Adora tells her firstborn Camille, with whom she has a strained relationship (to put it mildly), “I just want things to be nice with us but maybe I don’t know how..” Interestingly it is this very notion of ‘nice’ that becomes the most oppressive and deceptive experience of young Camille, and later Amma’s growing years.

This ‘Culture of Nice’ is in fact the pervasive ‘Culture of Silence’ that women all over the world, particularly in India, are all too familiar with. 

It takes different forms, but always towards the same goal — to silence the not-so-nice details of what the experiences; sometimes intimate experiences of women might be. This Culture of Silence is propagated from the child’s earliest experience of being parented by society in general. Amongst the values that girls receive in our early years — apart from those of being obedient, dutiful, respectful, homely — we also receive the twin headed Chimera in the form of shame and guilt.

“Have some shame!”

“Oh for shame!”

“Shameless!”

“Shameful!”

“Ashamed.”

“Do not bring shame upon…”

Different phrases in different languages, but always with the same implication. Shameful things happen to girls who are not nice and that brings ‘shame’ on the family or everyone associated with the girl. And nice folks do not talk about these things. Nice folks go on as if nothing has happened.

It is this culture of silence that women across the world today, are calling out in many different ways. Whether it is the #MeToo movement or a show like Sharp Objects; or on a lighter and happier note, even a film like Veere Di Wedding punctures this culture of silence, quite simply by refusing to be silenced and saying the not-nice things, or depicting the so called ‘unspeakable’ things that could happen to girls. By talking about the unspeakable, you rob it of the power to shame you; you disallow the ‘Culture of Nice’ to erase your experience. You stand up for yourself and you build your own identity.

And this to me is the most liberating aspect of being an actor, and even just a girl at a time when shows like Sharp Objects and Big Little Lies (another great show on Hotstar Premium), and films like Veere Di Wedding and Anaarkali Of Aarah are being made.

The next time I hear someone say, “Nice girls don’t do that!”, I know what I’m going to say — I don’t give a shit about nice. I’m just a girl! And that’s okay!

Swara is a an award winning actor of the Hindi film industry. Her last few films, including Veere Di Wedding, Anaarkali of Aaraah and Nil Battey Sannata have earned her both critical and commercial success. Swara is an occasional writer of articles and opinion pieces. The occasions are frequent :).

Watch the trailer of Sharp Objects here:

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This article was published by the Scroll marketing team with Swara Bhasker on behalf of Hotstar Premium and not by the Scroll editorial team.