Professional Documents
Culture Documents
Over the past year, 28-year-old Paramesh- The National Health Insurance today has any kind of health-care cover, be
wari Arun, a part-time maid in south Delhi, Scheme was launched by Indias Ministry it community insurance, employers expen-
has borrowed the equivalent of US$ 1000 of Labour and Employment in April 2008. diture, social insurance etc, noted a July
to pay for her six-year-old sons medical Recently, I had to have an operation, 2009 report by the Federation of Indian
treatment. Despite this expenditure, they says Gupta. I went to a private clinic. The Chambers of Commerce and Industry.
still do not know what ails their son or smart card took care of the hospitalization As a percentage of GDP the overall
whether he is likely to get better. charges. Now I am back at work. This cash- health expenditure in India is low, says
This medical problem, which started less insurance scheme is a big help. Dr Varatharajan Durairaj from the World
innocuously when my son Vigneshwaram Health Organizations Department of
came home from school one day complain-
Health Systems Financing. It was estimated
ing of a pain in the leg, has thrown our to be 4% in 2008, according to the most
family finances out of gear, says Arun. She
The estimated recent National Health Accounts. Given
and her husband, a chauffeur, together earn share of household that the government share of health spend-
about US$ 250 a month, barely enough to out-of-pocket ing is low, out-of-pocket payments are the
feed a family of four in Delhi. expenses in total dominant source of health financing.
The Aruns are not covered by health Indias health-financing system is
insurance, so the unforeseen expenditure on
health spending is
much more complex than those found in
one of the highest in
doctors fees, tests, medicines and their sons other developing countries. It does not
hospitalization has strained their finances. the world. fit into the definition of a tax-based or an
The couple, which has one other child, live Varatharajan Durairaj insurance-based system. It is still evolving,
in Dakshinpuri, one of several resettlement says Durairaj. The flow of money from
colonies established in the late 1970s for communities, philanthropists and house-
rural migrants who previously were forced Arun and Gupta exemplify the emerg- holds, for example, is not well documented.
to squat alongside open drains, river banks ing challenges and opportunities in India, While the amount and flow of government
and railway tracks in Indias capital. where the majority of the estimated popula- spending are known to a larger extent,
About 10 kilometres from Dakshin- tion of 1.2 billion spread across 28 self- estimates on private spending are based
puri, 40-year-old Sunita Gupta, a shack governing states and seven territories within on responses from surveys of households.
dweller, flashes her biometric smart card. It the federal republic does not have access However, the estimated share of household
is one of her most prized possessions, giving to quality health care. out-of-pocket expenses in total health
her access to the government-sponsored One of the major reasons that Indias spending is one of the highest in the world,
National Health Insurance Scheme for poor incur debt is the cost of health care. with more than US$ 40 billion spent.
families living below the poverty line. Less than 15% of the population in India There are centrally funded schemes,
but public health care is largely the respon-
sibility of state governments, and financing
varies from state to state. Workers in the
organized economic sector in India make
up less than 10% of the total workforce,
says Ravi Duggal, a senior trainer and health
analyst with the International Budget Part-
nership, which aims to reduce poverty and
improve the quality of governance around
the world. Corporate insurance schemes
are insignificant, though in numbers, given
Indias size, they may sound huge.
Additionally, India has several com-
munity health insurance schemes pro-
WHO/Patralekha Chatterjee
schemes operators are too accustomed to ing a critical role in the National Health Pradesh. The satisfaction rating was 90%
being unregulated. But the world over, the Insurance Scheme. In some places, such (good to excellent) in Kerala, 86% (good
only solution is organizing the entire health as Kerala, it has increased the earnings of to excellent) in Delhi, while Jaunpur district
system of a country under a single-payer government hospitals, and some institu- in Uttar Pradesh showed a 70% satisfaction
mechanism that regulates it. All resources tions are using the money to strengthen rating. We are collating the feedback from
are pooled in a single authority, such as the their infrastructure. the field and using it to improve the design
National Health Insurance in Canada or The scheme aims to protect house- of the scheme.
the National Health Service in the United holds living below the poverty line from The National Health Insurance
Kingdom. Brazil and Thailand have also liabilities arising from hospitalization. Scheme has distributed more than 15 mil-
moved in this direction. Beneficiaries are entitled to up to 30 000 lion smart cards across 26 states, covering
In India, financing outpatient care for rupees (US$ 640) of cover for most of more than 55 million people. But as it scales
the poor is a key concern. Financial con- the diseases that require hospitalization. up, it is facing challenges on several fronts.
straints cause many to skip antenatal care Coverage extends to five family members, We have to build capacity at every
or postpone treatment for minor ailments. including the head and spouse and up to level hospital, bureaucracy, insurance
In response, the Federal Governments three dependents. Beneficiaries pay less companies for effective implementation
flagship National Rural Health Mission than US$ 1 to register. The central and of the scheme, says Swarup. Second, there
has used conditional cash transfers to give state governments then pay the premium is a need for greater awareness of the scheme
money to households in return for specific to the insurer, which is selected by the state among the public. Third, we need to im-
actions, such as regular attendance at school government. prove quality of services at the hospitals.
and health clinics, and participation in im- Participating households can choose Until there is a buy-in at every level, it will
munization campaigns. between public and private hospitals. Every not be a huge success.
While debate continues on the best beneficiary family is issued with a biometric Arun Nair, a researcher at the Delhi-
model for Indias health-care financing, smart card that stores members fingerprints based National Health Systems Resource
initiatives such as the National Health In- and photographs. After the insurance Centre, says the information gap between
surance Scheme are getting off the ground. company is selected, it must engage both patients and hospitals needs to be ad-
About 75% of the financing for this public and private health-care providers dressed. Many patients are not fully aware
scheme is provided by the national govern- based on prescribed criteria. These hospitals of their entitlements, and can be exploited
ment, the remainder by state governments, are required to install the hardware and in the absence of standard treatment
says Anil Swarup, the director general of software to process smart-card transac- guidelines.
labour welfare in the Federal Ministry of tions. The scheme provides an incentive to Ish Kain, a National Health Insur-
Labour and Employment. The National everyone involved. ance Scheme field coordinator in Guptas
Health Insurance Scheme is doing well. In There have been three evaluations of neighbourhood of Tigri, agrees: Many
the Garhwa district of Jharkhand state, for the National Health Insurance Scheme to patients are semi-literate or illiterate. They
instance, there has been 80% enrolment date, says Swarup. They were conducted are not aware of the full range of benefits
of beneficiaries. The private sector is play- in Kerala, Delhi and one district in Uttar under the scheme, nor aware of their rights.
Sometimes hospitals take advantage of their
ignorance.
I did not have to pay for my uterus
operation, says Gupta, but I was charged
for diagnostic tests. She is not sure whether
such tests are paid for under the scheme,
and in any case, has not been given any
receipts.
Despite these problems, the scheme
offers some hope to the poor of India
requiring affordable health care. The
National Health Insurance Scheme is the
first integrated effort by the central and
state governments to provide social health
protection to the informal sector, says Nair.
That is a big step forward.
However, sustainability is a key ques-
tion. The National Health Insurance
Scheme will remain as a transitory measure
WHO/Patralekha Chatterjee