The Neo-liberal movement has picked
up its pace from early 1990 across the globe. Few countries voluntarily
embraced the principle and few were forced to adapt to the practices as part of
structural adjustment programme (SAP). Neo-liberal advocates for free markets
with minimalistic government performing only the functions that enhance or
enforces hassle free market environment for better efficiencies. They advocate
for freedom of choice without any coercion from the state. The neo liberals
strongly believe in property rights and lower tax. The state has to reduce its
role in service delivery take budget cuts to tax its citizens less and allow
market to take over as markets are considered to be efficient and effective
than state. The neo liberals also advocate to state to minimize its subsidy and
cut on all welfare programmes which are denting the budget and leading to
fiscal deficit. They also believe in creation of social safety nets by market
based approach. They argue allowing market in social security Programme would enhance the choice available
for the poor and ultimately poor can chose rather accepting what state offers
him. The conditional cash transfer programme or state backed health programmes
fall into this category where the individual is empowered to access the market
and choose what suits his requirement. Neo liberals argue that by adapting to
these policies leakages in the state welfare expenditure can be minimized with
an improved service delivery. In the next section I would be analyzing whether
markets can replace state to deliver primary good like health?
Health status
of India is abysmal with less that 4 % GDP is being contributed from health
sector. Until 1980 the health care was
primarily serviced by government. Late 1980 and liberalization of economy with
reforms in health sector has seen mushrooming of private nursing homes and
corporate hospitals. Government
is in the process of adequately strengthening the health institutions for basic
healthcare, lack of specialist doctors and equipment 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. These facilities though available
in corporate sector are catering mainly to the affordable sections of society
and are beyond the reach of poor families living in villages. Because of this
gap poor patients are constrained to go to private hospitals for treatment and
in the process incur huge debts leading to sale of properties and assets or
are, sometimes, left eventually to die. This was seen as opportunity and the
agricultural surplus was diverted to invest in high end hospital with latest
equipment in private sector. While structural adjustment and budget deficits
has done little in improving and upgrading the standards of public funded
hospitals. In Andhra Pradesh tertiary health care involving super specialty is
majorly controlled by private hospitals. Private hospitals usually formed
cartels to virtually keep cost of treatment high depriving poor from accessing
advanced health care facilities. Those poor who availed these facilities are often
pushed into debt traps because of these health financial shocks leaving them no
option other than to commit suicides. In Report of the Commission on Farmer’s Welfare, Government of
Andhra Pradesh, Hyderabad by Ghosh, Jayati
(2006) it was suicide in poor farmer families is linked to the health shocks.
To address this issue of financial health shock state has come up with
innovative market based health service scheme Rajeev Arogyasri for BPL households.
The
key objectives of any publicly-funded health insurance programme are
multidimensional. Besides improving health outcomes, it is expected to enhance
access and availability of essential healthcare services. But the critical goal
of any health financing strategy is to protect households from financial catastrophe
and impoverishment. This is expected to substantially reduce the households’
out-of-pocket (OOP) spending on healthcare. Rajeev Arogasri is a first of its
kind in India where tertiary care was made available for poor household by
government free of cost. The programme is cash less hospitalization where poor
can avail services without any expenditure. Under this scheme 938 procedures are covered. The amount covered is Rs.2 lakh with
additional buffer amount of Rs.50,000. A private insurer is selected through
completive bidding and the community health insurance model was created. A
network of Private and government hospitals were empanelled under the scheme
where health facilities can be availed. This neo liberal market schemes looks
glossy from outside. Poor are extremely as for the first time they are able to
access corporate health services free of cost. But did the progamme deliver a
better health services to poor than state ?
There
is no doubt that opening up of market has increased the access for poor to
health services. But the market has exploited the scheme and distorted the
schemes vision. Under Arogyasri only tertiary health care is covered. After the
progamme came into place the funds from health budget are being diverted to the
scheme putting the primary and tertiary care in an abysmal state. Arogyasri
also has a targeting issue it identifies 80% of state’s population as poor. The
scheme appoints Arogyamitra, scouts to identify the patients and refer them to
doctors. Arogyamirtas by and large colluded with private hospital and are
directing patients to the private hospitals. The private hospitals are also
being choosy about the cases the pick. Data Healthcare Models in the Era of
Medical Neo-liberalism [1]
say that the private hospital are selecting patients based on various factors.
Cases which involve high risk, more post operative care, low returns are
re-directed to government hospital. For example cases like spine injury might
need long post operative care which can potentially block the bed in private
hospital and the maximum amount what one can claim under Arogyasri this is
making them to divert these cases to Public hospitals. The procedures are dived
into two categories first categories has 352 cases funded by star insurance
company and the rest are funded by Arogaysri trust. The private hospitals are more inclined in
taking up cases those are reimbursed by the insurance company as there are no
delays. Private hospitals also started encouraging the surgical procedures for
treatments even though the ailment can be treated otherwise as non- surgical
procedures are not covered under the schemes. After the scheme was introduced
there was sudden rise in caesarians as poor people were forced to undergo
instead of normal delivery. There are also cases where old women were selected
and were done hysterectomy bribing them. Corruption was also rampant extra
service fees were collected from patients even though everything is covered
under the scheme. This raises the questions of moral ethics and the scheme has
tested moral limits of markets again.
The
government has used ICT technologies to cull the fake claims done by private
hospitals but the in a neo liberal approach the scheme has failed. The neo
liberal schemes are supposed to give choice of selection to patients where then
wish to claim their “quality treatment”. But the private hospitals jeopardized
the health of patient. Patient no more has the right to select it’s the market
which has power to select what they ought to do. Ultimately the cases are
diverted to public hospital whose pockets are already picked by private
hospitals due to the scheme.
As
a policy designer one can encourage market based approaches but one has to also
consider the limits of market in service delivery. When it comes to basic services like health
market can distort the goals and give us biased outcomes. At least now
government has to open its eyes and start investing in public hospital and use
the same insurance schemes to funds them. Diverting these funds from private
hospitals to government can create necessary infrastructure which in long term
will make medical cost affordable to the society or else we will be reach a
point where no one would be able to afford health without an insurance. The
million dollar question is what if government withdraws the scheme? Already this
insurance market based schemes has pushed up health costs which already started
effecting who are not covered under the scheme. Can poor afford this high cost
without the schemes the government’s goal should be creation of sustainable
institutions which can deliver services at a affordable costs.
No comments:
Post a Comment