Rajasthan's ambitious health insurance scheme excludes many poor patients

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.

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.