Health for the BOP: The way ahead…

This is Part 3 of a four part blog series where Shelly Batra, founder of Operation ASHA, reflects on some of the challenges associated with providing health care to the bottom-of-the-pyramid (BOP) and how we can overcome them moving forward. Did you miss the earlier posts? Read Part 1 and Part 2.

If we look beneath the surface, we can see the cracks in the Indian health care system. There are multiple challenges that exist, which are as follows:

  • skewed doctor patient ratio,
  • not enough beds,
  • long lines for tests and medicines,
  • crowded OPDs so doctors barely get a minute to examine and prescribe,
  • long waiting list for OTs, cancer treatment, or dialysis, heart surgery and transplants.

India’s doctor patient ratio is 1:800 in cities, but 1:3000 villages or even worse. The WHO recommends a doctor patient ratio of 1:1000. But absenteeism is common, a government job being a euphemism for a cushy life where one can get a salary and benefits and pension for doing a negligible amount of work. At the PHCs, you often find that there are no docs, no nurses, no paramedics or staff. The centres may be closed and shuttered for weeks, often there is no equipment and theft of medicines and disposable is a regular feature. And all this is because there is no accountability. The infrastructure exists, but is being misused. It’s a behemoth, guzzling funds.

The Government makes tall claims. For example, in 2006, the government of India declared that there is 100% DOTS coverage, which means the entire country has facilities for TB treatment. Unfortunately, the truth is very different from reality. There are 2 million new cases of TB every year in India, and half a million deaths. This is because the facilities exist, but are so remote that the poor cannot access them. It takes 2 days to go to the next village by a bullock-cart. How can someone go 60 times over 6 months for TB medicine? A similar situation exists in cities. People earning less than a $ a day cannot spend 20 cents for the bus fare and spend the whole day standing in lines for treatment, because, this would mean there is no food today, and no job tomorrow.

Now the government has several schemes in place for the needy. It is providing control of communicable and non-communicable diseases, providing curative as well as preventive/promotive care through a chain of primary, secondary and tertiary care health institutions. The government has also launched the National Rural Health Mission (NRHM) in 8 states. Some of these schemes were well conceptualised, but implementation has become a challenge. These are:

  1. Health Insurance for the BOP: This is known as RSBY, in which a smart card is issued to BOP families. This scheme has now been extended to unorganized workers like street vendors, domestic helps, beedi workers and those working in building and construction sites. But the reality is that even the smart cards have not been issued to all, and if issued, are worthless. The RSBY card entitles a person to up to Rs. 30,000 in health-benefits (for admission). But no nursing home is willing to accept these patients, because the government has not paid up for the past bills. So the patients keep running from pillar to post for admission, and when they do not get admission anywhere, they go back to the public hospitals.
  2. All BPL patients suffering from mental disorders like depression, anxiety, adjustment and personality disorders, alcohol and drug abuse will get a free one-time grant of up to Rs 1 lakh for treatment at any super-specialty government hospital/institutes. Hospitals have been given a corpus of funds Rs. 10- 50 lakhs, for distribution.
  3. Vandemataram scheme- This is another optimistic idea, but quite impractical. The idea is that private nursing homes will do free distribution of RCH ( Reproductive & Child Health) services, i.e. immunisation, giving condoms, pills, ORS, iron and folic acid etc. But who is responsible for doing this work? what is the payment? How much is the work done? Is the distribution actually for free? These are questions that need to be answered. Another thought that comes to mind is that why on earth would a for-profit revenue generating nursing home waste time on this? The few private nursing homes who might be willing to do this get so disgusted and disillusioned by the hurdles they face in obtaining the free supplies that they just give up. In a nutshell, these schemes amount to unrealistic expectations on the part of the government.

So what is the solution?

Check back for Part 4 and the final part of this blog series.