“When they gave the card, they said it would be useful for my family and me. It has never been of any use. All I can do is see my own face on the card every day.”
—Elderly woman from Bengaluru
“I tried using it in a couple of times. They said it is of no use. Now I don’t even know where it is. When they gave the card they said you could get all the treatment you want for Rs 30,000.”
—Woman interviewed in Bengaluru
These are two examples of the struggles that women from marginalised communities in the city and state have to face in accessing healthcare through social health insurance schemes; they end up getting no benefits, according to an assessment by public health researchers from Bengaluru. What is more shocking, said the researchers, is the illegal practice of selecting patients who did not fit into the scheme, but whose medical condition offered an opportunity for the network hospitals to make money. Such patients were encouraged to keep in touch with the field coordinator with the promise of treatment, said the findings published in the “Indian Journal of Gender Studies”.
SCHEMES ARE OF LITTLE HELP
The researchers looked at two schemes — Rashtriya Swasthya Bima Yojana (RSBY) and Vajpayee Arogyasri Scheme (VAS) — meant for addressing the burden of healthcare costs for those who lived below poverty line (BPL). The team focused on poor, marginalised women and used data from three focus group discussions conducted with domestic workers, construction workers and other daily wage women workers in two low-income communities (Nakkal Bande and Byappanahalli) in Bengaluru urban, and observations of VAS health camps in Haveri and Raichur.
Dr Sylvia Karpagam, public health doctor, told Bangalore Mirror that it is through women’s experiences that the team realised that empanelled hospitals lack awareness of the scheme. A domestic worker from Jayanagar told them: “I went to a government hospital as my husband needed admission. The hospital was not even aware of this card and asked me who had issued it.”
Dr Karpagam said that more importantly, women spoke of RSBY’s irrelevance given that it did not protect them from everyday illnesses that did not need hospitalisation, but for which they still had to spend a considerable amount.
For instance, a construction worker in Byappanahalli said, “On an average, I spend Rs 500-1,000 per visit to a doctor for problems like fever, cough, cold, vomiting and diarrhoea. The doctor orders tests and prescribes medicines. This card is of no use for such problems.”
Women did not know from where to seek information related to RSBY cards and treatment or where to register their complaints. The RSBY Society “had an incongruous grievance redressal mechanism” involving usage of the RSBY website and an automatic unique complaint number. “Even the official in charge of the scheme agreed it was a difficult system for women without access or skills to use computers,” added Dr Karpagam .
Domestic workers’ union and construction workers’ union were unequivocal in their condemnation of the scheme, said the paper.
“In the name of insurance, people are being cheated and their money snatched. These schemes have not helped anyone,” a representative of the domestic workers’ union in Bengaluru said. A representative of the city’s construction workers’ union added, “If government hospitals work well, we don’t need insurance and we don’t need schemes and cards”.
In Bangalore urban, informal sector workers’ unions reported getting VAS cards in addition to RSBY cards, but the experience was similar. “We have got cards, but they are of little use,” they said.
The team found that patients were excluded from the scheme as the condition was not covered or the patient was too ill or due to errors in the BPL card. “In one of the camps, over 50 per cent of 88 patients visiting were excluded because their condition was not covered under the scheme. Among them was a 60-year-old widow who sought treatment for her son, who had suffered a stroke. She was told that stroke is not covered under this scheme as the treatment does not involve surgery. She was not offered any alternative source of treatment,” said the paper.
A 60-year-old in the fourth stage of cancer was also denied treatment. The marketing executive from the network hospital told the research team, “We can’t guarantee that she will survive. For us there is a strict guideline that the patient should not come in the ambulance from the camp. What’s the point in taking patients who may not survive?”
The researchers state that it was the fine print, as in any insurance scheme, that finally determined one’s access to treatment. “In this case, the fine print indicated that critically ill patients made poor business sense as they may die and money would not be reimbursed. Commercial considerations seemed to govern patients’ access to treatment under the scheme rather than seriousness of the patient’s condition or the urgency of the need for treatment: this is one of the worst forms of violation of medical ethics,” they added.
The team said their interactions indicate that the camps were recruiting grounds for private hospitals to bring in paying cases even when the scheme did not cover them. “They carefully picked those patients who would bring in revenue,” said Dr Karpagam.
For instance, says the paper, the marketing executive decided that a 50-year-old woman with leukaemia should be referred to the hospital for treatment even though she was not covered under the scheme. “In the case of the boy with a lesion near the lung, the marketing executive persuaded hard to get the case referred to his network hospital and said it will not cost more than Rs 10,000. However, the patient decided against it as he could not afford to pay Rs 10,000,” it said.