The government has undertaken demonetisation to curb corruption and unearth black money. Our leaders have called on the country to move to a cashless economy. What about healthcare?
In the immediate aftermath of demonetisation, media has reported on patients being denied medical care by hospitals, which refused to accept old currency while new currency was in short supply. Some incidents of deaths due to denied medical care were also reported.
If any service has to be rendered cashless at the point of delivery, it is healthcare. That is a prime requirement of universal health coverage (UHC), adopted as a part of the Sustainable Development Goals. It is the hallmark of a civilised society that the medical needs of all persons are met with an assurance of access to affordable care of dependable quality. The ability to immediately pay at the time of care should never be a barrier to getting care.
This calls for a system of prepayment, from which the care provider can draw payment for the service rendered, without harassing the patient or family. Such prepayment is built in to a tax-funded healthcare system, which is based on public financing. Government hospitals are expected to function on this basis. Even private healthcare providers can be made to provide cashless prepaid service through a health insurance system, which may be wholly or partially government-financed or privately-purchased.
UHC involves the provision of a defined package of health services to all. The government acts as a purchaser, guarantor and regulator, with both public and private care providers having an opportunity to participate in delivering care. The system operates on the principle of ‘risk pooling’, wherein the contributions to the financing pool come from a large number, even though the number needing care at any given time is much less. This way, the healthy subsidise the sick, recognising that people may move across these categories over different time periods.
An insurance system too involves risk-pooling and will succeed only if a larger number of healthy persons (at any time) subsidise the fewer number of persons who are sick (at that time). Such a scheme should not exclude persons with pre-existing medical conditions. A contributory social insurance scheme usually draws insurance payments from salaries. Over 90 per cent of the workforce in India is in the informal sector, where salary deduction is not possible. For such persons, voluntary enrolment in a government-sponsored social insurance scheme, like the Rashtriya Swasthya Bima Yojana (RSBY), is the only option if free care is not assured through public sector health services.
However, RSBY and similar state government-funded health insurance schemes only cover costs of hospitalised care for some conditions—up to a limit. They do not cover additional costs of in-patient care, nor do they cover follow-up care after discharge.
They do not cover out-patient care and medicines, which account for 70 per cent of out-of-pocket spending, which is very high. Primary care services, which are frequently accessed by majority of the population for common ailments, are not covered by these schemes. As a result, much of healthcare-related expenditure remains a cash-based burden for the poor and lower middle class. In situations where access to readily expendable cash becomes highly restricted, the poor and the near-poor face an insurmountable barrier in accessing healthcare.
India needs to evolve a system of UHC, which combines health financing mechanisms into a single pre-paid system of service provision that covers in-patient and out-patient care in an essential health package. Never again should a newborn die because a doctor demanded cash from the distraught mother nor a husband grieve over a wife who was turned away from a hospital because of inability to pay instantly. We need a fail-proof system of prepaid cashless service built in to the UHC framework. Is it coming? email@example.com