Sulakshana Nandi
CASE STUDY ON THE IMPACT OF PPPs THROUGH PUBLICLY-FUNDED INSURANCE SCHEMES ON WOMEN IN INDIA, WITH SPECIAL REFERENCE TO CHHATTISGARH STATE
The largest Public-Private Partnership initiated by the Indian government is the publicly-funded health insurance scheme, entitled the Pradhan Mantri Jan Arogya Yojana or PMJAY. The UN Structural Adjustment programs of the 1990s led to the withdrawal of government from the social sector and damaged India’s public-health sector. Although the United Progressive Alliance endeavoured to reverse this situation from 2004 and made progress in improving public health care through the National Rural Health Mission (2005), the National Urban Health Mission (2013) and other public programmes, the arrival of the National Democratic Alliance (NDA) in 2014 brought this to an end, with the reduction of funding for health and social programmes to the proportions during the Structural Adjustment programs.
Parallel to National Rural Health Mission (NRHM), many Indian states began introducing publicly-funded health insurance schemes with the aim of protecting the poor from catastrophic health expenditure. The Rashtriya Swasthya Bima Yojana (RSBY) or National Health Insurance Scheme (2007) was the first such scheme at national level aimed at insurance cover for India’s poorest citizens requiring hospital care. It was also the first time the government had contracted private health-care providers on a large scale to provide health care.
The RSBY has been expanded by the NDA in terms of population coverage and insurance coverage per household in the Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (AB-PMJAY). The government pays the annual premium and families do not need to pay for enrolment. Such Publicly-Funded Health Insurance schemes (PFHI) as the PMJAY are governed by contractual agreements between the government and the private sector and are, therefore, considered to be PPPs. Under these schemes, private and public hospitals are empanelled through a contract to provide services and forms of treatment at fixed rates, and the hospitals are not permitted to take additional money from the patients. The Modi government has modified the institutional and governance arrangements of the PMJAY to include the “for-profit” private sector and their organisations, bypassing the Ministry of Health. Health care is no longer viewed as a right, but as a commodity, by the right-wing neo-liberal NDA government.
India’s mixed health system consists of a complex network of public health-care facilities and programmes aimed at providing universal preventative and curative health services at low or no cost. There is also a large formal “for-profit” private health sector working in urban areas on a “fee-for-service” basis. The Rashtriya Swasthya Bima Yojana (RSBY) or National Health Insurance Scheme was designed by persons critical of the public provision of health services, and who had faith in the concepts of efficiency, productivity, competition, and individual choice promoted and provided by the neo-liberal model. Thus, the PHFI schemes became a “business model” which was intended to be profitable for all the parties involved, prioritising profit-making over people’s health. The PMJAY was to help India towards Universal Health Coverage and the Sustainable Development Goals.
In order to complement this scheme, not only have the normal regulatory and statutory compliances been eased for the construction of private hospitals, but the conversion of public hospitals into profit-making hospitals is also planned. This will have disastrous effects on the poorest, the scheduled tribes and castes, the rural populations, and, in particular, women.
In the promoting, implementing and developing of the PFHI schemes in India, the participation of the private health sector, international agencies, including the World Bank, the World Health Organisation and the International Labour Organisation, philanthropic foundations, and international development banks is very visible. Indeed, the “engagement of national and state governments with the ‘for-profit’ private health sector through the PFHI schemes is on a scale that is unprecedented”. Moreover, private hospitals, especially corporate ones, as well as doctors’ associations have acted as pressure groups, “demanding that the government should increase the rates for the procedures under the PFHI schemes, provide more subsidies, and reduce regulation”. Consultancy agencies, such as PwC, also demand that the PFHI schemes be made more profitable for the private sector. However, in both the regulatory framework and the functioning of the PFHI schemes, there is no formal role for the community, for women’s organisations, or any other civil society entity to participate or have a voice and make itself heard.
The national Clinical Establishments Act was passed in 2010 after intense negotiations with the private sector, but it failed to include some critical aspects of patients’ rights, regulations, and did not even display treatment rates. Although the state under scrutiny in this article, Chhattisgarh, has an act which does incorporate patients’ rights, they are not adequately implemented. Given that India’s “for-profit” private health sector is known for unethical practices and extorting money from patients, the poor legal framework, lack of transparency, and regulatory failure and failings only serve to exacerbate illegality, not to impose legality. This is further compounded by conflicts of interest in which the officials with the responsibility for fixing the treatment rates and for monitoring the hospitals are themselves involved in private practice and own private hospitals.
Although the objectives of the RSBY were ‘to improve access to quality health care, to provide financial protection from hospitalisation expenses, to provide the beneficiaries with the power to choose from a national network of providers, and to provide a scheme which the non-literate could easily use” (Jain, 2014), in which girl child, women and senior citizens were to be a priority, enrolment does not translate into real access to healthcare for all women and many claims packages have a clear male and geographical bias. Unethical and illegal practices are commonplace in private “for-profit” hospitals, with unjustified operations/forms of treatment, including forced hysterectomies and unnecessary Caesarean Sections, and “Out-of-Pocket” payments being demanded for services that should be cashless.
The favouring of the PMJAY and the RSBY over the public health system, and the resulting shifts in funding towards the private system, has deprived the public system of the finance for public hospitals, primary health care and other health programmes, which affects women, the young and the old, and the poorer strata of Indian society disproportionately. In response to this, the Jan Swasthya Abhiyan (People’s Health Movement) has put up resistance and documented the implications of the PFHI schemes for people, especially the poor, women, and the scheduled tribes (STs) and scheduled castes (SCs) communities. As I stress, women have no role in the decision-making or at any stage of the PMJAY implementation and monitoring, even though they are the ones most affected by it. The under-funding of the public health system in favour of the PPPs only serves to exacerbate this iniquitous situation. With the private sector “cherry-picking” the services that it provides, and the transformation of health from a right to a commodity, the supply or refusal of treatment makes the poorer and weaker sections of society even more vulnerable, and makes health care a business determined by profit, not by medical ethics or patient needs. And, with regard to women, the scheme enables private interests to gain and maintain control over women’s own bodies, which are now seen as a means of making profit, and are subjected to unnecessary procedures and forms of treatment for private gain. This, in the twenty-first century, is simply unacceptable.
Sulakshana Nandi is the State Convener of Public Health Resource Network (PHRN), Chhattisgarh. She is also a founding member of Chaupal, a Tribal Resource Agency that supports community-based organisations in working on the right to food and health, forest rights, and gender and tribal rights. She is involved in research, capacity building, and advocacy on issues related to health equity and access, and public policy and programmes for health and nutrition, with a focus on gender and vulnerable communities. Sulakshana Nandi is Co-chair of People’s Health Movement Global. She holds a PhD in public health from the University of Western Cape, South Africa.
Courtesy : DAWN Informs ,March 2021. dawnfeminist.org
NAYA GANATANTRA 
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