While cruising through the chaotic streets of Chennai and Trichy in Balaji’s (our wonderful, agile driver) small minivan, I’ve spotted numerous modern glassy buildings glistening in the bustling cityscape – those glitzy buildings were often private hospitals. In India, private institutions account for 80% of outpatient care and 60% of inpatient care; and 86% of health care expenditures are out-of-pocket (check out NEJM article on health care in India). I was initially surprised by these numbers, given that government hospitals can provide diagnostics, services, and medications free of cost. As I thought more about this concept, it rasied some concerns. I wondered about access to government centers for those living in rural settings, long wait times at government centers that would deter impoverished individuals in urban and rural settings who depend on their daily wages, and the convenience and ease of access to private hospitals that could quickly lead to a path towards medical bankruptcy.
Some of these concerns are addressed with the implementation of Rashtriya Swasthya Bima Yojana (RSBY) – a health insurance scheme that provides coverage of people living below the poverty line (less than $1.90/day according to The World Bank – India poverty profile) and unorganized workers (i.e. domestic workers, sanitation workers, rickshaw/auto/taxi drivers). The goal of the program is to cover 70 million households by the end of 2017. Currently, 36 million households are enrolled. Under the plan, families pay Rs 30 per year (approximately $0.50 USD) to obtain a smart card which allows them to access care at government or select private hospital across all of India. The smart card system uses biometrics (fingerprints/photo collected at time of enrollment) and also facilitates a cashless transaction system. Participants are covered up to Rs. 30,000 (approximately $475 USD) per year for hospitalizations and it also includes transportation costs (Rs 100 per trip/Rs 1000 per year). Notably, there is no outpatient coverage in RSBY.
During our time in Trichy, I was able to see RSBY in action at Sundaram Hospital. Sundaram Hospital is a private hospital where we had the opportunity to observe rounds on the wards, tour their modern facilities, and discuss some of the costs/daily operations that are unique to private institutions. While I was intrigued by the wide array of interesting medical cases (PCP pneumonia, tuberculosis, and LOTS of dengue), I was happy to see patients of all socioeconomic backgrounds being treated in the same state of the art facility. However, the harsh reality that majority of Indians still lack health insurance still exists (17% of population is insured – see NEJM article link above) and those who are covered seem to be on the extreme ends of the financial spectrum. What about the people who aren’t the super rich or the super poor… what about the people in the middle?