RIGHT TO SOCIAL SECURITY HEALTH INSURANCE IN

INDIA
Prof. Raj Varma
Symbiosis Law School, Pune
 The right to social security has been considered a fundamental right for every human
being by the ILO.

BACKGROUND According to the International Labour Organisation, social security means providing protection to the
people and their families in the face of vulnerabilities and contingencies.

The elderly population are considered the most vulnerable and owing to their age-related ailments such as
disability, mental health, diabetics and a few others, the senior citizens are naturally susceptible to the risk
factors involved in their day to day health. Health has been a priority since generations. Various studies have
shown that these elderly lack social security with regard to health insurance

This topic also assumes relevance as COVID 19 pandemic presents a range of specific risks for older persons.
As the virus spreads rapidly to developing countries, overwhelming the health and social protection systems,
the mortality rate especially that of vulnerable persons has been on the rise. Denial of health care, abuse and
neglect in institutions and care facilities, increase in poverty and unemployment, the impact on well-being and
SIGNIFICANCE mental health effects the elderly at large.

There is a need for a comprehensive healthcare facility for health insurance in India, most importantly the implementing
mechanisms that are available to realise rights envisaged as a welfare state and to study the present government policies
introduced in support of health insurance covering the senior citizens of the Indian society.
 LITERATURE REVIEW

As per a recent report from the “Ministry of Statistics and Programme Implementation” the vulnerable population in
India is growing and they require state help and social security for raising Human Development Index Standards.

Women, Children, elderly in India are more vulnerable because of the less government spending's on social security system.

Health insurance cover that is elderly sensitive is virtually non-existent in India. In addition the pre-existing illness are
usually not covered making insurance policies unviable for the elderly.
According to the 15th Finance Commission, only 0.95 per cent of the GDP was spent in the year 2017-18 against 2.5 per cent
that the National policy on health aspired for.
The ageing population puts an increased burden on the resource of a country and has raised concerns at many levels of the
government in India.

The unorganised sector consists of about 93% of the workforce. But this sector seems to be the most neglected when it
comes to old age security. The people working in this sector retire without any benefit unlike that of the organised sector.
Social security with regard to health insurance is generally linked to work. The state of the elderly after they quit their work is
devastating. Healthcare affordability worsens due to financial constraints.
 Public v Private Healthcare

► The fundamental difference between public (or social) and private insurance is that while
public insurance spreads risk across robust and frail populations and provides access to care
to those with healthcare needs, commercial insurance tries not to include those who are
most likely to use services as that would increase their costs. That is why even in the
United States (US), in order to address this market failure, the government intervenes by
providing insurance (Medicare, which is federally administered) to the elderly people who
otherwise would not have been covered under any private health insurance plan.
► Public and private health insurance systems coexist in most countries often within the
framework of a two-tier system.
► The first-tier usually consists of government-subsidised essential medical care and a
second-tier of optional or supplemental care is paid for privately by those who have the
means. In most countries, equity of healthcare access is a political priority. Even in the US,
which is known for its reliance on private providers and employment–contingent plans, the
poor and elderly are publicly insured (Medicaid and Medicare).
 Public v Private Healthcare

► All insurance, whether paid out directly by individuals to commercial insurers or covered by the
state, is in the end paid by households either as premiums or via taxes. However, the
government has an important role to play in terms of regulating the behaviour of private
actors, establishing conditions of access and for minimising agency problems. The key issues
that arise when considering the optimal design of health insurance is balancing the gains
obtained in the form of risk-sharing against the costs from moral hazard, adverse selection and
supplier-induced demand
► In theory, there are some effi ciency gains to be had from a single insurer (for example, the
government) since adverse selection can be avoided. On the other hand, a market for private
insurance, in theory, should drive down costs by way of the competition between providers.
 Public v Private Healthcare

► The Canadian system and the French system allow competition between public and private
healthcare providers enabled by patient free choice even though there is public fi
nancing. However, empirical evidence on competition among health insurers does not
necessarily support the above theoretical prediction.
► In many states of India, contracted private insurers made huge profits under the RSBY,
Rajiv Gandhi Jeevandayee Arogya Yojana (RGJAY) and other insurance programmes as the
claim ratio remained low, whereas in others (for example, Kerala) where utilisation of services
by the enrollees was relatively higher, insurance premiums have significantly increased in the
last seven years.
► Concerning the evidence on competition among hospitals, studies conducted in US suggest
that introduction of competition and markets into hospital care did not yield any reduction in
cost of care; on the contrary, costs continue to rise at double digit rates and there is mixed
evidence on quality and on health outcomes in US and UK
 Public v Private Healthcare

► The gains from competition within a dual system can be lost if physicians also move
between both sectors. When there is a cap on public sector remuneration, physicians
allocate more of their time and effort into the more remunerative private sector, leading to a
reduction in the amount of healthcare provided overall unless the government can raise the
public sector wage
► A key issue for determining whether crowd-out will occur, therefore, is whether public and
private physicians and specialists are substitutes or complements. A study using data from Italy
that accounts for both unobserved heterogeneity and the simultaneous nature of the
utilisation of medical care, finds that general practitioners, public and private specialists are
substitute sources of medical care
 BRIEF OVERVIEW AND ANALYSIS
Various programs and schemes such as below:
1. Pradhan Mantri Jan Arogya Yojana (PM-JAY)
2. National Rural Health Mission
3. National Urban Health Mission
4. Janani Suraksha Yojana
5. Rashtriya Swasthiya Bima Yojana (RSBY)
6. Central Government Health Scheme (CGHIS)
7. Universal Health Insurance Scheme
8. The National Health Assurance Mission (NHAM)
 National Rural Health Mission

► The National Rural Health Mission (NRHM) was launched on 12th April 2005, to provide accessible,
affordable and quality health care to the rural population, especially the vulnerable groups.
► NRHM seeks to provide equitable, affordable and quality health care to the rural population, especially
the vulnerable groups. Under the NRHM, the Empowered Action Group (EAG) States as well as North
Eastern States, Jammu and Kashmir and Himachal Pradesh have been given special focus. The thrust
of the mission is on establishing a fully functional, community owned, decentralized health delivery
system with inter-sectoral convergence at all levels, to ensure simultaneous action on a wide range of
determinants of health such as water, sanitation, education, nutrition, social and gender equality.
► NRHM focuses on Reproductive, Maternal, Newborn, Child Health and Adolescent (RMNCH+A)
Services. The emphasis here is on strategies for improving maternal and child health through a
continuum of care and the life cycle approach. It recognises the inextricable linkages between adolescent
health, family planning, maternal health and child survival. Moreover, the linking of community and
facility-based care and strengthening referrals between various levels of health care system to create a
continuous care pathway is also to be focussed.
 National Rural Health Mission

► The key features in order to achieve the goals of the Mission include making the public health delivery
system fully functional and accountable to the community, human resources management, community
involvement, decentralization, rigorous monitoring & evaluation against standards, convergence of health
and related programmes form village level upwards, innovations and flexible financing and also
interventions for improving the health indicators.
 National Rural Health Mission

► At the National level, the NHM has a Mission Steering Group (MSG) headed by the Union Minister for
Health & Family Welfare and an Empowered Programme Committee (EPC) headed by the Union
Secretary for Health & FW. The EPC will implement the Mission under the overall guidance of the MSG.
► At the State level, the Mission would function under the overall guidance of the State Health Mission
headed by the Chief Minister of the State. The functions under the Mission would be carried out through
the State Health & Family Welfare Society.
 National Rural Health Mission

► Core Strategies
• Train and enhance capacity of Panchayat Raj Institutions (PRIs) to own, control and manage public health services.
• Promote access to improved healthcare at household level through the female health activist (ASHA).
• Health Plan for each village through Village Health Committee of the Panchayat.
• Strengthening sub - centre through an untied fund to enable local planning and action and more Multi-Purpose
Workers (MPWs).
• Strengthening existing PHCs and CHCs, and provision of 30- 50 bedded
• CHC per lakh population for improved curative care to a normative standard (Indian Public Health Standards
defining personnel, equipment and management standards).
• Preparation and Implementation of an inter - sectoral District Health Plan prepared by the District Health Mission,
including drinking water, sanitation & hygiene and nutrition.
 National Rural Health Mission

► Core Strategies
• Integrating vertical Health and Family Welfare programmes at National, State, Block, and District levels.
• Technical Support to National, State and District Health Missions, for Public Health Management.
• Strengthening capacities for data collection, assessment and review for evidence based planning,
monitoring and supervision.
• Formulation of transparent policies for deployment and career development of Human Resources for
health.
• Developing capacities for preventive health care at all levels for promoting healthy life styles, reduction in
consumption of tobacco and alcohol etc.
• Promoting non-profit sector particularly in under-served areas.
 National Rural Health Mission

► Supplementary Strategies
• Regulation of Private Sector including the informal rural practitioners to ensure availability of quality
service to citizens at reasonable cost.
• Promotion of Public Private Partnerships for achieving public health goals.
• Mainstreaming AYUSH – revitalizing local health traditions.
• Reorienting medical education to support rural health issues including regulation of Medical care and
Medical Ethics.
• Effective and viable risk pooling and social health insurance to provide health security to the poor by
ensuring accessible, affordable, accountable and good quality hospital care.
 National Rural Health Mission

► Institutional Mechanisms
• Village Health & Sanitation Samiti (at village level consisting of Panchayat Representative/s, ANM/MPW, Anganwadi worker,
teacher, ASHA, community health volunteers
• Rogi Kalyan Samiti (or equivalent) for community management of public hospitals
• District Health Mission, under the leadership of Zila Parishad with District Health Head as Convener and all relevant
departments, NGOs, private professionals etc represented on it
• State Health Mission, Chaired by Chief Minister and co - chaired by Health Minister and with the State Health Secretary as
Convener- representation of related departments, NGOs, private professionals etc
• Integration of Departments of Health and Family Welfare, at National and State level
• National Mission Steering Group chaired by Union Minister for Health & Family Welfare with Deputy Chairman Planning
Commission, Ministers of Panchayat Raj, Rural Development and Human Resource Development and public health
professionals as members, to provide policy support and guidance to the Mission
• Empowered Programme Committee chaired by Secretary HFW, to be the Executive Body of the Mission
• Standing Mentoring Group shall guide and oversee the implementation of ASHA initiative
• Task Groups for Selected Tasks (time- bound)
 National Rural Health Mission

► Impact Analysis
► The National Rural Health Mission (NRHM) has been a watershed in the history of India's health sector.
As a previously unattempted investment, governance, and mobilization effort, the NRHM succeeded in
injecting new energy into India's public health system. A huge expansion of infrastructure and human
resources is the hallmark of the NRHM action. Demand-side initiatives led to enhanced utilization of
public health facilities, especially for facility births. The impact is visible. The Mission has brought
Millennium Development Goals 4 and 5 within India's grasp. Acceleration in infant and neonatal mortality
reduction is especially notable. The NRHM has created conditions for the country to move toward
universal health coverage.
► (Ref: The National Rural Health Mission in India: its impact on maternal, neonatal, and infant mortality
Shyama Nagarajan, Vinod K Paul, Namrata Yadav, Shuchita Gupta )
 National Rural Health Mission

► Impact Analysis
► Has India’s national rural health mission reduced inequities in maternal health services? A pre-post repeated cross-sectional
study (Sukumar Vellakkal, Adyya Gupta, Zaky Khan,David Stuckler, Aaron Reeves, Shah Ebrahim, Ann Bowling, and Pat
Doyle)
► Results: Inequities in institutional delivery declined between pre-NRHM Period 1 (1995–99) and pre-NRHM Period 2
(2000–04), but thereafter demonstrated steeper decline in post-NRHM periods. Uptake of institutional delivery increased
among all socioeconomic groups, with (1) greater effects among the lowest and middle wealth and education tertiles than
highest tertile, and (2) larger equity impacts in the late post-NRHM period 2011–12 than in the early post-NRHM period
2007–08. No positive impact on the uptake of ANC was found in the early post-NRHM period 2007–08; however, there was
considerable increase in the uptake of, and decline in inequity, in uptake of ANC in most states in the late post-NRHM period
2011–12.
► Conclusion: In high-focus states, NRHM resulted in increased uptake of maternal healthcare, and decline in its
socioeconomic inequity. Sstudy suggests that public health programs in developing country settings will have larger equity
impacts after its almost full implementation and widest outreach. Targeting deprived populations and designing public health
programs by linking maternal and child healthcare components are critical for universal access to healthcare.
 Rashtriya Swasthya Bima Yojana

► The workers in the unorganized sector constitute about 93% of the total work force in the country. The
Government has been implementing some social security measures for certain occupational groups but the
coverage is miniscule. Majority of the workers are still without any social security coverage. Recognizing
the need for providing social security to these workers, the Central Government has introduced a Bill in the
Parliament.
► One of the major insecurities for workers in the unorganized sector is the frequent incidences of illness and
need for medical care and hospitalization of such workers and their family members. Despite the expansion
in the health facilities, illness remains one of the most prevalent causes of human deprivation in India. It has
been clearly recognized that health insurance is one way of providing protection to poor households
against the risk of health spending leading to poverty.
 Rashtriya Swasthya Bima Yojana

► However, most efforts to provide health insurance in the past have faced difficulties in both design and
implementation. The poor are unable or unwilling to take up health insurance because of its cost, or lack of
perceived benefits. Organizing and administering health insurance, especially in rural areas, is also difficult.
► Objective
Recognizing the diversity with regard to public health infrastructure, socio -economic conditions and the
administrative network, the health insurance scheme aims to facilitate launching of health insurance projects
in all the districts of the States in a phased manner for BPL workers.
 Rashtriya Swasthya Bima Yojana

► Salient features
Funding Pattern
► Contribution by Government of India: 75% of the estimated annual premium of Rs.750, subject to a
maximum of Rs. 565 per family per annum. The cost of smart card will be borne by the Central Government.
► Contribution by respective State Governments: 25% of the annual premium, as well as any additional
premium.
► The beneficiary would pay Rs. 30 per annum as registration/renewal fee.
► The administrative and other related cost of administering the scheme would be borne by the respective
State Governments
► Implementing Agency & Formulation of Projects
► The State Government while formulating the pilot project will determine the implementing agency on
behalf of the State Government.
 Rashtriya Swasthya Bima Yojana

► Eligibility
• Unorganized sector workers belonging to BPL category and their family members (a family unit of five) shall
be the beneficiaries under the scheme.
• It will be the responsibility of the implementing agencies to verify the eligibility of the unorganized sector
workers and his family members who are proposed to be benefited under the scheme.
• The beneficiaries will be issued smart cards for the purpose of identification.
 Rashtriya Swasthya Bima Yojana

► Benefits
► The beneficiary shall be eligible for such in-patient health care insurance benefits as would be designed
by the respective State Governments based on the requirement of the people/ geographical area.
However, the State Governments are advised to incorporate at least the following minimum benefits in
the package / scheme:
• The unorganized sector worker and his family (unit of five) will be covered. Total sum insured would be Rs.
30,000/- per family per annum on a family floater basis.
• Cashless attendance to all covered ailments
• Hospitalization expenses, taking care of most common illnesses with as little exclusion as possible
• All pre- existing diseases to be covered
• Transportation costs (actual with maximum limit of Rs. 100 per visit) within an overall limit of Rs.1000.
 Rashtriya Swasthya Bima Yojana

► Revamped RSBY
► A revamped RSBY was launched in October 2014 to include the following.
1. Enrollment with RSBY to be linked with opening of bank account and issuance of Aadhaar card.
2. Scheme currently covers 3 crore workers. It will be expanded to include construction sector also.
3. Single central smart card to be issued to include other welfare schemes like Aam Aadmi Bima Yojana and
National Old Age Pension Scheme.
 Rashtriya Swasthya Bima Yojana

► Health and Family Welfare Ministry to Implement RSBY Scheme from April 1, 2015
► The Rashtriya Swasthya Bima Yojna (RSBY ) of the Labour and Employment Ministry will be
implemented by the Ministry of Health and Family Welfare. In pursuance of a recent policy decision of
the Government, the Labour and Employment Ministry is handing over the RSBY scheme to the Ministry
of Health and Family Welfare with effect from 1st April 2015.
► The RSBY, the health insurance scheme for BPL (below poverty line) families was launched for the
workers in the unorganized sector in the FY 2007-08 and it became fully operational from 1st April 2008.
It provides for IT-enabled and smart–card-based cashless healthy insurance, including maternity benefit
cover up to Rs. 30,000/- per annum on a family floater basis to BPL families (a unit of five) and 11
occupational groups in the unorganized sector. The "Unorganized workers social Security Act, 2008"
came into operation w.e.f 31st December 2008 and it encompassed ten social security schemes
benefiting the unorganized workers including the RSBY.
 Rashtriya Swasthya Bima Yojana

► Impact Analysis
► RSBY did not affect the likelihood of inpatient out-of-pocket spending, the level of inpatient out of pocket spending
or catastrophic inpatient spending. No statistically significant effect of RSBY on the level of outpatient
out-of-pocket expenditure and the probability of incurring outpatient expenditure.
► In contrast, the likelihood of incurring any out of pocket spending (inpatient and outpatient) rose by 30% due to
RSBY and was statistically significant. Although out of pocket spending levels did not change, RSBY raised
household non-medical spending by 5%. Overall, the results suggest that RSBY has been ineffective in reducing the
burden of out-of-pocket spending on poor households.
 Janani Suraksha Yojana

► Janani Suraksha Yojana (JSY) is a safe motherhood intervention under the National Rural Health
Mission (NHM). It is being implemented with the objective of reducing maternal and infant mortality by
promoting institutional delivery among pregnant women. The scheme is under implementation in all
states and Union Territories (UTs), with a special focus on Low Performing States (LPS).
► Janani Suraksha Yojana was launched in April 2005 by modifying the National Maternity Benefit Scheme
(NMBS). The NMBS came into effect in August 1995 as one of the components of the National Social
Assistance Programme (NSAP). The scheme was transferred from the Ministry of Rural Development to
the Department of Health & Family Welfare during the year 2001-02. The NMBS provides for financial
assistance of Rs. 500/- per birth up to two live births to the pregnant women who have attained 19 years
of age and belong to the below poverty line (BPL) households.
 Janani Suraksha Yojana

► When JSY was launched the financial assistance of Rs. 500/- , which was available uniformly throughout
the country to BPL pregnant women under NMBS, was replaced by graded scale of assistance based on
the categorization of States as well as whether beneficiary was from rural/urban area. States were
classified into Low Performing States and High Performing States on the basis of institutional delivery
rate i.e. states having institutional delivery 25% or less were termed as Low Performing States (LPS) and
those which have institutional delivery rate more than 25% were classified as High Performing States
(HPS). Accordingly, eight erstwhile EAG states namely Uttar Pradesh, Uttarakhand, Madhya Pradesh,
Chhattisgarh, Bihar, Jharkhand, Rajasthan, Odisha and the states of Assam & Jammu & Kashmir were
classified as Low Performing States. The remaining States were grouped into High Performing States.
 Janani Suraksha Yojana

► Background on JSY
► Thousands of women in India die every year due to pregnancy related complications. Similarly, every
year more than 13 lakh infants die within 1year of the birth and out of these approximately 2/3rd of the
infant deaths take place within the first four weeks of life. Out of these, approximately 75% of the deaths
take place within a week of the birth and a majority of these occur in the first two days after birth.
► In order to reduce the maternal and infant mortality, Reproductive and Child Health Programme under
the National Health Mission (NHM) is being implemented to promote institutional deliveries so that skilled
attendance at birth is available and women and new born can be saved from pregnancy related deaths.
► Several initiatives have been launched by the Ministry of Health and Family Welfare (MoHFW) including
Janani Suraksha Yojana (JSY) a key intervention that has resulted in phenomenal growth in institutional
deliveries.
 Janani Suraksha Yojana

► Background on JSY
► Thousands of women in India die every year due to pregnancy related complications. Similarly, every
year more than 13 lakh infants die within 1year of the birth and out of these approximately 2/3rd of the
infant deaths take place within the first four weeks of life. Out of these, approximately 75% of the deaths
take place within a week of the birth and a majority of these occur in the first two days after birth.
► In order to reduce the maternal and infant mortality, Reproductive and Child Health Programme under
the National Health Mission (NHM) is being implemented to promote institutional deliveries so that skilled
attendance at birth is available and women and new born can be saved from pregnancy related deaths.
► Several initiatives have been launched by the Ministry of Health and Family Welfare (MoHFW) including
Janani Suraksha Yojana (JSY) a key intervention that has resulted in phenomenal growth in institutional
deliveries.
► Objective
Reducing maternal and infant mortality by promoting institutional delivery among pregnant women.
 Janani Suraksha Yojana

► Target Group and benefits

► The scheme focuses on poor pregnant woman with a special dispensation for states that have low
institutional delivery rates, namely, the states of Uttar Pradesh, Uttarakhand, Bihar, Jharkhand, Madhya
Pradesh, Chhattisgarh, Assam, Rajasthan, Orissa, and Jammu and Kashmir. While these states have
been named Low Performing States (LPS), the remaining states have been named High Performing
states (HPS).
► The scheme also provides performance based incentives to women health volunteers known as ASHA
(Accredited Social Health Activist) for promoting institutional delivery among pregnant women. Under this
initiative, eligible pregnant women are entitled to get JSY benefit directly into their bank accounts.
 Janani Suraksha Yojana

► Impact Analysis
► Overall, institutional deliveries increased by 42.6% after implementation, including those among rural, illiterate and
primary-literate persons of lower socioeconomic strata.
► early initiation of breastfeeding and postnatal check up was consistently higher among JSY beneficiaries compared
to non-JSY beneficiaries.
 PMJAY

► Ayushman Bharat (PMJAY) was launched as a step towards Universal Health Coverage (UHC).
UHC entails ensuring all people have access to quality health services – including prevention,
promotion, treatment, rehabilitation, and palliation – without incurring financial hardship. The
concept covers three key elements — access, quality, and financial protection. India is
committed to achieving Universal Health care for all by 2030, which is fundamental to
achieving the other Sustainable Development Goals.
► The PMJAY was a step in this direction providing insurance cover to the poorest 40 per cent
of the population. Over 50 crore Indians are covered under the scheme with an insurance
cover of Rs 5 lakhs per family. PMJAY provides comprehensive hospitalisation cover for
secondary and tertiary care.
► The financial implications of hospitalisation can be devastating. PMJAY was conceptualized to
provide financial protection against hospitalisation to the most vulnerable parts of our
society. The average hospitalisation at Rs 20,000 per episode is more than the annual
consumer expenditure of nearly half our population.
 PMJAY

► Further, delayed hospitalisation can be debilitating and have long-lasting negative effects.
PMJAY has averted these disastrous consequences for over 1.2 crore treatments under the
scheme to date. Beyond providing much-needed cover, PMJAY also re-invigorated India’s
health landscape by ushering in demand-side financing and laying the foundations of a
modern IT platform for health.
► PMJAY has scored over its predecessor – Rashtriya Swasthya Bima Yojana (RSBY) – on several
measures. It covers a larger population, provides a more comprehensive benefits package,
and has a wider hospital network for availing care. In terms of operations, it has superior IT
and governance systems, and is building state capacity in management and governance.
Availability of portable benefits where eligible individuals can seek care anywhere in India is
an example of this capacity.
 PMJAY

► Further, the second pillar of Ayushman Bharat plans to transform 1.5 lakh sub-centres and
primary health centres into health and wellness centres (HWCs) to provide comprehensive
and quality primary care. These HWCs – of which almost 50,000 are already functional – will
provide a wider range of service including screening and treatment for non-communicable
diseases, and chronic communicable diseases like tuberculosis.
► These initiatives were in part a response to India’s high Out-of-Pocket (OOP) spending —
health spending through payments at the point of care — at almost 60 per cent, one of the
highest in the world. Over two-thirds of OOP spending is on account of out-patient
consultations, medicines and diagnostic tests accompanying it. In-patient care
(hospitalisation) including its pre and post-event ambulatory care, which is the focus of
PMJAY constitute less than a third of total OOP.
 PMJAY

► In 2014, more than 300 million people in India bore the burden of catastrophic spending of 10
per cent or more of their household expenditure on healthcare; besides absolute spending,
OOP spending was estimated to push an estimated 85 million people into poverty in the
same year. Primary healthcare is the cornerstone of an effective and sustainable health
system for achieving universal health coverage, and out-patient care is the principal means of
accessing primary care.
► As India marches down the path of UHC, the burden of household OOP spending on
non-hospitalisation care (or out-patient care) must be the focus. Average OOP spending on
out-patient care is over Rs 1,250 per person per annum, a conservative estimate based on NSS
2017-18. It has reduced from Rs 1,450 in the 2014 NSS primarily due to fewer reported
outpatient visits per person. Lack of financial protection for out-patient care pushes millions
into poverty each year. An average person seeks 1.8 consultations per year almost 70 per cent
of which are in the private sector. Majority of out-patient spending – around 70 per cent — is
on medicines.
 PMJAY

► OOP spending on out-patient care is a double threat. Not only is the financial burden larger, it
is also harsher on poorer segments of the population. Imagine a family engaged in part-time
agricultural labour in rural UP — they likely belong to the bottom 20 per cent and will spend
almost 6.5 per cent of their total household expenditure on out-patient care.
► Contrast this to a typical urban household with the earning members employed in the IT
industry. They will belong to the top 20 per cent and will spend less than 3.5 per cent of their
household expenditure of out-patient care, nearly half that of the family in rural UP.
► This poses large costs – immediate and long-term – for those in the bottom half of our
country since every rupee spent on medicines and consultations is a rupee not spent on food
or education.
 PMJAY

► The National Health Policy (NHP) 2017 commits to free provision of primary care by the public
sector, an assured, comprehensive primary care with linkages to referral hospitals, assured
free drugs, diagnostic and emergency services to all in public hospitals. Hence, it has to be
provided by the government. Yet the public sector catered to only 30 per cent of all
out-patient care in 2018 as per the 75th round of NSS.
► There are three areas to focus on.
► First, to carry on the promise of the National Health Policy by ensuring availability, access, and
utilization of high-quality primary care through government health services. Only one-fourth
to one-third of out-patient care is sought in government facilities in urban and rural areas
respectively, despite the availability of free or low-cost treatment for a wide range of primary
care services. Researchers have pointed to issues like poor quality of care, long wait times and
high health worker absenteeism with the government provided services, driving people –
poor and rich alike – to private care. The public sector needs to be made accountable for
providing accessible and efficient primary care and integrate it with secondary care under
PMJAY.
 PMJAY

► Second, there is virtually no insurance product available for out-patient care. Inclusion of
out-patient packages in insurance policies, including in PMJAY, can help improve financial
protection. As a starting point, diagnostic services and preventive check-ups targeting
common non-communicable diseases can be included in the benefits package. They will
improve the chances of a complete cure, in addition to preventing cost escalation, by
enabling earlier identification and management of NCDs.
► However, appropriate mechanisms will have to designed to incentivize providers to focus on
preventive rather than curative care.
 PMJAY

► Third, the high OOP spending on medicines must be addressed. Medicines account for 70
per cent of the total out-patient spending, more than twice that of consultation fees and
diagnostic tests combined. Rationalizing the use of medicines and further increasing
provision of free medicines can significantly help reduce the financial burden of out-patient
care. National Health Mission’s Free Drugs and Diagnostics Services Initiatives needs to be
made more effective in line with the promise in the National Health Policy. Reducing overuse
of medicines – especially anti-microbials – has the additional benefit of combatting the
growing drug resistance problem.
► The way forward requires careful thought and planning. The National Digital Health Mission
(NHDM) provides this opportunity by improving data linkages between the National Health
Mission (NHM) and PMJAY. Availability of portable benefits, telemedicine and wide network of
diagnostic labs does hold the promise of extending the reach of primary care to all citizens.
 RECOMMENDATIONS FOR SENIOR CITIZENS
Under the Maintenance and Welfare of Senior Citizens
Amendment to Sec 1 (b) to include “health”
Amendment to Sec 19 to include “mandatory home based care for the senior citizen”
Amendment to Sec 21 to include “the positive image and dignity of the elderly”
Recommendations under the Unorganised Workers Social Security Act, 2008
the act should specify sections focusing on the existence, legal authority and nature of the National Social security Fund and
an appropriate mechanism at the State level to ensure health care with an enforceable timeline for the elderly.
there must be explicit reference to migrant elderly workers, women elderly workers, and elderly who belong to the
disadvantage’s groups in the initial coverage for unorganised workers.
the Act must have a transparent grievance redressal and include powers to penalise the lawbreakers.
registration of unorganised workers should be mandated and social security identity cards should be issued irrespective of
any kind of employment for the elderly (Casual or regular) to ascertain their identity as senior citizens.
the advisory board (National Social Security Board & State Social Security Board) should possess substantial powers to
execute, monitor or enforce social security regulations.
Delinking work from health insurance.