With most surgical infrastructure concentrated in urban areas, seeking surgical treatment for people in rural areas is a nightmare. Poorly equipped and overburdened public health centres make things worse by pushing people requiring urgent care to private health centres that are known to leave patients with huge financial burdens.
Ayushman Bharat Pradhan Mantri Jan Arogya Yojana, the government’s flagship programme, was offered as a bandaid for the fractured Indian health system. AB PMJAY is a health insurance scheme that offers needy families free treatment up to Rs 5 lakh per annum in impaneled hospitals. However, enrolling in this scheme is often more difficult than fighting the disease itself.
Seeking treatment for a painful neck swelling, Sohan Lal, a 68-year-old farmer from eastern Madhya Pradesh, arrived at Jan Swasthya Sahyog, a hospital in rural central India. The search for a diagnosis – multiple consultations with doctors, and the tests they ordered – had already drained Sohan’s savings.
Following a thorough clinical examination and some basic tests, the doctor diagnosed him with cancer of the parotid gland (a salivary gland located over the cheek). The cancer had spread to the lymph nodes in the neck. The treatment was however not the only struggle that he had to go through.
Besides low haemoglobin that prevented him from getting treatment, just like most people from rural India, Sohan was also low on finances. Even though the treatment costs at JSS are highly subsidised, poor people seeking care there often struggle to pay even the smallest of amounts. To continue further treatment, for the poor, enrolling into the AB PMJAY scheme is the only option.
To enrol in the scheme and get an AB PMJAY card, a patient needs to prove that they fit the inclusion criteria of being socioeconomically backward by showing multiple documents like the Samagra ID card, the ration card, and an Aadhaar card.
As Sohan was unaware of this scheme, he lacked the required documents. For most people in remote and rural areas returning home to get the documents is also not an option as they often travel hundreds of kilometres for treatment.
For some people like Mukesh, another farmer seeking treatment at JSS, even having all the correct documents prevented him from receiving the scheme’s benefits. A mismatch in his name’s spelling in his ration and Aadhaar card meant that a digitised and empowered India could not identify that “Mukesh” and “Mukes” were the same person who was desperately seeking treatment.
The doctors found donors for his treatment as they feared that the duration taken in correcting the spellings, a herculean task in itself, would outlast the time Mukesh was left with. Similarly, a mismatch in age also denies people an AB PMJAY card till the discrepancy is corrected.
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Manju, a 70-year-old lady with tongue cancer, was facing a struggle not so unique in remote areas. Having worked in the field all her life, her hardened fingers had lost the fingerprints needed to prove her biometric existence. She too was denied an AB PMJAY card. Was her suffering, not only from the disease but also from poverty and social isolation, not enough to qualify her for a PMJAY card? Just like Manju, many other people have also lost their right to health after losing their fingerprints due to chronic undernutrition, long hours of manual labor, or to disease process itself.
The mandatory OTP verification further adds to the problems. The PMJAY card is denied even after dealing with all the hurdles mentioned above if the OTP can not be shared for verification. Most of the time people in need of the benefits of the scheme are migrant labourers. Due to their financial constraints and often due to theft, they are not able to use the same number for a long duration of time. Frequently updating the number in government documents is practically impossible considering their slow functioning. People living in tribal areas often lack a phone. The need for OTP therefore denies them the care they need.
If by chance, everything goes well and the patient is enrolled in the scheme, reimbursement can still be denied to the hospital because of the stringent criteria set for it. For example, an infection needs to be proved using a positive culture test to get the reimbursement. Not all infections always yield a positive culture and often the limitations of the labs in resource-limited settings fail to provide the necessary test results needed to prove a clinically apparent disease.
In Sohan Lal’s case, somehow we were able to manage all these hurdles and he underwent a successful surgery. As per plan, he was referred for radiation therapy to another centre which was situated 350 km from his home and 150 km from our centre.
Over the years, my experience with PMJAY has raised several questions in my mind. Why is a health insurance scheme and not public health infrastructure our government’s main priority to address people’s healthcare needs? Why is the scheme designed to be so difficult for patients? Is our health system and its policies really designed keeping the people in mind?
Sohan was lucky. However, countless people are struggling to access the most basic healthcare services. It’s been 78 years since independence. How many more years will it take till the government realises the importance of maintaining good health and providing access to a good public healthcare system?
Dr Deepak Chandra Badhani is a Senior Resident in the Department of Surgery at Jan Swasthya Sahyog, Ganiyari, Chhattisgarh. Views are personal and do not reflect the views of the organisation the author works with.
This article first appeared on Nivarana, a platform founded by Dr Parth Sharma, which focuses on India’s rural health issues. Read the original here.