#India – Womb and Wolves #Vaw #Womenrights #medicalethics


By Swagata Yadavar, THE WEEK
Story Dated: Monday, April 15, 2013 15:8 hrs IST
Guddi devi, 27: She had sought treatment for a simple stomach ache. The doctor prescribed hysterectomy. Today, with all her vitality sapped, she feels it was the biggest. Photo by Amey Mansabdar

“I feel sick.”
“I feel sick.”
“I feel sick.”
These words still echo in my ears. They did not come from a dying man or a depressed woman. They were whimpered by scores of ‘normal’ women in India‘s rural hinterlands.
The cause lay in two words uttered by their unscrupulous doctors: bacchedani kharaab. These gullible women were told their uteri were faulty, and that they had to be removed.
THE WEEK’s journey through some villages in Bihar and Rajasthan revealed the plight of women—many of them allegedly unmarried—whose wombs were removed as “treatment” for everything, from a simple stomach ache to menstrual issues.
Why? The reason, again, lay in two words: filthy lucre.


Sunita Devi, a 35-year-old labourer of Latbasepur village in Bihar’s Samastipur district, would tell us more. It all started with a debilitating stomach pain, which she had ignored for long. Thanks to the Rashtriya Swasthya Bima Yojana, she hoped to finally get proper treatment at a private hospital.
At Krishna Hospital, one of the hospitals empanelled in the rural health scheme, Sunita was told she needed an appendicitis surgery. And a hysterectomy, too.
She underwent both eight months ago. Today, she is feeble. “I often get palpitations,” she said. “I get frequent headaches and gas trouble.”
The mother of five can no longer work in the fields. She now assists at a small shop in the village. The plight of her two sisters-in-law who also underwent hysterectomies is no different.
Three years ago, the RSBY, which entitles families below poverty line to free treatment up to Rs.30,000 a year, was implemented in Samastipur district of Bihar. It was a godsend for the rural masses. But, in the hands of greedy doctors, it became a cruel instrument to siphon off public money.
The Samastipur scam came to fore when District Magistrate Kundan Kumar found an alarming number of hysterectomies conducted by private nursing homes during an RSBY meeting. Of 14,851 procedures conducted under RSBY between 2010 and 2012 in 16 empanelled hospitals in Samastipur, 5,503 were hysterectomies. That is about 37 per cent of all procedures. In some hospitals, more than 50 per cent were hysterectomies, which costs the highest of all procedures under the RSBY scheme.
Kundan Kumar organised a five-day medical camp to ascertain if the procedures conducted were needed. About 2,600 women who had undergone hysterectomy attended the camp. The expert team found 717 cases of unwanted surgery, 124 cases of underage surgery, 320 cases of fleecing and 23 cases of non-surgery.
The magistrate’s report clearly pointed to gross unethical practices. For instance, Anita Devi, 23, who complained of abdominal pain and white discharge, had been operated upon. The expert team commented: “Conservative treatment should have done, hysterectomy not justified.” Similar was the case of Ratna Devi, 40, who underwent hysterectomy for appendicitis.
The report noted that many beneficiaries mentioned by the private hospitals could not be traced. In many cases, the hospitals simply swiped their RSBY cards but never conducted the procedures. There were also instances of procedures being marked against the name of dead people. Worse, some hysterectomy ‘cases’ reportedly turned out to be men!
It was found that many of the private hospitals and nursing homes did not have the requisite infrastructure for the procedures. Only some of them had well-trained surgeons, and in a few cases, operations were conducted by non-medical practitioners.
Subsequently, 12 of 16 nursing homes in Samastipur were de-panelled from the list. FIRs, too, were lodged against five of these guilty hospitals under various sections.

Sangita devi, 26: She underwent hysterectomy two years ago. Her husband says the doctor who operated upon her often hassles her for signatures on “some paper”. Photo by Amey Mansabdar

The involved doctors, meanwhile, were doing their best to cover their tracks. “Dr Thakur from Krishna Hospital often comes to our house asking for our signature on some paper,” said the family of Sangita Devi, 26. Sangita underwent hysterectomy two years ago. Since then, she has been battling frequent spells of weakness, dizziness and  headaches. She now weighs just 30kg and can hardly manage any work. She has already spent Rs.5,000 on medicine and the frequent trips to the doctors are eating away most of what her husband earns. When THE WEEK contacted, Dr Thakur refused to meet us.

Next, THE WEEK travelled to Rajasthan’s Dausa district, where a high number of hysterectomies was reported recently. Guddi Devi, 27, felt sick, though she technically was not. Her bones and joints ached all day. Fatigue bound her to bed. Food did not interest her. And her eyesight was fading. It was nothing but a clear case of premature menopause, courtesy the hysterectomy and oophorectomy she underwent three years ago.
“I had gone to the doctor, complaining of stomach ache. He told me that my uterus should be removed or I would get cancer,” she said. Her family, which owns just a small piece of land, was convinced to go for the “life-saving” surgery costing Rs.16,000.
“I feel weak all the time. I constantly fall ill, and the stomach pain for which I sought treatment initially persists,” said the mother of three. She has already paid another 110,000 on treatment of these symptoms, often travelling two and a half hours by tractors and buses to the nearest hospital. Now, her 12-year-old daughter, Rinki, takes care of all the household responsibilities. “I am upset about spoiling her education,” added a sullen Guddi.

Angoori devi, 34: She underwent hysterectomy as treatment for excessive menstrual bleeding. She recalls that about 40 women were admitted along with her in the same hospital for hysterectomy. Photo by Amey Mansabda

Every village THE WEEK visited had similar stories to tell. “I went to the doctor for excessive menstrual bleeding and he advised hysterectomy,” said Angoori Devi, 34, of Sikandara. “She cannot do anything now; she gets easily tired,” complained her daughter, Guddi. The family had to sell their buffalo to pay for the surgery, which gave her joint aches, indigestion, dizziness and fatigue as companions.
“When I was admitted in the hospital, there were about 40 women who were undergoing the same operation,” Angoori recalled about her stay at Madaan Hospital. Activists in the area said as many as 2,300 women in the region have undergone unwanted hysterectomies at private hospitals in the past two years.
An RTI application filed by advocate Durga Prasad Saini of Dausa revealed that of 385 procedures conducted over six months in three private hospitals of Bandikui town in 2010, at least 226 were hysterectomies. And of them, 185 were below the age of 30.
“Is there an epidemic in Dausa that forces women to undergo hysterectomy?” asked Saini, who is also National General Secretary of Akhil Bharatiya Grahak Panchayat (ABGP). “If there was a suspicion of cancer, why was not a single biopsy done?”
What compounds the issue in such villages is the people have no one else to go to. For instance, the post of a gynaecologist had been lying vacant for many years in the community centre in Bandikui despite repeated requests.
Though the centre got a gynaecologist, it wore a dark and deserted look when we visited. “Tell us how we will manage when such a big centre only has five doctors,” said an employee. On the other hand, there are five big private hospitals in the town, doing well.
“The doctors have an understanding with the rural practitioners, who are promised a commission on referrals,” alleged Dr O.P. Bansal, who runs a hospital in Dausa. Even employees at government hospitals act as agents who take patients to private clinics.
Hysterectomy was so ubiquitous in the town that some households had three generations of women who had gone under the knife. Take the case of Sushila Devi of Maanpur village who had gone to Katta Hospital to meet a relative, Guddi Devi, admitted for hysterectomy. Sushila, too, got caught in the trap and was operated upon three days later.
Guddi Devi, a mother of four, was advised hysterectomy to cure body ache. Now, she can no longer work as a labourer. “I feel dizzy when I am in the sun, I cannot lift heavy loads and get frequent palpitations,” she said.
Surprisingly, despite protests and frequent media reports, no action was taken against erring private hospitals. “They have consent papers from the women, so we cannot do anything unless the Clinical Establishment Act is passed,” said O.P. Baherwa, chief medical and health officer, Dausa.

Vimla Devi, 20: Her caesarian section that went wrong was followed by a hysterectomy. The childless couple has filed a police case. But her husband, Mahendra Kumar, says the cops have been threatening him to not pursue the case. Photo by Amey Mansabdar

Many FIRs, too, were lodged in the local police stations against the doctors. Mahendra Kumar filed a case against Madhur Hospital and its owner Dr Rajesh Dhakar, after his 20-year-old wife, Vimla Devi, was subjected to hysterectomy following a failed caesarian section.
The crestfallen childless couple alleged that the police did not investigate the matter properly and threatened ‘action’ if Kumar pursued the case.
The attitude of officials at Dausa was, indeed, sympathetic towards the doctors. “People here attack the doctors and threaten to destroy the hospital, hoping to get compensation,” said District Collector Pramila Surana. Police Inspector Rohitash Devanda said he had not come across any cases against doctors since he took charge 10 months ago. “These people blackmail doctors to gain money. If some patients die during treatment, it does not mean the doctors are at fault,” he said. A clock bearing Madhur Hospital’s name hung on his office wall.
The RSBY triggered a uterus loot in Chhattisgarh, too. Health Minister Amar Agrawal stated that 1,800 hysterectomies were done in just eight months last year. It was estimated that at least 7,000 hysterectomies were conducted in the state over the past three years under the RSBY scheme. The issue, which was noted by the National Human Rights Commission, led to a furore and licences of 22 private hospitals were cancelled.
Down south in Andhra Pradesh, it was the state government’s insurance scheme, Arogyashri, that led to rampant exploitation. Ever since the scheme was implemented in 2007, there was an exponential rise in hysterectomy cases.
Hyderabad-based NGO Centre for Action, Research and People’s Development found that 171 women under age 40 in just one administrative block of Medak district had undergone hysterectomy. About 95 per cent of them had gone to private clinics for treatment and 33 per cent had their ovaries also removed.
A survey by the Andhra Pradesh Mahila Samatha Society found that as much as 32 per cent of about 1,000 women who underwent hysterectomy were below age 30.

These case studies and statistics point to deep rot in the health care system. In fact, it is disheartening to see a project like the RSBY—termed by the World Bank as “path-breaking”—being exploited. The RSBY was seen as a prelude to the Centre’s ambitious Universal Health Coverage, which is expected to be implemented under the 12th Five-Year Plan (2012-17).
While private health providers bring better infrastructure and quality, they also bring in the risk of greed and exploitation. Without proper monitoring, this kind of public-private partnership is a cause for concern, said Padma Deosthali, coordinator of Centre for Enquiry into Health and Allied Themes, Mumbai. “For instance, there is no mention of quality of care in the empanelment under the RSBY scheme. Not even basic standards like presence of a qualified medical practitioner and nurse,” she pointed out.
“More than treating health problems, the focus is on procedures and surgeries, which was exploited by private nursing homes,” said Dr A.V. Sahay, medical officer and district head of Bihar Swasthya Seva Sangh. He also stressed on the need for enhancing the public health care system and improving the “reproductive hygiene” of women in rural regions.
Dr Yogesh Jain of Jan Swasthya Sahyog said a major flaw in the scheme was that it did not cover out-patient treatment and, hence, encouraged unwanted hospitalisation. Without strict guidelines, doctors cannot be expected to regulate themselves, he added.
Currently, however, the Central government has directed all state nodal agencies of RSBY that approval from the insurance company concerned is mandatory for hysterectomies performed on women under age 40.
But does the issue end there? The brouhaha shall pass. The scam will turn stale. But what about the innocent women who went under the knives for no reason? Sadly, no one, except a few NGOs, has reached out to them.
“The cost of maintaining the health of a woman who had undergone hysterectomy with medicines and supplements is Rs.18,250 a year,” said Dr Prakash Vinjamuri of Hyderabad-based Life HRG, which studied the surgery’s impact on women in Medak district of Andhra Pradesh in 2011.
The toll is not just monetary. Loss of vitality and libido affects the psychological and social health of the woman. The study in Medak, for instance, found women whose uteri were removed faced domestic violence over sexual issues, and many husbands had extra-marital affairs. The worst part was the impact on the next generation, as children of these women are forced to quit school to handle household chores.
When and who will compensate for all these losses?

Vital loss

Hysterectomy  is the surgical removal of the uterus but may also involve removal of the cervix. A patient may require 3-12 months for full recovery.

TYPES
Radical hysterectomy
Removal of cervix, upper vagina, lymph nodes, ovaries and fallopian tube. Recommended in case of cancer.

Total hysterectomy
Removal of uterus and cervix.

Subtotal hysterectomy
Removal of the uterus.

RISKS
* Excessive blood loss, injury to ureter and bladder
* Cardiovascular disease
* Osteoporosis
* Decline in psychological well-being
* Decline in libido
* Premature death
* Affects the functioning of ovaries in 40 per cent of women

Early menopause
The average age of menopause in India is 51 years, and removal of ovaries advances it by 3.7 years. Menopause leads to a drop in oestrogen (female hormone) level, causing calcium loss and bone breakdown.

When is hysterectomy needed?

Hysterectomy should be a last resort in conditions such as cancers of the reproductive system, severe infections, persistent vaginal bleeding, uterine prolapse, endometriosis and to prevent further conception.

Before undergoing hysterectomy, one should undergo either a hormone test, sonography or a pap smear to test for cancer.

 

#Chhattisgarh #Andhra – Setback to health insurance


Published on Down To Earth (http://www.downtoearth.org.in)

Setback to health insurance

Author(s):

Kundan Pandey

0 Comments
Author(s): Kundan Pandey
Issue Date: Apr 30, 2013

Private hospitals in Chhattisgarh, Andhra refuse to treat under government insurance scheme

Strengthening primary healthcare facilities would cost one-third of what governments spend on health insuranceStrengthening primary healthcare facilities would cost one-third of what governments spend on health insurance (Courtesy: swasthindia.in)

LAST year when the Chhattisgarh government announced health insurance scheme for people above the poverty line (APL), it was touted as an initiative to improve healthcare delivery in the state. But within a few months of introducing it, Mukhyamantri Swasthya Bima Yojana (MSBY) has turned out to be a political gimmick to capure the vote bank as the government faces elections in October-November.

The state launched MSBY on the lines of the Centre’s Rastriya Swasthya Bima Yojana (RSBY), which caters to people below the poverty line (BPL). It provides cover for hospitalisation cost up to Rs 30,000 for a family of five on floater basis. The state has roped in the 350 private hospitals under RSBY for its MSBY scheme. But the hospitals are not willing to admit APL patients under the scheme, saying the insurance amount is too less.

Like RSBY, MSBY sets down the amount a hospital can charge for the treatment of a particular disease. For example, hospitals under the scheme can charge Rs 3,500 for treating pneumonia or malaria and Rs 9,500 for jaundice. The private hospital authorities say they treat BPL patients at such low rates as a welfare scheme. It would be difficult to provide the care to all at such low fees.

Ajay Sahay, president of the Chhattisgarh chapter of Indian Medical Association (IMA), says, “We have informed the government about our demands to increase the insurance amount to somewhere between Rs 1.5 lakh and Rs 2 lakh.” On April 4, a group of private hospital authorities held a meeting with the state’s health minister, principal secretary and other government officials to discuss their grievance. “Instead of proper solution, they proposed increasing the cost of one treatment and reduce that of the other. They also said that we would have to treat MSBY beneficiaries, if we want to treat people under RSBY,” says Sahay. “We are now left with no option except refusing BPL patients as well.” Sahay alleges that the government did not consult the private health sector while planning MSBY, but now it wants the sector to implement the scheme before the elections.

Can private players help?

In December last year, the Chhattisgarh government had tried to outsource diagnostic facilities for government hospitals to strengthen its public healthcare system. But no private party showed interest to provide diagnostic facilities in remote areas of the state.

“It is not strange or unexpected,” says T Sundararaman, executive director of National Health Systems Resource Centre, a technical support institution with the National Rural Health Mission. Private sector works for the maximum margin and is demanding just that, he adds. But increasing the insurance amount is not the solution, Sundararaman says, citing the example of Andhra Pradesh, where the private health sector is demanding an increase in the insurance amount from the existing Rs 1.5 lakh.

Private hospitals in Andhra Pradesh have threatened to discontinue providing treatment under Rajiv Arogyasri scheme for BPL category from May 3 if their demands are not met. Every year about 200,000 patients undergo surgery under the scheme for 938 listed diseases.

B Bhaskar Rao, president of Andhra Pradesh Specialty Hospitals Association (ASHA) says the government launched the scheme six years ago. But there has been no hike in the amount despite requests by the private doctors’ association. “We demand that the government raise the insurance amount by 30 per cent and thereafter increase it by 5 per cent every year,” says Rao.

To achieve universal healthcare, senior public health specialist Sakthivel Selvaraj, says governments should focus on strengthening primary healthcare facilities. After all, this would cost one-third of what they spend on insurance, he says, adding, “We have never invested sufficiently in public health system which can solve the problem.”

 

Andhra Pradesh – Private hospitals may pull out of Aarogyasri #healthcare


As was anticipated and warned, the private healthcare industry is showing its true colours and indulging in supplier ‘hold-up’ and increasing the costs.

TNN | Apr 4, 2013,

HYDERABAD: Private hospitals in the city will pull the plug on the state’s flagship Aarogyasri scheme from May 3 after the government refused to accept a minimum 30% hike on the existing tariffs and said henceforth they would only admit patients who can be discharged before the deadline.

If private hospitals go ahead with their plans, thousands of poor people will be denied quality care in top private hospitals in Hyderabad and elsewhere in the state, and is likely to force the government to take action.

About 250 private hospitals in the state treat about 2 lakh patients annually under the Aarogyasri scheme for the 938 listed ailments and diseases.

“It is a sad decision but we are not in a position to carry the burden of the scheme anymore,” said Dr B Bhaskar Rao, president, ASHA.

“Since the scheme’s inception in 2007, costs have gone up steeply but the government is still reluctant to revise the tariffs. Initially, we were told that 28% of the population falls under BPL and will be covered under the scheme, but the fact is 82% of the population is eligible to avail this scheme,” he said.

“We have been requesting the government for a revision since last two years, but nothing has been done.”

In another development, the AP Private Hospitals and Nursing Homes Association (APNA) and AP Specialty Hospitals Association (ASHA), served a notice to the CEO of Aarogyasri trust, demanding a minimum 65% hike in the tariffs, over and above the revised tariffs for healthinsurance scheme for state government employees and their dependants for twin sharing of rooms.They also demanded a 100% hike over and above the revised tariffs for single private rooms. The notice comes at a time when the state government is planning to launch the scheme for government employees on the lines of Aarogyasri from Ugadi.

 

Setback to Chhattisgarh health care services


SUVOJIT BAGCHI, The Hindu, March 30, 2013

Private hospitals refuse treatment under government insurance schemes

The Chhattisgarh government has had to accept yet another setback while trying desperately to rope in private players to strengthen public health care services.

At least 20 major private hospitals have refused to provide treatment under the Chief Minister’s health insurance scheme — Mukhyamantri Swasthya Bima Yojana (MSBY). Reportedly, they are also not following guidelines to provide treatment under the national health insurance scheme, Rashtriya Swasthya Bima Yojana (RSBY), and are charging money from the patients.

Hospital owners claimed that the insured amount paid for treatment of the patients below poverty line (BPL) under RSBY is “very low.” In addition, introduction of a scheme for the people above poverty line (APL) under MSBY will “seriously damage business and thus will affect services.”

State health officials, hospital management and representatives of insurance companies and Third Party Administrators (TPA) held a meeting on Thursday. According to local news reports, Director, Health Services, Dr. Kamalpreet Singh, said rates had already been “upwardly revised” under RSBY and MSBY after consultation with private hospitals.

Under the new list, 272 categories of treatment, commonly called ‘packages,’ were increased by four to 200 per cent. Another 22 packages had been added and the new list will be applicable from April 1. However, major private players are not happy with the revised rate list and refused to implement the insurance schemes in their hospitals. The move angered the government and the health department has decided to de-panel the hospitals, the sources said.

Earlier this month, the government faced a setback while trying to introduce the policy of Public Private Partnership (PPP) in public health facilities. No private diagnostic centre had come forward to set up radiology and laboratory facilities in the two most underdeveloped divisions with high percentage of rural population — Bastar in south and Surguja in north Chhattisgarh following governments directives.

The Chhattisgarh Government’s Directorate of Health Services had to seek fresh bids for newly aligned divisions. According to the sources, while a good number of applications were filed for affluent divisions such as Raipur and Bilaspur, not receiving a single application for the poorer divisions illustrate the private players’ reluctance to acknowledge health care as a social service. However, the proponents of Chhattisgarh’s public-private venture in health care were optimistic about its future, even after these recent rounds of setbacks.

 


  • Major private players are not happy with the revised rate list
  • Government to “de-panel” hospitals that refuse to cooperate

 

#India- Forced hysterectomies, unscrupulous doctors #Vaw #Reproductiverights


Swapna Majumdar/Women’s Feature Service

Consider this chilling statistic: In the last two years, in various states of India, more than 30,000 women were reported to have undergone hysterectomies.

In 2011, 16,000 women opted for hysterectomies in Bihar; doctors performed about 7,000 uterus removal surgeries over a period of 30 months in Chhattisgarh, while a total of 11,000 such procedures were done over a period of two years in Andhra Pradesh.

Not only is this sudden rise in hysterectomies deeply worrying, even more serious is the fact that 80 per cent of the women who underwent them were between the ages of 20 and 40 years. Health activists contend that rural women living below the poverty line (BPL) are being advised to go under the knife to avail of their health insurance money provided under the Rashtriya Swasthya Bima Yojna (RSBY), the union government’s premier insurance scheme that provides health coverage to underprivileged families.

According to reports, in Bihar’s Samastipur district alone, 14,851 BPL women were admitted to 16 private hospitals in the past one year to avail the benefits under the RSBY scheme. In Chhattisgarh, private nursing homes billed the state government Rs 2 crore under the scheme for conducting hysterectomies of 1,800 women over a period of eight months last year. In Andhra, under the Aarogyasri scheme, the state health insurance plan, a sum of Rs 2.9 crore was paid for 656 surgeries carried out in 2009-10.

According to Sulakshana Nandi of the Jan Swasthya Abhiyan, a collective of over a thousand NGOs working on health rights, “The RSBY and similar health insurance schemes are incentivising unethical practices leading to the large number of irrational and unnecessary surgeries.”

Here’s why health activists are concerned. Under the RSBY, cashless insurance of Rs 30,000 is given yearly to a BPL family – and a doctor can charge a hefty Rs 12,500 for a hysterectomy. In Andhra, for instance, a hysterectomy can cost up to Rs 60,000 – an amount that was reimbursed under the state’s Aarogyasri scheme.

Nandi, who has done four studies assessing the implementation of the RSBY in Chhattisgarh, points out that private hospitals were cherry picking the patients they wanted to treat. “Doctors chose patients who needed high-end surgeries that are more expensive and, therefore, more profitable. For example, a hysterectomy is considered a more profitable surgery compared to a caesarean section. It is ironic and scary that a woman can, in some sense, have easier access to hysterectomy than simple treatment for her problems at an early stage of any uterine infection because of RSBY and other insurance schemes,” she contends.

In Andhra Pradesh, ‘aarogyamitras’, or health helpers, are appointed by private hospitals to scout around for patients who can be enticed to get operated upon in private hospitals, reveals N. Purendra Prasad of the Department of Sociology at Hyderabad University. Prasad, along with research scholar P. Raghavendra, found that “a spurt in unnecessary surgeries had been reported after Aarogyasri was launched. For instance, in district Warangal’s 13 private and five government hospitals, 38,090 cases, of which 3,346 operations related to hysterectomy, were reported from August 1, 2008 to August 21, 2010. As there was scope for quick money to be made in surgeries, private hospitals used registered medical practitioners (RMPs) to refer poor women with gynaecological problems as hysterectomy cases”.

Unfortunately, it is the women who are ultimately paying a very heavy price. When Rajamma of Kannaram village in Andhra’s Medak district went to the doctor complaining of pain in her lower abdomen, she was wheeled in for a hysterectomy. All she was told was that this would help relieve her pain. Rajamma was just 20.

But it was not just Rajamma who went under the knife. Almost all the women in Kannaram village had undergone hysterectomy for routine complaints like abdominal pain or white discharge. This was revealed by the Centre for Action, Research and People’s Development (CARPED), a Hyderabad-based NGO. The 2009 survey found that most of the women in the 125 households in the village had undergone procedures to remove their uterus. This was backed up by a study in the same year by the Andhra Pradesh Mahila Samatha Society, a state government organisation, which found hysterectomy cases in women between the ages 25 and 40 had increased by 20 per cent since Aarogyasri was launched in 2007. Of the 1,097 women surveyed in five districts, 30 per cent reported that doctors had told them that they would die if they did not get operated.

In Chhattisgarh, health activists say that poor illiterate women complaining of back pain were warned that they would contract cancer and die if their uterus was not removed, even as those suffering from excessive bleeding or vaginal discharge too stood no chance of escaping the surgery. While the procedure may have been necessary for some, in most cases it was not required.

According to Dr S.V. Kameswari of Life-HRG, a Hyderabad based NGO providing healthcare to rural women and campaigning against the unnecessary hysterectomies in the state, the reason for the indiscriminate usage of surgical treatment in the state was a combination of the socio- economic and cultural background of the women. “The lack of awareness of the women and the power of the medical practitioners to influence their decision led to the spate of unnecessary hysterectomies,” she contends.

Dr Kameswari, who studied the medical ethics of hysterectomies in rural Andhra Pradesh, found several aberrations. “Instead of following the normal protocols while examining women with complaints of abdominal pain, bleeding or vaginal discharge doctors performed or advised hysterectomies,” she reveals.

Standard protocol demands that women have to be informed about the after-effects of such a surgery. Medical studies have established that those who have undergone hysterectomy face long term health implications, including a higher risk of heart disease and osteoporosis. They are also more likely to become depressed.

At least Dr Kameswari’s study had a positive outcome. “We were called by officials of the Aarogyasri scheme to discuss the data emerging from our study. Other experts were also consulted. Thereafter, revised guidelines were issued banning private hospitals empanelled under the scheme from conducting several surgical procedures including hysterectomies, appendectomy and the removal of the gall bladder,” she states.

While governments of Chhattisgarh, Bihar and Andhra Pradesh have initiated action against erring hospitals, nursing homes and doctors, health activists argue that great damage has already been done. They say that the number of unnecessary hysterectomies conducted may have come down in Andhra after the guidelines were revised in April 2010, but it could not undo the harm done to the thousands of women who were encouraged into removing their uterus.

It cannot assuage the grief of women like Rani whose chances of having a second child have ended because of a callous system. Much to the shock and horror of the 19-year-old who was admitted to a private hospital for a severe stomachache, her uterus was removed instead of being operated for appendicitis, as her family had imagined.

Health activists believe that unless there is an effective, efficient and accountable public health system, unethical practices will continue. The absence of quality healthcare in rural areas forces women to approach “good doctors” in towns. The doctor’s advice to remove their uterus makes them believe that it will end their medical problems once and for all. What makes the procedure more attractive is that being covered by the RSBY or other government sponsored insurance schemes, it is free. They are neither informed about its long-term consequences, nor the alternative medical treatments available.

Not only is a more robust monitoring of the insurance schemes needed, focused attention on improving basic health services could save women like Rani from losing a second chance at motherhood.

#India #Budget2013 and Health Sector


Ministry of Health and Family Welfare

* Budget Allocation of Rs.37, 300 crores to the Ministry of Health and Family Welfare.  Of this, the new National Health Mission that combines the rural mission and the proposed urban mission will get Rs.21,239 crore, an increase of 24.3 percent over the RE.

* Allocation of Rs. 4,727 crores for medical education, training and research

* Allocation of Rs. 150 crores for the National Programme for the Health Care of Elderly. This programme is being implemented in 100 selected districts of 21 States.  Eight regional geriatric centers are being funded for the development of dedicated geriatric departments.

* Allocation of Rs. 1,069 crore to the Department of AYUSH for mainstreaming Ayurveda, Unani, Siddha and Homoeopathy through the National Health Mission

* Allocation of Rs.1,650 crore for he six AIIMS-like institutions being set up

ICDS

* Allocation of Rs. Rs.17,700 crore in 2013-14, compared to Rs.15,850 crore in 2012-13, which is an increase of around 11.7%

* A multi-sectoral programme for reducing maternal and child malnutrition that was announced last year will be implemented in 100 districts during 2013-14 and it will be scaled up to cover 200 districts the year after.  Allocation of Rs. 300 crore for the programme in 2013-14.

Health Insurance

The Rashtriya Swasthiya Bima Yojana covers 34 million families
below the poverty line.  It will now be
extended to other categories such as rickshaw, auto-rickshaw and taxi drivers,
sanitation workers, rag pickers and mine workers.

The Budget proposes a comprehensive and integrated social
security package for the unorganised sector that will benefit the poorest and
most vulnerable sections of society.  The
package should include life-cum-disability cover, health cover, maternity
assistance and pension benefits.  The
present schemes such as AABY, JSBY, RSBY, JSY and IGMSY are run by different
ministries and departments.  The Budget
proposes to facilitate convergence among the various stakeholder
ministries/departments so that we can evolve a comprehensive social security
package

Direct Taxes

Contributions made to the Central Government Health Scheme are
eligible for deduction under section 80D of the Income-tax Act.  The budget proposes to extend the same
benefit to similar schemes of the Central Government and State Governments.

Indirect Taxes

The budget proposes to provide for MRP based assessment in
respect of branded medicaments of Ayurveda, Unani, Siddha, Homeopathy and
bio-chemic systems of medicine.  There
will be an abatement of 35 percent.

Source: http://indiabudget.nic.in/bspeecha.asp

 

 

Healthcare Models in the Era of Medical Neo-liberalism #mustread


A Study of Aarogyasri in Andhra Pradesh, EPW

By-N Purendra Prasad (purendra.prasad@gmail.com) teaches at the department of sociology, University of Hyderabad

and P Raghavendra (raghavendra868@gmail.com) is a research scholar in the department of sociology, University of Hyderabad.

The experiment in restructuring the healthcare sector through the Aarogyasri community health insurance
scheme in Andhra Pradesh has received wide attention across the country, prompting several states
governments to replicate this “innovative” model, especially because it supposedly generates rich electoral
dividends . However, after a critical scrutiny of this neo-liberal model of healthcare delivery, this paper
concludes that the scheme is only the construction of a new system that supplants the severely underfunded
state healthcare system. It is also a classic example of promoting the interests of the corporate health
industry through tertiary hospitals in the public and private sectors.

Medical neo-liberalism is characterised by the commodification of health that transforms individuals
from patients to consumers. Unlike patients, consumers who seek healthcare bear the responsibility for the
choices they make or fail to make regarding their health. As consumers are positioned to make choices about healthcare,
they also have the obligation to utilise products and services that are available to ensure good health or to treat illness and
disease. Fisher (2007) points out that patients as consumers have embraced the neo-liberal logic of healthcare so that they
too see illness in reductionist terms and seek pharmaceuticals as targeted magic bullets. With growth in customised products
and medical costs, access and affordability to healthcare has become a key issue across the world.
In the Indian context, the increased disease burden on the poor along with rapidly growing healthcare costs has been the
subject of debate for sometime now. Services in government healthcare institutions have declined over the past two decades
at the primary and secondary level, leaving the sick-poor with no option but seek private healthcare services. Several
studies have pointed out that rising expenditure on health and education is one of the main contributory factors to high
indebtedness and subsequent suicides among peasants in different parts of the country in the last 10 years (Sarma 2004;
Ghosh 2006).
Clearly, healthcare has assumed huge political signifi cance for the neo-liberal state with new and innovative (populist)
healthcare programmes being launched in several states in different forms. Among these, Rajiv Aarogyasri, a community
health insurance scheme introduced by the Government of Andhra Pradesh (AP) on a pilot basis in 2007 and implemented
in 2008 is being hailed by many experts as a model to be emulated – the scheme covers 6.55 crore people belonging to
183 lakh below the poverty line (BPL) families.Aarogyasri needs special attention as it is supposed to have mobilised a large number of voters for the ruling Congress Party during the 2009 assembly elections who helped it return
to power for a second term. This scheme’s popularity is so huge that several delegations from different states in India have
been regularly studying its logic in order to replicate it and reap similar political benefi ts. States such as Kerala, Tamil
Nadu (Kalaignar Scheme), Delhi (Apka Swasthya Bima Yojana), and Karnataka have already formulated a similar template
and are in the process of implementing it. The Maharashtra  government too announced the Rajiv Gandhi Jeevandayee Arogya Yojana, a free medical care scheme for the poor in 2011, committing Rs 800 crore in the fi rst phase to benefi tnearly 50 lakh families earning below Rs 1 lakh per annum ineight districts.

A national social health insurance scheme called the Rashtriya Swashthya Bima Yojana (RSBY) waslaunched as a centrally-sponsored scheme in 2008 to cover 2.3 crore families and seven crore benefi ciaries. The AP government has already announced that Aarogyasri will soon become a  universal health scheme and cover non-BPL families as well.

Given the pre-eminence of the scheme, it is important to assess the scheme by locating it in the historical evolution of healthcare systems in India in the context of its underlying socioeconomic and political dynamics.

Read full article here

 

Immediate Release-Planning Commission of India to hand over Health Care to Corporate Sector


 

English: Montek S. Ahluwalia, Deputy Chairman,...

English: Montek S. Ahluwalia, Deputy Chairman, Planning Commission, India, speaks at the closing plenary of the World Economic Forum’s India Economic Summit 2008 in New Delhi, 16-18 November 2008 (Photo credit: Wikipedia)

 

 

 

 PRESS STATEMENT

 

 

Planning Commission of India to hand over Health Care to Corporate Sector

 

The draft health chapter of the 12the Five Year Plan document is being discussed for final adoption by the Planning Commission by the end of August, 2012. The Jan Swasthya Abhiyan (Peoples Health Movement – India) expresses concern regarding the present recommendations and plans outlined in the draft chapter. The chapter fails to build on the recommendations of the High Level Expert Group (HLEG) set up by the Planning Commission, misquotes the Group’s recommendations in many places and ends by proposing a plan for restructuring the country’s health system that would effectively hand over health care to the corporate sector. It is particularly problematic that the plan document invokes the concept of Universal Health Care, while actually proposing a strategy that is far removed from the basic tenets of Universal Health Care.

 

The Plan document recommends increase in public expenditure on health from the present 1% to 1.58% of GDP. This is in sharp contrast to the HLEG recommendation of increasing this expenditure to at least 2.5% of the GDP and also at variance with the earlier pronouncements by the Prime Minister. Secondly it proposes that the Central government’s (which collects most of the taxes ) share in the additional health expenditure would be less than half of what states would contribute and that Centre’s contribution would be conditional on states’ contribution!   The Planning Commission seems to have decided thatIndia will continue to be among the bottom 10 nations in terms of percent GDP spending on health.

 

What is of even greater concern is the strategy proposed for restructuring of the country’s health system in the document. The Plan document proposes a transition from: “….the present system which is a mixture of public sector service provision plus insurance, to a system of health care delivered by a managed network”. There is, thus, a road map envisaged where the Government will abandon its central role of providing health care and become primarily just a ‘manager’ of the new system envisaged.

 

The document’s vision of ‘universal provision of public health care’ includes two components.  “..preventive interventions which the government would be both funding and universally providing” (see annexure) and  “clinical services at different levels, defined in an Essential Health Package, which the government would finance but not necessarily directly provide”. What, in essence, this formulation proposes is that the Government would, over time, confine itself to providing a small package of services and would be primarily just a purchaser of virtually all clinical services from the  corporatised private sector. The Government would thus finance (with public money), strengthen and bolster an already resurgent corporate sector providing medical services. On the face of it, this appears an almost diabolical ploy to hand over the profit-making clinical services sector to corporate hospital chains. It would also decisively halt and eventually reverse the moderate achievements of the National Rural Health Mission, in expanding public health infrastructure and services in parts of the country.

 

The public health system will now be asked to compete with the private sector to attract patients. A system is envisaged where: “each citizen family would be entitled to an Essential Health package in the network of their choice. Besides public facility networks organized .. private and NGO providers would also be empanelled to give a choice to the families”. Even this truncated role of the public system is qualified by the proviso that” “..public facilities will have to be strengthened, networked, and their managers provided sufficient autonomy to purchase goods and services to fill gaps as per need”. In other words, public only in name, but would be vitiated by the logic of the market and by the incorporation of private players into its fold.

 

The HLEG had, in its report, commented that: “since there is virtually no focus on primary level curative, preventive, and promotiveservices and on long-term wellness outcomes, these traditional insurance schemes often lead to inferior health outcomes and high health care cost inflation”. Yet the Planning Commission’s document repeatedly talks about expansion of the health insurance scheme called RSBY and its vision of Universal Health Care is nothing but a more expanded version of the RSBY scheme.

 

The document announces another bonanza to the corporate medical sector in the form of grants to set up hospitals and private medical colleges. It says: “Health has now been included with other infrastructure sectors which are eligible for Viability Gap Funding up to a ceiling of 20% of total project costs under a PPP scheme. As a result, private sector would be able to propose and commission projects in the health sector, such as hospitals and medical colleges outside metropolitan areas, which are not remunerative per-se, and claim up to 20% of the project cost as grant from the Government”. It may be noted that the only eligibility requirement is the location, and not any contribution to public health goals.

 

This document proposes that  public health facilities will have “flexibility” to raise their own finances. The Plan document says: “Tertiary care facilities would have an incentive to generate revenues if they are provided an autonomous governance structure, which allows them flexibility in the utilization of self-generated resources within broad policy parameters laid down by the Government”. There are several ways in which such flexibilities can be misused, including in the form of levying of user charges and arrangements with private entities that seek to extract benefits that conflict with the public health goals of public institutions.

 

The HLEG  had recommended : “enforcement of price controls and price regulation on essential and commonly prescribed drugs”. However, this document does not even  mention drug price regulation, in spite of a pending Supreme Court directive that the Government should expeditiously put in place a system to control the prices of drugs. Neither is the recommendation of the Expert  Group, that the production of drugs and vaccines in the public sector be incentivised, reflected anywhere in this  Planning Commission’s chapter.

 

The ideological bias of the Planning Commission’s report is clear when it says: “A pure public sector delivery system involves funding a large public sector health system, with little incentive for the service providers to deliver a quality product”Such an assertion flies in the face of global evidence that the best performing health systems are those that are publicly financed and where health care is provided either almost entirely by the public sector or by a combination of the public sector and non-corporate  providers. Neighbouring Sri Lanka has been long held as an example of such a system, where over 90% of in-patient care and over 50% of out-patient care is provided by the public sector. Mortality and morbidity rates in Sri Lanka are far better than in India, in spite of the country having a lower per-capita GNP. Thailand, in recent years, has made rapid strides in providing universal access to health services by increasing public finances and by significantly expanding public provisioning of health services. In contrast, the United States, provides ‘choice’ between public and private providers but is by far the worst performing health system among all developed countries, in spite of spending over 8% of GDP on health care.

 

The Planning Commission’s recommendations, perhaps make some sense if seen purely in the context of neoliberal economic policies. Injection of public funds into a floundering economy through the financing of the private, corporate controlled, hospital sector may seem attractive in such a context. But the strategy is disastrous in public health terms, and is designed to finish of the vestiges of a public health system that still survives in the country.

 

 

 

Ministry opposes plan to overhaul healthcare #Goodnews


The ministry has asked Planning Commission to rewrite its chapter on health in the 12th 5-year Plan document

Vidya Krishnan

New Delhi: The health ministry has opposed the Planning Commission’s proposal for a radical overhaul of the public healthcare system, saying it deviates from the government’s primary goal of providing health coverage to all.

The ministry has asked the apex planning body to rewrite its chapter on health in the 12th five-year Plan document that covers FY12-17, a top ministry official said, asking not to be identified.

 

Voicing opposition: Health secretary P.K. Pradhan (PIB)

Voicing opposition: Health secretary P.K. Pradhan (PIB)

 

Several of the commission’s suggestions contradict recommendations of the high level expert group (HLEG) on universal health coverage, or UHC, set up by Prime Minister Manmohan Singhin October 2010 with the mandate of developing a framework on affordable healthcare for Indians, this official said. The bone of contention is the Planning Commission’s proposal to switch to a “managed healthcare network” model in which public and private hospitals may have to compete with each other for patients. 

Also, under the plan, the government’s primary healthcare function will be limited to essential interventions such as immunization, antenatal care and disease-control programmes, leaving clinical services to the managed-care model. The government’s role will in effect diminish from providing health services to managing the network.

Under the managed-care model, while networks of largely private hospitals will be paid per patient registered, doctors will be paid per prescription, according to the Plan document. The transition to this model is proposed to happen over two Plan periods (2012-17 and 2017-22).

“We have to learn from the Chinese experience where reform led to creating of public doctors with a private mindset. China is now revising its health policy because of growing inequity,” said Dr. Srinath Reddy, who headed the HLEG.

“We have to ensure the public sector remains committed to providing quality healthcare without chasing money in any and every manner. We need to develop a model of UHC wherein the private sector will assist the public sector in serving a public purpose rather than privatising the delivery of public sector healthcare,” he added.

HLEG members will meet on Thursday to discuss the health plan and will give their feedback to Montek Singh Ahluwalia, deputy chairman of the Planning Commission.

The health ministry will within 10 days send its feedback strongly advising the Planning Commission to rewrite certain aspects of the health chapter, said health secretary P.K. Pradhan, who was also a member of the HLEG that drafted the report on providing UHC in India.

“Our main objective is to strengthen the public health sector. At this juncture, we are convinced that a network-based approach will be very difficult to achieve that objective,” he said.

“Having read both documents, I know that some of the strategies made in the plan document are far removed from the basic tenets proposed by HLEG,” said Abhay Shukla, public health activist with Jan Swasthya Abhiyan, a non-governmental organization.

“The Plan document gives two scenarios of India’s public health reforms. Either the public health system should start behaving like the private sector, with performance-based remuneration, etc., or it should compete with the private sector and reshape itself in the image of the private sector to compete effectively,” Shukla said. “In both cases, privatization and coporatization of healthcare in India appear as the dominant direction. They (Planning Commission) are using HLEG’s name to push these recommendations.”

The Plan document also proposes a significant expansion of publicly funded insurance schemes such as the Rashtriya Swasthya Bima Yojana to provide universal health coverage whereas the HLEG had recommended strengthening public sector hospitals instead of using the insurance route to provide health services.

vidya.krishnan@livemint.co

Bihar: Private hospitals removing uterus and making money of the insurance scheme


 

RSBY logo

RSBY logo (Photo credit: Wikipedia)

 

 

30 JULY 2012

 

 

Bihar: It is reported that some of the private hospitals at Bihar is using Government’s insurance scheme provided for the people below the poverty line (BPL) and against the moral principles they earn money with or without the knowledge of the people.

The centre has launched the insurance scheme for the BPL during 2008 in the name of Rashtriya Swasthya Bima Yorjna (RSBY) with the aid of the state government to serve the BPL in healing the diseases. Under the scheme, the beneficiary has to pay a registration fee of Rs.30/-, and the state government will pay the premium. Under the scheme, the beneficiary will be covered for Rs.30,000/- and could take medical treatment in the approved hospitals under the scheme.

But, now a fraudulent medical business scheme has come to light where some of the private hospitals are performing unnecessary organ removal, mostly removing uterus for profit of the hospital and to pocket the insurance money.

It is reported that private hospitals in Bihar state has performed more than 15,000 hysterectomy (removal of uterus by surgery) in the last one year to earn the insurance amount of Rs.30,000/- allotted by the scheme.

The preliminary enquiries has shown that Samastipur district alone in the state, has performed around 15,000 hysterectomy surgeries on women in the last one year including uterus removal on unmarried girls below the age of 22.

Following the allegations, the Samatipur district magistrate Kundan Kumar has ordered a probe about the unnecessary hysterectomy including around 5,500 urgent surgeries carried out.

Six teams are being organized including doctors and the team will submit their report within 31 July.

“The probe will bring out the glaring anomalies in the execution of the scheme by private hospitals,” said, the District Magistrate.

”It is learnt that the private hospitals have claimed upto 12 crores under the scheme by the last one year and the in-depth probe will do the needful take necessary stern action against them on the basis of the inquiry.” he added.

It is also reported that many of the private hospitals has claimed insurance money without performing any operations at all.

“Door-to-Door” search and ultrasound tests will definitely reveal whether really the beneficiary had under gone the surgery – said Kumar.

The district administration of Samastipur has organized for camps during first week of August to enable the BPL families under the scheme to lodge complaints against erring hospitals.

A district official who visited the nursing homes under the scheme said that many of the nursing homes approved under the scheme do not have necessary facilities to perform surgeries.

“Nurising homes found guilty would be deleted from the approved list soon,” said Amrit Lal Meena, principle secretary of the state labour resources.

The RSBY scheme is suspected to have such wrong doings not only in Samastipur district, but also in the other states.

Bihar Chief Minister Nitish Kumar has ordered the district magistrates and civil surgeons to inspect all eligible private nursing homes to investigate the scam and ensure whether they are equipped to provide proper healthcare to the poor.