Gujarat Experiments With Expansion of Public Health Insurance

Sami Siva/Pulitzer Center on Crisis ReportingYasin Mirza, an auto-rickshaw driver, after undergoing a triple bypass surgery at V.S. Hospital in Ahmedabad, Gujarat, in February.

AHMEDABAD, India — After Yasin Mirza, a 65-year-old auto-rickshaw driver, suffered a heart attack while sitting on his bed at home after eating dinner, he required expensive triple bypass surgery. As a person who was officially classified as poor, he knew to use the Mukhyamantri Amrutum Yojana, Gujarat's state health insurance plan, when seeking care at the government V.S. Hospital here.

The government plan insures families up to 200,000 rupees, or $3,400, for critical illnesses, so he did not pay one rupee out of pocket. When asked whether he would have been able to pay for the 100,000-rupee operation himself, Mr. Mirza, who was recovering at the hospital, smiled.

"Never," he said.

Government health insurance programs like Mukhyamantri Amrutum Yojana, which was initiated in 2012 in Gujarat, have become a popular answer for the question of how best to treat India's large population of sick residents living below the poverty line. Similar plans are offered in states like Tamil Nadu, Andhra Pradesh, and Karnataka.

But while patients like Mr. Mirza are satisfied with their insurance, success on the whole has been mixed. Critics say that not enough people know such plans exist, and the ones who do inevitably find themselves relegated to a public hospital system that is riddled with problems. (P.K. Taneja, Gujarat's commissioner of health and medical services, declined to comment.)

The administration of Narendra Modi, Gujarat's chief minister, first introduced its Chiranjeevi Yojana health insurance program in 2006 to cover people below the poverty line, or more than 20 percent of the state's 60 million residents. The insurance was intended to encourage mothers to deliver their babies in private hospitals so infant and maternal mortality rates in the state would fall.

But the plan was unsuccessful in reducing infant and maternal deaths, according to a Duke University study released in 2013. The researchers, who surveyed 5,597 households in Gujarat from 2005 to 2010, also concluded that women were likely to have been charged for extra services not covered by the plan.

But rather than backing away from its health insurance program, Gujarat has expanded it in the years following Chiranjeevi Yojana's inception, leading to the creation of the large-scale Mukhyamantri Amrutum Yojana and making the state one of the nation's leading advocates of these plans for the poor.

One critic of Gujarat's health insurance system for the poor is Dr. Hanif Lakdawala, the director and managing trustee of Sanchetana, a nongovernmental organization devoted to providing health care to slum dwellers in urban areas of the state.

Dr. Lakdawala said few slum residents were aware of Gujarat's health insurance programs because of a lack of effort on the government's part to register people who were below the poverty line, which is 1,152 rupees per month. Patients need to show a sticker on their I.D.s that show they are officially classified as poor before they can use the state health insurance.

He also said the plans serve more as a political posture than a useful solution to the state's many health care problems, mainly because they emphasize the poverty status of the patients.

That stigma causes hospital staff members to shunt these patients off into more crowded wards, he said. Dr. Lakdawala said the lower-income patients he works with often avoid government health care because of the treatment they receive from an underpaid and overworked medical staff.

Instead of expanding the insurance program, Dr. Lakdawala recommends first improving the standards at local primary care centers, and then increasing the number of them to provide a better coverage of patients who are unwilling or financially incapable of traveling to larger government hospitals.

Sami Siva/Pulitzer Center on Crisis ReportingThe patients' ward at the V.S. Hospital in Ahmedabad, Gujarat, in February, where those who are eligible for government health insurance program have surgical procedures performed free of cost.

Given the state of public health care, which Dr. Lakdawala called "outright bad" in Gujarat, poor patients would be better off avoiding government hospitals for treatment, but many private clinics in the state refuse to accept the yojana because of the program's low reimbursement rates and delay in distributing payments. Private practice doctors are not required by law to accept the insurance.

Dr. Vishal Choksi, a cancer surgeon at the Ahmedabad branch of the private Apollo Hospital chain, is the doctor whom oncology patients would want to see in an emergency. Dr. Choksi comes from a family of cancer specialists and trained at the Memorial Sloan-Kettering Cancer Center in New York, one of the world's leading institutions in the field.

But if patients come to see him at the hospital with only the Mukhyamantri Amrutum Yojana as coverage, they will be turned away, he said.

"The financial difference in pay in not accepting the plans is significantly less than what we would receive," said Dr. Choksi, who worked for one year at a government hospital, M.P. Shah, before moving into private practice. "Also because of government bureaucracy, doctors don't even receive any remuneration for a year or more."

Having the yojanas is better than nothing, Dr. Choksi said, but the plans relegate patients to poorer quality government care that may not be as equipped to save lives for serious procedures like the ones he performs.

He also says that government hospitals in Gujarat have issues with debt because of the number of poorer patients they accept who cannot pay for their procedures. It makes them more likely to cut costs on what is known as consumables — pumping equipment, tubing and blood bags — by either reusing them illegally or purchasing poorer quality materials. Problems like this are not specific to Gujarat, but are instead endemic at government hospitals throughout the country.

Prof. Ashok Yesudian, head of health system studies at the Tata Institute of Social Sciences, said the growing national enthusiasm for the plans appears to be merely a politically expedient solution to a complex problem.

It's easy for politicians to point to these programs as proof that they are helping the poor, he said, but they do little to actually help the poor.

"The poor in this country are falling ill because they are accustomed to living in extremely unhygienic conditions," Dr. Yesudian said. "The real priority should be health education, to teach patients how to take control of their own lives."

Michael Edison Hayden is a writer based in Mumbai, India. You can follow him on Twitter @MichaelEHayden. Research for this series was funded by a grant from the Pulitzer Center on Crisis Reporting.