Sunday, January 22, 2017

Affordable Care in Rural India

I just returned from India, where I visited Flame University (the name is derived from "Foundation for Liberal  and Management Education") in Pune.

At a meeting with Professor D.S. Rao, Provost and Dean of the Flame School of Business, I learned about Yeshasvini, a cooperative health insurance venture for farmers in the state of Karnataka. At the depressing moment where the new U.S. administration  is preparing to tear down President Obama's extension of health insurance to a wider population, it was heartening to learn about a program working to advance Obama's ideals by insuring the poorest of the Indian poor.

India does not have a tradition of paying for health care through insurance. The majority of health care is still paid for on an out-of-pocket basis. Even though costs are much lower than in the U.S., for the large population of rural poor, modern health care is unaffordable.

Yeshavini, started in 2003, offers a limited insurance package to members of rural farm cooperatives on a prepaid basis for less than $5 per year per insured person! The state of Karnataka matches some or all of the farmers' payments. Karnataka, approximately the size of Nebraska, has a population of 64 million. As of 2014-2015, 3.8 million were enrolledin Yeshasvini.

Yeshavini's mission is noble:
"To bring health care of International Standards within the reach of every cooperative farmer of Karnataka. We are committed to the achievement & maintenance of excellence in health care for the benefit of farmer cooperator."
Even in India, $10/ year cannot provide "health care of International Standards." The package is largely for surgical services at 550 participating hospitals. Non-surgical treatment for cancer and diabetes is  not covered. But hazards faced by farmers like snake bites. goring by bulls, and accidents involving agricultural machinery are.

From a U.S. perspective, Yeshasvini is best thought about as a "proof of concept." In 1969 when I first encountered the concept of prepaid health care delivered by the not-for-profit Harvard Community Health Plan to a defined population on a prepaid basis, I thought this was the right way to provide modern health care. I still do. I joined the group in 1975, and while I ended my practice in 2008, I still get my own  care from the group and I work with it on establishing its new ethics program.

Somewhere between the pared-down Yeshasvini program in Karnataka that is affordable to poor farmers but covers too little and the super-comprehensive U.S. programs that cover too much and are a stretch for all but the wealthiest, is the golden mean of health care. But Yeshasvini supports the view that health care should be (a) population oriented, (b) prepaid, and (c) not-for-profit.

That's a perspective likely to come under attack from the newly installed Republican administration!


Sridhar Chari said...

Dear Dr Sabin
In recent months a private sector initiative in the same State ( Karnataka) has introduced Telemedicine combined with a savings plan in villages . The savings pays for Insurance cover with a large Firm in the private Insurance sector. A kiosk in the village managed by a Doctor provides immediate clinical tests with the data logged on to a Computer accessible by experts elsewhere. In case the doctor feels a specialist treatment is required in a Hospital, the savings backed insurance provides the cover and the Internet backed database provides access on line to the Specialist
. It is proposed to establish links with Hospitals in a ll the major cities of the State .

Jim Sabin said...

Dear Sridhar Chari
Thank you for this information. While I don't understand all the details, there's no doubt that telemedicine can be very useful for rural populations. I'm glad to learn about what is happening in Karnataka. If there is an English language website that tells more about the telemedicine program, I'd be very interested in seeing it.
Jim Sabin