Veena: How would you help us understand Aarogyasri?

Raghavulu: The Aarogyasri programme started with Y S Rajasekhar Reddy. However, the money for the programme came from the National Rural Health Mission (NRHM) budget. On one side it caught the imagination of the people, but on the other that imagination is a simple illusion. It included super-specialty hospitals with some operations that required huge amounts of money. It got the people’s support through examples. In a village or in poorer section housing, one person may be treated for kidney disease, or some serious illness. The others in the village think that they will get the same treatment. But if you calculate how many cases, how many such treatments were given, you will find that the programme has become a drag on the general health sector. Because apart from the central funds, the remaining funds are siphoned from the state budget and the proportion of the health budget spent on general health care has reduced and has been diverted to Aarogyasri. That is one bad effect. The other is, what ever money is spent on Aarogyasri is cornered by the private hospitals with very little going to government hospitals. That too had a telling effect on the infrastructure and maintenance of the government hospitals which deteriorated. There is also anecdotal evidence that in a number of cases, hospitals thrive on Aarogyasri. The third problem is corruption, because private parties are influencing decisions, especially in orthopedic cases. So even if the programme ran properly it was a drag on the health budget, but with huge amounts of corruption there is a much greater drag. Many private hospitals, even mid-size ones have prospered. So what we feel is that in the long run, the Aarogyasri programme cannot survive. However, politically this opinion is not palatable, even to a section of the poor. However, we need to tell the truth. That is why we termed this as Corporatesri, not Aarogyasri!

That is one element; the other element is the public health services, which are also distorted by this Aarogyasri scheme. Because wherever the public hospitals have the Aarogyasri scheme, a portion of the money is given to the doctors. Many of these doctors also concentrate on Aarogyasri cases because they get more money. This incentive reduces public health care for non-Aarogyasri patients. In addition, the departments that don’t get Aarogyasri money are also run down. This widening ineffectiveness is the reason why dengue and malaria are not taken care of and there is a general collapse of the health care system. Tertiary hospitals have survived, but primary and secondary levels have almost collapsed. Take for example in social welfare hostels, especially in tribal areas, eczema is rampant. Because of eczema, students are unable to concentrate on studies. The disease is easily treatable, and preventable with a small expense, yet it is neglected. CPM treated all these school children in Vishakapatnam district – all the mandals, we organized the teachers and doctors and gave the children clothes, washed sheets, etc., and it helped. It should be annual. That is it. Also preventing malaria is not too difficult.

Veena: Politically now, how should one argue about Aarogyasri?

Raghavulu: The public can’t understand the nuances of the programme, but the general demand for inclusion of everything under Aarogyasri is one type of expression of discontent with the system. But if you give all health care under Aarogyasri, it means that we are talking about health care both private and public. We are demanding that we overhaul the health care system. When the government framed the NRHM it was formulated in such a way that everybody was covered. It had both private and public, which is why privatized health care was introduced in this. We demand a level playing field, but this system today is biased toward the private sector.

Srivats: Level playing field between corporate and public sector, and also between rich and poor?

Raghavulu: Yes. In Kerala, though they can’t exclude private sector because of the central government policy that if you exclude the private sector, funds won’t be given. This is the linkage to the reforms. We were told in the Kerala model, they will fix the rates in such a way that the corporate hospitals are not interested.

Veena: Is that what is happening?

Raghavulu: Yes, when Prabhat Patnaik was the vice chairman, that system was set up in Kerala. There the public health system utilizes all the funds and it has improved because of the additional input. We are also asking for the same system. We are not immediately going to change the whole policy, but this kind of measure can be taken.

Veena: Recently in the CGGS, the corporate hospitals are charging a higher rate for CGHS patients than for ordinary patients.

Raghavulu: They are opening special Aarogyasri wards etc. The policy change can be done by state government.

Srivats: But you don’t think that if you let it privatize like this the competition will build up and the rates will come down?

Raghavulu: As it is in our state, the private sector is an equal sector to the public. Rates are not coming down.

Srivats: No I am asking if there are enough funds, will more hospitals come in and the larger number of suppliers, and in spite of this the rates still won’t come down?

Raghavulu: As it is the number of private hospitals is increasing. Our hospital at Nellore, Ramachandra Reddy Hospital didn’t take Aarogyasri. We said, “It is a government scheme, why can’t you use those funds and improve your services?” They said that they couldn’t indulge in the necessary malpractices – without a payback cut, the money wouldn’t be released. If you bribe them they won’t care about the conditions, but if you don’t they will harass you – so they didn’t take the Aarogyasri programme.

Veena: Does this mean that their patient load came down?

Raghavulu: No, our hospital has low rates. If they had taken the Aarogyasri money they may have benefited, by some funds. But the other things they can’t do, that’s why they didn’t take the programme.

Veena: Would you agree that anyway Aarogyasri has come, and you cannot stop it now?

Raghavulu: Yes, Aarogyasri was originally intended to introduce general privatized insurance gradually through the government. As the full fledged insurance scheme comes, there would be no Aarogyasri. Once that happens, the government would pay the premium for some people, and other institutions would do so for other people—that is the way they want to go. But this process is not smooth. The initial idea of the government was: “it is a temporary phenomenon, we can run it for three, four or five years and then the private insurance schemes will take over”. But it seems that this is not happening. People want it to continue, and the government has to see how to restrict it.

Srivats: So raising the expectations seems to be important?

Raghavulu: Yes, it is, but this kind of expectation is only in Andhra Pradesh, not in other states.

Veena: No, but other states are starting Aarogyasri, Maharashtra has its own version of Aarogyasri.

Raghavulu: If the government steps up its budget, it can’t politically sustain the programme. Malaria, dengue, filariasis are all increasing. They cannot withdraw the demand for Aarogyasri, but if the service increases how that demand will be met and the balance sheet will be drawn is not very easy.

Veena: But if it is possible to force the government to extend the Aarogyasri programme to primary and secondary care, it would be good, wouldn’t it?

Raghavulu: That is what the people are doing. They are asking the government to include more diseases. But the government is not willing to extend the programme. Take for instance fever cases – like dengue cases – every case of fever was treated as dengue, until it was proven not to be dengue. By that time all the patient’s money was spent. That is why the demand for Aarogyasri coverage for dengue is coming.

Veena: But it is true that every year, at this time after the rains, there is a huge increase of fever, diarrhea, etc.

Raghavulu: Not only tribal areas, also urban areas. This is because the municipal system has collapsed because of the reforms and privatization. They are asking the municipalities to raise funds, but they are not doing so. That is why in every town in the last few years, mosquitoes are multiplying.

Veena: Is it possible that preventive measures will be ensured?

Raghavulu: We have discussed this in the party also. The drinking water system has collapsed, as has the drainage system. Problems continue to exist not only in urban areas, but in large panchayats too. That’s why there are fevers and diarrheas etc. Without government’s intervention families cannot do anything about diarrhea, malaria, etc. The unfortunate thing is that political parties are least interested in this. Mass organizations too are too busy.

Veena: Is CPM is the only party that has some connection to medicine?

Raghavulu: But even we feel that what we are doing is reactive, and episodic, not continuous. Not active. Now we are thinking about active continuous activity in the health sector.

Veena: One of the problems is with the ESI sector. It is capable of working. But 95% of the people are in the unorganized sector!

Raghavulu: Our trade union movement is concentrating on ESI. The problem is, our CITU is relatively weak in the private unorganized sector. In organized sector and small scale sector, we are trying to be active. But wherever we are active we are forcing the managements to contribute to ESI. Even the public sector organizations are feeling that the general trend is towards private. Government authorities should force management to go to government hospitals and ESI. But managements do not think on these lines. We organized two major strikes in Hyderabad recently on ESI. One was held to protest that the hospital location was not convenient; another, to enforce provident fund and ESI.

Veena: The Aarogyasri idea it is spreading in different states. Corporates are well placed to push for fund sanctions. They run Aarogyasri.

Raghavulu: How to proceed with Arogyasri is a challenge that we are now addressing.