It took 12 months and visits to four hospitals for 14-year-old Ajay Pawara, diagnosed with a hole in his heart in 2015, to undergo a surgery under the Mahatma Jyotiba Phule Jan Arogya Yojana (MPJAY). While he is happy to see his son healthy and back in school, Ajay’s father Lehsingh Pawara rues having missed work for several days and the Rs 5,400 he spent in travel expenses for his son’s operation in Thane, 390 kilometres away from home in Vadi village, Nandurbar. Though they visited three hospitals, empanelled under the health insurance scheme, in Nandurbar, these hospitals do not carry out even common surgeries.
The MPJAY, which was earlier known as the Rajiv Gandhi Jeevandayee Arogya Yojana, is a health insurance scheme offered by the Maharashtra government for patients below and above the poverty line. It covers 971 procedures and provides a maximum health coverage of Rs 1.5 lakh annually per family. Maharashtra is now in the process of integrating the National Health Protection Scheme, announced by the Union government, but, even as the state plans to raise insurance coverage to Rs 5 lakh, there are several issues that have to be addressed in the existing scheme. These issues include lack of awareness, poor roll-out in rural and tribal talukas and long-distance travel for patients seeking to avail its benefits.
When Ajay was diagnosed with a heart condition, Pawara, a jowar cultivator, had just Rs 300. He first visited Nandurbar civil hospital, which is empanelled under MPJAY, where doctors told him there was no facility to conduct the surgery. He then visited a private empanelled hospital twice in Nashik. “They also told me they could not do the surgery,” he said. In 2016, he travelled to Dhule Civil Hospital, only to be rebuffed again. “Ajay was becoming weaker every day. If I had the money, I would have paid for the procedure in a private hospital,” Pawara said.
In 2016, they travelled to Jupiter Hospital, Thane, where Ajay was finally operated under MPJAY. The hole in his heart measured 24 mm. “After surgery, we had to go for multiple follow-ups to Thane. I borrowed money for transportation,” Pawara said.
A study, published in 2017 by the Centre for Enquiry into Health and Allied Themes, showed that the lowest number of surgeries under MPJAY have been performed in Gadchiroli and Nandurbar, 5,952 and 8,775 surgeries respectively, while 2.23 lakh surgeries were done in Mumbai in the past five years.
The MPJAY covers 484 hospitals – of which 11 per cent are in Mumbai – catering to 38.6 per cent of the total patient load in Maharashtra. “Merely 12 per cent of the hospitals in the 12 least urbanised districts are empanelled, creating a gap in the availability of the network hospitals. The gap worsens in tribal districts, including Nandurbar and rural Thane,” the report said. According to the report, the distribution of the empanelled hospitals are skewed, with rural and tribal districts like Gadchiroli, Nandurbar, Beed, Parbhani, and Chandrapur having the least number of hospitals that come under the scheme.
The reasons for the poor coverage include the strict criteria that hospitals must adhere to in order to be empanelled. In Nandurbar, for instance, the 32-bed Kulkarni Hospital applied for empanelment, but then withdrew its request in 2017. “At least 99 per cent of my patients are eligible under the scheme. But the criteria for empanelling a hospital are too strict,” said Dr Darshan Kulkarni. MPJAY mandates National Accreditation Board of Hospitals (NABH) certification, infrastructure audit, record maintenance and HR quality, apart from a grading process, to empanel a hospital. Kulkarni said it was financially not feasible to spend on infrastructure while still keeping costs low for patients in tribal regions. “A hospital I know had to submit forged pictures and documents to get empanelment. What is the purpose then?” Kulkarni asked. Insurance coverage under MPJAY excludes some common procedures such as hysterectomy and appendix procedures for private hospitals. Kulkarni said several patients visited his hospital for these two procedures.
Nandurbar District Collector Mallinath Kalshetty said, “We have requested the state government to relax norms for enrolling hospitals. Several of our private hospitals are willing to treat patients under the scheme.”
Excessive paper work has also led to the rejection of applications by many patients. Since 2012, when the scheme started, 55,213 applications for surgeries were rejected on various grounds, the latest MPJAY data showed. In the absence of treatment options under the scheme, several patients either pay for the procedures at private hospitals or go untreated. Very few, like Ajay, can gather the resources to travel far for treatment.
Since 2015, Dilip Patle (35) has been diagnosed with, but not treated for, a metastatic carcinoma in his neck. In his three visits to Nandurbar Civil Hospital, doctors suggested that he travel to Nashik. “If I leave, who will earn?” he asked, as he sipped tea in his bamboo hut in Dhadgaon. A bulge on his neck leaves him with a severe pain in his head, making it difficult for the farmer to work. The doctors at the Nandubar Civil Hospital did not inform him that he was eligible for free medical oncology treatment under the insurance scheme. He also does not have an MPJAY card. Since 2015, he has delayed his treatment, fearing expenses and the need for long-distance travel.
“That is another problem with the scheme – poor awareness. In 2016, the enrollment rate was only 2.45 per cent of the total number of eligible people,” said Soumitra Ghosh, assistant professor at the Tata Institute of Social Sciences. According to him, the insurance company is supposed to raise awareness, enroll patients and receive the premium from the government. “But, the target population does not know about the scheme’s existence.” he said.
Data from MPJAY showed that of the 971 surgical procedures covered under the scheme, most applications are for medical oncology, with 4.1 lakh patients applying for pre-authorisation. However, radiation oncology is available in only nine per cent of hospitals and interventional oncology in 15 per cent of empanelled hospitals.
Unlike Patle, Swaroop Singh (40), a farmer in Taloda, decided to spend Rs 50,000 for four cycles of chemotherapy at Kulkarni Hospital in Nandurbar. The sole breadwinner of his family, Singh knew he could not afford to spend months in Mumbai for treatment of carcinoma in his testes. He decided to opt out of MPJAY to eliminate the time and expenses involved in travelling. “We are trying to treat him at a subsidised cost,” said surgeon Dr Shashank Kulkarni. Since 2012, 16.99 lakh surgeries were conducted under MPJAY, and in 15.41 lakh cases, the amount was paid by the state government. Private hospitals accounted for 74 per cent of these claims. According to a state government officials, a plan to integrate MPJAY with the national health protection scheme is underway. The premium is expected to be Rs 1,082 per family, according to the estimates of the Niti Aayog, of which Rs 433 will be the state’s share. Officials also said more surgeries were slated to be added to the existing list of procedures covered under the scheme.
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