As India debates universal health coverage,one of the first schemes of this nature that attempted to provide a semblance of state-guaranteed healthcare to the needy Andhra Pradeshs Arogyashri is proving a heavy burden on the exchequer. Not only does the scheme take away about 50 per cent of the total Plan money on health in the state,it has also garnered criticism for promoting costly surgical interventions,many of them in the private sector,over primary and preventive healthcare. From Rs 50 crore in 2007 when it started,the total expenditure incurred by the Andhra Pradesh government on the Rajiv Arogyashri Community Health Insurance Scheme (RACHIS) now stands at approximately Rs 1,400 crore annually,providing coverage to 233 of the 255 lakh BPL families in the state. This is an increase of a whopping 2700 per cent in five years. In the same period,the Plan fund for health has grown up by about 200 per cent. A brainchild of late Andhra chief minister Y S Rajashekhara Reddy,the scheme covers surgical procedures costing up to Rs 2 lakh. It is one of the most popular schemes in the state and YSR is credited as having been one of the first politicians in the country to have understood the political potential of healthcare. However,the scheme has consistently been criticised for its emphasis on surgical care at the cost of preventive medicine. As early as in 2009,when the scheme was just 18 months old,a study commissioned by the Andhra Health Department,done by Mala Rao of the University of East London,had faulted RACHIS for its assumption that the public sector was providing primary healthcare to the extent that it should. A more balanced approach that strives to prevent disease and promote health,as well as to provide safe,high-quality treatment through an integrated model encompassing primary,secondary and tertiary care,would be of greater benefit to the BPL families in AP and prove to be more cost effective for the government, it said. Srikant Nagulapalli,CEO of the Arogyashri Trust,refuses to comment on whether the burgeoning Arogyashri bill is starting to affect primary healthcare but concedes that it indeed comprises half the total Plan expenditure for health in the state. However,it is difficult to provide primary healthcare with the demand-side financing model of Arogyashri. That can only happen through supply-side financing,which the government is already doing. There is a debate going on about whether primary healthcare is being neglected but the process for strengthening it is already underway through other schemes like the NRHM, he says. The state Health Department has incidentally commissioned another assessment of the scheme by the Public Health Foundation of India (PHFI) and the Academic Staff College of India,where Mala Rao is an advisor. She says one of the things she would attempt to explore in this second study would be whether Arogyashri is drawing resources away from primary healthcare. However,she admits: There are no equations one can apply to this. There are no standards for how much a government should spend on tertiary care. So there are no easy answers to that. The Arogyashri model of reimbursing procedures in the private sector,which was seen to promote unnecessary surgeries,too has come under fire.
