What do people need from Aarogyasri

[wpcol_1third id=”” class=”” style=””]Is it delivered? How comprehensive is treatment under Aarogyasri?

Rajan Shukla

What does a common citizen expect from the state in terms of health care?

As an individual, Sreya would want her and her family’s health care needs to be taken care of. Whether it was the delivery of her first child; or the breathlessness that her father is suffering from for the last one year for which no doctor seems to have a cure; or her back ache or body ache which seems to have a mind of its own, flaring up without warning; or the sugar which her mother-in-law suffers from and requires her to spend Rs 2000 every month on drugs and investigations (she is often without any medicine); or the fever which her son suffered last month (some doctors said it was dengue and they had to spend Rs 8500 for the different investigations and treatment the doctor ordered). Can she afford all this from her family’s combined earnings of Rs 10,000 per month? She wanted to educate her son in a private English school, but now he is unable to go to any school because he attends to his grandfather when they have gone to work. After much planning and anticipation, she was able to purchase gold earrings two years ago but had to sell them off to the moneylender to be able to afford treatment for her son’s illness. Does she get the health care she and her family need? Can she afford it? What is the quality of health care her family received? These are the questions our public representatives need to ponder on and understand before they advocate any major policy change in our health care delivery system. Around 80% of the families in Andhra Pradesh would have an annual income less than Sreya’s.

[/wpcol_1third] [wpcol_1third id=”” class=”” style=””]How much of this expectation does the AP state meet through Aarogyasri and the public health system?

All of us like Sreya’s family need appropriate affordable treatment without incurring any catastrophic health expenditure. This means quality health care should be available within reach both geographically and financially. It should be adequately supported by a referral system for secondary/tertiary care and have a mechanism of financial protection. To the advantage of AP’s BPL population, the state does have a financial protection mechanism for health care expenditure, the Rajiv Aarogyasri health insurance scheme, but it only covers the tip of the iceberg in terms of catastrophic financial burden of the needy population. Aarogyasri does not cover sugar problems, BP, back pain, dengue, or common things like fever, malaria, loose motions, eye infections, ear infections, headaches, vision problems, injuries, joint pains, coughs, burning in the urine, white discharge, and treatment of anemia—which is said to be prevalent in over 70% of women and children. It does not cover burning and acidity in the stomach, piles, infertility—but we still believe that Aarogyasri is so important for AP!

So who gets any benefit from Aarogyasri?

When the condition of the people suffering from all the above problems gets worse, when complications set in and they get admitted into a hospital, then at that point, maybe Aarogyasri helps. That is, only if malaria turns out to actually be cerebral malaria or dengue goes on to cause bleeding disorder, or the cough in a child becomes a pneumonia with respiratory failure, or long standing acidity in the stomach leads to perforation, or the recurrent white discharge becomes a cancer, is one eligible to access Aarogyasri. By this time the patient would have spent Rs. 30,000 to Rs. one lakh, the family is in a desperate situation, having exhausted their saving, mortgaged their land and indebtedness looming on the horizon. This is despite the fact that basic medical courses teach how such problems can be avoided: malaria can be prevented by public health measures like mosquito control, early diagnosis and treatment of fevers; a cough of 3-5 days duration can be treated successfully with antibiotics in the child, or in old people; acidity or ulcers diagnosed in the early stage can be treated and healed, etc.

[/wpcol_1third] [wpcol_1third_end id=”” class=”” style=””]The problem is that Aarogyasri is useful for some listed conditions which need hospitalizations. It is not for many others.Outpatient expenses like initial consultations, drugs and diagnostics are not covered under Aarogyasri. These account for 2/3 of the patients’ out of pocket expenditure (OOP). Many studies have documented that hospitalization expenses account for only about one-third of the overall OOP expenditure. OOP is globally recognized as the major cause of catastrophic health expenditure which wipes the patient out financially. Almost 26% of the households incur catastrophic health expenditure at one time or the other. It has also been established that 40% of the households experiencing hospitalization incur catastrophic health expenditure, and a majority of these hospitalizations are due to health care needs not covered under Aarogyasri. What the scheme does cover is 953 procedures (170 medical and 783 surgical) which are mostly tertiary care. So a poor patient has to either incur OOP expenditure or wait till his condition deteriorates so that he has complications which can be effectively covered under Aarogyasri.

A classic example is a person suffering from dengue fever. The scare of dengue fever provokes so much anxiety that every fever is suspected to be dengue. Early dengue can be difficult to differentiate from other viral infections. Sophisticated and expensive tests make detection more accurate in the first seven days but are not easily available. Routine tests are not reliable in early stages and in case of patients who have had repeated episodes of dengue fever over the years. The risk of complication is higher in persons suffering from repeated episodes. In this scenario, instruments called cell counters have become the mainstay of diagnosing and predicting dengue complications. The rate of progression of the dengue is unpredictable. Thus, even a slight normal fluctuation in WBC or platelet counts against the backdrop of the dengue scare has resulted in both physicians and public seeking over-investigation and over-treatment. The health care industry has exploited this scare to the fullest. Even in genuine cases of a drop in platelet count, most of the cases respond to symptomatic treatment and maintenance of proper fluid balance. Packed cell transfusion or platelet transfusion are required only in high-risk patients having a very low platelet count (below twenty thousand). Such treatment is also useful when there is a higher platelet count (twenty one to forty thousand), but there is risk of bleeding. In an endemic area, it is found that only 30% of patients having low platelet counts will require packed cell or platelet transfusion. However all cases of suspected dengue fever are advised admission to hospital, for active observation with IV fluids and other supportive treatment. Aarogyasri covers only the management of low platelet counts requiring platelet transfusion. Routine hospitalization is not covered under Aarogyasri.
[/wpcol_1third_end] Some examples of irrational coverage under Aarogyasri are given below:

Cause and symptoms	Possible diagnosis	Range of treatments available	Coverage under Aarogyasri
Consumption of harmful substances which cause vomiting, drowsiness, loss of consciousness, etc.	1. Corrosive Poisoning (Vasmol, acid poisoning)	Stage 1: Hospitalization to minimize damage, maintain vitals and nutrition. Stage 2: Ventilator support, reconstruction of upper GI tract after primary healing. Stage 3: Prolonged hospitalization until primary healing or death.	Not covered under Aarogyasri.
	2. Non Corrosive Poisoning (rat poison, pesticide poison or drug overdose -- paracetamol, etc.)	Stage 1: Stomach wash, specific antidotes, close observation. Might need short 24-48 hrs observation in ICU, maintenance of vital functions, nutrition, etc. Stage 2: Prolonged hospitalization for 5-20 days in some cases. Stage 3: Approximately 25% of hospitalized cases will need ventilator support.	Only OP poisoning (Stage 3) cases requiring ventilator support are covered. Coverage needs to be renewed every week. Treatment for other cases of poisoning is not covered.
Unexplained vaginal bleeding, change in menstrual cycle pattern, blood tinged vaginal discharge during sex	Cervicitis, pelvic inflammatory disease (PID), vaginal carcinoma, cervical cancer	Stage 1: Antibiotic & personal hygiene for Cervicitis and PID. A strong screening program is required for early detection of cervical cancer. Stage 2: Hysterectomies for cervical cancer. Stage 3: Anti cancer treatment with chemotherapy and radiation therapy.	Stage 1: Treatment like PAP smear for screening for cervical cancer can prevent or allow early treatment, but is not covered under Aarogyasri. Antibiotic treatment of Cervicitis, PID – not covered. Stage 2: Hysterectomies are covered only in government hospitals. Stage 3: Only management of cervical cancer is covered under Aarogyasri.
Snake bite, local rash, local necrosis, shallow breathing, bleeding, etc., or scorpion bite.		All snake bite cases require hospitalization for observation. Poisonous snake bites require anti-snake venom and hospitalization for 3-10 days. Some types of snake bite require ventilator support. Others may require prolonged hospitalization and surgical treatment in case of massive tissue damage.	Medical observation and treatment is not covered. All medical management of snake bite and only scorpion stings requiring ventilator support are covered under Aarogyasri. Surgical procedures are not covered.