As planned, the issues related to Sahayog were
discussed in an informal sharing session on the first evening. Abhijit and
Satish from Sahayog were present, and presented a first-hand account of the
ordeal they went through. A long discussion ensued, but in the time available,
satisfactory attention could be paid only to the human-rights violation angle,
about which members unequivocally expressed their sense of outrage.
Possibilities for independent groups to go to Almora, assess the situation
first-hand and help set in a healing and recovery process were discussed.
Abhijit welcomed any such possibilities and reiterated that Sahayog was open to
criticism and suggestions from other individuals and groups on all aspects of
the issue. The dynamics of responses by different individuals and groups in such
situations (starting with MFC’s response to the crisis) were also discussed.
Various suggestions were made, such as filing complaints to the law commission,
filing a PIL, involving the press council, examining ethical aspects of the
doctor’s behavior, among others. No formal resolutions were passed.
Those issues formally discussed are reported below.
Some issues could not be discussed for lack of time on the last day: editorial
guidelines for the bulletin and other MFC publications (Padma has drafted some
preliminary guidelines, which she will post on the forum soon), details of
e-archiving of bulletin and the issue of invitation to ministers / bureaucrats
to MFC meets (on which the OC for the next meet can take a decision).
At the last meet in Jan 2000, the tentative theme
decided for the next annual meet was “Health Rights and Health Insurance”.
About half a day was devoted to discussing the ramifications of this theme in
preparation for the next meet.
Sunil Nandraj made a brief presentation on health
insurance. He outlined the different kinds of insurance possible, and of
various health insurance schemes (other than life insurance) currently
operational in India. This includes the ESIS, CGHS (both of which have limited coverage),
the schemes of GIC (Mediclaim with small variations) and a few community-based
health insurance schemes run largely by NGOs. Mediclaim is the only one that is
general purpose, and available to all, but having limited clientele so far
(1.67 million insured under it currently) due to poor marketing. It is an
idemnity type insurance, excludes many health problems and conditions, and
disbursement of claims tend to be delayed in many cases. NGO-run schemes are
highly variable and are often dependent on additional funds from other sources;
they may involve premium in cash or in kind. All schemes put together cover
some 30 million Indians so far.
The passage of the Insurance Regulatory Development
Authority (IRDA) bill last year marks the entry of private interests in the
insurance arena. It allows private enterprise subject to certain important
conditions. The company can be exclusively Indian or may have a collaborating
transnational partner who may own upto 26% of the company. It must have a paid
up capitalisation of at least Rs 100 crores, and a detailed business plan
before it begins operations. Transfer of funds out of the country is
prohibited. Many aspects, particularly about the rules and regulations and the
exact shape of the insurance schemes and their coverage are still not clear.
Some concerns are – what happens to existing health insurance schemes? What
about those who cannot afford the schemes? Would it support primary health
care? What would be the impact on provision of health care and cost of care?
What kind of regulatory controls would be appropriate? What about consumer
information and redressal mechanisms? What kind of exclusion causes would
operate, and how would they affect coverage? How do we handle hazards of
over-utilization, supplier-induced demands like unnecessary investigations and
procedures, prolonged admissions, etc.? There is also the problem that health
insurance falls under the Ministry of Finance rather than Health. All this
seems to make universal access to health care farther than ever before.
Amar spoke at some length on the issue of right to
health. At the outset, he pointed out that we would have to decide from what
perspective to discuss the theme. One way would be to discuss right to health
care and to discuss insurance from that perspective only. Else, to discuss
health insurance, so that the "technical" aspects of it could get
discussed, but do that in the context of universal access to health care. He
talked about three generations of human rights, and explained that right to
health and health care are different from the political rights in the sense
that they cannot be achieved without creating enabling conditions, ie the
universal access health care service.These enabling conditions are difficult to
create. Even in those countries that have nearly universal access to health
care, health care is not a fundamental right. But all of them have done this
through enacted enabling legislation, and carried out radical reforms in health
financing. He suggested that in the next annual meet some background material
on cross-country comparisons should be prepared.
The group then discussed the issue from the
perspective of planning the theme meet. After much discussion, a consensus was
reached on the final focus: Universal Access
to Health Care through Insurance: Problems and Alternatives.
A tentative structure for the next meet’s theme
discussion was arrived at:
1.
Private
insurance – current developments – impact
2.
Problems
and possibilities for interventions
3.
Universal
Health Insurance – is it possible?
"Of
a list of possible background papers needed, the following
commitments were made:
a.. Health Insurance and existing
legislation (3 papers): Amar
Jesani
b.. Universal Health Insurance -
other country experiences: Ravi
Duggal
c.. Glossary of Health Insurance
Terms: Sunil Nandaraj
d.. Health Insurance in India - an
Overview: Sunil Nandaraj
e.. Regulation of health
insurance: Sunil Nandaraj
f.. Implications in terms of
health Access and behaviour: Neha
Madhiwala
g.. Exclusion clauses: Ravi Duggal
h.. The Sevagram experience in
Health Insurance: Ulhas Jajoo
i.. Microcredit Insurance:
Shashikant Ahankari
j.. District Financing: Dhruv
k.. Basic Assumptions of Health
Insurance: Sunil Kaul
l.. Tools used in insurance
planning / risk assessments: Ritu
m.. Restructuring rural health
services in view of universal health
insurance: Sham
"In addition, the following
possibilities were considered:
a.. IRDA Bill - Niranjan Pant /
Narendra (Padma to follow up)
b.. Health insurance and Voluntary
Sector: Vijayan Das (Anand to
follow up)
c.. Indian Experiments - SEWA,
Tribhuvandas Foundation: Ken Ranson
(Sunil Nandraj to follow up)
d.. SEWA experience: Anil Gumber
(Padmini to follow up)
e.. ? ACCORD experience: Dhruv (
if yes from Devadasan / ACCORD)
f.. Tribhuvandas Foundation
Experience: Chinu (to follow up)"
Deadlines for submission of these papers were
decided. Some of these papers will appear in the bulletins before the meet,
some will be separate backgrounders.
The
next few issues of bulletin will carry announcements of the meet along with a
call for papers, and a circular will be sent out about 10 weeks before the
meet.
Arun Dolke and Sridhar briefly laid out the current
state of functioning of the mfc e-forum and website. Both are currently on free
internet sites. The e-forum is an unmoderated email exchange forum using free
services of e-groups, an internet site specializing in hosting such for a. At
present mfriendcircle@egroups.com has about 70 members. Initially the exchange
was being moderated / facilitated manually by Arun, but is now automatic – all
members listed receive any of the mail that is posted by any member. It has
been quite enthusiastically used in the past few months, particularly during
the Sahayog episode, and members seem to find it useful for sharing news and
views. It was decided that, to help members make best use of it, a simple list
of guidelines will be drafted and circulated by Arun. The list will remain
unmoderated, but members can refer to Arun in case of problems.
A “trial” website has been created on a free site by
Nobhojit Roy. Members who have visited it have found it easy to access and
uncluttered. Being a free site, it has certain limitations of space and
unrequited advertisements, besides an element of uncertainty. While there are
technical solutions to such problems, they demand a fair degree of competence
with internet programming, which the group at present does not possess. An
alternative is to have a paid website, which will cost something to buy and
maintain. Concrete offers have come from individuals to sponsor the website,
and help finish its construction, provided members of MFC help maintain it
(update it from time to time). The maintenance would require very little
programming skills, and can be a responsibility shared by a number of members.
The website can have a number of sections, including the announcements of dates
and agenda of meets, plans and activities of each cell, part or whole of the
bulletin and its archives, and linkages to other sites, etc. The e-forum can
also be hosted from this site instead of the egroups site. After some
discussion, the consensus was that MFC should have a website; a concern was
raised about the cost of paid websites in the long run. Some alternative names
(URLs) for the website were suggested, since some of the obvious ones (mfc.com
or mfc.org) were already taken: possibilities could be mfc.net.in or
medicofriendcircle.com or .org. The discussions about the content mainly
revolved around the issues of how much of the bulletin could go on to the
website to be available free to all. How would free availability affect
circulation, which was unsatisfactory anyway? Would it make sense to have all
archives online? Strong views were expresed for both, having the bulletin
available free, and otherwise. At the end, it was decided to make a
conservative beginning, and review periodically. The current issue will be
announced on the website, but the full text will not be available till the next
issue is announced. Selected articles could be made available, but not the
entire archives. A postbox could be created for visitors to communicate with
the editor. These decisions would be reviewed in the next meet.
Neha briefly talked about her plans for the bulletin
and the problems she is facing. As before, the limited number of regular
subscribers (apart from the 130 or so life subscribers) is making the bulletin
financially unviable, and a sustained effort is needed to remedy this. Since
the bulletin is being refurbished and a renewed effort being made to ensure
regularity, members felt it would be quite possible to raise the number of
subscribers over time. There are problems reaching old subscribers, and ways to
make this possible with the help of active members were discussed. It was
decided to form a support group in Bombay constituted by local MFC members who
could help the editor in production. Similarly, to ensure contributions from a
wider variety of subjects and people, the constitution of an editorial board
made up of members from around the country was mooted. It was strongly felt
that both these groups should be formal entities, to be announced in
appropriate fora, and from which names of members not actively participant be
deleted after a brief trial. The local support group will be constituted in
Bombay. The EC and a couple of members who volunteered would constitute the
editorial board till the time of the next meet. Neha would refer to any / all
of them as needed. Some problems regarding registration of the bulletin also
needed to be sorted out.
Sridhar briefly gave an overview of the PHA process
so far and MFC’s involvement in it. As decided at the end of the last meet, the
convenor represented MFC at two PHA planning meets in Bangalore and Hyderabad.
In the process, MFC became part of the National Coordinating Committee, and the
convenor is formally on the National Working Group of Jan Swasthya Sabha.
Forthcoming events are another working group meet on 12-13 August and the
National and International assemblies in Calcutta and Dhaka in December. MFC as
an organisation will at some point be expected to make a financial contribution
to the process. The issue of any necessity for a formal MFC presence in the PHA
process was raised, since many members as individuals were actively involved.
After some discussion, it was decided to ask the convenor to continue to formally
represent MFC through to the Dhaka meet. Several other members expressed their
willingness to attend the National and International Assemblies.
Anant and Abhay Shukla had drafted a manifesto and a
charter for the PHA process, which has been widely circulated. A revised draft
was sent to Anant and after further modifications, it was placed at the meet
for discussion. The Women and Health cell discussed it at length in their cell
meet, and then a detailed discussion (largely in the form of feedback) took
place with the larger group. It was pointed out that the role of MFC here is in
helping PHA put together a credible charter, which will be finalised in the PHA
process. This is not meant to be MFC’s vision of a charter. It was suggested
that it was time for MFC to put together all the wisdom form past debates and
come up with a vision for health that was MFC’s own. This would, of course,
take time. It was decided not to present the feedback given as MFC’s consensus,
but rather as feedback from individual members and from the Women and Health
cell. Anant will forward the suggestions and comments to the concerned body in
the PHA process.
(inputs from
Padma, Sridhar, Sunil, Neha and Amar)