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Date posted: September 23, 2012

A ‘Twisted’ Health Scheme
Editorial- Economic and Political Weekly
Vol – XLVII No. 38, September 22, 2012

State health insurance schemes are being abused to profi t private care providers.

The “uterus removal scams” in Chhattisgarh and Bihar that came to light recently are a textbook case of how government welfare schemes, supposedly meant for the poor, end up harming them when there are no monitoring and accountability mechanisms in place. Under the Rashtriya Swasthya Bima Yojana (RSBY or the National Health Insurance Scheme), families living below the poverty line (BPL) can claim insurance of up to Rs 30,000 for treatment. This provision was misused by private doctors to remove the uteruses of 16,765 women in 11 districts of Bihar in the last two years and 1,800 hysterectomies were performed in Chhattisgarh.

According to preliminary reports from district magistrates, a majority of these surgeries were not required; both state governments have ordered further probes into the surgeries. In 2010, a similar racket came to light in Andhra Pradesh when health activists reported (and the government admitted) that unnecessary hysterectomies were being performed on a massive scale to gain insurance money under the state health insurance scheme, Arogyasri. In fact, these rackets are a result of the coming together of many aspects that plague the Indian health system, both public and private. (In Bihar and Chhattisgarh all the surgeries were performed in private hospitals.)

Many of the women questioned by the media and health activists said that they were forced to go to private clinics because the government healthcare centres did not treat them. Whether this was because the government centres could not or would not treat them requires further investigation, but in either case this shows that women’s gynaecological problems are not considered important enough in the provision of primary healthcare. In any case, a hysterectomy is the last resort when other forms of medication, therapies and less invasive surgeries have failed or would be ineffective to treat the conditions.

The removal of the uterus not only means that the woman will not be able to reproduce but when accompanied by the removal of ovaries, it also leads to hormonal changes that can severely affect her health and quality of life. Medical literature is replete with the physical and psychological side-effects of this surgery. A large number of the women subjected to these surgeries in the three states are below 40, with some of them being in their late teens and early 20s. The enormity of the toll such an operation will take on the health of many of these women, who are poor, undernourished and have to work in brutally hard conditions, cannot perhaps even be imagined.

The issue here is not just the fact of these surgeries but that they were conducted under the RSBY scheme. This has to be more closely scrutinised. Media reports and the findings by health activists suggest that a large number of the registered clinics are not owned by qualified medical practitioners and are also not well-equipped. The examples of Chhattisgarh and Bihar show how lax is government oversight on the health sector.

As far as the role of the surgeons involved in these scams is concerned, it is the responsibility of medical associations to ensure that their fraternity adheres to medical ethics. The doctors in Chhattisgarh threatened to go on strike saying that all of them are being tarred by the same brush and hounded by the authorities. There was a similar situation in Maharashtra when the crackdown on sex-selective abortions began in Beed and Yavatmal districts a few months ago. The doctors’ representatives said that their members were “scared” to perform even medically required pregnancy terminations in the face of “harassment” from the authorities. If upright doctors are indeed being persecuted by the authorities, their professional associations are all the more obliged to treat this as a priority issue.

The hysterectomy scams in Chhattisgarh and Bihar should serve as a wake-up call about problems in our public health policies and their dire consequences.

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