In India, the out-of-pocket expenditure on healthcare for 2012 stood at 86 per cent according to World Bank data. This means that 86 per cent of the country's population had to depend on its own income instead of health insurance or government aid to meet health expenses. For the same year, the world average was 69 per cent; the figures for two of India's BRICS partners - Brazil and South Africa - stood at 57 and 78 per cent, respectively. Among the states in India, this was particularly hard on the people of Rajasthan. There statistics showed that nearly 3 per cent of impoverished households had found themselves pushed below the poverty line because of the expenses incurred in medical services. So, in 2011, the state government launched the Mukhyamantri Nishulk Dava Yojana, or the chief minister's free medicine initiative, under which patients could get free generic medicines from designated drug distribution centres, or DDCs. Based on a universal access model, the scheme allows any person to avail of this benefit, irrespective of whether he or she is a resident of Rajasthan. This had also led to the creation of the Rajasthan Medical Services Corporation, or RMSC, a body dedicated to the tendering, procurement, quality check, storage and disbursement of medicines. The effect had been immediate: an increase in in-patient and out-patient visits at hospitals from 3.5 million in 2010 to 7.8 million in 2013, according to a World Health Organization study.
However, the hugely popular initiative launched by the Ashok Gehlot-led Congress government had found itself caught up in politics. During campaigning for the 2013 assembly elections, the Bharatiya Janata Party's Vasundhara Raje, who now heads the government, had described the medicines being distributed as "poison". With BJP in power, beneficiaries of this scheme and civil society members believe that the initiative may be scrapped altogether. Officially, though, the scheme continues to exist a year since Raje took office as the state's chief minister, with an allocated budget of almost Rs 300 crore.
A general perception that the initiative has been considerably scaled down prevails in Jaipur, the state's capital. While the official line is to praise the scheme and the current management heading it, many hark back to the time under Samit Sharma, RMSC's first managing director. "He treated this scheme like his baby and would sometimes work for a straight 24 hours without a break," says an official at the medical, health and family welfare department, government of Rajasthan. "It is doubtful that anyone can match his level of commitment." The other issue, he adds, is that Naveen Jain, the incumbent managing director of RMSC, is also the mission director for the National Health Mission: "This is no reflection on Jain's capabilities, but his time and attention is, quite naturally, divided." At his plush office in Jaipur's Swasthya Bhawan, Jain is a man of many words. "People say that because I have dual charge, I am unable to devote time to the free medicine scheme. That is completely untrue," he says dismissively.
Solving a crisis
Though not a doctor by profession like Sharma, Jain says that his training as a company secretary and finance major has aided in reorganising processes to make them more efficient. He rattles off figures, World Health Organization studies and the awards he has won. "There are some basic issues with the tendering process that can be solved with some simple, scientific logic," he continues. For example, medical institutions share their projected demand for one year with RMSC, which then procures drugs. Jain says that simple things like increasing this time span to two years can save a lot of time. "There were some drug shortages last year when the new government had just come in. But that shortage has now been met. It is very easy to hear rumours, but it is difficult to manage free drugs for a population of nearly 70 million and it takes time to overcome these challenges," he explains. Another health department official says that even though it seemed that BJP might scrap this scheme and replace it with state-sponsored health insurance, there has been no dearth of funds for the free medicine scheme. "But it does suffer from an acute shortage of manpower, especially in terms of computer operators and pharmacists," says the official.
A waiting game
Just two kilometres from Swasthya Bhawan, the queues outside the DDC at Jaipur's leading Sawai Man Singh Hospital appear heartening. On closer look though, the dejection and fatigue on the faces of those who have been standing in the queue for over an hour is evident. Clueless patients, especially those who belong to lower-income groups, struggle to catch the attention of pharmacists and doctors, in a scene reminiscent of New Delhi's All India Institute of Medical Sciences, or AIIMS. But local news reports suggest that Sawai Man Singh attends to 500,000 more patients in a year than AIIMS.
Sita Ram, a 21-year-old accountancy student, says that the doctors at the out-patient department (OPD) may prescribe drugs that are not available at the DDC. "I usually get all the cheaper medicines there. But for expensive antibiotics like cefixime, I have to go to chemists outside, which can sometimes mean an additional cost of Rs 700-800," he says. But has it always been this way? "There isn't much difference in the scheme under the two governments. Life is as hard as it used to be," he rues. Jagdish Prasad Yadav, a farmer in Manoharpur, has travelled 60 kilometres for his wife to consult an ear, nose and throat specialist. "We got only half the medicines that were prescribed. They say we'll have to come back tomorrow for the rest," he says. Medicine shortage aside, this scheme, which was particularly attractive for its universality, seems not have have reached the migrant workers in the state. A driver who hails from Uttar Pradesh's Agra, Bobby Singh says that this scheme is only meant for the residents of this state. "I don't think I'm eligible for this. Plus I don't have an Aadhaar card yet," he says, a sign that the scheme's universal accessibility hasn't been publicised widely.
At Jaipur's drug warehouse, a group of young officers and doctors are struggling to keep the hope alive. Rafique Khan, district project coordinator for RMSC, walks through the medical storage unit explaining each step of the procurement process in minute detail. Despite the ongoing construction work nearby, the storage units are spotless, with neatly labelled cartons that are stacked alphabetically. Here too, there exists an admiration for the way that Sharma managed day-to-day affairs. "He is a doctor, so he understood exactly what the patients and caregivers required from the process. Something as simple as making sure a doctor answered the medical helpline made all the difference," he says. So does he sense that things are not the same as they used to be? "Each government has a different style of functioning," he trails off.
Room for improvement
D G Shah, secretary-general of the Indian Pharmaceutical Alliance, believes that both RMSC and the free medicine scheme have suffered because they were driven by one individual. "Sharma showed up pharmaceutical companies in a poor light. He had to cajole doctors into prescribing the drugs procured by the government even though they had no confidence in the quality of these drugs," he says. But he adds that such schemes can go a long way in helping the pharmaceutical companies to get more people to trust and adopt allopathic medicines. "The pharmaceutical industry services such schemes because this fulfils their social obligation without losing a huge market share." He also believes that schemes like these can eventually lead to a stage where drug control norms can be eased to allow pharmaceutical companies to stay incentivised in the market. "I have been advocating that the Tamil Nadu model be replicated, especially since it was implemented much more effectively," he adds. The Tamil Nadu model is similar to Rajasthan's, with the Tamil Nadu Medical Services Corporation, an autonomous body, procuring drugs through tenders and distributing them free. But, says Shah, the Tamil Nadu scheme was not driven by an individual like the Rajasthan scheme had been. Cipla, one of the largest suppliers for RMSC, declined to comment.
Doctors themselves are more sceptical. A private medical practitioner, requesting not to be named, says that the drugs available at the DDCs are "useless". "The quality control process that the government talks about has many loopholes and the drugs are sometimes well past their expiry date," she says. Jain dismisses this argument. "Doctors don't want this scheme because this means that they do not get a commission from the pharmaceutical company for prescribing their branded drugs."
Ashok Panagariya, neurologist and former vice-chancellor, Rajasthan University of Health Sciences (Jaipur), says that medical schemes of this sort are important but should only be implemented on a cross-subsidy basis. "In a welfare state, we must help the poor and needy, but not make such schemes universally free," he says. An immense drawback of this scheme, Panagariya adds, has been the flooding of tertiary care centres with OPD patients, leaving doctors with little time to address critical cases or even undertake academic research. "What we need to understand is that out-of-pocket expenditure on healthcare does not merely constitute drug costs. These patients are usually critically ill and treatments and surgeries drain them to poverty," he explains. He advocates the step towards universal free insurance, which will move beyond treating this issue "symptomatically".
Civil society activists, though, are vehemently opposed to any alternatives like an insurance scheme. "This will lead to the impoverished being exploited," says Chhaya Pachauli, an employee of NGO Prayas, which is also associated with the Jan Swasthya Abhiyan. "Doctors will get a chance to prescribe unnecessary procedures to prolong treatment and make money." She also says that the scheme is too popular for the government to shut down. "But it is subtly ensuring that it fails by eroding the supply chain and other infrastructure," she claims. Sachin Pilot, Rajasthan's Pradesh Congress Committee president, says that it is unfortunate that a welfare scheme is being viewed through a "political prism". "The present government does not have the courage to scrap the scheme, so it is allowing it to self-destruct," he says. He too, it seems, is waiting and watching like the poor people standing in queues for free medicines.
