Believe it or not, intellectual dishonesty is the greatest bane of Indian bureaucracy
The call was from the Prime Minister’s office and the Principal Secretary to the Prime Minister (PM) was on the line. I was posted as Secretary, School Education and Literacy and into the last year of my 38-year-long career in the civil service, but the conversation we had did not relate to education.
“Anil, can you brief the Prime Minister on Health Insurance?” was his question. I couldn’t fathom the context. Yes, I had been involved in visualising, conceptualising, articulating, implementing and evaluating arguably the largest health insurance scheme Rashtriya Swasthya Bima Yojana (RSBY) in the world. This scheme had come to be recognised by International Labour Organisation (ILO) and World Bank as one of the finest. But the scheme had fallen from grace as it was considered to be a scheme of the ‘previous’ government. Moreover, a Group of Secretaries, none of whom had any clue about the nuances of health insurance, had condemned the scheme that was subsequently starved for funds.
“Sir, but what have I to do with Health Insurance?” I asked, thoroughly puzzled.
“No, the Prime Minister is keen on providing health insurance (‘assurance’ as it was called) to the citizens of the country and the Health Ministry has been trying to evolve a scheme. However, there hasn’t been a consensus”, he concluded.
The Group of Secretaries that had condemned and dumped RSBY had not suggested any alternative. They soon discovered that it was easy to ‘destruct’ but very difficult to ‘construct’. The officers in the Health Ministry were struggling to come up with a scheme to the liking and satisfaction of the PM even after three years of the announcement made by him to provide health assurance to the masses.
“But sir, what is my locus standi to provide my inputs and suggestions to the PM on health insurance?” I countered.
The Principal Secretary had a ready answer, “There is a meeting scheduled for the review of certain proposals of the Health Ministry. We will line up a review of the Education Ministry as well. Hence, you will be present when the discussion on health insurance will take place. If the PM asks you about your views on the health insurance scheme, you can give your input.”
Some of the officers of the Health Ministry and NITI Aayog (National Institution for Transforming India) had taken inputs from me in the recent past while formulating the ‘new’ health insurance scheme that was primarily structured along the lines of RSBY. A very competent team in NITI Aayog, headed by one of its members, V. K. Paul and comprising officers like Alok Kumar, who was well-versed in the nuances of health insurance, was working on it. The earlier attempts had failed but this team had now come up with a new proposal to convince the PM about the scheme. I saw this as an opportunity to revive RSBY which had earned encomiums from World Bank and other international organisations but was discarded unceremoniously thereafter. The scheme benefited hundreds of thousands of poor people. There were indeed some issues with the scheme but then no scheme was perfect. So, I agreed to attend.
The meeting started late in the afternoon at 7 Race Course Road, the residence of the PM. Apart from a couple of Ministers, there were a few officers as well. The Health Secretary made a presentation on the proposed health insurance scheme. Everyone was apprehensive about the PM’s response. I had been informed that on a few occasions in the past when the scheme was presented to him, he was unhappy.
On this occasion too he didn’t appear to be very impressed. However, he turned towards me and remarked, “Anil, you have handled Health Insurance in the past, what is your comment?” I spoke for around 15 minutes outlining the need for health insurance and the strengths of the proposed scheme. The country had so far gone with the supply side management of healthcare. All public funding was routed through government agencies and hospitals and it was believed that the government hospitals would deliver. However, in the absence of any “incentive” to deliver the goods and services efficiently, inefficiencies had crept into the system.
RSBY had clearly demonstrated that the demand side management (wherein entitlement to seek services was placed in the hands of the beneficiary and he had the right to choose from a set of empanelled public and private hospitals) can work to bring in efficiency and a greater sense of satisfaction amongst the beneficiaries. There were indeed some shortcomings but that was true of most of the initiatives. The PM listened very patiently (which is one of the most remarkable features of his functioning). He appeared quite convinced with the rationale provided by me. He did ask a couple of questions (his yearning for details is amazing) and then a decision was taken in principle to go ahead with the scheme. Ironically, one of the Secretaries who had condemned and dumped RSBY as a part of the Group of Secretaries maintained a studied silence despite the fact that RSBY was now being revived, though in a modified form.
I wondered whether he was right in choosing to remain silent when he had so vehemently argued against health insurance as a part of the Group of Secretaries.
As I walked out of the room, a Joint Secretary in the PMO who was present during the meeting came up to me and asked, ”Sir, you were aware that the PM was unhappy with the approach of engaging with the insurance companies but you still advocated that approach?” My answer was simple, “I expressed what was best irrespective of the views of the PM. He is the ultimate decision-maker. It was my job to convey to him my views. It didn’t really matter to me whether he would be happy or unhappy. I don’t expect anything from him now or even after my superannuation”.
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The morphed version of RSBY that became a part of Aayushman Bharat is doing pretty well now. Prime Minister Jan Aarogya Yojana (PMJAY) is based on the same principles as its predecessor though the scale and coverage are much more and the technology much more sophisticated.