A survey of 51 patients outside Mumbai’s Tata Memorial Hospital, which specialises in cancer care, showed 44% of them to be without an income. Another IndiaSpend survey which was conducted a few months ago found patients sleeping on pavements with families, braving the elements as they battled a painstaking treatment process.
It is now well-documented that an illness can wipe out a family’s savings and push them into crippling debt. Tuberculosis (TB) can take people off work for years. Often, the medications are so harsh that patients are known to stop taking them because of sheer discomfort and pain. Sometimes, they even commit suicide.
While TB diagnosis and treatment is available for free under India’s Revised National Tuberculosis Control Programme (RNTCP), most patients prefer private care. This may or may not lead to better treatment, but it is almost always expensive. Worse, treatment — whether in public or private facilities --- lasts an agonising six months or a year. It may be more for the drug-resistant variety. Given these, can financial incentives help patients?
Studies in Brazil, Swaziland and the United States on whether financial incentives improve TB treatment outcomes suggest that they help adhere to treatment procedures and timelines. One study from Peru concluded that financial incentives also reduced catastrophic costs for poorer households.
The next question is on how one distributes the financial benefits to patients who are spread far and wide receiving treatment and medicines via different routes, public and private.
One answer could lie in the Direct Benefits Transfer (DBT) scheme already being used to distribute upfront cash payments instead of subsidies for popular consumption items such as cooking gas. And, more specifically, for at least 10 schemes run by the Ministry of Health and Family Welfare. For example, DBT is used in Rashtriya Arogya Nidhi (RAN), a scheme providing financial assistance to poor patients suffering from major life-threatening diseases to access treatment at super-specialty government hospitals or institutes. “Revolving funds” of Rs. 50 lakh per hospital have been provided in 12 government hospitals and institutes, and they are allowed to provide treatment of up to Rs. 2 lakh. An amount beyond Rs. 2 lakh has to be referred to the Health Ministry. Data show that approximately Rs. 15 crore was given out to 376 patients last year.
Interestingly, the likely National Strategic Plan for TB Elimination (2017-25), or NSP, talks of a technology-led approach which will help transfer cash incentives directly to patients. It proposes that every patient holds a smart card linked to his or her Aadhaar number.
The smart card, which can also be used to withdraw cash from ATMs, will work across public and private sectors and is expected to help a patient have access to insurance and other potential benefits. It will also act as an easy identifier in follow-up treatments and visits.
Of the Rs. 12,327 crore proposed in the Budget to implement the NSP, nearly a fourth or Rs. 2,800 crore is expected to be used to provide cash transfers to incentivise completion of treatment and other support to approximately nine million TB patients.
A sum of Rs. 500 per month per patient will be made available to all TB patients during treatment. This is expected to cover costs spanning diagnosis, drugs, commute and follow-up examinations. These patients would automatically get linked to other social welfare schemes when eligible.
The scheme is worth watching closely as it straddles several areas such as the nature of TB whose cure spans long periods, and contributes to impoverishment. Second is the financial condition of patients and possible frustration with TB’s strong dosage and treatment tenure. And, finally, the social experiment in some ways, which tests if a suffering patient will bear harsh treatments if incentivised financially.
The success of this, even in small measure, could change the perception of how governments assist citizens suffering from the disease. It could help them being seen as a benevolent participant in the healing process apart from, of course, saving the tax payer’s money that is usually lost in leakages.
Govindraj Ethiraj is a senior business journalist and founder