Insurance does not cover the womb’s woes –

Tell tales of women in poverty & weak governance

Bharath Bhushan Mamidi &Venkat Pulla

Poverty As Human Rights Violation,

An Asia Pacific Colloquium

1-2 July 2013, Penang, Malaysia

Hysterectomy • Hysterectomy is a major surgery. It involves surgical removal of one or several of the organs: cervix, uterus or womb, fallopian tubes and both ovaries.

• Hysterectomies include ‘radical hysterectomy’ (removal of cervix, upper vagina, lymph nodes, ovaries and fallopian tube), ‘total hysterectomy’ (removal of uterus and cervix with tubes, and ovaries) and ‘subtotal hysterectomy’ (removal of the uterus leaving the cervix intact).

• Hysterectomies result in sudden onset of menopause causing "hormone imbalance" that require long term treatment

• Removal of ovaries also increases the woman's risk of death by 40 per cent.

• Besides direct surgical risks, hysterectomised women suffer long -term physical and psychological effects including severe depression, increased risk of osteoporosis, heart disease, loss of libido, joint pains, etc.,

Coerced hysterectomies- violation of women’s sexual & reproductive health rights

• Majority of hysterectomies are performed among women aged between 40 and 50 across the world (Hysterectomy Association-UK)

• It is widespread among women in thirties in some regions of India

• It is the second most common surgery among rural women in Andhra Pradesh next only to cesarean section delivery

• Hysterectomies are rampant across the country & most of them are coerced

• The unnecessary hysterectomies among women in younger age have severe consequences • There is little understanding & research on the impact of early hysterectomy on the health of the women

Marginality & Violation of human rights

88 women in one village hysterectomised

8 hysterectomised women in a hamlet of 13 families!

All six women of a family have undergone hysterectomy

35.3 % of hysterectomised women were Lambada tribal women while STs formed 17 % of total population in the mandal

“Most patients were from the Lambada tribal community, poor and illiterate” Dr K R. Antony, former Health & Nutrition specialist for UNICEF 

There was little consideration to the terms of consent given that the majority of women were from the lower income group and illiterate

Who are the victims of coerced hysterectomies? Most of the hysterectomised women are illiterate belonging to Lambada tribe, backward castes and aged between 20 and 35 years

• Around half of the women (53.3%) have 3 to 4 children, 29.7% have one or two children.• 13.2% women did not have a male child, 21% did not have girl child.

“My daughter stopped going to school to help in household chores, because I am not able to handle myself”, Ms. Sita aged 30

“What do I do, I don’t feel like earlier. And I cannot have a son. He married another woman” Ms.Lakshmamma aged 37

Consequences of early hysterectomies

Shattering costs, impoverishment, and additional insecurities “Now I cannot earn anything. I can not work in the field for a few hours like I used to do in the past. I also need money for medicines regularly. I have become a burden to my family. How long my husband would tolerate me, I don’t know”, Ms Sharada, aged 35.

“We had to sell our cattle to mobilize money for the operation. That was our only asset”, Ms Shyamala of 32 years old

Most of them spent more than Rs 10,000 each. 88.3% of them spent anything from Rs 10,000 to Rs 17,000 each.

Colossal loot, indirect expenses and long term costs

More than 6 million INR was spent by affected households in the mandal Often these women are not able to undertake physical work and lose their earnings from wage labor Cost of medicines and supplements to maintain the health of a hysterectomised woman is Rs.18,250 a year

Consequences of early hysterectomies

“I am robbed of my life and my body. I did not know I was buying death. I thought the operation was going to relieve me from regular pain & death from cancer. I am cheated and ruined. I suffer more now”, Ms Lakshmi aged 35

“They said you have sores on your ulcer. They asked us to come next day. They asked us for money and we took the money. Along with uterus they removed the appendix also. I don’t have children” Ms Jyothi, aged 38

Similar story of women suffering from routine ailments were scared to get operated immediately or would die.

Reason for surgery is any small complaint from stomach pain to cyst. 72.94% of them had complaints of bleeding/ white discharge, stomach pain (13%), cysts (4.26%), other problems (10.12 %).

Women after hysterectomy faced domestic violence over sexual issues, and their spouse had extra-marital affairs (Yadavar, 2013).

Rajiv Arogyasri Community Health Insurance Scheme

• RACHIS launched in April 2007 is a ‘cashless’ scheme to provide access to BPL families for hospitalisation costs up to Rs. 150,000 per family per year • 23.3 million families (around 87% of the state population) have health coverage under the scheme* • Scheme covers 938 in-patient surgical & medical treatments • 380 empanelled hospitals

Insurance company pays the hospital bills, while government pays premium of Rs 210 per household per annum to the insurance company for every enrolled BPL family Insurance Co. & hospitals identify & screen patients requiring healthcare

Activities from 1 April 2007 to 18 January 2013 35,713 medical camps conducted 1753466 Surgeries conducted (25.13% in Govt &74.87% in Private hospitals) Rs. 47,230 million total cost (22.68% Govt & 77.32% to Private hospitals) *Estimates of BPL by Government of India are around 40 % while state government data shows 87 %.

Rajiv Arogyasri Community Health Insurance Scheme (RACHIS)

RACHIS has four major players in implementation of the scheme:

Aarogyasri Health Care Trust (AHCT): AHCT is responsible for oversight of the whole scheme, decides prices for therapies, preauthorization for treatments, manages contracts with insurer, empanelled hospitals, approves claims, etc.

Insurance company: The insurer bears risk and manages all back end insurance operations like claims processing, reimbursements to providers, and oversight of hospitals. Also generates demand for the scheme by holding health camps across the state through network hospitals to enrol eligible beneficiaries.

Network hospitals: There are 380 network hospitals empanelled to serve the patients i.e., the BPL households.

Aarogya Mithras: Aarogya Mithras are the primary contact with patients in the hospitals and are responsible for community outreach.

Arogyasri - evil surpasses the little good?Arogyasri has been subject of several studies and severe criticism from civil society, opposition parties, experts of the Government of India among others

High Level Expert Group Report on Universal Health Coverage for India, of the Planning Commission of GOI (2011) says •approach of state sponsored health insurance schemes are entirely focused on hospital networks instead of primary care services •It would “lead to inferior health outcomes and high health care cost inflation” •“there is virtually no focus on primary level curative, preventive, and promotive services and on long-term wellness outcomes” •financial risk protection to the BPL families is not much /true under health insurance schemes- which do not cover out-patient expenses, high frequency low cost treatments, and purchase of drugs by households

National Commission on Macroeconomics of Ministry of H&FW in 2005 criticized•corporate hospitals indulging in overuse of diagnostic needs •“no country relies on private insurance to resolve the problems of financial risk protection for the poor and the ill. And regulation is required to minimize some of the adverse impacts”.  

Insurance to loot health & lives of the poor?Corruption and financial malpractices •Promoting interests of corporate healthcare industry focused on tertiary care through private hospitals, and neglecting and underfunding state healthcare system (Prasad & Raghavendra 2012). •Inequities in healthcare access continue: “disadvantaged sections such as females, SCs and STs” continued to have lesser access (The AHCT working paper No. 1)•Unfair model on economic parameters : “Implementation of the scheme through the insurance mode is highly inefficient in terms of cost benefit ratio. Government hospitals were subject to discrimination under insurance mode” (The AHCT working paper No. 1). •Mushrooming of private hospitals only to corner state funds: It is not only looting public money but also robbing the lives & body of the poor. •Indiscriminate and unnecessary surgeries: thousands of indiscriminate hysterectomy, stent surgeries, and laminectomy (spinal surgery) procedures were done

Hysterectomies under Arogyasri in Andhra Pradesh

Year Amount spent Rs in million

Number of hysterectomies

Average cost of hysterectomy (Rs)

2008-09 150 10,334 145152009-10 390 12,212 319362010-11 190 6,189 307002011-12 140 4,943 28323

Civil society fight against coercive hysterectomies

• CARPED advocacy, community mobilisation since 2005 involved public hearings, media sensitization• Other studies in Medak and AP – APMSS (2009), Life HRG (2010). •GOAP regulated hysterectomies under Arogyasri (Jan 2011), & withdrew in July 2012 • Central Minister for Health & Family Welfare initiated probe into allegations of misuse in Bihar in August 2012 & cancelled registration of 9 doctors for irregularities in hysterectomies in Chhattisgarh. • GOI directed all RSBY state nodal agencies to comply with new guidelines on hysterectomies •National Human Rights Commission cancelled licenses of 22 pvt hospitals in Chhattisgarh for irregularities in hysterectomies. •Supreme Court of India issued notices to state governments for compensation to victims of unlawful hysterectomies on 18 March 2013

Hysterectomies on national agenda

English media reports include

Greedy doctors con 600 tribal women into surgery Roli Srivastava, Mumbai Mirror, September 17, 2005

Lambadas lose uterus, savings to ‘docs’ Roli Srivastava, Times of India, June 14, 2007

Menopaused 20 – somethings, Moyna, Down to Earth, June 15, 2010

The uterus snatchers of Andhra, Roli Srivastava, Times of India, Jul 31, 2010

Womb removal: Andhra's big medical scandal, Uma Sudhir, NDTV, August 27, 2010

Bereft and barren, Hemchhaya De, The Telegraph October 10, 2010

Does Healthcare Need Healing? Satyamev Jayate, Episode 4, 27 May 2012

Put errant doctors on the mat, K R Antony, The Hindu Op Ed, Debate @ The Hindu, August 22, 2012

Secret behind rash of hysterectomies out, Rahul Devulapalli, TNN Sep 28, 2012

SCIENCE AND ENVIRONMENT ONLINE

Down To Earth

THE TIMES OF INDIA

MUMBAI MIRROR

Discussion

•How to make government responsible to arrest unethical trends of commercialization of healthcare & unprecedented incidence of hysterectomies, caesarian deliveries, appendicitis, etc

•How to make health policy shift from tertiary care & network of private hospitals in cities to primary & secondary care to effective primary & secondary care to prevent from becoming seriously ill

•How to make private healthcare accountable & transparent and ensure government play pro-active role in arresting unhealthy trends and abuse of healthcare?

•How to make real the informed choice and consent for surgery?

Thank you

vpulla@csu.edu.aumbbhushan@gmail.com