DENYING TREATMENT DENYING LIFE
PREFACE We, the United Human Rights Federation (UHRF) are an organization functioning for the human rights since last several years. We work for the cause of Human Rights at national and international level. The UHRF is an organization of international ramifications and is operational in different fields all over the world for protecting the human race with its dignity. We make efforts to provide solution to the problems being faced by the people while appraising the cause and extending helps to the masses and societies of the world through our organization. We are recently researching on the plight of the poor patients from EWS (Economically Weaker Section) in India. Even as we see long queues of patients waiting to get treatment in government hospitals in the Capital, around 40 per cent of the beds reserved for poor patients (EWS category) in private hospitals are lying vacant. According to the Committee constituted by the hon’ble High Court for EWS patients, many of the 45 private hospitals in Delhi are not abiding by the court directive and are keeping beds reserved for EWS quota empty. Even children from the EWS in Delhi are unable to avail treatment at private hospitals despite the fact that these hospitals have reserved beds and out-patient department facilities for people from EWS category. There were also many instances when poor patients, who are entitled to free treatment at private hospitals, were reportedly asked to pay fees. Interestingly, even government hospitals are not free for all EWS patients. Government hospitals charge their patients for certain services like MRI and Ultrasound. These services are free for patients below poverty line. EWS, on the other hand, is defined as anyone earning less than the minimum wage for unskilled labour in the city. The poverty line is Rs. 619.91 a month for a person in Delhi, while a person from EWS category is one who earns less than Rs. 7,722. Thus, while EWS category patients are exempted from charges in certain identified private hospitals, many of them have to pay in government hospitals.
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HEALTH CARE IN INDIA Healthcare today is the world’s largest and fastest growing industry. In India healthcare is an US $ 17 Billion industry accounting for 4% of GDP. Public health care system is responsible for spending of 1% of the GDP (effectively about Rs. 1,000 per capita ). In contrast approximately 3% of the GDP ( an average of Rs. 3,675 per capita ) per annum is spent in the private sector on healthcare. With the demand for healthcare far exceeding supply, India’s healthcare industry is expected to grow by around 13% a year for the next five years. Today, the average Indian is spending more on his well being than ever before. The proportion of households in the low income group has declined from 59% in 1990, to 49% in 1996 and more urbanization has increased the middle & higher income groups from 14% to 20%. Increase in purchasing power of the middle class, higher literacy rate, awareness and education on preventive and curative health care, have all made the Indian an active participant in the health care, rather than a passive recipient.
Public Health Care The Indian population has reached a 1.2 billion figure according to the 2011 census. The public health care delivery system has long been catering to nearly 75% of the Indian population comprising rural India and the lower income / below poverty line group in Urban India. Various national health programmes, health insurance schemes like ESIS and CGHS, primary & secondary health centres, municipal and government hospitals are the only options for the middle and lower income groups, who cannot afford the treatment in private hospitals.
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KEY LINKAGES IN HEALTH CARE SECTOR Health and health care need to be distinguished from each other for no better reason than that the former is often incorrectly seen as a direct function of the latter. Heath is clearly not the mere absence of disease. Good Health confers on a person or groups freedom from illness and the ability to realize one's potential. Health is therefore best understood as the indispensable basis for defining a person's sense of well being. The health of populations is a distinct key issue in public policy discourse in every mature society often determining the deployment of huge society. They include its cultural understanding of ill health and well-being, extent of socio-economic disparities, reach of health services and quality and costs of care. and current bio-medical understanding about health and illness. Health care covers not merely medical care but also all aspects of pro-preventive care too. Nor can it be limited to care rendered by or financed out of public expenditure within the government sector alone but must include incentives and disincentives for self care and care paid for by private citizens to get over ill health. Where, as in India, private out-of-pocket expenditure dominates the cost financing health care, the effects are bound to be regressive. Heath care at its essential core is widely recognized to be a public good. Its demand and supply cannot therefore, be left to be regulated solely by the invisible had of the market. Nor can it be established on considerations of utility maximizing conduct alone.
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ALLOTMENT OF LAND TO PRIVATE HOSPITALS AND DISPENSARIES BY DELHI DEVELOPMENT AUTHORITY Delhi Development Authority (DDA) was established to promote and secure planned development of Delhi on 30th December, 1957 under the provisions of the Delhi Development Act, 1957. It acquires land and develops lands and properties. It also disposes of plots and properties for commercial, industrial, institutional and residential uses in accordance with the provisions of the DDA (Disposal of Developed Nazul Land) Rules, 1981 popularly known as Nazul Rules. Of these Rules, Rule 5 stipulates that DDA may allot Nazul lands for construction of hospitals and dispensaries to social or charitable institutions. The premium and ground rend for this purpose will be determined by the Government of India. Allotment of Nazul land to public institutions is subject to fulfilment of certain conditions prescribed in Rule 20 which, inter alia, states that an institution seeking allotment of institutional land should be a society registered under the Societies Registration Act, 1860, or such institution should be owned and run by the Government or any local authority or constituted or established under any law for the time being in force.
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Till May, 2003, DDA had allotted land to 65 social or charitable institutions for construction of 53 hosptials and 12 dispensaries under Rules 5 and 20 of Nazul Rules. The allotments were made at concessional premium and ground rend fixed by the Union Ministry of Urban Development from time to time upto 1995-96 and at rates fixed by the DDA in consultation with the Ministry thereafter subject to the condition that the institution shall serve as a general public hospital with at least 25 percent of total indoor beds reserved for free treatment to indigent patients and that it would provide free treatment to 40 percent patients in the outdoor department. The primary objective of providing free treatment to the poor patients has, however, not been achieved even after a lapse of period ranging from 4 to over 30 years from the date of allotment of land.
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GOVT. ALLOTTED FREE LAND FOR HOSPITALS WITH STIPULATION OF FREE TREATMENT TO POOR In the past DDA and Land & Development Office of Govt. of India had allotted land to the registered societies and trust on concessional rates (predetermined and zonal variant rates) for establishment of hospitals and also stipulated the conditions that they would provide certain percentage of beds in the hospitals free for the poor /indigent category patients. Similarly in the OPD, it was stipulated that free treatment has to be provided to the patients belonging to the indigent category. These hospitals came into functional stages during different times and had the conditions varying from 10% of free beds in the IPD to 70% IPD beds in some of the cases, however in most of the cases it was 25% free IPD beds. There are some hospitals in which earlier there were no conditions imposed but the same were imposed later on and still there are some other hospitals where no conditions have been imposed by the land allotting agencies at all.
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Due to lack of proper guidelines for providing free treatment, and also there being no proper criteria of eligibility as who would be considered poor, and what constitutes the freeships on the free beds, and also due to unwillingness on the part of some private hospitals, it was not being implemented in a proper way, despite the government doing its best efforts. The govt. constituted different committees in the past in order to find out a solution to the problems being encountered by the private hospitals while giving free treatment and also the problems being faced by the govt. A high power committee under the chairmanship of Justice A.S. Qureshi was also constituted in the year 2000 and the recommendations made by the said committee regarding the conditions that there should be 10% free beds in the IPD and 25% of the patients in the OPD should be provided free treatment. It was also recommended that the conditions should be uniform and applicable to all the allottees with or without having conditions and the free treatment should be totally free. Delhi Govt. found these recommendations reasonable and accepted the same and intimated the concerned land allotting agencies, to solve this whole gamut of problems.
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POOR PATIENTS SUFFER AS DELHI'S PRIVATE HOSPITALS LEAVE 40 PERCENT OF RESERVED BEDS EMPTY Even as we see serpentine queues of patients waiting to get treatment in government hospitals in the Capital, around 40 percent of the beds reserved for poor patients (EWS category) in private hospitals are lying vacant. According to the Hon’ble Delhi High Court-constituted committee for EWS patients, many of the 45 private hospitals in Delhi are not abiding by the court directive and are keeping beds reserved for EWS quota empty. There were also many instances when poor patients, who are entitled to free treatment at private hospitals, were reportedly asked to pay fees.
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AS MANY AS 45 PRIVATE HOSPITALS IN THE CAPITAL HAVE FLOUTED THE COURT DIRECTIVE ON TREATMENT OF EWS Around 40 percent of beds for EWS patients are lying empty in private hospitals. Out patients are sometimes asked to pay for their medicines. The situation is not very good and poor patients are at the receiving end, private hospitals have developed “many tricks� to avoid admitting poor patients. Even when a patient requires an ordinary bed, private hospitals tell them that they need to be admitted for ICU bed. Then they show that ICU beds are not available and in this case the poor patient approaches another hospital, According to data (real-time availability of free beds) maintained by the directorate of health services, 293 out of 674 beds (43 percent) were empty on Sunday, June 26. On March1, 2014, as high as 47 percent beds were empty. The figure hovered between 39 to 48 per cent the whole month, according to the data.
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As a result of a PIL filed by a lawyers group (Social Jurist) in 2002 with a view to enforce free treatment of poor persons in hospitals built on land allotted at subsidised rate, the Hon’ble High Court of Delhi on 22 March 2007 had decreed that 10 percent of the total beds in the IPD must be reserved and 25 percent of the patients in the OPD should be treated free of cost if the patient belonged to the Economically EWS. This decision was subsequently upheld by Hon'ble Supreme Court in 2011. Ÿ EWS patients can go directly to such private hospitals. They can also be referred by
Government hospitals. Every Government hospital was mandated to create a special referral center managed by a senior officer round the clock for this purpose. Ÿ The study found that while some hospitals are adhering to the judgment, there is no
dearth of those hospitals which are reluctant to follow the guidelines. Some of them are also facing contempt of court. Ÿ The reluctance to treat poor patients free of cost is also realized in the form of poor
conditions in EWS wards, as seen from the reports of the Monitoring Committee. Ÿ While some EWS patients have benefitted from the implementation of this judgment,
its full potential is yet to be realized. Lack of awareness among the genuine EWS patients as also general reluctance on the part of several private hospitals are the major road-blocks in attaining absolute success. Ÿ There is a felt need to increase awareness among the target population with regard
to this crucial provision of free treatment. Proactive measures need to be taken to promote confidence of people in such facilities. Ÿ It is a matter of grave concern that even after Hon'ble Supreme Court’s mandate,
Govt of NCT of Delhi is not able to ensure that facilities earmarked for the poor are actually provided to them!
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THE MANY FACES OF CORPORATE HOSPITALS: A WOLF DRESSED IN A SHEEP’S CLOTHING In a corporate set up, we often see multiple innovative incentives implemented to lure doctors in all possible ways so as to generate revenue from them. The obsolete incidence of natural deliveries is a classic example of the enormous greed enrooted deep in the doctor’s mind. Doctors known for their heightened cerebral capacity are misusing the superpowers that they have gained through their sheer hard work for unscrupulous, corrupt clinical practice. In the race to earn higher profits, conscience has taken a back seat with doctors opting for a quick race rather than a marathon to make their clinical practice flourish. Patients often feel they are held hostage by hospitals and doctors and are helpless as it’s a matter of life and death. Taxing the patient and the fat fee gained through it is not commensurate with the blessings and goodwill showered on us by our patients. There is an absolute need for doctors to redress their ideologies towards patient care and adopt the Hippocratic principles in their clinical practice. Lastly in the present scenario there are not many doctors who can say with their hand on their heart that their decisions towards patient care have been only on the basis of need rather than money making; however, at some point in time their unethical practice will keep resonating in their minds like a tuning fork for the rest of their life.
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INDIA’S PRIVATE HEALTH CARE SECTOR TREATS PATIENTS AS REVENUE GENERATORS India's private health care sector "treats patients as revenue generators" argues a senior doctor in. The private healthcare providers in India "are above the law, leaving patients without protection. Many patients mentioned unnecessary investigations and surgical procedures. One example was gynaecologists performing ultrasounds without indications in pregnant women who complain of trivial abdominal pain, then fabricating false reports of cervical abnormalities and advising the women to have cervical stitches, with the pretext of preventing miscarriage. Few patients request a second opinion, and the doctor does not give them any documents to avoid being found out. Another example told by a pathologist was referred to as the "sink test." The referring doctor advises a battery of laboratory tests despite no suspicion of pathology. Only a few of the tests are performed, and the extra blood collected is dumped in the sink. Fabricated results are then given in the normal range for all tests that were not performed. The patient pays a large sum, which is shared by the referring doctor and the pathologist. "These interviews indicate the alarming extent of the deterioration of rationality and ethics in India's private medical sector and the need for stringent, transparent, and mandatory regulation. Indian medical associations claim that few doctors indulge in unethical and irrational practices, but several interviewees opined that few doctors are unaffected by increasing commercialisation.
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Some doctors also pointed to the failing of institutions such as the Medical Council of India and suggested that they should be restructured to include representatives of patients and civil society organisations. One fact - paying money does not guarantee good healthcare, The private healthcare system largely treats patients as revenue generators, without rationality or medical logic. Private healthcare in India is "totally unregulated and unaccountable" and believes "the commercial transaction between patients and doctors must be severed.� Ultimately, the only solution for India would be accountable social regulation of the private medical sector, and the movement towards a combination of social insurance and a tax based system for universal healthcare, he concludes. Senior advisor on health systems in New Delhi, argues that private healthcare providers in India are above the law, leaving patients without protection. “Current regulatory and accountability mechanisms are not sufficient to ensure quality and prevent negligence," he writes. "Politicians at the highest levels must ensure private healthcare delivery is properly regulated to stop people being subjected to irrational and unethical practices."
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PROVISION OF FREE TREATMENT FOR ECONOMICALLY WEAKER SECTIONS IN DELHI Registered societies and trusts in Delhi have been allotted land by the Delhi Development Authority (DDA) and Land & Development Office (L&DO) of the Government of India (GoI) on concessional rates (predetermined and zone variant rates) for the establishment of hospitals. In return, the hospitals have to compulsorily reserve certain percentage of beds in the In Patient Department (IPD) as well as facilities in the Out Patient Department (OPD) for poor patients. As these hospitals started becoming operational, they were asked to reserve between 10 to 70 percent of beds in the IPD. However, currently, it is 10 percent in IPD. In the absence of proper guidelines and monitoring mechanisms, the unwillingness on the part of some private hospitals to provide such facilities, and definitional dilemmas and tribulations (who should be considered poor, what constitutes the freeships on the free beds, etc.) has meant that the implementation of such provisions was, and still remains unsatisfactory. Further, looking at the historicity of such subsidies to large corporates, it is evident that the track record of private providers in meeting the public obligations has been questionable. For instance, the case of Apollo Hospital, which was built on land provided at a throw - away price by the Delhi Government, and was openly flouting the terms of the contract, is well known.
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The Delhi government constituted various committees to find a solution to the problems between the private hospitals and the government in the implementation of these free facilities. But due to lack of a stringent regulatory and monitoring mechanisms, the hospitals continued to disregard the conditions stipulated by the government, resulting in a number of cases where patients have been denied treatment. A high level committee under the chairmanship of Justice A. S. Qureshi was constituted in the year 2000 to investigate this issue. It took note of the following concerns and gave the following recommendations: a) Review the existing free treatment facilities extended by charitable and other hospitals that have been allotted land on concessional terms/rates by the Government. b) Suggest suitable policy guidelines for free treatment facilities for needy and deserving patients and to specify the diagnostic, treatment, lodging, surgery, medicines and other facilities that will be given free or partially free. c) Suggest a proper referral system for optimum utilization of free treatment by the deserving and needy patients. d) To suggest a suitable enforcement and monitoring mechanism for the above, Including a legal framework. The Qureshi Committee recommended the provision of 10 per cent free beds in the IPD, and free treatment for 25 per cent of the OPD patients. It was also recommended that the conditions should be uniform and applicable to all the allottees with or without any conditions, and free treatment should be completely/entirely free.
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The Delhi government found these recommendations reasonable and accepted them. The committee found that in spite of the government directives, the hospitals were not abiding by the terms of the agreement, by which they had received government subsidies. Following this, a lawyers group (Social Jurist) filed a Public Interest Litigation (PIL) wrote petition in 2002 stating that conditions of allotment of land to hospitals, particularly with regard to free treatment for the poor persons were not being fulfilled. The final judgment was pronounced by the Hon’ble High Court of Delhi on 22 March 2007. It took into consideration the recommendations of the Justice Qureshi Committee report and decreed that 10 percent of the total beds in the IPD must be reserved and 25 percent of the patients in the OPD should be treated free of cost if the patient belonged to the EWS The court also observed that government hospitals should refer poor patients to private hospitals where the requisite facilities are available. The court examined 20 private hospitals during the hearings and directed that all other hospitals identically placed should strictly comply with the terms of free treatment to indigent or poor persons. The guidelines therefore were applicable to all private and government hospitals functioning under the control of the Central Government, Delhi Government, Municipal Council of Delhi, and New Delhi Municipal Council. Some of these hospitals included All India Institute of Medical Sciences (AIIMS), Institute of Human Behaviour and Allied Sciences (IHBAS), etc., which are available for the general population, and Railways, Employees State Insurance, Cantonment Hospitals, etc., where, besides their own employees covered under their schemes, patients of general population are also extended facilities when found to be needing treatment in private hospitals.
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Category – A: List of Identified Private Hospitals Providing Free Treatment with an Updated Position of Free Beds Available:
S. No
1.
2.
3.
4.
5.
6.
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Name and Address of the Free Beds Hospitals Available Indian Spinal Injuries Centre, Opposite Police Station, Sector-C, Vasant Kunj, Delhi-110070
Pushpawati Singhania Research Institute, Sheikh Sarai, Phase-II, Saket, New Delhi-110017
National Heart Institute, 49, Community Centre, East of Kailash, New Delhi-110065
Mai Kamli Wali Chari Hospital, Plot No. 12, J-Block, Community Centre, Rajouri Garden, Delhi-110027
Saroj Hospital, Sector-14. Extn Near Madhuban Chowk, Rohini, Delhi-110085
Shanti Mukund Hospital, 2 Institutional Area, Vikas Marg Extn, VikasMarg, Delhi-110092
14
11
5
5
11
14
7.
8.
9.
Venu Eye Institute & Research Centre, Plot-1, Sheikh Sarai, New Delhi110017
Primus Super Speciality Hospital, Chander Gupta Road, Chanakyapuri, Delhi-110021
Gujarmal Modi Hospital, Mandir Marg, Saket, Delhi110017
42
10
10
10.
Kottakkal Arya Vaidyashala, Karkardooma, Delhi-110092
4
11.
Amar Jyoti Charitable Trust, Karkardooma, Delhi-110092
2
12.
13.
Bimla Devi Hospital, Plot no. 5, Pkt. B, Mayur Vihar-II, Delhi-110091
Batra Hospital,1, MB Road, Tughlakabad Institutional Area, New Delhi-110062
3
50
19
14.
15.
Bagwan Mahavir Hospital, Sector-14 Extn, Madhuban Chowk, Rohini, New Delhi-110085
Jeevan Anmol Hospital, MayurVihar, Phase-I Delhi110091
Delhi ENT Hospital & Research Centre, FC-33, Plot 16. no. 13, Jasola, Delhi-110017
17.
18.
19.
20
Sir Ganga Ram Hospital, Hospital Marg, Rajinder Nager, Delhi-110060
National Chest Institute, A133, Niti Bagh, Gautam Nagar, Delhi-110092
Mata Chanan Devi Hospital, A-21/D, Janakpuri, Delhi110058
3
5
2
68
2
21
20.
R B Seth Jessa Ram Hospital, WEA, Karol Bagh, Delhi110005
8
21.
Khosla Medical Institute & Research Society, K.M.I. & R. Centre, Paschim Shalimar Bagh, New Delhi110088
7
22.
Rockland Hospital, B-33,34, Qutab Institutional Area, New Delhi-110016
11
23.
Bensups Hospital, A Unit of B R Dhawan Medical Charitable Trust, Bensups Avenue, Sector-12, Dwarka, Delhi-110075
3
24.
Flt Lt Rajan Dhall Hospital, Sector-B, Pocket-I, Aruna Asaf Ali Marg, Vasant Kunj, New Delhi110070
11
25.
Dr B L Kapoor Memorial Hospital, Pusa Road, New Delhi-110005
7
TOTAL
329
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Consistent legal advocacy efforts have led to the recent judgement by the Hon’ble Supreme Court, in August 2011, directing the ten hospitals (Category B) to comply with the guidelines. Following the Hon’ble Supreme Court Judgement, (September 2011), the Hon’ble Delhi High Court has directed the Delhi government to file a status report on the number of poor patients given free treatment by private hospitals in the last four years as per the earlier order. (The Times of India, 26 September, 2011). While the need and the significance of such legal directives as useful instruments cannot be underestimated, the proper and transparent implementation of such provisions also needs to be strengthened much more at various levels. The non - compliance of the hospitals even to the legally bound provisions definitely highlights the urgent need for a more stringent regulatory mechanism. Further, it is important to point out that provisions such as free treatment can only be in addition to and not a substitute for a stronger public health system. Universal accessibility and availability of comprehensive health care for everyone can only be achieved or envisaged through provision of comprehensive public health care.
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EMERGING ISSUES I. Lack of Transparency and Access to Information with regard to Provision of Subsidies The lack of transparency and access to information with regard to granting of subsidies was a major gap that emerged from the study. There was no public information regarding the selection criteria based on which the hospitals have been granted subsidies as well as the selection procedure that was followed. The diverse categories of hospitals, ranging from charitable trust hospitals, small private hospitals, big hospital groups, as well as international hospital chains also reiterates the need for defined criteria for hospital selection even prior to grant of subsidies towards provision of free treatment. The prior processes of application granting of subsidy, process of granting land through auction needs to be further investigated, and made transparent and standardised.
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II. Impact of Collaborations on Provision such as Free Treatment It was clear from the study that many of the hospitals that had been granted subsidies are now entering collaborations of various kinds with larger health care chains like Fortis etc. There is a definite impact of such arrangements on the functioning, management and priorities of the hospitals under consideration. It is significant to examine the impact of such collaborations on the implementation process for the provision of free treatment, and access by the EWS patients. Whether such collaborations have a negative influence on such provisions needs to be further examined.
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III. Larger Socio - Economic Factors and Access The provision of free treatment cannot be viewed in isolation, as it is a well-established fact that there are other larger socio- economic, political factors that determine health status. The understanding of poverty and the constituency of poor, the costs of living (food, water, housing, education, exclusion, etc.) in general and health care in particular are extremely important determinants of health. Thus, a particular percentage of free treatment in designated hospitals in lieu for subsidies provided by the government is not sufficient. The state needs to take more concrete steps towards ensuring that a majority of the people are able to access and afford quality health care, whereby provision of free treatment is a part of a more comprehensive health care. Further, the poor in Delhi comprise about 14.7 percent of the total population, i.e. about 22.93 lakh population. Considering this, the extent of in - patient services (number of beds) for such provisions (approximately 500 across 40 hospitals in Delhi) is extremely limited and inadequate. It is worth reiterating that given the high costs of health care and the abysmal state of public health, free treatment provisioning by private hospitals can only be seen as supplementary to a strengthened and comprehensive public health care system.
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IV. Insufficient Access for Vulnerable and Marginalised Groups
Significantly, the category of EWS patients is not homogenous and comprises of people from amongst the most vulnerable communities migrants, homeless, displaced, single women headed households, etc. who may have higher health care needs but where access is denied due to lack of eligibility proof (as a majority of them are also floating population).
These are also the communities who have the least access to information about such provisions. It then becomes essential to ensure mechanisms and creation of strategies that enable easy access to the provisioning of free treatment. Further, given the sheer magnitude of persons who fall in the EWS category, combined with insufficient information about the hospitals providing free treatment, the need to strengthen public health cannot be ignored.
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V. Eligibility Proof for Accessing the Provisions The documents required for eligibility proof varied across hospitals and were usually at the discretion of the hospital. Some hospitals required income proof, while some others asked for residence proof in addition to an 'undertaking' from the patient. While a member of the inspection committee opined that a declaration from the patient was sufficient documentation, the guidelines themselves are not very clear about this. The guidelines include a format of an undertaking and one of the clauses merely states, “The hospital shall maintain the records which would reflect the name of the patient, father's/husband's name, residence, name of the disease suffering from, details of expenses incurred on treatment, the facilities provided, identification of the patient as poor and its verification done by the hospital.� Some of the hospitals also based their assessment of eligibility on the appearance and/or speech of the patients, which may be extremely arbitrary, based on stereotypes of EWS patients, at the cost of excluding those who fall outside these stereotypes. Further, a majority of the population in the category of the vulnerable group might not have the requisite documents of eligibility (such as BPL card etc.), thereby also limiting their access to such provisions.
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VI. System of Referral Referral systems between public and private hospitals as well as between private hospitals need to be examined and strengthened to ensure maximum utilization. But while these referral systems need to be streamlined to enable better access; referrals also need to be examined carefully to ensure that the limited provision of treatment in a specific number of hospitals does not facilitate abdication of responsibilities by the public health system in providing requisite health care facility. The role of the state in providing comprehensive health care is not in any way reduced and understated even with a streamlined referral mechanism between the public and private sectors.
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VII. Monitoring and Redressal Systems At present the monitoring systems for hospitals for provision of free treatment includes regular daily updates to a centralized authority (DHS) by the hospitals with regard to bed availability, quarterly reports and monitoring by the designated monitoring committees. The monitoring is primarily limited to ascertaining whether the mandated obligations are being fulfilled by the hospitals and does not assess treatment quality, violations, access, etc. Currently, most of the hospitals in the sample are sending updates once instead of twice daily. There is not much information about the quarterly reports in the public domain. With regard to the inspection committee, which comprises merely of three members, efficiency, regularity and quality of inspections have emerged as serious concerns. Further, existing grievance redressal is located in the hospital with the nodal officer playing a central role, pointing to high possibility of compromised or non-objective response, and lowered accountability to the poorest. Monitoring systems discussed here need to be located in the larger framework of unregulated, unmonitored private health sector, whereby a more stringent monitoring mechanism for such provisions form a part of this structure.
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VII. Patients' Rights
Even without the perspective of the patients accessing the provision, the study does highlight the important issue regarding the patients' rights. Interaction with the members of the Inspection Committee and media reports highlight the fact that rights of the patients are not ensured even within the legally obligatory framework as mandated by the state. Further, insufficient or lack of access to services and information and poor regulatory and monitoring mechanism among other things severely impinges on the rights of the patients, who are already marginalized and vulnerable. Addressing the rights of the patients hence becomes a critical component.
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CONCLUSION In the current framework of the functioning of the health system in general and the private sector in particular, the provisions as examined in the study point towards a positive direction in terms of making a special provision for the economically poor. Further, such provisions are also an effort to make the private sector at least somewhat more accountable towards fulfilling the obligatory role of providing services to the marginalized and vulnerable. However, as the study has shown, provisions such as these also pose problems in terms of implementation, non - compliance, redressal, etc. A.
Public Advocacy
•
In absence of stringent regulatory mechanism, the role of various groups and networks such as health rights and patients' rights groups in public advocacy with regard to the issue is extremely crucial. Public advocacy needs to be strengthened along with simultaneous positive changes at the structural level.
•
Pro - active engagement of various stakeholders from different segments can be instrumental in the formulation of Patients' Rights Charter. The Charter can be an important instrument not only for awareness generation, but also towards protecting the rights of the patients accessing these provisions.
B.
Revisiting the Systems and Processes
The Functioning of the referral system needs to be undertaken to address the identified gaps in the system. Such a relook should include existing pattern of referral, the distribution of patients referred to the respective private hospitals, the nature of treatment And geographical location. This can increase the effectiveness and better utilization of services within such provisions.
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The effectiveness of the existing monitoring mechanism needs to be assessed and reviewed. While the existing effective mechanisms needs to be further strengthened, at the same time, the gaps need to be addressed. A closer look at the maintenance of records and inspection reports by the hospitals and the DHS and the functioning of the existing committees becomes imperative in this regard. Further, in the context of the recent Supreme Court Judgment, the monitoring mechanisms need to be scrutinized. The Judgment itself points to the lacunas and the in adequacy of the existing monitoring mechanisms. C.
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Strengthening Good Governance and Transparency
•
Information with regard to registration, financial and management records, patient records of 'charitable' and trust hospitals, as well as private hospitals needs more transparency. All records and information should be publically available. Such information will be instrumental towards ensuring the accountability of the private sector.
•
The categorization of the hospitals even within the private sector needs more clarity interims of operational reality. The type of ownership, management policy and systems, previous or past records of the hospitals in fulfilling such legal
obligations, are important factors that can be considered in this context. This will be useful in creating customized policies and mechanism. As such, the categorization of the hospitals needs to go beyond for–profit and not-for-profit, as neither of these categories are uniform or homogenous. D.
Utilization of Services
•
The actual effectiveness of such provision needs to be measured through a careful analysis of the utilization pattern. This becomes important as the mere existence of provisions and services does not guarantee access and benefits. The assessment should be both qualitative and quantitative (including numbers and trends in utilization of free service, completion and effectiveness of the treatment, input output analysis of costs, cases of patients' rights violations and existence of minimum standards of care), so as to inform the policy (on the free treatment for EWS) and its implementation, as well as inform similar initiatives in the future.
•
Formulation of strategies for information, rights and awareness amongst individuals from the EWS category is of utmost importance. The collaborative roles of the state, the private sector as well as the non-state actors (including the Non Governmental Organizations) in ensuring utilization requires further investigation. The question of whether DHS should play a central role in the same can needs to be examined. Non-availability of information is also closely related to the utilization pattern and should not be a limiting factor for not being able to access the existing services.
While an attempt has been made here to categorize the areas of further engagement under different sub heads, it is important to point out that all of these are interconnected. Future research on the specific aspects as mentioned above for further evidence building is extremely crucial. Advocacy and campaigns on components of Right to Health and Health Care and regulation of the private sector, amongst other things, will also be benefited by the evidence that is gathered. Last but not the least, engagement at a policy level towards making positive changes cannot be over emphasized. We do hope that this study (with all its limitations) will serve as an important resource towards the future course of action. 33
5 Delhi Hospita ls Fined Rs. 70 0 Crore For Refusing Fr ee Treatment T o Poor elhi
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