Free Treatment in the Private Sector: Myth or

Free Treatment in the Private Sector:
Myth or Reality?
A Pilot Study of Private Hospitals in Delhi
A Report
Sama – Resource Group for Women and Health
The information provided in this report is for wider dissemination, and may be used
by anyone with due acknowledgement to Sama.
First published in 2011
Published by:
Sama- Resource Group for Women and Health
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Main Road Shivalik, Malviya Nagar
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Ph. No.: 011-65637632, 26692730
E-mail: [email protected]
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Acknowledgements
Study Team: Preeti Nayak, Ishita Sharma, and Radhika Gambhir
We would like to thank the doctors and staff members of the hospitals who took time out and
shared information with us, without which the study would not have been possible. We also
express our thanks to Mr. Ashok Agarwal for sharing his experiences with us.
A special thanks to Mr. Sunil Nandraj for providing critical inputs and suggestions as we
conceptualised the study. Thanks are also due to Dr. Amit Sengupta and Dr. Ramila Bisht for
their insightful and thorough review of the study report. For editing of the document we thank
Ms. Preeti Jhangiani.
For revisions and reviews we would like to extend a heartfelt thanks to Deepa Venkatachalam,
as well as Ranjan De. A big thank you to Sarojini N for providing comments, feedback and
suggestions throughout the study. We would also like to acknowledge all the team members of
Sama for their support and encouragement.
We thank Oxfam India Trust for supporting this study. Special thanks to Mr. Avinash Kumar
and Mr. Deepak Xavier from the Trust, for their support and encouragement.
iii
Preface
The pilot study is situated within the framework of understanding the functioning of the private
sector in regards to policy and access to health care for the poor. It attempts to understand and
explore the legal provision of free treatment for the Economically Weaker Section (EWS) in
the context of subsidies provided to the private hospitals by the State Government.
The report is divided into four chapters - the Introduction, Methodology, Findings and
Emerging Concerns, the Way Forward, followed by the Annexures.
The Introductory chapter is divided into two parts; the first part briefly lays out the context
of the study through focusing on the current patterns of the health care system in India. This
is followed by an overview of health care provisions in Delhi, including the provision of free
treatment.
The second chapter on Methodology outlines the research and writing process, the mapping
and selection of hospitals for the study, and the limitations of the same.
The key findings, related discussion points and emerging areas of concern are highlighted in
chapter three - Findings and Emerging Concerns.
The Way Forward analyses areas of concern, to offer suggestions to strengthen provision of free
treatment and access for the poor.
This is followed by the Annexure which includes a literature review on the information available
on the private sector, and access to health care for the poor. The Annexures also include relevant
legal documents and information regarding the provision for free treatment which have been
utilised during the course of this study.
This pilot study has focused on documenting the perspectives of providers of health care and
their analyses. This needs to be further consolidated and complemented with experiences of
patients to understand the ground realities vis-a-vis access to free treatment in designated
private hsopitals.
iv
Contents
Acknowledgements..................................................................................................... iii
Preface..........................................................................................................................iv
Introduction................................................................................................................. 1
Methodology.............................................................................................................. 15
Findings and Emerging Concerns............................................................................. 20
The Way Forward....................................................................................................... 47
References.................................................................................................................. 50
Annexures.................................................................................................................. 51
Annexure 1: Literature Review........................................................................... 51
Annexure 2: The DHS and Nursing Homes Cell............................................... 76
Annexure 3: High Court Guidelines................................................................... 78
Annexure 4: Comparison in the Delhi and Mumbai Judgements....................... 88
Annexure 5: Policy Guidelines for Free Treatment............................................. 90
Annexure 6: Table of Findings............................................................................ 93
Annexure 7: Undertaking from DH3 Hospital................................................... 95
Annexure 8: Pamphlet from DH1 Hospital....................................................... 99
Annexure 9: Referral Table for Hospitals in the Study..................................... 100
Annexure 10:Quarterly Report Format.............................................................. 104
Annexure 11:Newspaper Clippings.................................................................... 105
v
chapter 1: Introduction
India offers a picture of dichotomy and paradox as far as the health system is concerned. The
country is typically characterised by a mixed health care system with significant heterogeneity
in terms of the types of establishments and service providers, a dominant private sector, and
inefficient delivery of government health services. The medical sector is seen as the next
big thing for the country with immense potential for growth in various segments such as
the pharmaceutical, medical equipment, etc. Along with this India has emerged as the hub
for medical tourism, which is witnessing a consistent upward trend. While these indicators
do project an optimistic picture of the health care scenario in India, the reality remains
far from desirable. The deteriorating public health standards and increasing privatisation of
health care has been a long-standing concern, which is even more pertinent today. The twin
processes of globalisation and liberalisation having created a ‘boundary’ free world, have
also disproportionately affected the distribution of resources amongst populations. Economic
globalisation is no longer restricted to goods but now also includes services. In India, over
the last decade or so, essential requirements such as health, education, sanitation, water and
electricity have become profit making ventures instead of being the responsibility of the State
(Society for Labour and Development, 2007). This is also directly related to the state adopting
pro market policies in the 80s and 90s, as part of the liberalisation process. The changes or
‘reforms’ carried out in the health sector (also known as the Health Sector Reforms) have led
to the growing privatisation of health care services. Health care in India is now viewed as a
private good to be accessed through the market, instead of being seen as the responsibility of
the State, resulting in affordable and quality health care being out of reach for the majority of
the population. At the same time poor health indicators and the resurgence of communicable
diseases have been a matter of concern, which remains unaddressed, even with the increasingly
sophisticated and advanced technologies in the health care sector.
Not surprisingly, India has one of the most privatised health care sector, with very high out of
pocket expenditure (almost 80 per cent). India ranks among the top 20 of the world’s countries
in its private spending, at 4.2 per cent of GDP (Chanda, n.d.). These factors directly impinge
on the access to health care for most people, especially for the poor. The private sector has
remained completely unregulated, also ‘helped’ by the laxity and lack of will by the state for a
systematic regulatory provision.
On the other hand, the public health system has been in shambles. The poor standard of
public health in the country has been both a historical and continuing concern. The Bhore
1
Committee (also known as the Health Survey & Development Committee) appointed in
1943, recommended a systematic action plan to strengthen the public health system of the
country with special emphasis on integrating preventive and curative medicine at all levels. By
the 1950s, vertical programming for disease control such as malaria eradication programme,
and family planning services became the focus of public health services, leading to a situation
where “for those public health programmes where there is no separate vertical structure, there
are no identifiable service delivery system at all” (Amrith, 2007). The National Health Policy
(2002) also clearly mentions a similar situation in 2002. It states,
It would detract from the quality of the exercise if, while framing a new policy, it were not
acknowledged that the existing public health infrastructure is far from satisfactory. For
the outdoor medical facilities in existence, funding is generally insufficient; the presence
of medical and para-medical personnel is often much less than that required by prescribed
norms; the availability of consumables is frequently negligible; the equipment in many
public hospitals is often obsolescent and unusable; and, the buildings are in a dilapidated
state. In the indoor treatment facilities, again, the equipment is often obsolescent; the
availability of essential drugs is minimal; the capacity of the facilities is grossly inadequate,
which leads to over-crowding, and consequentially to a steep deterioration in the quality of
the services. As a result of such inadequate public health facilities, it has been estimated that
less than 20 percent of the population, which seek OPD services, and less than 45 percent
of that which seek indoor treatment, avail of such services in public hospitals. This is despite
the fact that most of these patients do not have the means to make out-of pocket payments
for private health services except at the cost of other essential expenditure for items such as
basic nutrition”(GOI,2002:2.4 ).
The government flagship programme, the National Rural Health Mission (NRHM), initiated
in 2005 provided some hope for better public health standards by initiating architectural
correction of the health system, decentralisation of health planning and monitoring. However,
six years since its launch, the situation is far from what the NRHM envisaged. Even in places
where Sub Centres, Primary Health Centres (PHCs) and Community Health Centres (CHCs)
exist, conditions are abysmally poor. Most of these centres are understaffed and function out of
rented or temporary premises, with figures being as high as 50 per cent for Sub Centres, 24 per
cent for PHCs and 16 per cent for CHCs ( JSA, 2009). However, the long-standing concerns
regarding the government’s endorsement of vertical programmes are still relevant, where the
larger structural issues and inter-sectoral linkages remain unaddressed. Even for NRHM,
the maximum funding has been towards programmes such as HIV and AIDS Programme,
Reproductive and Child Health Program (RCH), medical education and AYUSH (Ayurveda,
2
Unani, Siddha, Homeopathy), and the actual strengthening of the public health infrastructure
remains grossly inadequate (CBGA, 2009).
While the scenario of the public health system continues to be bleak, private health care
accounts for 75 per cent of the total expenditure in India (Chanda, n.d.). The spending
within the private sector is also not uniform and the distribution of the spending is as
follows: employers contribute nine per cent of the total expenditure; another nine per cent
comes from health insurance, and the largest section of about 82 per cent from personal funds
( JSA, 2006, 2009).
Although the cost of health care in the country has increased over the years, government
spending in this crucial field remains minimal. The Union Government’s allocation for Health
and Family Welfare has increased only marginally from 2.1 per cent in 2010-11 (Revised
Estimates) to 2.4 per cent in 2011-12 (Budget Estimates). The total allocation of the Union
Government for Health and Family Welfare shows a negligible increase from 0.32 percent
of Gross Domestic Product (GDP) in 2010-11 (RE) to 0.34 percent of GDP in 2011-12
(BE). Further, as a proportion of GDP, the combined expenditure of Centre and States on
health came down to 1 per cent in 2009-10 from 1.02 per cent in 2008-09 (CBGA, 2011).
This is way short of the recommended 2 per cent of public health spending by the National
Health Policy (2002)and the 5 per cent by the World Health Organisation. Refer Table 1 for
combined expenditures by Centre and States on Health and Family Welfare.
Table 1: Combined Expenditure of Centre and States on Health and Family Welfare
Centre’s Expenditure
(in Rs. Crore)
States’ Expenditure (in
Rs. Crore)
2004-05
8085.95
188771
0.25
0.83
2005-06
9649.24
22031
0.26
0.86
2006-07
11757.74
25375
0.27
0.86
2007-08
14410.37
28907.7
0.29
0.87
Centre’s Exp as % of
GDP
Total Exp
(Centre+ States)
as % of GDP
Source: UPA’s Promises & Priorities: Is there a Mismatch? Union Budget 2011-12, CBGA
A weak public health system with a lack of comprehensive care (both in terms of financing and
implementation) has also meant that other kinds of alternatives such as the collaboration between
the public and private sector in terms of Public Private Partnerships (PPPs) are increasingly
being seen as possible solutions. However, the fundamental differences in the priorities between
3
the public and the private sectors, along with the assumption that privatisation or PPPs per se
lead to improved quality and access, are problematic and need to be challenged.
In addition, the existing legal vacuum and non-regulation have only compounded the problem
of transparency and accountability. Therefore, there is an urgent need to address the concerns
related to the unregulated private sector. The importance of an effective regulatory framework
should be balanced with a strengthened public health set up, with the state fulfilling its role of
provider of the health care services.
Delhi: the State under Consideration
The Health Profile of Delhi
The trends in health care provision, seen nationally are also reflected in Delhi. Being the national
capital, Delhi offers a wide range of health care services both in the public and private sectors
that are utilised by Indians as well as foreign nationals. The profile of public and private sector
establishments range from dispensaries and urban health centres at the primary level, to multispeciality medical colleges and hospitals. The trend of increasing privatisation of health care
is also seen in Delhi with both outpatient and inpatient care dominated by the private health
sector, as in the rest of the country. The state also receives a large number of people from other
parts of the country for accessing health care facilities.
As far as indicators for health are concerned, the state of Delhi has better health indicators
than many other states in the country. Life expectancy at birth at 69.6 years is higher than the
national average of about 65 years. The birth rate, death rate and infant mortality rate in Delhi
are better than the national averages at 18.4 (22.8 for Delhi), 4.8 (7.4 for Delhi) and 35 (53 for
Delhi) respectively. The Maternal Mortality Ratio (MMR) for Delhi is 172, which is again an
improvement on the national MMR of 254 (PHFI, 2011).
The Department of Health and Family Welfare of Government of National Capital Territory
(NCT) of Delhi is the body responsible for the provision of health care in the state, while
the Directorate of Health Services (DHS) Government of NCT of Delhi is the main agency
committed to delivery of health care services. The Department of Health and Family Welfare
is headed by the Principal Secretary, and liaisons with other local bodies like the Municipal
Corporation of Delhi (MCD), New Delhi Municipal Council (NDMC), Cantonment Board
and other Government and Non Government Health Care Organisations functioning in
Delhi. Figure 1 details the main bodies and public health institutions (both governmental
and autonomous), and the linkages between these. (For a more detailed explanation of the
functioning of the DHS and Nursing Homes Cell refer Annexure 2).
4
Figure : Structure of Ministry of Health and Family Welfare Department
Principal Secretary
Department of Health and Family Welfare, Govt. Of NCT of Delhi
Directorate of Health
Delhi Govt Hospital
Minister, Health and Family Welfare
Autonomous Bodies
Local Bodies
IHBAS
• MCD
Delhi AIDS Society
• NDMC
Directorate of Food
• Cantonment Board
Adulteration
• Other Govt and Non Govt
Services
C.A.T.S
Healthcare organisations
Drug Controller
Other National
programmes
The inadequate infrastructure with regard to public health is reflected in the number of
health centres at different levels. In March 2008, there were only 41 Sub Health Centres in
the State, against the population norm of 188. Similarly there were only 8 Primary Health
Centres as against the mandated 31, and there were no Community Health Centres when
there should have been 7 (PHFI, 2011). These figures for the public health infrastructure
are for the rural areas of Delhi. In addition, the bigger tertiary level hospitals are exceedingly
overburdened and insufficient to cater to the growing demand for quality health care.
Therefore, not surprisingly, one also finds a dense concentration of private clinics and
hospitals providing health care services. In 2009, nearly half of the total hospital beds
(42 per cent of 36,352 beds) in Delhi were in the private sector. The growth in the number of
beds and the bed population ratio from 2004 to 2008 is indicated in Table 2. Significantly,
while the number of beds has increased over the years, the bed to population ratio has come
down, indicating the decrease in the availability of the number of beds for the people.
Table 2: Expenditure and budgetary Allocation for the Health Sector by the Government of NCT of Delhi
Year
Number of Beds
Number of beds per 1000 persons
2004
32941
2.14
2005
32998
2.08
2006
33278
2.04
2007
35520
2.12
2008
36352
1.14
Source: National Health Accounts, Directorate of Health Services, Government of National Capital Territory of Delhi.
5
As compared to the other states, the spending on health sector by the Delhi government is
one of the highest in the country at nearly 9.4 per cent of the total outlay of the government
in 2008-2009, and approximately 1.19 per cent of the State Gross Domestic Product (SGDP).
Over the years while the state government’s spending has increased, it is still inadequate for
provision of quality public health services. Refer Table 3 for spending on health sector by
government of Delhi.
Table 3: Spending on Health Sector by the Government of NCT of Delhi
Year
GSDP at current prices
(Rs. in crore)
Exp. On health
(Rs. in crore)
% of GSDP on
Medical Care
2003-2004
79468
705
0.89
2004-2005
92053
832
0.90
2005-2006
105814
907
0.86
2006-2007
125281
1123
0.90
2007-2008
143911
1715
1.19
Source: National Health Accounts.
The low priority accorded to the health sector in the overall budget can be seen in the plan outlay of
the state government, with only a marginal increase. While there has been an overall increase in the
budget, the share allocated for the health sector has decreased over the last few years. Comparative
figures for the total plan expenditure vis-à-vis the expenditure on health sector over the last years
(from 2004-2009) is indicated in Table 4.
Table 4: Health Expenditure as Percentage of Total Expenditure
Annual Plan
Total Plan Exp.
(Rs. In Crores)
Exp. on health Sector
(Rs. In Crores)
% of total Plan
Exp.
2004-2005
4260.53
469.89
11.03
2005-2006
4280.87
543.33
12.69
2006-2007
5083.70
720.50
14.17
2007-2008
8747.53
864.37
9.88
2008-2009 (RS)
10000.00
945.37
9.45
Source: National Health Accounts.
Looking at the per capita spending on health care by the state, the figures for Delhi are considerably
higher when compared to the other states. The table below provides a comparative analysis of the
per capita spending on health care between Delhi and all the other states.
6
Table 5: Health Expenditure of Delhi in Comparision to Other States
Year
Delhi
All States
2004-2005
549
180
2005-2006
625
230
2006-2007
685
260
2007-2008
693
NA
Source: National Health Accounts.
Data also shows that the expenditure on a single instance of hospitalisation in Delhi is relatively
higher than the average all-India spending. Table 6 presents the average medical and other
expenditure per hospitalisation incurred in different types of health facilities. A substantial
difference can be seen in the cost of accessing health care in the public and the private sector.
Table 6: Expenditure by Source of Treatment
State
Expenditure by Source of treatment
Other
Expenditure
Total
Expenditure
Government
Private
All
Delhi
3,847
14,065
10,568
338
10,906
India
3,877
11,553
8,851
516
9,637
Source: Government of India (2004), Morbidity, Health Care and the Condition of the Aged, January-June, as cited in India’s
Healthcare in a Globalized World: Healthcare Worker’s and Patients’ Views of Delhi Public Health Services, 2007,
Note: Per Hospitalisation Case during 365 days preceding the survey in urban areas.
Provision of Free Treatment for Economically Weaker Sections (EWS) 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 per cent of beds in the IPD. However, currently, it is 10 per cent 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
7
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.
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. Qureshi1 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 utilisation 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.
Source: www.indiankanoon.org/doc/1508125
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.
1
Note: A similar committee known as the Dhumal Committee was set up in Mumbai to look into the monitoring of charitable hospitals. Both,
the Qureshi Committee Report and Dhumal Committee Report were instrumental in guiding the course of the action of the judiciary in the
two cities that resulted in modifications in the existing laws. For a brief comparative analysis of the judicial decisions in Delhi and Mumbai.
Unfortunately, however, the unilateral approach of taking into consideration only free or subsidised services does not allow for looking at other
aspects of the functioning of these hospitals such as partnerships and collaborations (See Annexure 4 for details).
8
Recommendation by the Qureshi Committee
“The existing free treatment facilities extended by charitable and other hospitals who have
been allotted land on concessional terms/rates are inadequate, erratic and far from what was
desired....”
The Committee recommended that:
“The government needs to intervene and to take action against all cases who have
contravened the terms and conditions of allotment. The allotments and leases could
be cancelled and necessary fresh agreements specifying fresh and uniform terms and
conditions. The committee also suggests that the tariff subsidised has been low and
could be charged on nominal market rates. And the new agreement should look into
the reconstitution of the managements with at least three nominees of the Delhi
government on board of all managements. And all defaulters should be made to pay
compensation which could be constituted as a welfare fund to benefit the poor.”
Following this, a lawyers group (Social Jurist) filed a Public Interest Litigation (PIL) writ
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 High Court of Delhi on 22 March 2007. It took into consideration the
recommendations of the Justice Qureshi Committee report and decreed that 10 per cent of the
total beds in the IPD must be reserved and 25 per cent of the patients in the OPD should be
treated free of cost if the patient belonged to the EWS (For details see Annexures 3 and 5).
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. (See Box 1 for guidelines issued by the Delhi High Court for the implementation
of the provision of free treatment).
9
Box 1 : Provisions in the Guidelines from the Delhi High Court for Private Hospitals:
1. As per the guidelines 25 per cent of patients in the OPD and 10 per cent of beds in the
IPD will be reserved for free treatment for the poor.. These patients will not be liable
to pay any expenses in the hospital for admission, bed, medication, treatment, surgery
facility, nursing facility, consumables and non consumables etc.
2. Any hospital found charging any money shall be liable for action under the law and
this will be treated as violation of the orders of the court. The Director/M.S./member
of the trust or the society running the hospital shall be personally liable in the event of
breach/default.
3. The hospital shall maintain the records with the name of the patient, father’s/husband’s
name, residence address, name of the disease, details of expenses incurred on treatment,
facilities provided, identification of the patient as poor and its verification as done by
the hospital .
4. The hospital shall also maintain details of referrals from government hospitals and
submit a report to the government hospital giving details of treatment provided to the
patient.
5. The records so maintained shall have to be produced before an inspection team consisting
of Sh Ashok Aggarwal, Ms ManinderAcharya and the MS of Dr Ram ManoharLohia
Hospital for verification as and when required. A quarterly report will be sent to DHS
in the first week of every quarter.
6. The details will have also to be made available to the monitoring committee constituted
by Delhi Government whenever required.
7. All private hospitals shall have to establish a twenty-four hour referral centre/desk
functional where the patients referred from government hospitals will report. The
referral desk shall be managed by a nodal person whose name, telephone number, e-mail
address and fax number should be prominently displayed shall and also be sent to the
government Hospitals and DHS. The hospital shall also display the facilities available
and the daily position of availability of free beds, so that the patients’ coming directly
to the hospital will know the position in advance.
8. Any changes in the information of the nodal person will have to be intimated to the
government hospitals and the DHS within 24 hours.
9. A referral desk must be set up within two weeks of the pronouncement of the judgment
failing which the Director of the hospital shall be held personally responsible.
10. The hospital shall send daily information of availability of free beds to this directorate
twice a day between 9-9.30 AM and 5-5.30 PM on all working days and also to the
concerned nearby government hospital to which the private hospital is proposed to be
10
linked for general and for specialized purposes. The details of geographical linkage, the
telephone numbers/fax numbers and the name of the nodal officer of Govt hospitals
shall be intimated shortly. In case no information is received with in the stipulate time
from the private hospitals then it shall be presumed that the beds are available in private
hospitals and the patient referred shall be accommodated.
11. The patient referred by government hospitals or directly reporting to the private hospital
shall be admitted if required, and treated free of cost. As per the court’s directions, these
patients shall not incur any expenditure for the entire treatment at the hospital.
12. After the discharge of such patients, the hospital shall submit a report to the referring
hospital with a copy to the DHS giving complete details of the treatment provided and
the expenditure incurred thereon.
13. Free treatment will be given to all patients without income or having income below Rs
5000/- per month.
14. Besides admitting of the patient referred from Govt Hospitals, the hospital shall also
provide OPD/IPD/Casualty treatment free to the patients directly reporting to the
private hospitals and would inform the nearest Govt hospital and to the DHS within
two days of his/her admission.
15. The patients admitted in any other manner not covered by the above guidelines shall
not be entitled to free treatment.
16. Hospitals that have been allotted land from the government on concessional rates
and have not yet completed the construction after taking possession shall be liable
for not complying with the conditions and might be asked to repay the authorities.
This decision however can only be taken by a special committee constituted for this
purpose.
17. DHS, GNCT Delhi, the Medical Superintendent of the government hospital of the
area where the private hospital is situated and the said committee will jointly work out
the details of recovery of unwarranted profits.
18. As per directions of the court, all 20 hospitals stated in the judgement and all other
hospitals identically placed shall strictly comply with the conditions of free treatment
to indigent/poor persons.
19. No benefits shall be applicable to such hospitals that had provided free treatment fully
or partially in the past with the higher conditions as applicable for the time with regard
to any set off of the expenses or otherwise on that ground.
20. The new stipulations (25 % free OPD patients and 10 % free IPD BEDS) shall be
prospective from the date of pronouncement of the judgement.
21. Hospitals that flout the conditions and continue to default, for them the conditions
shall operate from the date their hospitals have become functional.
11
Given below is the list of hospitals identified for provision of free treatment as per the directives
of the Delhi High Court. This list issued by the DHS was published through a General Public
Notice in different national dailies on 21 November 20092.
Category – A: List of Identified Private Hospitals Providing Free Treatment with an
Updated Position of Free Beds Available:
S. No
Name and Address of the Hospitals
Free Beds
Available
1.
Indian Spinal Injuries Centre, Opposite Police Station, Sector-C, Vasant Kunj,
Delhi-110070
14
2.
Pushpawati Singhania Research Institute, Sheikh Sarai, Phase-II, Saket,
New Delhi-110017
11
3.
National Heart Institute, 49, Community Centre, East of Kailash,
New Delhi-110065
5
4.
Mai Kamli Wali Chari Hospital, Plot No. 12, J-Block,
Community Centre, Rajouri Garden, Delhi-110027
5
5.
Saroj Hospital, Sector-14. Extn Near Madhuban Chowk, Rohini, Delhi-110085
11
6.
Shanti Mukund Hospital, 2 Institutional Area, Vikas Marg Extn, VikasMarg,
Delhi-110092
14
7.
Venu Eye Institute & Research Centre, Plot-1, Sheikh Sarai, New Delhi-110017
42
8.
Primus Super Speciality Hospital, Chander Gupta Road, Chanakyapuri,
Delhi-110021
10
9.
Gujarmal Modi Hospital, Mandir Marg, Saket, Delhi-110017
10
10.
Kottakkal Arya Vaidyashala, Karkardooma, Delhi-110092
4
11.
Amar Jyoti Charitable Trust, Karkardooma, Delhi-110092
2
12.
Bimla Devi Hospital, Plot no. 5, Pkt. B, Mayur Vihar-II,
Delhi-110091
3
13.
Batra Hospital,1, MB Road, Tughlakabad Institutional Area, New Delhi-110062
50
14.
Bagwan Mahavir Hospital, Sector-14 Extn, Madhuban Chowk, Rohini,
New Delhi-110085
3
15.
Jeevan Anmol Hospital, MayurVihar, Phase-I Delhi-110091
5
16.
Delhi ENT Hospital & Research Centre, FC-33, Plot no. 13,
Jasola, Delhi-110017
2
17.*
Sir Ganga Ram Hospital, Hospital Marg, Rajinder Nager,
Delhi-110060
68
18.
National Chest Institute, A-133, Niti Bagh, Gautam Nagar,
Delhi-110092
2
19.
Mata Chanan Devi Hospital, A-21/D, Janakpuri, Delhi-110058
21
12
20.
R B Seth Jessa Ram Hospital, WEA, Karol Bagh, Delhi-110005
8
21.
Khosla Medical Institute & Research Society, K.M.I. & R. Centre, Paschim
Shalimar Bagh, New Delhi-110088
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 Delhi-110070
11
25.
Dr B L Kapoor Memorial Hospital, Pusa Road,
New Delhi-110005
7
TOTAL
329
* These Hospitals appealed in the Hon’ble High Court, Delhi.
Category – B: List of Private Hospitals that got an Interim Stay From Hon’ble Supreme Court Against the
Order of Hon’ble High Court
S. No
Free Beds
Available
Name and Address of the Hospitals
26.
Dharamshila Hospital & Research Centre, Vasundhara Enclave, Delhi-110096
20
27.
Jaipur Golden Hospital, 2, Institutional Area, Sector 2, Rohini, Delhi-110085
26
28.
VIMHANS, Nehru Nagar, Delhi-110065
9
29.
Bhagwati Hospital, C-5/OCF-6, Sector-13, Rohini,
Delhi-110085
3
30.
Max Balaji and Diagnostic Research Centre, 108-A,
IP Extension, Patparganj, Delhi-110092
15
31.
ShriBalaji Action Medical Institute, FC-34, A-4, PaschimVihar, New Delhi-110063
20
32.
Sunder Lal Jain Charitable Hospital, Phase-III, Ashok Vihar, Delhi-110055
23
33.
Escorts Heart Institute, Okhla Road, Okhla,
Delhi-110025
26
34.
Max Devki Devi Heart Hospital, 2 Press Enclave Road, Saket, New Delhi-110017
19
35.
Deepak Memorial Hospital, 5 Institutional Area, Vikas Marg Extn, Delhi-110092
10
171
TOTAL NUMBER OF BEDS
Gross Total (A+B) of 35 Hospitals: 500 beds
Note: There are changes in the number of free beds in some of the hospitals after this public notice was issued.
Three hospitals refused to provide free treatment stating that they were not covered under
the directions of the Hon’ble High Court of Delhi, and have also appealed to the Hon’ble
High Court.
13
Category – C: List of Private Hospitals That Refused to Provide Free Treatment and Appealed
in the Hon’ble High Court, Delhi
S. No
Name and Address of the Hospitals
36.
Rajiv Gandhi Cancer Institute & Research Centre, D-18, Sector-V, Rohini, Delhi-110085
37.
Mool Chand Khairati Ram Trust & Hospital, Ring Road, Lajpat Nagar,
Delhi-110024
38.
St. Stephen’s Hospital Society, Tis Hazari Court, Delhi-110054
The monitoring and the implementing body for the provision of free treatment is the Nursing
Home Cell of the Directorate of Health Services, Government of NCT of Delhi. However,
the implementation process and the non compliance to the provision remained an issue in spite
of the high court guidelines. There has also been a change in the income limit as the eligibility
criteria to access the facilities under this provision. Following changes in the Minimum Wages
Act, the limit was increased from Rs. 4000, and is currently Rs.6084.
Consistent legal advocacy efforts have led to the recent judgement by the Supreme Court,
in August 2011, directing the ten hospitals (Category B) to comply with the guidelines.
(For media reports on the Supreme Court Judgement, refer Annexure 1).
Following the Supreme Court Judgement, (September 2011),
the 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.
14
chapter 2 : Methodology
Within the framework of understanding the functioning of the private sector with regard to
policy and access to health care for the poor, the study specially focuses on analysing only one
particular aspect, that of providing 25% free OPD and 10% free IPD treatment for EWS
category patients in all hospitals benefitting from government subsidies. Furthermore, this
free treatment for the EWS category has been a matter of much public debate, bringing out
multiple inter-connected issues such as grievance Redressal, patients rights, and condition of
urban health care amongst others. This analysis can also give us an insight into larger trends and
issues for both public and private health care in India.
Objectives
The objectives of the pilot study (henceforth referred to as study) were:
• To understand and explore the legal provision of free treatment for the Economically
Weaker Section (EWS) in the context of subsidies provided to the private hospitals by the
State Government.
• To identify future areas of research on the aspects that requires further investigation.
• To suggest potential areas of inquiry in the future for better implementation of the provision
of free treatment.
Research Design and Process
Some of the aspects examined as part of the study were as follows:
• What were the systems in place at the hospitals for providing free treatment to EWS
category patients?
• Was the treatment being provided completely free of charge or were certain/specific
services on a paid basis?
• How were the monitoring and evaluation systems between the hospital and the Nursing
Homes Cell functioning?
• How was the referral system between the private hospitals, government hospitals and
Directorate of Health Services functioning?
• What was the attitude of medical staff towards this provision?
• What was the utilization of free treatment by patients at these private hospitals?
This study is based on information gathered from nine hospitals in Delhi, which have received
government subsidy in the form of land on the condition of providing a proportion of free
15
IPD and OPD care to EWS patients as per the guidelines issued by the Delhi High Court
(discussed in Chapter 1).
The study was conducted from October 2010 to June 2011, and included both primary and
secondary research, where primary research was carried out using semi structured interviews
with key informants like doctors, nodal officers and other staff members at the identified private
hospitals.
A list of open ended questions and guidelines for observation, keeping with the provisions
mentioned in the guidelines were developed to assist in gathering information.
In addition, background information about the identified hospitals was substantiated through
the websites of the hospitals and other online sources. The review of secondary material for
the study was done to develop perspectives on the issue, and to gather information on the
previous research work that had been undertaken on the same. This helped identify law gaps in
the existing literature, sharpen our understanding of the subject under research and tailor the
objectives, rather than duplicate, the existing literature pool.
Secondary research comprised of literature review of journals, reports (published and
unpublished), periodicals and the media clippings. Articles, reports and news clippings
from 2000 to mid 2011 were mapped, with greater focus on the years 2007 to 2011 as the
guidelines were issued by the Delhi High Court in the year 2007. (For the Literature Review
see Annexure 1).
The Study Team
The study was carried out by a three member team. The research team was trained by other
experienced members in the organisation, as well as by external resource persons through
orientations and capacity building sessions from the very beginning of the research process.
The theme of the orientations varied according to the ongoing stage of the study. The various
orientation sessions were aimed at - developing a conceptual understanding of the rationale
and objectives of the research, skills for conducting literature review, understanding of research
design, sampling, developing interviewing and documentation skills and data analysis. The
team held regular meetings to share their experiences, discuss problems faced in the field, while
interviewing, mapping or while analysing the interviews.
Every field visit was followed by an informal meeting where the team shared observations and
preliminary findings. Regular research meetings were also held to take stock of the progress of
the study and to collectively find solutions for challenges faced in the field.
16
Mapping and Selection of Hospitals
In addition to the list of hospitals provided through the public notice (in Chapter 1), another list,
the List of identified Private Hospitals Beds Status (sent daily to Directorate of Health Services)
was obtained from the website of Health & Family Welfare Department of Government of
NCT of Delhi. From this list of forty hospitals, based on their location and convenience, twelve
hospitals were approached for gathering information on the provision of free treatment. Of
the twelve, three hospitals refused to provide any information citing confidentiality. Therefore,
the final sample size for the study was nine hospitals, which included five Multi-Speciality and
four Super-Speciality hospitals.
The names of the hospitals have been codified to maintain confidentiality and anonymity.
Key Informants
The key respondents in this study included (a) staff members from nine hospitals in various
designations; (b) an advocate, who is also a member of inspection committee for the provision
of free treatment constituted by the Delhi High Court.
Table 7 lists the designations of the key informants interviewed in the nine hospitals.
Table 7: Key Informants
S. No
Hospital (code)
1.
DH1
Alternative / Assistant Nodal Officer
2.
DH2
FOS & Administration
3.
DH3
Chief Public Relations Officer/Assistant Nodal Officer, Additional Medical
Superintendent, Marketing Manager
4.
DH4
Assistant Nodal Officer, Administrative Staff
5.
DH5
Alternative Medical Superintendent
6.
DH6
Assistant Manger, Department of Education
7.
DH7
Deputy Medical Superintendent
8.
DH8
Social Worker
9.
DH9
Medical Superintendent
Key Informants Hospital
Data Collection
Tools of Data Collection
The team collected data through use of qualitative techniques and indepth-interviews with key
respondents. Interview Schedules or lists of open ended questions were developed to assist the
team in the interview process.
17
Once the interviews had been completed, any gaps in information that emerged through review
processes were filled. Codification was done in the interest of maintaining anonymity. The data
was crosschecked for errors and inconsistencies.
Field-diary
A field diary was maintained by the research team members to record the dates of the field visits
and interviews with all respondents.
Permission letter for the provider
A formal letter was developed for hospitals that stated the study objectives prior to the
interviews.
Data Analysis
Data was analysed based on information gathered with regard to the provisions as mandated
by the guidelines. This included analysis in terms of access, utilisation patterns, systems of
monitoring, mechanisms for referrals, criteria for eligibility, etc. Secondary data was analysed
to identify trends in utilisation of the provision of free treatment and gaps or violations in this
regard.
The Media as a Source of Information
The media has played a vital role in reporting discrepancies in policy and the corresponding
health services being provided at charitable hospitals and other private hospitals for EWS.
News reports were analysed to assess the status of service provision, as well as to substantiate
the primary research being done concurrently. Reports highlighting the violations of patients’
rights vis-à-vis access to free treatment and non-compliance by the hospitals by both print and
television media were also included. Newspapers were collated to follow the updates on the
High Court Judgment in the case of Social Jurist, A Lawyers Group vs. Government of NCT
of Delhi and Ors.
As mentioned earlier, newspaper articles from 2000 to mid 2011 were mapped, with greater
focus on the years 2007 to 2011, when private hospitals that received government subsidies
came under the scrutiny of the Delhi High Court. The last two years (2009-2011) have seen a
further increase in coverage of news relating to free health care facilities for EWS.
Limitations
It is important to establish at the outset that no definite generalisations can be made from the
research results. While qualified inferences can be drawn from the primary data, it must be
borne in mind that the small size of the sample, was limiting.
18
• Since the study was mainly focused on the provisions for the EWS from the hospitals’
perspectives, it does not provide the information from the patients’ perspectives. This gap
needs to be addressed in the next stage.
• The research team had to rely on the information provided by the hospitals and the secondary
data. Since the patients were not a part of the study, there is no adequate and accurate way
of knowing the exact operationalisation of EWS provisions from patients’ perspectives.
• Authorities such as DDA and Directorate of Health Services were unresponsive to sharing
of information, which led to gaps in information, particularly on the functioning and
implementation aspect of the provision.
• The non-functionality of government related websites, particularly the Nursing Homes Cell,
within the Directorate of Health Services (DHS) and Department of Health and Family
Welfare (Delhi Government) also hampered the assessment of monitoring and regulatory
systems that govern the implementation of free treatment.
19
chapter 3 : Findings
This Chapter is divided into two parts; the first (Part-A) describes the findings from the data,
the second (Part-B) discusses the emerging issues from the findings at different levels with
regard to the provision for EWS (See Annexure 6).
PART - A
I. Profile of Hospitals offering Facilities of Free Treatment
The hospitals in the sample were located in the central and eastern parts of Delhi, with a
majority located in southern part of the city.
The profiles of the hospitals that comprised the study sample were diverse (Refer Table 9). Of the
nine hospitals that were interviewed, five were multi-speciality hospitals that provided services
for a range of health issues. Four in the sample were super-speciality hospitals that provided
specialised services for specific (orthopaedic, ophthalmic) problems. Four of the hospitals in the
sample also claimed to be centres for research.
Table 7: Hospitals that were part of the Pilot study
S.
No
Hospital
(code)
Type of Hospital
Speciality/
Multispeciality
Research and
Educational Institutes
Nature
1
DH1
Multi-speciality
Charitable Private Hospital of a Trust
Society
2
DH2
Multi-speciality
Affiliated with an International Health
Care Chain
3
DH3
Multi-speciality
4
DH4
Multi-speciality
5
DH5
Multi-speciality
6
DH6
Super-speciality
Charitable Society
7
DH7
Super -speciality
Private Hospital
Medical Research
Centre
Tie up between private Health Care chain
and a Memorial Foundation to manage
and operate the hospital
Established as a Charitable trust, now a
100% subsidiary of International Health
Care Chain
Teaching Institute and
Research Centre
20
Run by a Research Foundation
8
DH8
Super-speciality
9
DH9
Super-speciality
Government affiliated Research,
Education Centre and Hospital
Educational and
Research Centre
Private Research Institute and Hospital
promoted by a Corporate House.
Educational Institute recognised by
National Board of Examinations (NBE)
Based on the total number of beds in the hospital, the size of the hospitals ranged from
67-bedded hospital, which was the smallest to the largest in the sample, with 680 beds. Three
hospitals (DH2, DH3 and DH6) had 100 and lesser beds, five hospitals had between 101-150
beds, and one hospital in the sample had more than 500 beds.
Three of the hospitals which had originally started as charitable trust hospitals had undergone
recent changes in management; two of them (DH2 and DH4) stated that they were affiliated
to, or had become a subsidiary of an international health care chain. The third hospital (DH3)
was managed by another private health care chain.
Two hospitals (DH1 and DH6) of the nine hospitals functioned as charitable trust hospitals,
i.e. they provided subsidised OPD treatment on the basis of socio-economic criteria, in addition
to the mandated free treatment for EWS.
While the hospitals were diverse in terms of services offered, and were unwilling to share the
details of their collaborations, the implications of shifts and collaborations on provision of free
treatment needs to understood better. This has also been stated in the next section.
Case of DH8
DH8 is a super-speciality hospital located in Delhi. It offers advanced surgical procedures and is also
an education and research institution. The hospital carries out research work in collaboration with
various Indian and international universities and research centres. DH8 was built in 1995 with support
from the Government of India and Italy. The hospital received subsidised land from the government and
has been functional since 1997. Apart from the land DH8 has not received any other form of subsidy
or concessions. DH8 is a 145 bed hospital, with a total staff of approximately 550 people (including
medical and paramedics). The hospital is built over a huge campus, with wide sprawling grounds and
buildings. In view of the facilities/services being offered, the hospital has been specially designed for
(disability) access.
The main entrance to the OPD registration has a notice board in Hindi as well as English, listing the
various treatments available, and details of availability of beds. The hospital has 14 beds reserved for
EWS patients. On the day of our visit all 14 allocated beds (in both critical and non-critical care section)
21
were occupied. Although the board reflected the correct occupancy status of beds, the date was that of
the previous day. The board was updated when the discrepancy was pointed out.
DH8 employs three social workers, who are responsible for all matters regarding provision of free
treatment to EWS category patients. The post of social worker is important for DH8 by virtue of the
fact that they deal with people with disabilities. Social workers mostly work with young EWS patients
who have lost the use of their limbs after an accident or other such incidents. They help them to
accept their disability, get comfortable with their bodies once again and rebuild confidence. They also
organise field trips to build confidence and for exposure to public spaces.
The hospital has 14 beds reserved for patients from EWS category. These patients come to DH8 from
different parts of the country, mostly through referrals from government hospitals in different cities,
as well as Delhi for inpatient treatment. They are also referred by non-government organisations.
Daily updates on status of availability of beds and quarterly reports on the treatment being provided to
EWS patients are sent to DHS.
Registration charges and treatment are provided free as per the directives of the High Court. The IPD
always functions at full capacity and has a waiting list of 7-8 months. This is because treatment or
rehabilitation of patients takes place over a period of a few months. Further, if the patient is not in a
position to afford a wheelchair at the time of discharge his/her treatment, the hospital provides them
with one at a subsidised rate or very often even free of cost. However this kind of assistance to patients
needs funds and the hospital is struggling and is in urgent need of resources to continue with it.
The OPD sees approximately 5-6 patients per day mostly from the neighbouring low income colonies.
Emergency services to such patients are provided free of cost. The hospital stated that there is no
difference in either the treatment or the services for EWS and non EWS patients. In case DH8 is not
able to treat a patient he/she is referred to nearby government hospitals such as Madan Mohan Malviya
Hospital.
The verification of a patient’s socio-economic status is done by means of whatever documents the
patient is able to provide including the BPL card, which shows the monthly income. If the patient does
not have any documents, he has to sign an undertaking form. While there is a waiting list for IPD and a
limited number of patients are treated, the hospital is not very strict with OPD patients with regards to
documents and identification. In fact in the absence of formal documentation the hospital sometimes
goes by the appearance, clothing, language and other such information to ascertain whether the
patient indeed belongs to EWS.
The staff were satisfied with the hospital’s policies and implementation of free facilities for EWS
patients. However, there have been instances of misuse of such provisions, where people from wellto-do families have attempted to avail of these facilities. For instance there have been cases where
English speaking people who looked ‘wealthy’ in appearance, and drove big cars asked to be registered
as EWS category patients. The social worker in charge sometimes receives calls by people in positions
of power asking to be admitted in the hospital under the EWS category. Such misuse of facilities was
common.
We were informed about two patients in particular who were getting free treatment under the EWS
category. The first was a woman hairdresser from Delhi who had no family or any other support
system. This patient was wheelchair bound. The second patient, also a woman, used to work as a yoga
instructor, and had been employed by the hospital as a therapist after her recovery.
22
II. Subsidies provided to the Hospitals
All nine hospitals received land at a subsidised rate from the Delhi Development Authority
and Land & Development Office of the Government of India. None of the hospitals
reported receiving any additional concessions or waivers in terms of water supply, electricity
supply, purchase or import of medical equipments etc. As mentioned previously, in lieu of
the subsidies received, the hospitals had to provide free treatment – 10 per cent IPD and 25
per cent OPD.
According to the senior authorities in DH9 in South Delhi while they had got land at a
subsidised rate, they still had to pay a substantial price. As one of the senior staff of the
hospital said, “We got only the land for the hospital from the government at a subsidised rate and
nothing else. Even the subsidy on the land was not that high, and we still had to pay a substantial
amount.” The Hospital does not get any other subsidy on equipment (like the equipment for
Dialysis etc.).
Case of DH6
DH6 a super-specialty ophthalmologic care institute and research centre is located in Delhi and gets
EWS patients from Delhi, its adjacent areas as well as other parts of the country. The hospital has
approximately 300 staff members including paramedical staff and the infrastructure of the hospital is
quite elaborate. DH6 is a 67 bedded hospital with separate OPDs for private and subsidised OPDs. In
addition the hospital also provides the provision of free treatment for the EWS category. While the main
hospital is in South Delhi, they also have satellite clinics in other parts of North India.
The entrance to the hospital has a notice board in Hindi and English, stating that the hospital has been
built on the land provided by the Delhi Development Authority and as per the government guidelines,
free treatment will be provided to patients whose monthly income is below Rs. 6084. There is another
notice stating that companies like Steel Authority of India Limited (SAIL) have provided financial
support to the hospital. However according to the staff this was a onetime contribution and not on a
continuous basis.
The hospital has a paid OPD (private OPD), a subsidised OPD for patients of lower socio-economic
background, a diagnostic block, wards (paid, general, subsidised and free), operation theatres and
other speciality clinics (including Paediatrics). The private and the subsidised sections are clearly
demarcated and are located in separate buildings, within the same complex. While the charge for the
private OPD per consultation is Rs. 500, the per visit consultation charges for the subsidised OPD is Rs.
300. The hospital staff mentioned that the difference in the charges are due to the kind and quality of
medical devices such as lenses (for eye care) etc. used during the treatment process. The information
regarding the provision of services to the EWS category is displayed near the reception. The EWS OPD
is a part of the subsidized OPD, and the hospital receives a number of patients from this category.
There is a public notice outside the OPD that mentions the name of the concerned person with whom
the complaint can be registered in case of denial or non-availability of services. The status of the beds
for the EWS category is also displayed in English at the reception.
23
The identification and verification of EWS status is done using the BPL card provided by the government.
If this is not available, then the patient signs an undertaking verifying his income. Identification is also
done through the general appearance, language etc of the patient. The registration, treatment, and
medication are completely free of charge for EWS patients. This also includes medicines for up to one
month as part of follow-up care. In cases where a patient is suffering from an additional ailment, he/
she is first referred to the appropriate hospital for treatment before taking up the eye related treatment.
For example, a patient with a heart problem will first be sent to a speciality heart care institute and
then treated for the eye ailment.
Doctors at DH6 perform about 800-1000 surgeries per month in the IPD and treat about 10-12,000
patients in the OPD. Out of this, approximately 50 per cent of the patients in the OPD and a lower
number in the IPD belong to the EWS category. Out of 67 beds, 42 beds are reserved for the EWS
patients. The number of beds in the paid/private section is twenty five. In all the hospital approximately
gets 2-3 EWS patients per day.
In case of an emergency, critical patients are taken in without any documents. A notice was recently (a
few days before the research visit) circulated by the senior management of the hospital, to ensure that
this rule is being strictly followed. Patients at DH6 come from different parts of North India. They are
also referred from government hospitals in and around Delhi. Similarly, the hospital refers patients for
different services to mostly government hospitals such as Safdarjung Hospital and All India Institute
of Medical Sciences (AIIMS).
The updated status of beds for the EWS Category is sent to the DHS at the end of each day. The
inspection committee set up by the government also visits the hospital periodically to monitor the
implementation of free facilities, although there is no fixed time for these visits.
Information regarding EWS facilities is disseminated through camps that are organised regularly by
the hospital in rural areas. DH6 is also planning to involve ASHAs so that they can play a more proactive
role in disseminating information. While the hospital willingly gave us details on the provisions,
questions on details of treatment, patient’s records or management systems were not answered. This
is because different sections of the hospital deal with different functions relating to the provision of
free treatment. Given this, it is difficult to build a comprehensive picture of the level and quality of
implementation of the existing provision.
III. Facilities provided by Hospitals under Provision of Free Treatment
All hospitals in the sample stated that they provided “everything as per the rules” for free treatment
to EWS patients. As per the High Court Guidelines for provision of free treatment,
25 per cent of patients in the OPD and 10 per cent of beds in the IPD will be reserved
for free treatment for the poor. These patients will not be liable to pay any expenses in
the hospital for admission, bed, medication, treatment, surgery facility, nursing facility,
consumables and non consumables, etc.
24
The patient referred by government hospitals or directly reporting to the private hospital
shall be admitted if required, and treated free of cost. As per the court’s directions, these
patients shall not incur any expenditure for the entire treatment at the hospital.
All nine hospitals, when asked initially, responded that patients did not have to pay anything
for registration, medicines, diagnostics, etc. However, on further probing, three hospitals
(DH1, DH3 and DH5) revealed that not all services were provided free and EWS patients
had to pay for some services such as food, medicines etc. At the time of the study, DH5
was offering free treatment only in their emergency and outpatient departments. Inpatient
services were not available in the hospital as the hospital building was being renovated and
therefore under construction. The hospital did not provide food to EWS patients free of cost.
One of the senior hospital staff said,
We are providing only outpatient and emergency services (currently). (Generally) All the
services are provided free of cost, and the patients have to only pay for the food that is
provided by the hospital.
At DH3, EWS patients had to occasionally pay for medicines; as medicines were not always
available in the hospital and had to be purchased. An officer of the hospital said,
We try to provide whatever facility is there in the hospital, but if we don’t have, we really
cannot do anything. ... Most of the medicines are available in the hospital, but if it is not
there, patients have to buy it from outside. We really cannot do anything.
Free treatment in one of the hospitals was not extended to cosmetic care or cosmetic surgeries,
though these services were available in the hospital. However, as a policy such facilities were not
covered within the purview of free treatment. The Assistant Nodal officer of DH1 shared,
Within the free treatment provision we only provide curative care in terms of life saving
facilities. The hospital does not provide cosmetic care. For example, if a person from EWS
category comes and asks for a free cosmetic surgery we cannot provide that. This will not
come under curative care.
Medicines contribute to the highest out of pocket expenditure at 77 percent of the total
health expenditure in urban India (Sakthivel, n.d.). Although only one hospital stated that
EWS patients have to buy drugs from outside in case of non-availability, this raises issues and
concerns with regard to the actual implementation process of such provisions. Further, in the
25
absence of regular monitoring and redressel systems, how the accountability of the hospitals is
ensured, remains problematic.
IV. Eligibility to access free treatment
Free treatment is accessible to patients who fulfil certain eligibility criteria. As per the guidelines
“Free treatment will be given to all patients without income or having income below Rs. 4000”.
As mentioned in the Introduction, the minimum monthly income criterion has undergone
revisions and in the course of the study was increased to Rs. 6084 per month, following
amendments in the Minimum Wages Act. All nine hospitals were following the revised
criteria and providing free treatment to all patients whose monthly income was Rs. 6084 or
less. However, seven of the nine hospitals had not made changes in the public notices displayed
for patients at the hospitals. This is discussed in further detail in another section.
According to the guidelines issued by the Delhi Government, any patient who wishes to avail of
the free treatment need not present any proof of her / his monthly income to prove eligibility.
However, eight hospitals (no information was available for DH5) in the study asked patients to
produce documents like Below Poverty Line (BPL) card, income proof, residence proof at the
time of admission in EWS category towards being eligible for free treatment (Refer Table 10).
Table 10: Eligibility Proof required by Hospitals
Hospital
(Code)
BPL Card
Any income
proof
Residence
proof
Appearance /
Language
Undertaking
DH1
-
DH2
-
Yes
-
Yes
Yes
-
Yes
-
Yes
DH3
DH4
Yes
-
-
Yes
Yes
Yes
Yes
-
-
Yes
DH6
Yes
-
-
Yes
Yes
DH7
-
-
-
-
Yes
DH8
-
Yes
-
Yes
Yes
DH9
Yes
Yes
-
-
Yes
For some hospitals the BPL card was sufficient proof, whereas others asked for a certificate of
income. The administrative head of DH2 Hospital said, “We see the BPL card for verifying the
income of the patient. That’s the only criteria we use.”
The hospital had also displayed certain additional conditions to be fulfilled by EWS patients in
order to avail the free treatment (See Box 2).
26
Box 2: Additional Criteria for Eligibility
• The total income of all family members should not be more than Rs 4000 per month. (The income
was still not updated to Rs 6084 as per the new minimum wages).
• Before standing in the queue kindly ensure that you should have a permanent residence proof.
Without that your free OPD Blue card will not be issued.
• Copies of the undertaking has been posted on board, kindly read and understand the undertaking
before taking position provided information in undertaking can be verified.
• If any declaration is found false/incorrect, you will have to pay the entire cost of treatment and the
hospital will be at liberty to take legal/criminal action against you including recovery proceedings.
The Assistant Nodal Officer of DH1 Hospital said that although they were not particular about
the BPL card, the beneficiary did need to produce an income certificate, “We are not very rigid
about the EWS patients producing the BPL card. They just need to show any document certifying
their monthly income.” Staff members in DH3 shared that they do see the BPL card, but also
considered the appearance of the patient as an important indicator of socio-economic status
and an additional factor to determine eligibility. As the Assistant Nodal Officer of DH3 said,
“One can easily make out about the socio-economic status and income level of these patients by their
appearance. Many a times they are already known to us. For example, many a times, women are
working as domestic help in a family friend’s home etc.” (See Annexure 7 for copy of the undertaking
given by DH3 Hospital)
Similarly, two other hospitals (DH6 and DH8) mentioned that the appearance and sometimes
even the language of the patients were closely observed to ascertain additional proof of
eligibility and genuineness of the patients’ claims. There, however, did not seem to be any
standard indicators amongst hospitals for such observation and conclusion and was based on
the discretion of the hospital staff.
In addition to these documents, the hospitals also got an undertaking from the patients.
However, they were silent about the need or circumstances in which an undertaking is required.
The undertaking, as per the guidelines, is a signed document given by the patient to the hospital
that ‘affirms and declares that the monthly family income from all sources is below the stipulated
amount’ – Rs. 6084 currently. It also accepts legal action and recovery proceedings by the hospital,
reimbursement of the treatment costs, if the declaration in the undertaking is proved inaccurate
or false. Some of the hospitals mentioned that the undertaking by the patient was necessary
regardless of other eligibility documents provided. All hospitals required a signed undertaking
from the EWS patients.
Two of the hospitals (DH3 and DH7) provided copies of the undertaking proformas that they
used. These were much more elaborate than the undertaking in the guidelines and required
information in areas given in the Box 3.
27
Box 3 : Undertaking Proforma from Hospital DH7
Patient Information – Name, age, address, sex; details of dependent family, earning members,
employment status, family income.
Residence – ownership / rental, value of ownership residence, years of living in Delhi.
Infrastructure in the home – electricity, water, cable, toilet. Other assets (television, radio, telephone,
mobile, credit card, air conditioning, vehicle, etc.)
Previous treatment in hospital / nursing home.
Employment categorisation, access to health insurance, other benefits through employment.
In Hospital DH1, undertaking was a must. It required income proof for proving eligibility.
In case there was no income proof available, the patient was expected to either get some
proof from the DHS or a referral from the government hospital. The hospital, in cases of
emergency, provided free treatment to those whom they perceived as EWS patients; they
were required to retrospectively, get the necessary documents as required by the hospital
(Refer Table 10).
According to a member of the Inspection Committee, set up to monitor hospitals in provision
of free treatment, however,
All they (patients) have to do is just walk into the hospital and they should be taken care of
and provided free health care by the hospital. Citizens must be trusted and upon seeing a
poor man hospitals must provide free treatment. A declaration form saying that the patient
is poor and is being provided free treatment must be filled and that is the only document
required. The patient may belong to any state in India and must be taken care of. In fact,
in a meeting about this, I had a lot of differences with others about patients requiring to
prove their eligibility.
It is evident that hospitals are following their own policies and there is lack of uniformity
and clarity vis-à-vis eligibility criteria documents required by the hospital for provision of
free treatment. Although the inspection committee member states that only an undertaking
is required, a range of documents in addition to the undertaking is demanded by hospitals to
provide free treatment.
The undertaking proforma used by some hospitals was claimed to be the government’s format.
This, however, included substantial information in addition to the undertaking format included
in the guidelines.
28
Case of DH1 Hospital
DH1 is a well known multi-speciality private hospital located in Delhi providing a wide range of services.
The hospital has 680 beds, and the number of patients has steadily increased over years. Almost 5-6
lakh patients avail its OPD facilities every year. In addition to the other OPD and IPD facilities, Casualty/
Emergency care is also part of the facility that is offered to EWS patients.
Apart from the land, DH1 has not received any other subsidy from the government such as electricity,
water, equipment etc. DH1 also has two designated staff (Nodal Officers) who are responsible for
systematic implementation of the EWS provision. Information regarding the provision of free treatment
and the names of the responsible Nodal Officers, along with their phone numbers is put up alongside
the inquiry counter. However, both the enquiry counter, and the information regarding the EWS
facilities are not prominently visible.
The hospital receives about 200 patients daily from the EWS category and as per the rules, has 68 beds
reserved for free inpatient care. Under the provisions for the EWS category, only curative treatment
or life saving services are provided as per the hospital policy. EWS patients do not have to pay for any
of these services (including boarding, lodging, medicines, diagnostic tests and operative procedures).
Although the hospital is well known for its cosmetic service, this is not included in the facilities
provided to EWS patients, as it is not in the category of curative treatment or care. To avail of EWS
provisions, the hospital requires a document certifying the patients’ income. While some hospitals
insist this should be the BPL card, this hospital accepts any income proof document.
DH1also has a separate Charitable OPD, where the cost of the treatment is 40 per cent lower than
the private OPD. The registration fee for the Charitable OPD is as low as Rs 20. Even the fee of the
consultants is Rs 20, while it is about Rs 500 in the private OPD. Whatever the hospital earns from the
private OPD is channelised into the Charitable OPD to provide subsidised treatment.
The hospital gets referrals from both government and private hospitals. There is a long waiting list
of patients requiring facilities at DH1 Hospital. The hospital refers patients to other hospitals such as
Kalawati Saran Children’s Hospital, Ram Manohar Lohia Hospital, and B L Kapoor Memorial Hospital .
While in DH1there is waiting list for beds, in a nearby private hospital, meant to provide free treatment,
beds are often vacant. The Nodal officer of the DH1feels that the reputation of the hospital is one of the
main factors for patients not shifting to other hospitals for treatment, even if they have to wait.
In order to disseminate public information regarding the EWS treatment facilities, DH1distributes
pamphlets in outreach camps that are conducted by the hospital. In addition to this, advertisements
are also placed in newspapers to generate awareness among the public.
As per rules, every evening at 5:00 pm, the updated list of the status of beds for the EWS category is
sent to the Directorate of Health Services. The Nodal Officer of the hospital feels non-availability of
beds is a real constraint for EWS patients. Well-off patients also misuse such facilities by not giving
the real details of their income.
The hospital reported that the non-availability of beds is the only complaint that EWS patients have.
The hospital refuses as many patients as it takes in. However, all emergency patients are always
accommodated.
29
V. Utilisation Patterns and Access to Free Treatment
The guidelines clearly state that 10 per cent of the total beds in the IPD should be reserved
for EWS and 25 per cent of patients in the OPD should get treatment free of charge and
emphasises,
The hospital shall also display the facilities available at the hospital and the daily position of
the availability of free beds quota, so that the patients coming directly to the hospital would
know the position in advance.
Based on the information on public display and through interviews with hospital staffs, two
hospitals showed nil utilisation of their IPD facilities for EWS patients, two others showed
utilisation of 50 percent and less of IPD facilities.
The staff of one of the hospitals with zero occupancy, reflected on possible reasons,
Not many patients from the poor category come to us. May be it is because of the location.
In spite of putting up information, even the poor family living just alongside the hospital,
does not come. Our own hospital guard also does not avail the facilities. Community
mobilisation is important.
The reasons for not availing treatment in the hospital may be due to lack of information about
treatment being free and the lack of proactive measures taken by the hospital in disseminating
information.
While information on utilisation of IPD was not available for two hospitals, of the remaining
three facilities, in DH1 bed occupancy was 55/68 beds (approximately 81 per cent), DH6
showed 33/42 beds (approximately 79 per cent) occupied.
Information regarding the number of free beds (critical and non-critical care) which is
mandatory was not publicly displayed in all the hospitals. Seven hospitals had displayed the
status of free beds in critical and non critical care. Table 11 from DH9 hospital indicates the
utilisation in IPD on the day of the visit by the research team.
Table 11: Occupancy of beds in DH9 (as on 24.05.2011)
Total No.
of Free
Beds
available
11
Total No. of Free Beds
Total No. of Free Beds
Occupied
Total No. of Free Beds Vacant
In Critical
Care
In NonCritical Care
In Critical
Care
In NonCritical Care
In Critical
Care
In NonCritical Care
03
08
01
01
02
07
30
This data clearly showed that only one bed each, in critical care and non-critical care was
occupied and the rest were vacant. Moreover, the data was not publicly displayed and was
provided to the member of the research team only when asked.
Similarly, the following data from DH7 revealed that all the beds in both critical and
non-critical care were unoccupied and the inpatient facilities for free treatment were
completely unutilised. The updated records from the DHS also showed that in the entire
month of May, the utilisation rates remained static (www.health.delhigovt.nic.in/mis/
frmlogin.aspsx)
Table 12: Bed Occupancy in DH7 (16.05.2011)
Total No.
of Free
Beds
available
11
Total No. of Free Beds
Total No. of Free Beds
Occupied
Total No. of Free Beds Vacant
In Critical
Care
In NonCritical Care
In Critical
Care
In NonCritical Care
In Critical
Care
In NonCritical Care
3
8
0
0
3
8
The data from DH6 as given in Table 13 reflected a comparatively better utilisation of
in-patient facilities although nine beds were still vacant.
Table 13: Bed Occupancy in DH6 (as on 24.05.2011)
Total No.
of ‘Free’
Beds
available
42
Total No. of ‘Free’ Beds
Total No. of ‘Free’ Beds
Occupied
Total No. of ‘Free’ Beds
Vacant
In Critical
Care
In NonCritical Care
In Critical
Care
In NonCritical Care
In Critical
Care
In NonCritical Care
04
38
-
33
4
5
Although free treatment norms also hold true for OPD, the hospitals that were part of the study
provided very sketchy information in this regard. Only three hospitals were able to provide data
on the OPD strength in the EWS category. While DH1 said that they received about 200
patients every day, DH6 received about 130 patients while DH8 provided free treatment for
approximately five to six patients daily in their OPD. Other hospitals were unable to provide
information about the number of EWS patients who accessed treatment in their OPDs at the
time of the interview.
31
Hospitals, which followed a policy of subsidised treatment, in addition to provision of free
treatment were accessed more than others. These hospitals were also more proactive in public
dissemination of information about free treatment. The super-speciality hospitals in the sample
also showed higher access /occupancy rates for free treatment, and even claimed that they had
a long waiting list. The Assistant Nodal officer at DH1 said,
Although we have a large number of beds, but then also there is a long waiting list of
patients requiring beds. Even if we suggest to them to go to some other hospital, they prefer
to be with us because they trust us. We also suggest that they go to another hospital, which
is not far, and has 30 free beds allocated for the EWS category. Most of the times the beds
are empty there.
The staff of DH9 also claimed a long waiting list despite flexibility in provision of free treatment
especially in the case of recurring treatment,
We do have a waiting list of patients, and since we are a super-speciality hospital,
patients also want to continue their treatment at one place. We are also not very
rigid about the number of allocated free beds, and there is flexibility. The dialysis machine
is also very expensive, and even for a hospital of our scale it is difficult to have the desired
number of machines. We have a long waiting list for dialysis since it is a life-long and
expensive treatment.
Thus, utilisation patterns varied widely amongst the hospitals. The main reasons cited by
these hospitals hospitals include, location and reputation of the hospital, lack of referral from
government hospitals and lack of mobilisation of the community to access these facilities.
Case of DH3 Hospital
DH3 is a multi-speciality hospital located in Delhi. DH3 Hospital was established as a charitable
hospital in 1988 with a bed capacity of 50 beds, with a vision to provide medical facilities to the poor
people. It is also a medical research centre. The infrastructure and size of the hospital is neither very
swanky nor very small. This is also evident in the profile of the people who access the medical facilities
at this hospital. They are mostly from low and middle income group and this is reflected in the visual
appearance of the patients in the waiting area (not necessarily in the EWS category). Since the year
2007, the hospital has had collaborative ties with another private health care chain (situated in NCR),
which manages and operates the functioning of DH3 Hospital along with providing the back up support.
An internet search of DH3 Hospital reveals that it does not have a separate website, and information on
the hospital is only available through the website of the collaborative health care chain.
Although the entrance of the hospital displays information about the provision of the free treatment
and the names of the concerned persons from the hospital, the minimum monthly income criterion
displayed the old figure of Rs. 4000, instead of Rs. 6084. It was not clear whether the status of the
32
beds was updated on the day of the visit. The information is in both English and Hindi. The reception
of the hospital gives the details of the status of the beds available (in both critical and non-critical
care) under the EWS provision. From the initial bed capacity of 50 beds, the total bed capacity of DH3
Hospital has now been increased to 100. As per the High Court guidelines 10 beds (10 per cent of the
total bed capacity) are reserved in the IPD for EWS patients. Out of these 10 beds, 6 are reserved for
men, 3 for women and 1 for emergency care. Since it is a multi-speciality hospital, it gets patients with
various medical conditions.
The hospital mostly gets patients from the local area and the adjoining border areas. The consultancy
charges in DH3 Hospital are around Rs 500-600, but for EWS patients consultation is given free. Once
the Consultant examines the patients, the Chief PRO (Public Relations Officer) also explains the
provision of free treatment to them, after which they have to sign an Undertaking form. The Chief
PRO is also one of the Nodal officers in the hospital for the implementation of the provision of free
treatment. If the patient is illiterate, the Undertaking is read and the explained to them by the Nodal
officers. The patients have to present the BPL card in order to avail the facility of free treatment. The
hospital has an in-house pharmacy from where EWS patients can get most of the medicines free of
cost. But, in instances where the medicines are not available, the patients have to purchase them
externally. The hospital receives and sends referral cases depending on the medical problems. The
number of EWS patients varies with season, location etc. The updated status of the beds is sent to the
Directorate of Health Services (DHS) at the end of the day. The hospital conducts camps from time to
time to disseminate information regarding free treatment. The pamphlet is in Hindi, so that most of
the people can understand the information. The hospital also has a Marketing Manager, who is also
responsible for information dissemination. The senior staff of the hospital feels that such policies
have definitely increased the number of poor people coming to the hospital and now patients come
and demand these services as their right. This is also to do with increasing awareness among patients
regarding these provisions. The hospital is empanelled to a large number of other institutions and also
has associated Third Party Administrators (TPAs) for the administration of health insurance.
VI. Public Dissemination of Information
As per the guidelines, with regard to public display of information,
Every private hospital shall have to establish a referral centre/desk functional round the
clock, where the patients referred from Govt hospital would be able to report. The referral
desk shall be managed by a nodal responsible person whose name , telephone , e-mail address
and fax number is to be sent to the government hospitals, DHS and should be prominently
displayed. The hospital shall also display the facilities available at the hospital and the
daily position of availability of free beds quota, so that the patients’ coming directly to the
hospital would know the position in advance.
The hospitals (except DH5), for which information was not available) used various means to
disseminate information about free treatment in their respective facilities. Eight hospitals
had displayed the mandatory public information as per the Delhi High Court Guidelines, in
33
English. Five hospitals had also displayed the information in Hindi; the sixth hospital’s display
was a summarised version in Hindi whereas one of the hospitals had displayed information only
in English. Most hospitals had prominently displayed the information about the land, income
eligibility criteria (currently Rs 6084), and contact details for the nodal officer, bed status / IPD
utilisation. One hospital (DH6) had also included the contact details of the person responsible
in case of complaints.
However, not all hospitals had revised the income eligibility criteria in the public display. Two
hospitals had made changes in the information notices. Five (DH1 DH3, DH4, DH7 and
DH2) of the nine hospitals had not updated this information at the time of the study; their
public notice continued to state Rs 4000 as the maximum monthly income permitted to be
eligible for free treatment. Notices in two did not mention the income amount; another did
not have in place a notice. However, the interviews with the hospitals affirmed that the revised
criteria were considered in providing free treatment.
Additionally, two hospitals distributed pamphlets in Hindi about the provision of free treatment
through their outreach and medical camps to inform people about facilities available and
eligibility. According to DH3, “We conduct different kinds of camps, and during these camps we also
distribute pamphlets giving information about free treatment”.
Another hospital, DH6 disseminated information through outreach camps and was also
planning to involve Accredited Social Health Activists (ASHAs) in the rural areas,
The information regarding EWS facilities is also disseminated through the camps that
are organised regularly by the hospital in rural areas. We are also planning to involve
ASHAs for further sharing of information, where they can play a more proactive role in
disseminating such information.
(See Annexure 8 for pamphlet by DH1 Hospital). Box 4 contains the different kinds of public
notices that were spotted at the hospitals.
Box 4: Public Notice
• In accordance with the directives laid down by the Hon’ble Delhi High Court xxxx DH6 will provide
free beds and treatment to such EWS patients whose monthly family income is either Rs 6084 or less
than that.
In case you have any complaints regarding this facility of free treatment please contact:
XXXXXXXX Ph. No. .......
34
• This hospital has been built on the land allotted by DDA / L&DO (Government of India) at concessional
rate. There is a provision for free treatment to the poor patients on 10% of the total beds and 25% in
the OPD. As per direction of the Hon’ble Delhi High Court only where poor patient’s family income is
Rs 4000 per month or less is eligible to draw the free treatment. He/She may contact the undersigned
for the same.
XXXXX, Ph. No. ........
In case of any complaint he/ she may contact the following –
XXXXX, Complaint Officer, Ph. No. ...........
One of the hospitals had not displayed any details with regard to free treatment, but had a
display of patients’ rights. Though, this was the only hospital in the sample survey to have
displayed such information for the patients, it highlights an important, but often neglected
aspect of patients’ rights.
The following information was displayed in the waiting area of the hospital:
Box 5: Patients Rights Charter
We respect your rights• Right to safety in the hospitals.
• Right to be informed about the patients.
• Right to choose.
• Right to be heard.
• Right to be represented.
• Right to redress.
• Right to fair settlement of laim and receive
compensation in lieu.
• Right to acquire skills and knowledge so as to
be an informed Consumer throughout life.
• Right to a healthy environment to enhance
quality of life.
• Right to basic needs.
VII. Limited Information about Provision of Free Treatment in Private Hospitals
The lack of utilisation of free treatment facilities also reflects the limited information available
among poor communities about such provisions by private hospitals. Nearly 40 hospitals in
Delhi, at different locations, with diverse health facilities, are providing free treatment but, as
discussed above, the utilisation of this provision has not been adequate. Generating awareness or
disseminating information on such provisions can be seen as one way of increasing utilisation.
For this we need to look closely at the collaborative roles of the State, the private sector and the
non-State actors (including the civil society organisations) at different levels.
While the guidelines make it mandatory for the information to be made public, it was evident
during the course of the study that this was not the case. The State as well as the service providers
35
need to make sure that not only is the information available to the patients, but that they are
able to access it as their right.
Case of DH9
DH9 is located in Delhi, and is one of the identified hospitals to provide free treatment to EWS patients.
It is a super-specialty hospital for Liver, Renal and Digestive Diseases. DH9 was established in 1996, as
a charitable hospital. Besides subsidised land, the hospital has not received any other kind of subsidy
from the State. In fact according to the senior authorities of the hospital even the subsidy on the land
was minimal.
The hospital has a capacity of 107 beds, out of which 11 beds are used to provide free treatment (3
for, for critical care and 8 for non-critical care). Information regarding facilities for EWS patients is
provided through a notice at the entrance of the hospital. The notice states that the as per government
directives, both inpatient and outpatient facilities for EWS patients are provided to those whose
monthly income does not exceed Rs 6084. Information regarding the availability of facilities is provided
both in English and Hindi. Information on the status of free beds, although displayed at the reception,
is not prominently visible. It is put up on an A-4 paper. As on 24 May 2011, the bed occupancy status
indicated 11 free beds. It was not possible to get information regarding the total number of patients in
the hospital and the proportion of EWS patients.
While 10 per cent of the beds are reserved for EWS category patients in the IPD, the hospital is flexible
with regard to the percentage of EWS patients it treats through its OPD services. The hospital also
provides free dialysis for patients. This needs to be seen with the perspective that dialysis is a long
term and very expensive treatment (a typical patient has to receive dialysis at the hospital 2-3 times
per week at the cost of two to four thousand rupees per sitting). The hospital can offer dialysis to only
5 patients at one time, and the waiting list is very long. The hospital maintains a waiting list and at the
time of our interaction, there were eight patients on this list. Free Dialysis machine is provided at the
initiative of the hospital itself.
The hospital gets referral patients mostly from Delhi, e.g. government hospitals in other parts of Delhi,
or from the Directorate of Health Services, though some referrals do come from other parts of the
country as well. Being a super-speciality hospital, DH9 does not provide all facilities, and if referred
patients are referred to other public health hospitals such as Safdarjung Hospital and AIIMS.
EWS patients have to produce a BPL Card or any other income document to avail of free facilities. In
the absence of any of these, they need to sign an undertaking form which states that their monthly
income is below the stipulated amount of Rs 6084. In many instances the hospital staffs use their
discretion to assess a patient’s socio-economic status through their appearance and language. Since
a substantial part of the facilities provided by the hospital includes services such as dialysis, resource
constraints with regard to equipment as well as finances are a big concern for the hospital. Financial
support by Civil Society Organisations (CSOs) is seen as an alternative fund raising avenue.
As per the High Court guidelines, updates regarding bed status are sent twice a day to the Directorate
of Health Services. Other regular updates with regard to the implementation of the provision are sent
in a more detailed manner in the form of monthly and quarterly reports to the concerned person in
DHS. Apart from this, there are no other additional monitoring mechanisms.
36
Hospital staff said that the criterion of maximum monthly income of Rs 6084 as a basis for EWS
treatment is too low, since it results in treatment being denied to many deserving patients. They felt
that the maximum limit of monthly income should therefore be increased. When asked about how many
patients they might receive if this were to happen, the staff were unable to estimate a number, since
they felt that theirs was a super-speciality hospital, and need for their services would be determined
by patient needs. Senior staff of the hospital also articulated the constraints they work under, given the
limited number of beds and the large number of patients they have to cater to.
VIII. Referral Systems
Almost all the hospitals in the pilot mentioned access by patients who were referred from
government as well as private hospitals. The system of referrals is central to the provision of free
treatment and access by EWS patients. The guidelines have set down certain norms to facilitate
effective referrals,
A referral desk must be set up within two weeks of the pronouncement of the judgment
failing which the Director of the hospital shall be held personally responsible.
The hospital shall also maintain details of referrals from government hospitals and submit
a report to the government hospital giving details of treatment provided to the patient.
The patient referred by government hospitals or directly reporting to the private hospital
shall be admitted if required, and treated free of cost. .... After the discharge of such patients,
the hospital shall submit a report to the referring hospital with a copy to the DHS giving
complete details of the treatment provided and the expenditure incurred thereon.
Further, the guidelines also lay a lot of emphasis on a systematic and well-functioning referral
mechanism between the government and private hospitals. They state,
For such eligible poor patients reporting to the casualty who needed immediate care and it
is found that the particular facilities are not available or the beds are not available and the
patients need urgent care, such patients may be referred to the private hospital where the
requisite facilities are available.
To facilitate more effective referral, the DHS has linked thirty-eight government hospitals to
private hospitals for referrals (See Annexure 9). Each government hospital has been linked to a
range of private hospitals based on geographical proximity and treatment facilities. For example,
a government hospital like Lok Nayak Hospital can refer EWS patients to 19 private hospitals
in Delhi for free treatment.
37
Reverse referrals also take place - from private hospitals to the government hospitals and
between private facilities to address the diverse needs of patients. For example, DH6 refers
patients to government hospitals such as Safdarjung and All India Institute of Medical
Sciences. DH8, in case of its inability to treat a patient, refers her / him to nearby government
hospitals such as Madan Mohan Malviya Hospital in South Delhi.
These hospitals also receive referrals from other private hospitals – for example, DH8 receives
EWS patients from Apollo and Escorts Hospital when there is requirement for specialised
services that the hospital provides.
However the implementation of the referral system remains weak, which is also evident
from the lack of utilisation of facilities in the hospitals in the study. No information was
available for two facilities. As the Inspection Committee member said, “Even though beds
are lying empty in many of the (private) hospitals, the government hospitals do not refer them to
these hospitals.”
In the absence of widespread public knowledge about entitlement to free treatment, lack of
information about the hospitals that have to provide services a streamlined referral system is
extremely important to ensure maximum access to treatment for EWS patients.
IX. Strengthening Linkages with Government Hospitals
Despite the guidelines clearly providing directions for referrals from government to private
hospitals, the system needs to streamlined further. The findings reflect ad hoc referrals and the
absence of reporting back by private to government hospitals from where the referral was made
to facilitate follow up with the patient.
There is also need for improved linkages between private hospitals to facilitate better referral for
specialised treatment as well as to facilitate utilisation of free treatment services.
X. Accountability - Monitoring Mechanisms and Redressal
That the private health sector in India is completely unregulated is a well recognised problem;
provision of free treatment by private hospitals, therefore, necessitates a stringent system of
monitoring and Redressal towards ensuring access to treatment free of cost for EWS patients.
The current system of monitoring includes daily and quarterly reporting by hospitals to the
DHS regarding the status of utilisation and availability of hospital beds for free treatment on
a daily basis. All hospitals (except DH5 for whom no information was available) confirmed
that a daily update was sent to the DHS with regard to the status of beds available. All the
hospitals, except for DH9, however, were not providing information twice a day, as stipulated
by the guidelines,
38
The hospital shall send daily information of availability of free beds to this directorate twice
a day between 9-9.30 AM and 5-5.30 PM on all working days and also to the concerned
nearby government hospital to which the private hospital is proposed to be linked for general
and for specialized purposes. The details of geographical linkage, the telephone numbers/fax
numbers and the name of the nodal officer of Govt hospitals shall be intimated shortly.
The hospitals felt that updates twice a day to the DHS was too tedious and was not possible to
do. DH6 said, “We send it only once in a day, in the evening. How many more times do we need to
send it? We have other work also, and we cannot do only these things throughout the day”.
With regard to information updates to government hospitals, no information was available
and in all likelihood was not taking place. This, despite the guidelines clearly placing the onus
on the private hospitals for non compliance with the monitoring and reporting system,
In case no information is received within the stipulate time from the private hospitals then
it shall be presumed that the beds are available in private hospitals and the patient referred
shall be accommodated.
The DHS, the central monitoring body for provision of free treatment compiles the updated
information from the 40 hospitals providing care to EWS patients. However, the DHS records
accessible through the website of Government of Delhi or the DHS (http://www.delhi.gov.
in/wps/wcm/connect/DoIT_Health/health/related+links/information+regarding+free+treatm
ent) show that they have not been updated since July 2011 (we were able to access the updated
records through a link given to us by the DHS). Further, repeated attempts to contact the DHS
for a meeting to gather information and records regarding monitoring and utilisation were
unsuccessful.
Additionally, a quarterly report is to be sent to the DHS in the first week of every quarter. This
report generally consists of details about treatment provided to the EWS patients. Although
hospitals stated that the quarterly reports were sent to the DHS, clarity about the report
content, process of examining and monitoring will require further inquiry (Refer Annexure 10
for Quarterly Report format).
The hospitals, as per the guidelines, are also expected to submit a report to the referring hospital
with a copy to the DHS, giving complete details of the treatment provided and the expenditure
incurred. It was not clear from the interviews whether this system was being followed at all.
An Inspection Committee has also been set up, comprising three persons – two advocates and
39
a medical superintendent of a government hospital to monitor the hospitals in their provision
of free treatment. The inspection committee is expected to conduct regular monitoring visits
to hospitals, inspect their records vis-à-vis free treatment. The hospitals are expected to present
all details and records maintained and stipulated by the guidelines must be provided to the
committee. Sufficient information about frequency and the regularity of visits by the inspection
committee was, however, lacking. Interaction with one of the members of the committee,
revealed the gaps in monitoring and the drawbacks of the committee. One of the members
shared,
The committee is not functioning the way it should. Many of the members are not interested.
Mr. XX from the DHS inspects one or two hospitals in a month. You can imagine how
much time it will take to inspect 40 such hospitals. On the day of our visits, the patients
themselves complain that once we go back they will not get the same facility.
XI. Lack of Systems for Redressal
The guidelines do not include any procedures for redressal in case of non-compliance by the
hospitals in following the norms for free treatment. It was also evident that the system for
addressing the grievances of EWS was extremely nebulous, and varied across hospitals. The
system for redressal seemed to be more or less left to the discretion of the hospitals.
Three hospitals, of the nine, mentioned the names and the contact details of the staff responsible
for addressing the grievances of the EWS vis-à-vis the facilities. This was in addition to the
nodal officers present at the hospitals.
All the hospitals in the sample, except one, had two nodal officers for overseeing the
implementation of EWS provisions, in keeping with the guidelines. These nodal and assistant
nodal officers included officeholders such as the Medical/Deputy Medical Superintendent,
administrative personnel, social workers and public relations officers.
About ten public interest litigations around the issue of free treatment have been filed, and
this is indicative of its non-provision and the need for more stringent monitoring and redressal
systems to ensure improved implementation and increased access to treatment for EWS patients.
Action on this front has largely been limited to legal intervention, through cases in the Supreme
Court and the High Court.
Strengthened monitoring and proactive engagement / advocacy by civil society groups are
necessary to stunt practices that might lead to violations of rights of the patients accessing such
facilities. As shared by an inspection committee member,
40
There is this group of middlemen, especially in the rural areas, who charge money from
the people promising them to arrange free of cost treatment in these hospitals. The poor
people do not realise that this is their right and there is a government provision for
these facilities. Many people who come to me for legal assistance have pointed out these
irregularities to me.
The misuse of free treatment facilities were also reported by hospitals, reiterating the need of a
better monitoring mechanism. Hospitals have mentioned the use of fake income certificates to
avail free treatment by those who are from higher income groups. The social worker of DH8
also shared, “We also receive calls by people in positions of power pushing for inpatient care under the
EWS category. Misuse of such facilities is common and needs to be addressed.”
DH1’s Assistant Nodal Officer said,
Yes, there are instances where the people from well-to-do families also try to avail the
facilities of free treatment. They somehow manage to get a fake income certificate, showing
a much lower level of income. Even if we know we can hardly do anything, as they produce
a certificate of income. But, sometimes when we are completely sure that it is not a genuine
case, we do carry out cross-verification.
While the guidelines must incorporate clear norms and define procedures to address noncompliance and the flouting of norms by hospitals, wider involvement of non-state actors or
civil society organisations is an urgent need in ensuring accountability and enabling access
to accurate information and thereby entitlements of the poor. Issues raised by hospitals with
regard to misuse of free treatment facilities also need to be addressed to ensure that the poor are
not deprived of their entitlements to medical treatment.
Mis-utilisation and under-utilisation of the provision of free treatment were observed during
the course of the study. Hence, along with a stringent regulatory and monitoring mechanism,
we also need to have in place an effective redressal system. However, according to our survey,
even if a hospital did have a grievance cell, its functioning remained questionable. Existing
redressal mechanisms are not implemented effectively. An efficient grievance cell is necessary
to ensure the maximum utilisation of such provisions
XII. Providers’ Perspectives on Provision of Free Treatment.
Most of the hospitals opined that the provision of free treatment was a positive step towards
strengthening access to medical care for the poor. The staff of DH3 said,
41
It (The change in minimum income criteria) is a positive step and many people will
benefit from it. There is definitely a positive impact of such policies on poor people accessing
health care. They are quite aware now, and they come and demand these facilities. They get
information from the hospital (the particular hospital under consideration) as well.
DH9’s staffs, while welcoming the increase in the income limit, also articulated that it was
inadequate because of the high cost of living,
While the change in minimum income criteria is welcome, more needs to be done. With
such high cost of living, even Rs. 10,000 is very less. The minimum income limit should be
increased, so that more and more people could be covered under such provisions.
The representative of DH7, however, suggested that the provision of insurance coverage is a
more effective way of increasing the access to health care, rather than subsidising the medical
care and having provision such as free treatment. According to him,
Don’t subsidise health care, but rather strengthen the insurance sector for health. This will
increase the access to services. Otherwise, to whatever extent the government subsidises
the cost; especially poor people will not be able to access the services. For example, look at
the Bihar model. Rs. 30,000 insurance has made so much of difference. The insurance need
not always be in the private sector. It is okay even if the government is providing it in the
public sector.
But while health insurance has been one of the options being promoted in order to increase
access to health care, it cannot be seen as an alternative to the provision of free treatment.
Moreover, the health insurance sector itself is not without problems and is not a uniform
mechanism. Even if insurance is provided in the public sector, as was mentioned by the health
care provider, it does not abdicate responsibility from the private sector to provide provisions as
under consideration of the study.
Although most hospitals felt that provision of free treatment had increased access to medical
care, some were concerned that in the absence of mobilisation of the poor, access to these
facilities remained limited. According to DH7,
Although the government has made provisions, the actual implementation and reaching
out to the people is extremely important. The linkage of the hospitals with the community
is still very weak, and there is no effort by the government to improve this. Perhaps the
government should think about a separate department of community linkages. This has
42
to be the watershed area with special focus on developing linkages with community. Our
hospital has no separate system for tackling poor patients. The treatment is the same, and
therefore the people looking at the patients (for all the categories) are the same. We don’t
have staff exclusively devoted for this. Personally also, I don’t see any need for this. Let the
government first mobilize the community to access proper health care.
Thus, some of the hospitals in the sample believed that dissemination of information about
the provision of free treatment as well as the mobilisation of the poor to access treatment from
mandated hospitals was the responsibility of the government. The above hospital DH7 also felt
that civil society organisations can play an important role in creating awareness generation for
such provisions.
The Assistant Nodal Officer at DH8 voiced the problem of shortage of wheel chairs in the
hospital, “Many a times we give the wheelchair to the patients at subsidized rates or free of cost when
the patients are discharged from the hospital. But, we also need financial resources for this, which is not
always possible.” This was shared in context of subsidies or free resources provided to patients
by the hospital, and were not part of the provision of free treatment. The question then arises
of who should be responsible for providing such resources, if the necessity arises, above and
beyond what the hospital is mandated to provide. Where the hospital is providing services as
per its full capacity can be questioned, the issue of whose responsibility the provision of essential
services is (within and outside the provision of free treatment), remains contested.
Part B: Emerging Issues
The findings of the study brought forward many important concerns with regard to accessing
facilities and available information, utilisation patterns, and the mechanisms of monitoring the
provision.
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.
43
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.
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.
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.
44
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.
V. 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 utilisation. 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.
VI. Monitoring and Redressal Systems
At present the monitoring systems for hospitals for provision of free treatment includes regular
daily updates to a centralised 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
45
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.
VI. Wider Engagement of Civil Society Organisations, Patients’ Groups
Civil society, interest and patient groups can play a substantial role at different levels in the
systematic implementation of the provision. This can be in terms of dissemination of information
among socio-economically vulnerable communities, monitoring of provision of treatment
through studies such as the present one, and through interactions with the communities
accessing these facilities. These groups can also play a pro-active role in highlighting the
violations of rights in such provisions and making it more accountable and transparent by acting
as pressure groups.
At the same time, organisations and networks’ advocacy for public health strengthening cannot
be underestimated. The effective utilisation of available treatment should not be perceived as
yet another justification for promoting privatization of health care and withdrawal of services
in the public sector.
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 (See Annexure 1) 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
marginalised and vulnerable. Addressing the rights of the patients hence becomes a critical
component.
46
Chapter 4: The Way Forward…
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 marginalised and vulnerable. However,
as the study has shown, provisions such as these also pose problems in terms of implementation,
non-compliance, redressal, etc.
Further, it needs to be reiterated that such an arrangement can neither be the answer to the
increasing inequities in health care system or the sub-standard condition of the public health
system in the country. Also, a comprehensive understanding of such provisions necessitates
unpacking of many different and subsumed layers (as reflected in Chapter 3). Within the
limited scope of the study, areas requiring further enquiry and systematic engagement have
also been identified. An attempt has also been made to draw linkages with larger issues with
regard to the provision of health and health care in the country, particularly in the context of
the private sector.
A. Public Advocacy
• In the absence of a 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
• A revision of 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 utilisation of
services within such provisions.
47
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 scrutinised. The Judgment itself points to the lacunas and
the in adequacy of the existing monitoring mechanisms.
• There is a need for a database, which incorporates complete information that is available
and accessible in the public domain. Hospital specific details of the patients, updates on the
utilisation pattern of the services, changes or amendments in the existing provisions, the role
and functioning of the implementing agency such as the DHS, among other things should
be a part of the database. This will not only be useful for the public dissemination of correct
information, but also for increasing transparency and accountability. Such a database will
also lead to better utilisation of these facilities.
• The redressal mechanism for addressing the instances of violations and denials need to
move beyond ensuring this through the role fulfillment by, and responsibility of the hospital
and nodal person. The mechanism should be much more comprehensive and should also
significantly consider patients’ socio-economic, cultural background, as well as sexual and
gendered identities. Needless to say, these are also the axis around which the violations of
the vulnerable and the marginalised are constituted. As mentioned previously, the need and
significance of a stringent regulatory mechanism cannot be overemphasised.
C. 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 categorisation of the hospitals even within the private sector needs more clarity in terms
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 customised policies and
mechanism. As such, the categorisation of the hospitals needs to go beyond for–profit and
not-for-profit, as neither of these categories are uniform or homogenous.
48
D. Utilisation of Services
• The actual effectiveness of such provision needs to be measured through a careful analysis
of the utilisation 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 utilisation 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 dissemination and rights 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
Organisations) in ensuring utilisation 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 utilisation 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 categorise 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 overemphasised. We do hope that this study (with all its limitations)
will serve as an important resource towards the future course of action.
49
references
i
Society for Labour and Development (2007). India’s Healthcare in a globalized world: HealthcareWorkers’ and
Patients’ Views of Delhi’s Public Health Services
ii
Chanda R. (n.d.). Foreign Investment in Hospitals in India: Status and Implications
iii
Amrith, S. (2007). Political Culture of Health in India; A Historical Perspective. Economic and Political Weekly
The National Health Policy, 2002, The Government of India, p.8 accessed at http://mohfw.nic.in/NRHM/
Documents/National_Health_policy_2002.pdf
iv
v
Jan Swasthya Abhiyan (2009), People’s Health Manifesto-2009, Health for all Now; A Call to all Political Parties
vi
Centre for Budget and Governance Accountability (2009), How did UPA spend our money (pp18-24)
vii
Chanda R. (n.d.). Foreign Investment in Hospitals in India: Status and Implications
These data on health care spending have been mentioned in various publications of Jan Swasthya Abhiyan in
the years 2006 and 2009
viii
Public Health Foundation of India (2011). Mapping the Regulatory Architecture for Health Care Provision in
LMIC Mixed Health Systems
ix
x
ibid
xi
Disciplinary and Transparency Forum, http://dtf.in/archives/1067, accessed on 20/11/10
xii
http://www.delhi.gov.in/wps/wcm/connect/066249004efcb37b1156afe99dafo5a/daily+bed+status-10-05-2010.
pdf
http://www.google.co.in/url?sa=t&source=web&cd=1&ved=0CBsQFjAA&url=http%3A%2F%2Fwww.google.co.
in%2Furl%3Fsa%3Dt%26source%3Dweb%26cd%3D1%26ved%3D0CBsQFjAA%26url%3Dhttp%253A%252F%252
Fdelhi.gov.in
xiii
xiv
S. Sakthivel, Institute of Economic Growth, (n.d.) Access To Essential Drugs And Medicine
Full list of referrals can be accessed at http://delhi.gov.in/wps/wcm/connect/19e810804f02b6ce8c30acb60aee
cb21/linkage+20.7.2009.pdf?MOD=AJPERES&lmod=1419706405&CACHEID=19e810804f02b6ce8c30acb60aeecb
21
xv
xvi
Economic Survey of Delhi, 2007-2008
xvii
Study of Private Hospitals in Maharashtra: Key Findings, 2006 Padma Desothali and Dr. Rita Khatri, CEHAT,
50
Annexures
Annexure 1 - REVIEW OF LITERATURE
Research Methodology
The review of secondary material or sources was done to develop a theoretical framework by
gathering information on the existing research work available, as well as identifying gaps in the
existing literature.
The reviewed literature includes:
l News media - coverage in newspapers, news magazines and television
l Literature published in Journals
l Films and other alternative mediums
Organisation of material
The review has been divided into three categories. While the contents overlap with one another,
the categorisation has been done on the basis of the primary focus of the article.
l Access and provisioning
l Analysis and critique of private health care and PPPs
l Recommendations for ‘health for all’
Summary of Findings
Why News Media?
As mentioned above, the media has played a vital role in reporting discrepancies in policy and the
corresponding health services being provided at charitable hospitals and other private hospitals
for EWS. News reports have been analysed to ascertain the status of provision of services,
as well as to substantiate the primary research being done concurrently. Investigative reports
by both print and television media, such as Tehelka Magazine and CNN-IBN respectively
have shed light on the utilisation of free OPD and IPD facilities. Newspapers have also been
scanned to follow updates on the High Court Judgment in the case of Social Jurist, A Lawyers
Group versus Government of NCT of Delhi and ors.
Media sources have been analysed in a thematic manner, and have been reviewed so as to
provide an understanding of some of the existing issues and challenges in the implementation
of the provision of free treatment to EWS patients in Delhi. As mentioned above, investigative
reporting, undertaken by news channels and papers have brought to light cases of mismanagement
and resistance by hospitals in providing free treatment.
51
Publications and Journals
If we look at charitable and trust hospitalswithin the private sector, the scope of research is
immense and multiple inter-connected issues come to the fore, that need to be tackled in a
systematic and realistic manner.
Debates on public health and the right to ‘health for all’ have greatly influenced the understanding
of public private partnerships. These discussions have also influenced the way private health care
and its functioning is viewed, assessed and critiqued.
The social responsibility of both health care systems as well as individual practitioners has
come under scrutiny. The increasing role of private health care, particularly curative tertiary
level healthcare has been critiqued, especially in a country where basic services and preventive
measures are of utmost importance.
The right to health, and questions pertaining to access and availability of health care to every
section of the society were issues that were raised across the articles reviewed.
Commonalities in demands
n Requirement of regulatory and monitoring systems
n Creation of mechanisms for accountability of public and private health providers
n Clarity on the responsibility of the government towards public health
l
Gaps
n Access to existing measures of providing equitable health care
n Lack of statistical data on access to health care by the urban poor
n Need for careful scrutiny of the multiple types of PPPs, existing in the country and
outside
n Regional bias in available literature towards Bombay, and to an extent Delhi. More
research is needed on provisions, as well as access to health care in other regions of the
country. While a few articles mention cities such as Bengaluru, Kolkata and Chennai,
comprehensive information on other cities is missing.
n Need for information to be in easily accessible, and transparency in registration, functioning
and records of charitable and trust hospitals, as well as private hospitals. This is essential
for understanding and tackling inequity in existing situations.
n Need for more information on workers’ and labour issues and their influence on accessing
health care and conditions within the hospital
l
52
Table 12: List of Titles
S. No.
Name of Article
Authors and Publication
Year of Publishing
Media-Print
1.
Private Hospitals earn huge profits; Savita Verma, Indian Express
ignore the poor
29th February 2000
2.
Health, for a price
Siddharth Narain, The Hindu
5th February 2004
3.
Charity on the death bed
Vineet Khare,Tehelka
12th November 2005
4.
Private hospitals get land free, but fail
to treat poor
Praveen Kumar, India Today
16th February 2009
5.
Court directs Apollo to provide free
medicines to poor and needy patients
The Hindu
23rd September 2009
6.
Health hoax
Vaishali Tanwar, Uday India
27th February 2010
7.
No place to be sick
Sopan Joshi, Tehelka
5th February 2011
8.
Doctor vs the people
Akshay Sawai, Avantika Bhuyan,
The Open Magazine
5th March 2011
Visual Media
9.
Incurable India
Directed by Umesh Aggarwal, A
Documentary by Doordarshan
2010
10.
Top Hospitals out of bound for Poor
Patients
Divya Iyer, CNN IBN and Cobrapost
December 2010
Journals and Publications
Access and provisioning
11.
The Poor and Health Service Use in
India
By Ajay Mahal, Abdo S. Yazbeck,
David H. Peters, G.N.V. Ramana,
The Health Nutrition and
Population Family, Human
Development Network, The World
Bank
12.
Govt. to crack the whip on 18 Delhi
Hospitals
By Sapna Dogra, printed in Express Issue dated 16-31
Healthcare Management
March 2004
13.
It’s Free, but is it fair?
By Jayata Sharma, printed in
Express Healthcare Management
July 2006
14.
Study of Private Hospitals in
Maharashtra: Key Findings
By Padma Desothali and Dr. Rita
Khatri, CEHAT
2006
15.
Privitisation of Health Care in India:
A Comparative Analysis of Orissa,
Karnataka and Maharashtra States
By Rama Vaidyanathan Baru,
Centre for Multi-Disciplinary
Development Research (CMDR)
2006
16.
India’s Health care in a Globalised
World: Health care Workers’ and
Patients’ Views of Delhi’s Public
Health Services
A Collaboration between Hospital
Employees Union, Jobs with
Justice and Society for Labour and
Development
2007
53
August 2001
S. No.
Name of Article
Authors and Publication
Year of Publishing
17.
Study of Charitable Hospitals:
Reviewing Options for Sustainable
Partnerships
By Dr. Utkarsh Shah and Dr. Dhaval N.D.
Bhatt, Supported by HOSMAC India
Pvt. Ltd. and HOSMAC Foundation
18.
Health Services as Analyser of Urban
Governance: A Study of Delhi
By, Stéphanie Tawa Lama-Rewal,
Centre for the Study of India and
South Asia, CNRS-EHESS, Paris,
and Centre de Sciences Humaines,
New Delhi
19.
The Private Health Sector in India
-Nature, Trends and a Critique
By Ravi Duggal, Centre for Enquiry
into Health & Allied Themes
(CEHAT)
2006
20.
Do charitable hospitals deserve tax
benefits?
Opinions-Duggal and Anupam
Verma, Express Healthcare
Management
Issue dated
16-30 September 2003
21.
Blurring of Boundaries: PublicPrivate Partnerships in Health
Services in India
By Rama V Baru and Madhurima
Nundy, Economic and Political
Weekly
2008
22.
National Conference Report “Emerging Health Care Models:
Engaging the Private Health Sector”
By Tejal Barai – Jaitly, Organised
by Centre for Enquiry into Health
and Allied Themes (CEHAT)
2009
23.
Effective public private partnerships
in healthcare: Apollo as a cautionary
tale
By George Thomas, Suneeta
Krishnan, Private Sector in Indian
Healthcare Delivery: Indian
Journal of Medical Ethics , Vol VlI
No 1
January-March 2010
24.
Consumer Perspective and
Government Policies to promote
private sector
Utkarsh Shah, Ragini Mohanty ,
Prin. L. N. Welingkar Institute of
Management Development and
Dec 2010
N.D.
Analysis and critique of private healthcare and PPPs
Research, Matunga, Mumbai,
Information Management and
Business Review, Vol. 1, No. 2, pp.
79-87
25.
Privatization of Healthcare in IndiaPublic health system collapsed due
to under-financing of public health
services
By Ravi Duggal, Coordinator
Centre for Enquiry into Health and
Allied Themes (CEHAT), Mumbai,
India
N.D.
26.
The Not-for-Profit Sector in Medical
Care
By Madhurima Nundy, Centre of
Social Medicine and Community
Health. Section 11, Financing and
Delivery of Health Care Services
in India.
N.D.
54
S. No.
Name of Article
Authors and Publication
Year of Publishing
Recommendations and effective strategies towards addressing health care for all
28.
Critical Issues in Regulatory
Provisions for Private Medical Sector
By Anant Phadke (This article is
based on discussions in various
meetings of representatives
of organisations in Mumbai &
Pune -- CEHAT, Association of
Medical Consultants, Mumbai,
Forum for Medical Ethics, ACASH,
Health Committee Lokvidnyan
Saanghatana Pune, WACHA ,
Women’s Centre. (In a way it
reflects the consensus amongst
these organisations as it emerged
during these meetings)
N.D.
29.
Mapping the Regulatory Architecture
for Health Care Provision in LMIC
Mixed Health Systems- A Research
Tool and Pilot Studies in Two Indian
States
Research Team- Dr. Kabir Sheikh,
Prasanna Saligram, Lakshmi E.
Prasad, Public Health Foundation
of India (PHFI),
2011
Literature Review
Media-Print and Television-A Thematic Summary
Privitisation of Health Care in Delhi
From the 1980s until the present, more than 400 private hospitals and nursing homes have
received concessions and subsidies from the Delhi Government (Tehelka, 2005, viewed on
28/5/11). The government has provided concessions in the form of free or discounted land
to private hospitals in return for a reservation of 25 per cent free beds in the inpatient
department (IPD) and 10 per cent free treatment in the outpatient department (OPD)
to EWS. The Apollo group was one of the first corporate hospitals to start with such a
partnership, and received 15 acres land at the rate of for Rs 1 per month, along with a grant
of Rs 16 crore for the building construction, with the condition that it would earmark 33
per cent of its total IPD capacity and 40per cent of OPD for EWS patients (The Hindu,
2009 viewed on 14/4/2011). There was great hope that such partnerships, would reduce the
burden on public health care, and ensure quality care for poor patients. By 2006 the situation
had changed drastically. An article in the Indian Express dated February 2000 (viewed on
4/14/2011) cited a report called Critical Conditions released by Worker’s Solidarity. The
report was based on a survey of wages, working conditions and terms of employment of
Class IV workers in eight of Delhi’s largest private hospitals- Apollo, Batra, Sir Gangaram,
Tirathram, Sunderlal Jain, B. L. Kapur and Jessa Ram. This report gave evidence that despite
55
having received government subsidies, private and charitable hospitals had failed to meet
their obligations towards poor patients.
Subsequent investigative reports by news media and activists brought to the fore numerous
cases of denial of treatment to EWS by the private hospitals. Finally in 2000 the Qureshi
Committee was constituted by the Government to investigate the facilities and provision for
EWS patients. This formed the basis of the High Court guidelines for the provision of free
treatment facilities to patients of EWS category, termed in private hospitals in pursuance of
directions issued by the Hon’ble High Court of Delhi in WP (C) no 2866/2002 in the matter
of Social Jurist, A lawyers group versus GNCT Delhi.
The Situation in Hospitals - Access to Free IPD/OPD Treatment
The following section is a compilation of news clippings and television reports from 2009 to
2011 that deal with access to free treatment by patients from EWS in the National Capital
Region (NCR). The incidents have been divided into the following categories (1)Denial of
treatment (2)Attitudes of medical personnel (3)Discrepancy in records.
Denial of Treatment
Vikas Sagar, 35 went to Apollo Hospital with a reference from the DHS but was refused free
treatment for his daughter under the EWS scheme.
On 15 November 2009, Farman was brought to Ram Manohar Lohia Hospital (RML) after
he suffered a stroke. As per the emergency clause he was admitted and underwent diagnostic
tests. When the tests revealed a blockage in the artery, the hospital refused to operate on him
until Farzana, his spouse submitted Rs 60, 000. When she was unable to deposit the money he
was discharged in 5 days. (The Hindu, 2010, viewed on 25/03/11).
As Dr. Mohanty says, (Uday India, 2010, viewed on 27/03/11) “even when hospitals do not
refuse admittance and emergency care, they charge for routine checkups and tests that the
patients undergo such as x-ray, ultrasound etc. and also charge for surgery.”
Tehelka published an article in 2005 before the High Court Judgment had been issued. This
article gave details of concessions received by major hospitals in Delhi and denial of treatment
to the poor. The reporters procured a list of EWS patients who had received treatment between
January 1 2004, and March 31 2005 at Shanti Mukund Hospital. When they tried to trace these
patients, they discovered that a lot of names and details were forged as the people on that list did
not actually belong to EWS. Moreover some people whose names figured on that list had never
even been hospitalized. But even after the High Court Judgment, and despite stricter guidelines
56
being put into place, the media has chronicled accounts of denial of treatment to EWS patients
in hospitals. CNN-IBN and Cobrapost did a feature together, where they accompanied EWS
patients to large private hospitals and were denied treatment.
Super-specialty Max Hospital in East Delhi-Patparganj is a private facility built on government
land procured at concessional rates. Tehelka’s investigative team reported on how a staff member
denied treatment to an EWS patient saying that the BPL card does not allow for free treatment
and that a committee has to first approve the patient. Furthermore, the staff member added that
rejection cards had to be provided by hospitals in the vicinity of the patient’s house before he/
she became eligible for treatment at Max-Patparganj. When the reporter tried to talk about
the scheme, he was told that the hospital did not offer any such facilities. Similarly at Escorts
Heart Institute (which is now a PPP), a 14 year old girl from Bihar, with a heart problem was
informed by the Medical Superintendent (Dr Gupta) that only BPL cards from Delhi are
recognised at the hospital as per the Supreme Court ruling.
In Fortis Hospital, Vasant Kunj, a patient was first asked for a government referral, and was then
informed that there were no beds available. On protesting that according to the notice outside
the room, 11 beds were available, the Medical Superintendent (Dr Sushmita) informed the
reporter that the notice had not been updated. Another doctor (Dr Mittal) informed a patient
that Dialysis was not available at Fortis, even thought the patient had a referral from AIIMS.
They told the patient that they had not received any referral from AIIMS, and that Dialysis was
not available for EWS patients. Saroja Devi (the patient) went to Fortis on 6 different days and
was turned back each time. When a request was submitted [under the Right to Information
(RTI) Act] by the investigative team to see the records of the hospital, they found that on five
of the six days that Saroja Devi was turned down, all 11 EWS beds were vacant.
Similar investigations were carried out at Rockland Hospital, Batra Hospital, and G. M. Modi
Hospital, with the same results.
All the above cases outline how lack of awareness of EWS patients results in the denial of
treatment for them. This is compounded by the unwillingness of the hospital to provide treatment
and the attitudes of doctors and staff (outlined in the next section). As Dr. Trehan points out
in an interview with Tehelka, (Tehelka 2011, viewed on 14/4/2011) the gap in monitoring and
regulation, compounded by lack of an effective grievance redressal system makes it impossible
to get treatment, particularly for EWS patients who are sick and might not have the time or the
means to get legal help. While hospitals may provide basic facilities and consultations, the more
expensive treatment, such as Dialysis is denied to such patients. As Trehan also points out, the
57
definition of the word ‘free’ is open to interpretation and not commonly understood. But with
the new guidelines, the High Court has clearly spelt out that all treatment and expenses are to
be taken care of by the hospital. Strict regulations and monitoring systems will help achieve
equitable access and proper standards of health care, but as a study by CEHAT (Deosthali,
Khatri, 2006) reports, a grievance redressal system that functions effectively is also essential and
is included within the international minimum standards of care. But a WHO study conducted
by consumer activist Bishon Mishra found out that only one per cent of cases related to health
care reach the consumer court, and that also only on grounds of medical negligence (Tehelka
2011, viewed on 14/04/11).
Attitudes of Medical Personnel
The larger question here is whether private hospitals should be expected to have a social
consciousness when the facilities that they are providing are in exchange for subsidies given to
them by the government. A non-discriminatory attitude and hence proper and fair treatment
cannot be cannot be ensured through force by the State. The article in Uday India (Health
Hoax, 2010) reveals that some hospitals have discriminatory facilities where they have separate
OPD counters for lower, EWS and general categories. The facilities for general patients include
a roof and seating, while the EWS patients are sometimes expected to wait outdoors, and have
no place to sit.
Hospital authorities on their part either deny that the treatment is not being provided to full
capacity or blame the lack of patients coming to the hospital. Dr. Dilpreet Brar from Max
Healthcare said in an interview with India Today, “lack of awareness is a major reason for not
having enough EWS patients at the hospital.” Another official from Jessa Ram Hospital in Karol
Bagh told a reporter from d-sector.org, “We have beds reserved for patients coming from humble
backgrounds, what else can be done.” This official however, refused to divulge details of how many
beds are being used by the poor (No beds for the poor, d-sector.org 2010, viewed on 18/4/2011).
Lack of motivation on the part of private hospitals continues to act as a critical barrier to access
to quality health care for the poor.
Discrepancies in Records
Apollo is supposed to have 200 beds reserved for EWS, but the average number of EWS
patients treated annually remains in the range of 15 to 20 patients. Only 3 out of 8 free beds
were occupied at Fortis, and 4 out of 10 free beds were occupied at Jessa Ram Hospital (India
Today, 2009, viewed on 19/4/2011). Max Devki Devi Heart Institute in Saket has 18 free
beds available for EWS out of which on an average only 3-4 beds are occupied (as informed
by the regional manager). The Indian Express reports that for three months before February
58
2010, when the article was written, not a single EWS patient was treated at Rockland Hospital
(The Indian Express, private hospitals dodge ‘poor’ clause, doors still shut to under-privileged,
February 2010, viewed on 24th May 2011).
The following list outlines some of the concessions given to charitable and private hospitals by
the government (Tehelka 2005, viewed on 14/4/2005).
l
l
l
l
l
l
In 1985, Jaipur Golden Charitable Clinical Laboratory Trust was allotted 2.085 acres at the
rate of Rs 10,000 per acre.
In 1990, Dharamshila Cancer Foundation and Research Centre got two acres for Rs 14.25
lakh per acre.
In 1982, Escorts Heart Institute and Research Centre paid a meagre Rs 10,000 per acre
‘provisionally’ for 1.7 acres.
In 1988, Shri Mukundi Lal Memorial Foundation for Heart and Medical Care got 1.707
acres for Rs 8 lakh per acre.
In 1986, Ganesh Dass Chawla Charitable Trust paid at the rate of Rs 10,000 per acre for
0.85 acres.
Land was given to several trusts and societies at throwaway rates. They also received tax
exemptions worth crores on their earnings and equipment.
Newspaper reports have also mentioned cases where hospitals in the NCR region have charged
patients from the EWS category. Some of these cases are listed below. While some of these
hospitals are known to provide free treatment, they are not consistent about it.
Mohit, son of a washer man in Vasant Kunj was charged Rs 3,840 for OPD treatment by Fortis
Hospital after a head injury.
Another EWS patient, Bano was asked to pay Rs 300 at Max Balaji Hospital for a doctor’s
consultation. (India Today 2009, viewed on 19/4/2011)
Bhram Pal Singh, a horse cart puller from Utter Pradesh was asked to pay Rs 36,000 for his
eye surgery at the Venu Eye Institute and Research Centre. This amount was later reduced to
Rs 10,000. When he expressed his inability to pay this amount, he was denied treatment at
the hospital. Advocate Ashok Agarwal was fighting his case. (Prokerela News 2010, viewed on
22/05/11).
While the court states that any proof of income can be used to assess whether the patient is
from the EWS category, hospitals do not have a uniform way of doing so. For instance hospitals
59
such as Sir Ganga Ram hospital only accept EWS patients who have a BPL card. The situation
and implementation of treatment to the poor in the NCR region seems ambiguous at best.
In terms of law, the Delhi High Court has taken a step forward and given strict and specific
guidelines so as to ensure equitable access to health for EWS. However the motivation for
actually implementing the free services and ensuring that they deliver, seems to be lacking.
In addition to that, employment conditions and profit-driven companies are a huge hindrance
to free treatment for EWS. But at the same time, we need to examine the larger structural
issues that are involved in the creation of private health care, hence leading to a situation where
the access to health care for poor people becomes almost impossible. The role of the State in
promoting tertiary and super-specialty care, and their inefficient regulatory and monitoring
mechanisms further impedes the progress which can be made by taking forward progressive
judgments, such as that of the High Court in 2007.
Review of Journals and Publications
Access and Provisioning
The poor and health service use in India
By Ajay Mahal, Abdo S. Yazbeck, David H. Peters, G.N.V. Ramana, The Health Nutrition
and Population Family, Human Development Network, The World Bank, August 2001
This report is an analysis of investigations from a World Bank financed research conducted in
2000 and the 52nd round of the National Sample Survey (NSS) conducted in 1995-96, which
included a special health module (NSSO 1998), along with additional analysis of the same
data.
The report analyses the use of preventive and curative care by the poor in India and aims to
identify the beneficiaries of the existing health services, both public and private, using data
collected from across India. It also sheds light on the distribution of benefits from public health
care facilities, variations in utilisation patterns between different economic classes and gender,
and rural-urban distinctions in accessing healthcare.
Some of the important findings are that publicly financed curative health care is more likely to
serve richer segments with private sector usage being even more skewed in favour of the rich.
The main beneficiaries of the public sector are people who live below the established poverty
line. In terms of state level variations, the study found that there is more equitable access to
healthcare in southern and western states.
60
In terms of recommendations, the report reiterates that publicly financed health services are
the best way to provide health care to the poor, even though there are problems regarding
accessibility. Moreover, the location of the facilities influences the extent to which the services
are used. The report also stresses on the need for documentation and monitoring, with clear
targets for health care services.
Govt to crack whip on 18 Delhi hospitals
By Sapna Dogra, printed in Express Healthcare Management, Issue dated 16th-31st March
2004
According to the Qureshi Committee report, around 18 private hospitals were found violating
their land allotment agreement by denying treatment to the poor. Delhi Development Authority
(DDA) and Land and Development Office (L&DO) were asked to file an ‘Action taken
Report’ against the offending hospitals. The hospitals which include establishments such as the
Dharmshila Cancer Hospital, Venu Eye Institute and Research Centre, Rajiv Gandhi Cancer
Hospital and Gujarmal Modi Hospital deny that they are violating the agreement. The article
reports on the contrary opinions and the ongoing discussion.
It’s free, but is it fair?
By Jayata Sharma, printed in Express Healthcare Management, July 2006
The article came out in 2006 following the submission of a report by the Mumbai High Court
appointed Dhumal expert committee. It reports on free treatment norms to be followed by
charitable trust hospitals in Mumbai. It also lists the recommendations and provisions made by
the committee and analyses current debates and trends connected with the implementation of
the act and resistance by the actors opposed to it. Lastly, it explores the controversy around the
composition of the committee and its recommendations. The report was a fall out of a PIL filed
by Advocate Sunil Punalekar in 2004.
Although the Mumbai report came out a year before the Delhi High Court Judgement, it has
parallels to the same.
Study of private hospitals in Maharashtra: Key findings
By Padma Desothali and Dr Rita Khatri, CEHAT, 2006
This study, aims to assess physical standards and quality of care provided by private hospitals in
a representative sample of private hospitals in Maharashtra. It also tries to understand concerns
61
pertaining to the Bombay Nursing Homes Registration Act (BNHRA) and accreditation
among hospital owners. The study was undertaken by CEHAT in the light of the amendments
to the existing BNHRA in 2006, and offers a comprehensive framework to assess the standards
and functioning of private hospitals.
The study surveyed 261 nursing homes in ten rural and urban districts of Maharashtra to
examine various issues such as human resources, standards of care, violation of patients’ rights,
system of grievance redressal, and registration and awareness of the BNHR Act. Some of
the major findings of this study were as follows: there was an average of 1.68 trained nurses
with the rest being either trained on call or unqualified. One-fourth of the hospitals did not
give discharge papers to the patients even when requested, and half did not give consultation
papers to outpatients as well. Moreover, there was no independent mechanism for redressal of
grievances. The Act has still not been implemented properly even after judicial intervention and
campaign by the civil society. The findings of this study makes us question whether the private
sector and the Government are really motivated to make public private partnerships work in a
manner which ascribes to minimum standards of care and quality of healthcare services.
Privatisation of health care in India: A comparative analysis of Orissa, Karnataka and
Maharashtra States
By Rama Vaidyanathan Baru, for the Centre for Multi Disciplinary Development Research
(CMDR), as part of its UNDP sponsored project “Economic Reforms and Health Sector in
India”, 2006.
The paper explores the evolution, functions and characteristics of the private health sector by
studying literature and data procured from the Ministry of Health and Family Welfare. It
studies the impact of the economic restructuring of the eighties, after the SAP to determine
changes in trends in the utilisation patterns for outpatient and inpatient care across three states
(Maharashtra, Karnataka, and Orissa). It also analyses income groups in relation to the structures
of provisioning. It goes on further to scrutinise briefly the commercialisation of health care in
Europe, Africa, Latin America, Asia and USA, where as a consequence of marketisation in
health care, there has been a reduction in access to health care for the poor and a simultaneous
increase in drug prices.
The above forms the framework for an overview of the private health services in India. The states
under scrutiny represent varying levels of development and urbanisation, with Maharashtra,
Karnataka and Orissa, representing developed, middle level, and poorly developed states
respectively. The paper studies variations across states, social groups, as well as income groups.
62
Its main objectives were “to identify trends in health service relative to the public sector for bed
strength at primary, secondary and tertiary levels, and examine utilisation patterns for inpatient and
outpatient care across income and social groups.”
The paper gives a comprehensive overview of shifts and trends in healthcare, and provides
insights into differences in private health care provisions in 3 socio-economically distinct states.
The Private sector at the primary level consists mainly of organised or unorganised individual
practitioners and is distributed across rural and urban areas, while secondary and tertiary level
care is largely present in urban areas. The findings clearly indicate that the least developed state,
Orissa, has the poorest health indicators and the structure of provisioning is reflected in its
utilisation trends, with the lowest utilisation being in Orissa, and the highest in Maharashtra.
The economically better off states are also those with higher private sector growth. In these
states, it is the upper and middle class that utilise these services.
According to the findings, the cost of medical care in both private and public sector has
increased, with the highest increase in outpatient care being attributed to Orissa. The rising
costs of public health care, drug prices and quality of care have led to greater utilisation of
the private sector. However scheduled tribes across all three states have very low utilisation,
which needs to be addressed. While the upper and middle classes have more options between
private and public health care, the poor are at risk of not being able to access any health care
because of the increase in prices, even in public health. The paper calls for a rational use of
resources and schemes such as social insurance and regulatory policies for public provisioning
and private health care.
India’s health care in a globalised world: Healthcare workers’ and patients’ views of
Delhi’s public health services
A Collaboration Between Hospital Employees Union, Jobs with Justice and Society for Labour
and Development, 2007
This report is based on the premise that the right to health care, labour rights and human rights
are integrally linked. It sees health workers and patients as part of the same exploitative system,
and attempts to create a link between them. Undertaken in 2006 using 500 questionnaires,
the report attempts to survey public health institutions in Delhi such as hospitals under the
Municipal Corporation of Delhi (MCD) and the Delhi Government, smaller health and sub
health centres, and dispensaries. In addition to that it draws from secondary sources such as
the Sample Registration System, Central Bureau of Intelligence, Government documents, the
National Sample Survey Organisation (NSSO) and human rights documents.
63
The objectives of the report were to assess the working conditions of the workforce in Delhi’s
public health institutions, and to examine the quality of health care and access in Delhi, from
the patients’ points of view. The paper introduces these objectives by outlining the role of
neoliberalisation, minimal intervention by state, primacy of market principles, restrictive labour
laws and the contractualisation of services in the public and private sectors. It also focuses on
declining social insurance and increasing out-of-pocket expenditure.
The paper provides information on the scope and functioning of the health care system in
Delhi. It lists multiple providers and analyses the inpatient and outpatient facilities provided by
the government and access to these by the poor and the working class. It also draws attention
to the increasing privatisation of outpatient care, with the government’s share being only onefourth of the total expenditure on outpatient care. Outsourcing of services such as diagnostics
also contributes to increasing prices. The report clearly shows that expenditure on consumables
and drugs constitutes the major chunk of out-of-pocket expenses. Government practices
further compound these concerns by not having regulatory laws governing drug distribution
and instead allowing distribution to be based on sales turnover, rather than where the drug is
required. Informal contracts with companies manufacturing medical equipment are a result of
such practices, and a cause for concern.
The report attempts to link health sector and labour law jurisprudence and sheds light on how
the health care system comes within the Industrial Disputes Act, hence providing a modicum
of security for workers. It also outlines the developments and concerns pertaining to labour laws
in the context of hospitals and cautions against slackening of these laws since that would lead
to greater exploitation, non-regulation and increase in the price of health care. It also touches
upon occupational hazards such as sexual harassment in the workplace.
The report espouses the need to develop a framework to enforce the right to health as a
fundamental right, and offers arguments towards developing a case for it. It goes on to analyse
health care reforms and failures in the United States of America as a case study for an industrial
society with no public health insurance.
Major findings indicate that 73 per cent of the surveyed population is dependent on public
hospitals, which is also a reflection of their economic status. The economically weaker sections
are more likely to belong to socially disadvantaged classes, such as scheduled tribes scheduled
tribes and religious minorities. The report analyses various statistics related to the patients
such as the type of transport used to reach the hospital, household size, employment, type of
treatment received and out-of-pocket expenses for treatment. These statistics are used to build
64
a profile of patients to allow us to understand how inequitable policies and lack of access to
affordable healthcare not only violate the patients’ right to access healthcare but can greatly
impoverish them as well.
The report then examines the health services from the point of view of the workers. Workers
surveys couched in the framework of labour rights reveal that overburdened health care workers,
falling wages, rising prices, deterioration of working conditions, and completely inadequate
physical infrastructure. privatisation and contractualisation of health care and employment make
labour vulnerable, and more and more services in health care are becoming contractualised, such
as diagnostic services, security personnel, nurses etc.
The survey of the socio-economic background of the workers revealed that 82 per cent of the
workers are from socially disadvantaged classes and are largely Hindu. The dominance of caste
category by type of occupation is clearly reflected.
The recommendations stress upon the need for a collaboration between workers’ rights and
patient welfare, and indicate that lack of health security is leading to greater poverty. It also
emphasizes the importance of a consultative, accountable and collaborative process to solve the
problems beseeching health care. Finally, the report asks for enforcement of standards of care
and public accountability to ensure the constitutional right to health care for all.
Study of charitable hospitals: Reviewing options for sustainable partnerships
By Dr. Utkarsh Shah and Dr. Dhaval Bhatt, Supported by HOSMAC India Pvt Ltd and
HOSMAC Foundation
The research covered seven charitable hospitals in Mumbai, Delhi and Bengaluru, including
interviews with activists, doctors, and people involved with health care. Interviews of
Administrators/CEO/Trustee of the hospital were conducted, with the objective of evaluating
the functioning of major charitable hospitals and reviewing the scope of a sustainable and
realistic partnership between the government and private charitable hospitals. As a background
to the debate the paper offers a comparison of judgements relating to public private partnerships
in health care, based on the Dhumal Committee report in Mumbai, and the Qureshi Committee
report in Delhi.
The paper highlights the need to move from an ‘obligation’ based attitude towards charitable
services, and to a realistic and mutual partnership between private and public sectors. It also
examines the failure of the charitable hospitals to fulfil their commitment towards providing
free or subsidized healthcare. The authors point to a lack of political will and motivation from
65
the government to monitor and enforce accountability. It also outlines the difficulties that the
hospitals are facing in sustaining charitable activities, and hence indicates the need to review the
concessions, subsidies and benefits granted by the State.
These findings are based on a survey of 31 key respondents (mentioned in the methodology as
being Administrative staff/CEO/Trustee of charitable hospital, and professionals associated
with healthcare systems.
The paper suggests that charitable hospitals are open to reconsider partnerships in a more
sustainable and feasible manner that provides scope for up gradation and improvement of
facilities, and there is a willingness towards resource sharing with the State in order to improve
the overall effectiveness of health care services. However, what this amounts to in more concrete
terms is not indicated. The question of sharing of responsibility and accountability between the
private and government actors is also left ambiguous.
Health services as analyser of urban governance: A study of Delhi
By, Stéphanie Tawa Lama-Rewal, Centre for the Study of India and South Asia, CNRSEHESS, Paris, Centre de Sciences Huamines, New Delhi
This paper analyses health services as an indicator of social inequalities (Fassin 2000) which
makes it a priori a privileged prism to study the social distribution of the costs and benefits
of the new urban governance. It considers the provision of public primary health services as a
case study of the changes brought about in urban governance in the past 15 years as a result of
economic liberalisation, politico-administrative decentralisation and the large consensus around
the desirability of good governance, with a special focus on New Delhi, India.
It maps the major players in the provision of primary health services and analyses the role,
motivation and functions of government officials, elected representatives, NGO’s and Residential
Welfare Associations (RWA) in effective functioning of the same.
The findings are based on an empirical survey conducted in Delhi in 2004-05, in four municipal
wards, with a representative sampling in terms of urban landscape, housing pattern and socioeconomic profile of the inhabitants. Data and archives of the Municipal Corporation of Delhi
(MCD) and the Delhi Vidhan Sabha have also been utilised.
While the study has found an increase in the participation of people in the management of local
affairs, class has appeared as a major element of urban governance, bypassing migrant workers
66
and poorer sections of society who do not have ownership of land or voting members with a
recognised political identity. Organisations such as RWA’s do not have a presence in low income
housing, and existing associations do not focus on the effectiveness of primary healthcare. The
universalisation of health has also not come up as a matter of concern or principle of action
amongst the actors who formed part of the study.
Analysis and critique of private healthcare and PPPs
The private health sector in India -Nature, trends and a critique
By Ravi Duggal, Centre for Enquiry into Health & Allied Themes (CEHAT), 2000
The paper traces the evolution of the private health care system from pre-colonial times in the
Indian Subcontinent. Giving a brief overview of medicine and healers, it moves on to trace the
beginnings of modern medicine under the British rule. Duggal identifies trends in the evolution
of modern health care. Some of these include biases towards provisions in urban areas, relegation
of curative care in urban areas, preventive care for rural areas and the country side, and racial
prejudices which have continued till date. He goes on to describe the transformation of the
traditional home-based petty ‘commodity producer’ of health care to the existing corporate and
institutionally qualified ‘producers’. He also warns of the dangers of a health care system which
is completely commodity-driven and market-oriented.
The paper speaks simultaneously of the decline and inadequate conditions of the public sector,
and the flourishing market-driven corporate sector, including the trend in medical education. It
analyses local sources and larger studies to determine existing trends and conditions.
The diversity and complexity of the medical system, both formal and informal is explained and
subjected to analysis. Current issues such as accreditation, regulation and monitoring, and the
pharmaceutical and medical equipment industries are mentioned in terms of their contribution
to the growing health care system.
The report ends with a review of health care utilisation and expenditures, leading to questions
surrounding public private partnerships in health care. The role of the State in contributing to
the growing private sector through subsidies, tax exemptions, and policy changes is emphasized.
This is explained in the context of neoliberalisation and politics of the World Bank.
While implementation of comprehensive regulations covering the health care sector and
an organised public-private mix is seen as the way forward, the role of private insurance in
increasing health care costs is highlighted as an eminent danger. The role of the State in
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providing quality care for the poor forms a focus area for the paper. Examples of both specific
and generic recommendations for reforms in health care are also touched upon briefly.
Debate - Do charitable hospitals deserve tax benefits?
Opinions-Duggal and Anupam Verma printed in Express Healthcare Management, Issue
dated 16th-30th September 2003
The article is in the form of a debate between Ravi Duggal and Anupam Verma.
Ravi Duggal is the co-ordinator of the NGO-Centre for Enquiry into Health and Allied
Themes. Anupam Verma is the Head of Operations at Hinduja Hospital, Mumbai.
Duggal argues that while provisions do exist under the law, most charitable hospitals do not
comply with them. He stresses the importance of auditing hospitals to assess their functioning.
He uses Mumbai as an example to illustrate the attitudes of charitable hospitals and asks for
transparency in giving concessions to the hospitals.
Anupam Verma on the other hand, writes about the nature of trust hospitals as philanthropic
institutions, and examines their role in assisting the government in providing health care at
minimal costs. He draws attention to the high cost versus price ratio and views tax concessions
as indispensable to enable hospitals to control their surplus margin. He believes that with the
withdrawal of exemptions concessions to poor patients will also have to be reduced.
Blurring of boundaries: Public private partnerships in health services in India
By Rama V Baru and Madhurima Nundy, Economic and Political Weekly, 2008
The economic crisis of the 1980s, coupled with the shift towards neoliberalisation resulted in
far-reaching changes in the country’s economy. These changes in turn, led to an increase in the
role of many bilateral and multilateral agencies such as the World Bank, the United Nations,
Pharmaceutical Companies and global alliances on diseases and prevention. The involvement
of a large number of private and public actors changed the nature of public private partnerships
and gave legitimacy to them.
This paper explores the evolution of these partnerships, their characteristics and functions, as
well as their constraints and concerns using two case studies: the Indian Revised National
Tuberculosis Programme (IRNTP) and the Reproductive Child Health Policy Programme
(RCHP).
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While the first case study of IRNTP illustrates the importance of a strong State programme
that is supplemented by PPP in terms of service delivery and provisions, the second case study
establishes the importance of optimal functioning of all the actors such as private practitioners,
government hospitals, and government provided supplies. Case studies from the RCHP are
based on the World Bank model of social franchising. Both programmes involve multiple levels
of partnerships and require foreign funding.
The process of ‘agencification’ within PPPs in hospitals is also analysed, and different levels of
such partnerships are explained. Some of the key challenges outlined and analysed in this study
are: the number of actors in the market, drawing and framing MoUs, organisational capacity
to define roles, administrative capacity for monitoring and impact on equity. Lack of clarity in
roles and responsibilities is compounded by the above-mentioned challenges and points towards
a need to critically analyse current models of PPPs being used.
National conference report - ‘Emerging health care models: Engaging the private
health sector’
By Tejal Barai – Jaitly, Organised by Centre for Enquiry into Health and Allied Themes
(CEHAT), 2009
Lack of research, and emerging evidence on the functioning of PPPs led CEHAT to organise a
2 day workshop on 25-26 September 2009, in Mumbai, named ’Emerging health care models:
Engaging the private health sector’.
Two key areas of concern were identified in the functioning of partnerships - contracts and
partnerships; their nature, implementation, monitoring and impact that characterize the role of
the private company and the government.
The conference report carried details of seven sessions in which the participants looked at issues
and challenges, perspectives, existing PPP models, scope of engaging the private sector, PPPs
under NRHM, emerging healthcare models and the future of health care.
The workshop was attended by a wide range of people and organisations, and various perspectives
of health care were discussed. Presentations made at the workshop included evidence based
papers, case studies, as well as policy related and government issued papers. Hence the paper
provides a detailed study of the different programmes, policies and trends related to PPPs in
India. It also outlines the need for conceptual clarity on what constitutes a PPP and stresses
the need for more systematic studies on the subject. It also attempts to understand the need for
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PPPs, whether they are a result of governmental inefficiency or a possible model of symbiotic
relationships that allows for sustainable and equitable use of resources.
The problems beseeching the private sector such as lack of regulation, lack of information, lack
of redressal mechanisms, existence of multiple models and growth of private insurance are all
seen to be detrimental to equitable access to health care.
The report also highlights the need for efficient functioning of PPPs and this requires an increase
in capacity, skills in monitoring, increased financial resources, etc. The report is a comprehensive
document that allows us to understand the variety and functioning of different types of PPPs
existing in the country, and the challenges and concerns that different stakeholders have to
confront, as well as best practices associated with them.
Effective public private partnerships in healthcare: Apollo as a cautionary tale.
By George Thomas, Suneeta Krishnan printed in the Indian Journal of Medical Ethics-Vol VlI
No 1, January-March 2010
This article briefly traces the evolution of PPP and points out concerns plaguing privatisation
of health care. The authors scrutinise what constitutes a public private partnership in health
care and cautions against the corporate hospital model such as Apollo Hospitals as a standard
for PPPs in healthcare. They urge the government to implement bills and drafts such as the
National Rural Health Mission and the Indian Public Health Standards.
This article examines the failure of the public health system as well as existing PPPs, and looks
towards the model of SEWA in Gujarat, as the way forward. It emphasized the need for having
clear incentives for private hospitals to provide free or subsidised health care, and stresses on
substantial improvements in regulations and enforcement at all levels.
Private sector in Indian health care delivery: Consumer perspective and Government
policies to promote private sector
By Utkarsh Shah, Ragini Mohanty, Prin. L. N. Welingkar Institute of Management
Development and Research, Matunga, Mumbai, Information Management and Business
Review, Vol. 1, No. 2, pp. 79-87, Dec 2010
This paper focuses on understanding the role, origins and functioning of the private health care
in India. It views the deficiencies in public health provisions as the key stimulus for the growth
of private infrastructure in health. It further attempts to analyse government initiatives that
promote the private sector. It makes a distinction between different types of PPPs and argues
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that segmentation of the Indian health care system cannot be done purely on the basis of the
organisational incorporation (i.e. profit or a trust). Hence even for charitable and trust hospitals,
generating surplus becomes critical for sustainability.
The authors touch upon two points: the quality of private sector and the perceptions of patients.
They argue that public sector inefficiency is responsible for the growth of the private sector,
and this has been compounded by the neoliberal reforms of the World Bank and other foreign
agencies. Hence the government has been forced to reduce public expenditure on health care.
The removal of price controls and state subsidies along with the demands of a growing and
more informed middle and upper middle class has further led to market segmentation for
tertiary health care.
Through a review of secondary literature, the paper goes on to focus on policy changes that have
led to proliferation of private companies in health care, and changing consumer perceptions
about the private sector. The paper also talks about government schemes targeted at the poor
for ensuring access to health care, but does not critique any of these.
Within the section on consumer perceptions, the authors argue that it is not the quality of care
that has led to increased usage of private health care facilities but rather the lack of trust in the
public sector. Public hospitals have not been utilised because of issues such as long waiting
time, lack of trust in doctors, and behaviour of staff and hygiene. Factors such as affordability,
quality and availability play a crucial role in deciding the type of facility being accessed.
In conclusion the authors reiterate that private sector health care is not only the way forward,
but projects it as essential for the guarantee of quality. They also mention the importance of
standardisation in a fragmented delivery system.
The not-for-profit sector in medical care
By Madhurima Nundy, Centre of Social Medicine and Community Health. Section 11,
Financing and Delivery of Health Care Services in India.
This article attempts to understand the characteristics of non-profit organisations and their
role in the delivery of curative health care services in India. Since there is no clear definition as
to what precisely constitutes a not-for-profit entity, the article uses the definition given by the
Planning Commission. According to the Planning Commission, a not-for-profit organisation
is a legal entity, registered within specified acts, such as The Societies Registration Act, Section
25 of the Companies Act or the Charitable and Religious Trusts Act 1930. Both Trusts and
Societies are exempt from income tax.
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The article is based on a study conducted by reviewing available literature and compiling and
analysing data from questionnaires (sent by not-profit entities providing health care). The
survey indicated that out of the 86 responses received via the questionnaire, 30 per cent were
dispensaries and the rest were hospitals. Out of all the hospitals, 43 per cent were in rural areas.
The article examines the response of the State to the role of voluntary organisations and the
existing models of partnership between them.
According to an estimate by the Independent Commission on Health in India (VHAI), there
are more than 7000 NGOs working in the field of health care. Despite this, the only source
of information on the total number of hospitals and beds in the not-for-profit sector is the
Directory of Hospitals, last published in 1988. This makes it very difficult to analyse the present
situation since there have been major changes in the field of health care in the last 10-20
years.
The research on utilisation patterns stresses on ascertaining how a charitable institution is
defined. If we go by the legal registration, then it includes a wide range of hospitals that may
otherwise be perceived as profit private hospitals. The 42nd and 52nd rounds of the National
Sample Survey (NSS) show low utilisation of outpatient care, maybe because the availability
of charitable hospitals in rural area is negligible compared to private doctors who are more
commonly available. The 52nd round of the NSS further shows that for every 100 patients
treated in charitable institutions there are more patients from higher income groups, with the
poor accessing public health facilities for the sole purpose of hospitalisation.
The paper then goes on to outline the financing of not-for-profit organisations. With
multiple sources of funding being the common strategy for these institutions, the sources
range from foreign funding to user fees applicable to patients. The cost of care at not-forprofit hospitals tends to be lower than private and public hospitals. Further, a study of two
charitable hospitals and one non-profit hospital in Delhi shows that common procedures are
cheaper at these hospitals than at private hospitals. Strategies such as using part time medical
staff, purchasing essential drugs from local non-profit organisations, and rationalisation of
health care, hence lessening overuse of technology and over-prescribing have led to substantial
cost savings.
The paper goes on to identify sustainability and competition as the two challenges faced by the
not-for-profit health sector. Also, the trends towards corporatisation of trust hospitals has led
to lack of transparency, which in turn makes it difficult to determine whether the hospital is
adhering to the conditions of cross-subsidisation such as free treatment.
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Finally, the paper emphasizes the importance of involving not-for-profit institutions in
fulfilling the call for expansion of health coverage (as stated in the National Health Policy
2002). This can be done by not only providing support and engagement in the implementation
and planning of the National Health Programmes, but also in various health and development
activities for the provision of comprehensive primary healthcare.
Recommendations and effective strategies towards addressing healthcare for all
Critical issues in regulatory provisions for private medical sector
By Anant Phadke (This article is based on discussions across various meetings of representatives
of organisations in Mumbai & Pune -- CEHAT, Association of Medical Consultants,
Mumbai,, Forum for Medical Ethics, ACASH, Health Committee Lokvidnyan Saanghatana
Pune, WACHA, Women’s Centre. In a way it reflects the consensus amongst these organisations
as it emerged during these meetings.)
This paper offers recommendations for regulation of the private sector. These recommendations
are the outcome of debates following the Bombay Nursing Home Registration Act (BNHRA,
1949), but are not specific to Maharashtra.
The paper stipulates that while self-regulation might be an ideal system, it is not feasible in
the current scenario. It talks in favour of state regulation, with the involvement of different
stakeholders who can participate in framing provisions, execution and monitoring, as in the
case of Maharashtra.
On the basis of the recommendations of Dr. Sunil Nandaraj, the paper talks about the
involvement of the stake holders in the regulatory process. It also includes a list of possible
stakeholders. As per the recommendations, the Clinical Establishment Board should be the
highest regulatory body and should set minimum standards. It also lists the limitations of the
proposed regulatory body.
The paper advocates unnecessary harassment of doctors by reducing administrative work,
mechanisms for which are outlined in detail. It asks for a single window system for registration
under different acts with a view to facilitate registration. The registration fees should be
minimal, (as according to a High Court verdict), and there should be an additional service fee
for providing regulatory services. The paper also recommends that there should be a penalty for
non-registration.
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With regards to obligations towards patients, the paper recommends that the hospitals must
provide life-saving first aid to all patients who need it. This includes medico-legal cases such
as an accident, criminal assault and burns cases. The nursing staff must also be trained to
administer life-saving first aid, and any other essential duties they might have to perform in
emergency cases. Further, the cooperation of all private clinics in implementing the National
Health Programme should be mandatory. It also outlines guidelines and obligations towards
HIV positive patients, through a standard orientation course aimed to combat discrimination
and standardise procedures. Such trainings could be funded either by the State, or privately by
the establishment.
The paper has specific recommendations for regulatory mechanisms, which can be implemented
at State level. The recommendations are based on a collaborative effort between different
stakeholders, such as medical professionals, the government, consumer activists and policy
makers.
Mapping the regulatory architecture for health care provision in LMIC mixed health
systems- A research tool and pilot studies in two Indian states
By the Public Health Foundation of India (PHFI), 2011 Research Team - Dr. Kabir Sheikh,
Prasanna Saligram, Lakshmi E. Prasad
This paper describes mixed health care systems in low and middle income countries (LMIC)
and proposes a methodology to asses them and identify gaps in them. The study is divided
into three parts: an introduction to mixed health care systems in LMIC, problems of health
care provisions necessitating regulations, and a literature review of regulatory approaches
to health care in LMIC, a policy research tool to map and identify gaps in the design and
implementation of regulatory policy, The report includes two pilot studies in Madhya Pradesh
and Delhi, India, which demonstrate the use of the research tool, and finally an assessment of
the methodology proposed in the paper.
The paper cites examples from LMIC in South and South-East Asia, Central America,
Central Asia and Africa to map various types of regulatory mechanisms such as direct
regulation, licensing and registration, market based regulations, voluntary accreditation,
educational bonds, pay for performance, results-based financing, contracting, co-production
and health insurance. It then analyses each one of these and identifies gaps in their design
and implementation.
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The research tool is based on ‘systems thinking’, which stresses upon mapping the system
through which regulatory mechanisms are implemented. It is exploratory and diagnostic
in nature, as opposed to an evaluation research. It provides a framework (as exhibited
via pilot studies in two states of India) for mapping laws and policies pertaining to the
prevailing regulatory architecture. It also helps to identify gaps in policy design and
implementation of regulatory policies such as cost and quality of care, conduct of providers
and accessibility to care.
The limitations of the research tool include the inability to gather complete and comprehensive
information due to inaccessibility to informants and information. Further, while the tool works
at provincial and state levels, it cannot be utilised in its current form to analyse lower levels
of functioning. The link between state and national regulatory mechanisms is also a source of
ambiguity.
In spite of the above, the research tool and the corresponding information can act as an extremely
useful mechanism to design, strengthen, compare and assess gaps in design and implementation
of regulatory mechanisms for mixed health systems. It can moreover be used by policy makers
and researchers at provincial, national and international levels, hence bridging a critical gap
between public and private health systems.
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Annexure 2: The Delhi Health Secretariat (DHS) and
nursing home cell
http://delhigovt.nic.in/dept/health/dhs1.asp
In Delhi, health care facilities are being provided by various Government & Non-Government
Organizations. Directorate of Health Services (DHS) Government of NCT of Delhi is
the major agency committed to delivery of health care; It co-ordinates with other Govt. &
Non-Government organizations for the improvement of the health of the citizens of Delhi.
The Directorate also co-ordinates the implementation of various National and State Health
Programmes.
The DHS is providing health care facilities at primary and secondary level to the citizens of
Delhi through the (spread all over Delhi), Dispensaries & Health Centres, Hospitals, School
Health Clinics and Mobile Health Clinics. Health care delivery outlets are being added to the
existing service depending on demand and subject to the availability of resources.
This Directorate regulates the health services being provided by Registered Private Nursing
Homes. The registration of the Nursing Homes is done subject to the fulfilment of prerequisite
of Delhi Nursing Home Registration Act and renewed on yearly basis.
Regular information is to be obtained from various Hospitals, Dispensaries and offices outlets
under the DHS, which are compiled and analyzed. On the basis of this data and its analysis,
the evaluation of various schemes is to be done and necessary corrective measures if needed
are taken. This Directorate has to also also collect information regularly from other agencies
on communicable disease and others public health importance for implementing public health
measures for prevention and control as and when required.
The Nursing home cell was established in the DHS with a view to register the private
nursing homes and hospitals as per Delhi Nursing Home Registration Act 1953 and
rules made here-under. The principal activity of the cell is to carry out registration and
renewal of registration every third year. The applications are invited and processed;
Inspections are carried out to see that the nursing homes maintain the standards and norms
as per the Rules in the said Act. Efforts are made to prevent the functioning of the nursing
homes providing inferior quality and suggesting appropriate action against the unregistered
nursing homes.
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Beside this, the Nursing Home Cell also has been entrusted with the following functions: -
• Monitoring of Free treatment to the eligible patients of EWS category provided by 40
identified Private Hospitals who had been given land on concessional rate by Land Alloting
Agencies.
• Updating the free bed availability on a daily basis.
• Implementation of Hon’ble High Court of Delhi judgement dated 22.3.2007 in WP (C)
No.2866/2002.
• Inspections by the Monitoring Committee of at least 4-5 hospitals in a month.
• Complaints regarding refusal/denial/unsatisfactory free treatment to the eligible patients of
EWS category.
• Compilation of Monthly and Quarterly Report in r/o free treatment.
• Compilation of referral cases from identified Govt. Hospitals to 40 identified private
Hospitals.
• Creation of Web Page for updating the data on availability of free beds in these hospitals.
• Monitoring of Free beds and treatment in Apollo Hospital in pursuance of the judgement
of Delhi High Court vide WP (C ) No. 5410/1997 and as per the direction of Hon’ble
Supreme Court SLP No. 29482/2009 dated 30.11.2009.
• An additional Nodal Officer of Govt. of NCT of Delhi is stationed at Apollo Hospital from
10.00 AM to 4.00 PM to facilitate the treatment of Eligible Patient as per norms.
• Compilation of quarterly report.
• Audit of Apollo Hospital on half yearly basis by the Officers from the office of Comptroller
& Auditor General of Accounts.
• Various Court Cases/ Matters pertaining to Pvt. Nursing Homes.
• Complaints against Private Nursing Homes in Delhi. Compilation of information about the
Foreign National Patients undergoing treatment in Delhi.
• Sending recommendation to Excise Department for procurement of Narcotic Drugs by
Private Nursing Homes.
• Replies pertaining to RTI/Parliament/Assembly Questions.
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Annexure 3: High Court Guidelines
Guidelines for provision of free treatment facilities to patients of EWS category in private
hospitals in pursuance of directions issued by the Hon’ble High Court of Delhi in WP (C) no
2866/2002 in the matter of Social Jurist Vs GNCT Delhi
Background
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.
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 AS 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.
A lawyers Group filed a PIL writ petition being WP(C) No. 2866/2002 praying that conditions
of allotment of land to hospitals, particularly in regard to free treatment to the poor and indigent
persons are not being complied with. During the course of hearing of the said case the interim
directions passed by the Hon’ble High Court from time to time were implemented.
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Present Situation
Now in the aforementioned PIL, the Hon’ble High Court of Delhi has pronounced the final
judgment on 22.3.2007 and has taken into consideration the acceptance of report of Justice
Qureshi Committee with regard to the recommendations that 10% of total beds in the IPD
should be free for poor and 25% of patients in the OPD should obtain free treatment. The court
had considered the details of 20 such private hospital allottes during the hearings and directed
that all other hospitals identically situated shall strictly comply with the term of free treatment
to indigent /poor persons of Delhi i.e 25% OPD and 10% IPD patients completely free of
charges in all respects.
The court had earlier also observed that only poorer and poorer categories of patients go to
general public hospitals ,and they do not go to the private hospitals due to which the earmarked
beds in the private hospitals remain unoccupied. Therefore the govt hospitals should refer the
poor patients to the private hospitals where the requisite facilities are available.
In pursuance of the said order and in order to implement the directions passed in the
aforesaid case , the Pr. Secretary (H) GNCT Delhi called a meeting on 3.4.2007 with
Additional Secretary Health, Medical Superintendents of Large Govt. Hospitals of
differemnt agencies in Delhi . , Director Of Health Services, Delhi Govt , the concerned
officers of DHS dealing with the issues pertaining to private hospitals, and the Govt
Counsel Ms Zubeda Begum who represented the case on behalf of Delhi Govt. and the
petitioner Sh Ashok Aggarwal advocate of Delhi High Court. After detailed discussions in
the said meeting and the decision taken in the previous meetings convened in pursuance of
the interim directions passed by the court from time to time , it was decided that guidelines
should be issued to all private hospitals and govt hospitals in the light of the directions
passed in the aforesaid court matter in particular to the referral of poor /EWS patients
from Govt Hospitals to private hospitals. The details of the Judgment are available on
Delhi High Court website and have also been made available at Delhi Govt website at
www.delhigov.nic.in, may please be referred to if required.
In the background of above, the following guidelines are being issued for all the private hospitals
& govt hospitals functioning under the control of Central Govt, Delhi Govt, MCD, NDMC,
AIIMS, IHBAS etc which are available for general population and Railways, ESI, Cantt.
Hospitals etc.where besides their employees covered under their scheme, in case patients of
general population are also being extended facilities by them and they find the eligible persons
needing treatment in private hospitals.
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The guidelines framed in this regard are as below:
(A) For Private Hospitals
1. The conditions of free patient treatment shall be 25% of patients for OPD and 10% of
beds in the IPD for free treatment. This percentage of patients will not be liable to pay
any expenses in the hospital for admission, bed, medication, treatment, surgery facility,
nursing facility, consumables and non consumables etc.
2. The hospital charging any money shall be liable for action under the law and it would be
treated as violation of the orders of the court. The Director/M.S./member of the trust or
the society running the hospital shall be personally liable in the event of breach /default.
3. 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.
4. The hospital shall also maintain details of reference from govt hospital and the reports
submitted by the private hospital to govt hospital in the form of feedback of treatment
provided to the patient.
5. The records so maintained shall have to be produced to the Inspection team consisting of
Sh Ashok Aggarwal . Ms Maninder Acharya and the MS of RML Hospital, as and when
required for its verification and quarterly details should have to be sent to DHS after
expiry of three months within first week of fourth month.
6. The details shall have also to be made available to the monitoring committee constituted
by Delhi Govt also as and when required.
7. Every private hospital shall have to establish a referral centre/desk functional round
the clock, where the patients referred from Govt hospital would be able to report. The
referral desk shall be managed by a nodal responsible person whose name, telephone,
e-mail address and fax number is to be sent to the Govt Hospitals, DHS and should
be prominently displayed. The hospital shall also display the facilities available at the
hospital and the daily position of availability of free beds quota, so that the patients
coming directly to the hospital would know the position in advance.
8. In case of any change in the nodal person , the same should also be intimated within 24
hours to Govt Hospitals and DHS, the list of which shall be provided shortly.
9. The establishment of referral desk should be ensured within two weeks of pronouncement
of judgment and the Director of the hospital shall be personally liable in the event of
default.
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10. The hospital shall send daily information of availability of free beds to this directorate
twice a day between 9 AM -9.30 AM and at 5 PM -5.30 PM on all working days. And
also to the concerned nearby govt. hospital to which the private hospital is proposed to
be linked for general and for specialized purposes. The details of geographical linkage,
the telephone numbers/fax numbers and the name of the nodal officer of govt hospitals
shall be intimated shortly. In case no information is received with in the stipulate time
from the private hospitals then it shall be presumed that the beds are available in private
hospitals and the patient referred shall be accommodated.
11. The patient referred by Govt. hospitals/or directly reporting to the private hospital shall
be admitted if required, and treat him totally free. As per court’s directions, these patients
shall not incur any expenditure for their entire treatment in the hospital.
12. After the discharge of such patients provided with the treatment, the hospital shall submit
a report to the referring hospital with a copy to the DHS indicating therein the complete
details of treatment provided and the expenditure incurred thereon.
13. The criteria of providing free treatment would be such person who has no income or has
income below Rs 5000/-per month for the time being.
14. Besides admission of the patient referred from Govt Hospitals, the hospital shall also
provide OPD/IPD/Casualty treatment free to the patients directly reporting to the
private hospitals and would inform the nearest govt hospital and to the DHS within two
days of his/her admission.
15. The patients admitted in any other manner, not covered by the above guidelines shall not
be entitled for claiming compliance of the conditions imposed.
16. Those hospitals which have the land allotted from the govt on concessional rates and
have not yet completed the construction after taking possession shall be liable for not
complying with the conditions and might be asked to repay to the authorities by a special
committee constituted for this purpose.
17. The special committee referred above consists of Chief Secretary GNCT Delhi, The
Finance Secretary GNCT Delhi and DHS GNCT Delhi and Medical superintendent of
the govt hospital of that area, where the private hospital is situated and the said committee
would work out the details of recovery of unwarranted profits.
18. As per directions of the court, all the 20 hospitals stated in the judgment and/or all other
hospitals identically situated shall strictly comply with the term of free patient treatment
to indigent/poor persons.
19. No benefits shall be applicable to such hospitals that had provided free treatment fully or
partially in the past with the higher conditions as applicable for that time with regard to
any set off of the expenses or otherwise on that ground.
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20. The above revised conditions i.e. 25% free OPD patients and 10% free IPD beds and
treatment on these beds shall be prospective from the date of pronouncement of judgment
in question.
21. Such hospitals which have not complied with the conditions at all and persist with the
default, for them the conditions shall operate from the date their hospitals have become
functional.
22. An Inspection Committee now constituted by the High Court consisting of Ms Maninder
Acharya, advocate, Mr Ashok Aggarwal Advocates of Delhi High Court and Medical
Superintendent of RML Hospital, would also inspect any of the private hospitals. The
inspection committee shall, have to be entertained and would be facilitated to carry out
physical inspection of the hospital where the free treatment has been provided and would
also be shown the records of having provided free treatment. The said committee has been
given the liberty to revive the petition or for issuance of any directions from the court
and wherever necessary for action against defaulters under the provision of Contempt of
Court act read with Article 215 of the Constitution of India.
(B) For Govt Hospitals
1. 2. 3. 4. 5. 6. Every Govt. hospital shall create a special referral centre within two weeks of
pronouncement of the said judgment, which shall be part of the casualty as well as the
OPD. The Government hospitals shall intimate the establishment of the referral centre
within one week of its establishment to DHS.
The referral centre shall have to be managed by a senior officer round the clock and shall
have a dedicated phone no, the fax and also the e-mail facility.
The patients having no income or income below Rs 5000/-per month shall be eligible for
getting free treatment at the private hospitals. (now it has been modified to Rs.4000/-per
family per month by the special committee vide order dated 2.11.2007)
For such eligible poor patients reporting to the casualty who needed immediate care and
if it is found that the particular facilities are not available or the beds are not available and
the patient need urgent care , such patients may be referred to the private hospitals where
the requisite facilities are available.
Before referral, the patient shall have to be provided necessary treatment, and only after
stabilization of his/her condition, he/she may be referred with proper life support, if
required.
In case a decision has been taken by the treating doctor of the concerned department and
the approval of the Professor/Senior doctor on duty to refer the particular poor patient to
private hospital where the requisite facilities are available, has been obtained, the matter
shall be referred to the nodal officer managing the special referral centre.
82
7. 8. 9. The nodal officer shall ensure that the Proforma I for referral in triplicate (i.e Proforma
I-A to be retained by the referring hospital, , I-B to be handed over to the patient, and
I-C to be provided to DHS) are filled properly and the Proforma II also has been filled
by the eligible patient or by his/her nearest relative and the Discharge card containing the
brief history of the treatment provided has been enclosed.
A Nodal officer shall also be designated at DHS who would be obtaining the details of
beds available at the private hospitals twice a day, once in the morning between 9-9.30
AM and then in the evening between 5-5.30 PM on all working days and shall transmit
the same to all the nodal officers appointed at govt hospitals. The private hospitals shall
also be asked to send the availability of free beds to the govt hospitals directly in order to
streamline the procedure in all the days.
The nodal officer before finally shifting the patient shall make liaison with the nodal
person at the concerned private hospital where such facilities are available regarding
confirmation of availability of beds, and then shift the patient in the hospital ambulance.
He would ensure that the proforma for referral and other enclosures are handed over to
the patient, so as to cause minimum inconvenience to the patient/relative.
10. In case of a patient directly being admitted by the private hospital through its casualty,
the private hospital shall be bound to intimate the DHS and the nearest govt hospital
within two days of his/her admission. The nodal officer of the said govt hospital or any
authorized officer of the concerned specialty for which the patient has been admitted
shall be under obligation to visit the private hospital and verify the fact in regard to the
genuineness of poverty of the person, the treatment provided to him, and the cost likely
to be incurred by the private hospital. He /She shall make record of his/her visit and send
to DHS.
Note:
If no information is received everyday in stipulated time the unrebuttal presumption will be that
the beds are available for referred patients and the private hospital authority will be bound to
receive and treat the patient irrespective of the vacancy.
In case the same is not done serious consequences shall follow including contempt of order and
judgment dated 22/3/2007 in WP(C ) No. 2866/2002.
83
Annexure 3A: UNDERTAKING AS IN GUIDELINES
I_______________________________
S/oD/oW/oSh.Smt.
______________________
permanent
R/o
________________________________________________________
and presently residing at _______________ aged about _______ years do hereby solemnly affirms
and declare that my monthly family income from all sources is less than Rs. 5000/-and the same may
be subjected to verification. (now it has been modified to Rs.4000/-per family per month by the special
committee vide order dated 2.11.2007)
I have been informed that I shall be provided treatment against free beds facility
at ______________________________ Hospital, which I understand is available to only for the under
privileged patients/poor patients. In case my above declaration is found to be false/or incorrect /
suppressed by me in order to get free treatment, I would be liable to pay the entire cost of treatment and
the Government/Hospital concerned would be at liberty to take legal/criminal action against me including
recovery proceedings.
I undertake to reimburse the amount spent on my treatment in case my declaration is found to be incorrect
or false.
________________________
Signature of Patient/Relative
Thumb Impression
Right Hand
Left Hand
(in case of female)
Name of Patient
Relative
(in case of Male)
VERIFICATION
Verified
at
Delhi
on
this
__________________
day
of
_______
20___,
that the contents are true and correct to my knowledge and nothing has been
concealed. I do hereby verify that the contents of the above declaration is true and correct to my knowledge.
It conceals nothing and no part thereof is false .
________________________
Signature of Patient/Relative
Thumb Impression
Right Hand
Left Hand
(in case of female)
Name of Patient
Relative
(in case of Male)
I would like to be treated in this very hospital with whatever facilities available here .
I am not willing to be treated at a private hospital or referred to a private hospital.
________________________
Signature of Patient/Relative
Thumb Impression
Right Hand
Left Hand
(in case of female)
(in case of Male)
84
Name of Patient
Relative
85
PROFORMA
Proforma I A
(to be retained by referring hospital alongwith proforma)
Name, age,
sex of patient
Father’s/
Husband’s
name
Permanent
and present
address with
tel. no. if any
Probable/
workable
diagnosis
Countersigned by HOD/ M.S.
Signature …………………………………...............................................
Name of the referring doctor …......................................………………..
Referral proforma must be sent alongwith a brief treatment resumes of the patient.
OPD/IPD
regn no.
DOA
(if admitted)
Deptt./
concerned
Enclosures
PROFORMA FOR REFERRAL OF ECONOMINCALLY WEAKER PATIENTS FROM GOVT. HOSPITALS TO
PVT. HOSPITALS AS PER DIRECTIONS IN PURSUANCE OF JUDGEMENT IN WP ( C) NO. 2866/2002 IN THE
MATTER OF SOCIAL JURIST VS. GNCTD.
Annexure 3B : PROFORMA AS IN GUIDELINES
86
PROFORMA
Proforma I B
(to be handed over to the patient alongwith proformsII)
Name, age,
sex of patient
Father’s/
Husband’s
name
Permanent
and present
address with
tel. no. if any
Probable/
workable
diagnosis
Countersigned by HOD/ M.S.
Signature …………………………………...............................................
Name of the referring doctor …......................................………………..
Referral proforma must be sent alongwith a brief treatment resumes of the patient.
OPD/IPD
regn no.
DOA
(if admitted)
Deptt./
concerned
Enclosures
PROFORMA FOR REFERRAL OF ECONOMINCALLY WEAKER PATIENTS FROM GOVT. HOSPITALS TO
PVT. HOSPITALS AS PER DIRECTIONS IN PURSUANCE OF JUDGEMENT IN WP ( C) NO. 2866/2002 IN THE
MATTER OF SOCIAL JURIST VS. GNCTD.
Annexure 3C: PROFORMA AS IN GUIDELINES
87
Proforma I C
(to be submitted to DHS, Govt. of Delhi along with proformsII)
PROFORMA
Name, age,
sex of patient
Father’s/
Husband’s
name
Permanent
and present
address with
tel. no. if any
Probable/
workable
diagnosis
Countersigned by HOD/ M.S.
Signature …………………………………...............................................
Name of the referring doctor …......................................………………..
Referral proforma must be sent alongwith a brief treatment resumes of the patient.
OPD/IPD
regn no.
DOA
(if admitted)
Deptt./
concerned
Enclosures
PROFORMA FOR REFERRAL OF ECONOMINCALLY WEAKER PATIENTS FROM GOVT. HOSPITALS TO PVT.
HOSPITALS AS PER DIRECTIONS IN PURSUANCE OF JUDGEMENT IN WP ( C) NO. 2866/2002 IN THE
MATTER OF SOCIAL JURIST VS. GNCTD.
Annexure 3D: PROFORMA AS IN GUIDELINES
Annexure 4: Comparison of the Delhi and Mumbai
Judgements
Source: Study of Charitable Hospitals: reviewing Options for Sustainable Partnerships
by Dr Utkarsh Shah, Dhaval Bhatt, supported by HOSMAC India Pvt Ltd and HOSMAC
Foundation
Particulars
Population to be served
Mumbai Interim Order
Free services to be provided to
individuals with income below Rs. 25,
000 per annum
Concessional treatment provided to
individuals with income below Rs 50,
000 per annum
Benefits to be provided
10% of the beds reserved for free
patients
10% of beds reserved concessional
patients
Delhi High Court Judgment
Free services provided to individuals
with income below Rs 5,000 per
month (an interim order, till the final
committee provides its inputs)
Free services to be provided to 10%
of In patient cases and 25% of out
patient cases
Terms of the benefits
The order states that beds be
reserved exclusively for the above
mentioned activities and can not be
utilised elsewhere
The order doesn’t make it mandatory
to reserve beds however would
required to provide the above
mentioned specific benefits
Definitions of ‘free’ and
‘concessional’ treatment
Free not to include cost of
consumables, medicines and non
routine investigations like MRI, CT
scan, etc which have to be borne
fully by the patient.
Free implies completely free
treatment inclusive of medicines,
consumables and everything required
during the treatment. Patient is not
expected to pay anything
‘Concessional’ includes 50% of the
bill, calculated based on the lowest
class rates
Funds to be created and
managed by
Indigent patients fund, with 2% of
gross billing of the hospital (not
including the bills of indigent patient
group) to be included and the
money to be used only for provided
charitable care to the weaker
sections of the society. The fund
is at the dispersal of the hospital
authorities.
88
‘Central corpus/pool’ to be created
by DGHS. This would be used for the
upliftment of health standards of the
poorer section of the society in Delhi.
However, no guidelines to creating a
fund at hospital level
Particulars
Monitoring and Evaluation
Mumbai Interim Order
‘Monitoring committee’ which will
evaluate the functioning of each
of the hospitals land meet at least
once a month. The committee is
also authorized to take corrective
action against the hospitals that are
defaulting
Delhi High Court Judgment
‘Special committee’ to examine
the records and make suggestions
to subsequent implementation of
the scheme. The committee would
conclude within 6 months of the
Charitable Hospitals.
‘Officer on Special Duty’ be
appointed to coordinate the activities
between the Charitable Hospitals
and government hospitals
Referrals
4-5 Charitable Hospitals to be
networked with one public hospital
A detailed process of referral cases
and its in terms of their treatment
Review authenticity of cases
Medical Social worker, would review
records and documents, with a
concerns over the fake documents
CMO/Head of department would
verify the genuineness of the case,
within 2 days of a referral or it
would be reviewed by the ‘Special
Referral Centres’ at all the Charitable
Hospitals
Responsibility for monitoring
Charity Commissioner to be
responsible for the monitoring and
evaluation
Director General of Health Services,
Delhi, responsible for the evaluation
of the services provided by the
Charitable Hospitals
89
Annexure 5: Policy Guidelines for Free Treatment
90
91
92
93
1952
1988
Unavailable
DH3
DH4
1954
DH2
DH1
Code
lishment
Year
of Estab-
Hospital
Multispecialty
Centre
Established as a
Charitable trust, now
a 100% subsidiary of
Fortis Healthcare
11
gency)
emer-
1 for
females,
3 for
male,
10 (6 for
Tie up between
Healthcare Chain and
a Memorial Foundation
to manage and operate
Research
9
Affiliated with International Healthcare
in 2001 (International
healthcare Chain)
Multispecialty
Yes
Yes
-
-
Charitable Private
Hospital of a Trust
Society
Multispecialty
68
Card
Medical
Bed
Capacity
BPL
Nature
Multispecialty
Research
and Educational
Institutes
Speciality/
Type of Hospital
AnnExure 6: Table of Findings
Yes
-
-
Yes
proof
income
Any
-
-
Yes
-
proof
Residence
-
Yes
-
Yes
Language
ance /
Appear-
Eligibility Criteria
Yes
Yes
Yes
Yes
Undertaking
Yes
Yes
-
-
Card
BPL
94
Unavailable
1995
DH7
DH8
1996
1980
DH6
DH9
2004
DH5
Super-specialty
Centre
Research
tional and
Educa-
Centre
Research
Private research
Institute and Hospital
Promoted by a Corporate.
Educational Institute
recognised by National
Board of Examinations
(NBE)
Government affiliated
research, Education
centre and Hospital.
In Collaboration
with Government of
Italy, United States of
America, as well as
International Educational Institutes
Super-speciality
tional and
Private Hospital
Educa-
Charitable Society
services
Super -speciality
hence
Centre
11
14
11
42
tinued
discon-
ongoing
struction
Con-
Research
Run by a Research
Foundation Foundation
and
Institute
Teaching
Super-speciality,
Multispecialty
-
Yes
Yes
-
Yes
Yes
Yes
-
Yes
Yes
Yes
Yes
Yes
Yes
Yes
-
Yes
Yes
AnnExure 7: Undertaking from DH3 Hospital
95
96
97
98
AnnExure 8: Pamphlet from DH1 Hospital
Note: The hospital mentioned that income level in the pamphlet will soon be changed to Rs. 6084/-
99
AnnExure 9: Referral table for hospitals in the study
S.No
Code
1.
DH1
Govt Hospital
Purpose
1.
DDU Hospital
For (a) for general purposes and (b)
2.
G.B. Pant Hospital
3.
GTB Hospital
for Cardiology,
4.
Swami Dayanand Hospital
5.
Kalawati and
6.
Sucheta
7.
Kriplani
Gastroenterology, GI
8.
Hospital
Surgery, Neurology, Neurosurgery,
9.
Baba Saheb Ambedkar Hospital
Nephrology,
Cardio Thoracic Vascular Surgery,
Plastic Surgery,
Hepatology, Psychiatry,
10. Chacha Nehru Hospital
Urology & Rehabilitation, Respiratory
11. Lal Bahadur Shastri Hospital
Medicine,
12. Dr. N.C Joshi Memorial Hospital
Oncology
13. Acharya Shri Bhikshu Hospital
(Medical, Surgical & Radiation
14. Sardar Vallabh Bhai Patel Hospital
Oncology) etc.
15. Bhagvan Mahavir Hospital
16. Institute of Human Behaviour and allied sciences (IBHAS)
17. Rao Tula ram Memorial Hospital
18. Civil Hospital
2.
DH2
1.
Lok Nayak Hospital
For general purposes and Cardiology,
2.
GTB Hospital
Neurology,
3.
RML Hospital
Neurosurgery, Urology, Nephrology,
4.
Kalawati and Sucheta Kriplani Hospital,
Respiratory
5.
Baba Saheb Ambedkar Hospital
Medicine etc.
6.
Susruta Trauma Centre
7.
Sanjay Gandhi Memorial
8.
Lal Bahadur Shastri Hospital
9.
Dr. N C Joshi Memorial
10. Hospital, Acharya Shri Bhikshu Hospital
11. Sardar Vallabh Bhai Patel Hospital,
12. Guru Govind Singh Hospital
13. Attar Sain Jain Hospital
14. Aruna Asaf Ali Hospital
15. Kasturba Hospital
16.
Civil Hospital
100
S.No
Code
3.
DH3
Govt Hospital
1.
Lok Nayak Hospital
2.
Swami Dayanand Hospital
3.
Susruta Trauma Centre
4.
Safdarjung Hospital
5.
Chacha Nehru Hospital
6.
Lal Bahadur Shastri Hospital
7.
Dr. Hedgewar Arogya Sansthan
8.
Jag Parvesh Hospital
9.
Rajiv Gandhi Superspeciality Hospital
Purpose
For General purposes
10. Institue of Human
11. Behaviour and allied sciences
(IHBAS)
12. Maharshi Balmimki Hospital
13. Delhi State Cancer Institute
14. Aruna Asaf Ali Hospital
15. Kasturba Hospital
16. Civil Hospital
4.
DH45
1.
All India Institute of Medical Sciences (AIIMS)
For general purposes and
2.
GTB Hospital
3.
RML Hospital
(b) for Cardiology
4.
Kalawati and
5.
Sucheta
6.
Kriplani
7.
Hospital
Respiratory
8.
Safdarjung
Medicine,
9.
Hospital
(Non- invasive), Nephrology, Urology,
Neurology,
Neuro Surgery, Plastic Surgery and
10. Institute of Liver and Billiary Diseases,
11. Pt. Madam Mohan Malviya
12. Hospital Dr. Hedgewar Arogya Sansthan
13. Guru Govind Singh Hospital
5.
DH5
1.
All India Institute of Medical Sciences (AIIMS)
(a) For general Purposes and (b) for
2.
RML Hospital
Oncology
3.
Susruta Trauma Centre
(Medical Oncology and Surgical
4.
Chacha Nehru Hospital
Oncology
5.
Lok Nayak Hospital
excluding Radiation Oncology), etc.
6.
Guru Govind Singh Hospital
7.
Kasturba Hospital
8.
Safdarjung Hospital
101
S.No
Code
Govt Hospital
9.
Purpose
Susruta Trauma Centre
10. Institute of Liver and Billiary Diseases
11. BJRM Hospital
12. Pt. Madam Mohan Malviya Hospital
13. Acharya Shri Bhikshu Hospital
14. Rao Tula Ram Memorial Hospital
15. Maharshi Balmimki Hospital
16. Kasturba Hospital
6.
DH6
1.
All India Institute of
2.
Medical Sciences (AIIMS)
3.
Guru Nanak Eye Hospital
4.
Lok Nayak Hospital
5.
Safdarjung Hospital
6.
RML Hospital
7.
Kalawati and Sucheta Kriplani Hospital
8.
Susruta Trauma Centre
9.
Chacha Nehru Hospital
For Opthamolagy
10. Guru Nanak Eye Hospital
11. Attar Sain Jain Hospital
7.
DH7
1.
DDU Hospital
For General purpose and (b) for
2.
Hindu Rao Hospital
Orthopaedics
3.
Kalawati and Sucheta Kriplani
, Joint Replacement, Spinal Surgery,
4.
Hospital
Rehabilitation
5.
Susruta Trauma Centre
etc.
6.
Satyawadi Raja Harish Chand
7.
Hospital
8.
All India Institute of Medical
9.
Sciences (AIIMS)
10. BJRM Hospital
11. Guru Govind Singh Hospital
12. Safdarjung Hospital
13. RML Hospital
14. Civil Hospital
102
S.No
Code
8.
DH8
Govt Hospital
Purpose
1.
All India Institute of Medical
For Neurosurgery, Neurology,
2.
Sciences (AIIMS)
3.
Safdarjung Hospital
Orthopaedic & Spinal Surgery,
4.
RML Hospital
5.
Kalawati and Sucheta
6.
Kriplani Hospital
7.
Susruta Trauma Centre
8.
Institute of Liver and Billiary Diseases
9.
Pt. Madam Mohan Malviya
Rehabilitation etc
10. Hospital
11. Dr. Hedgewar Arogya
12. Sansthan
13. Guru Govind Singh Hospital
9.
DH9
1.
All India Institute of
For Gastroenterology,
2.
Medical Sciences (AIIMS)
3.
Safdarjung Hospital
GI Surgery, Hepatology,
4.
G.B. Pant Hospital,
5.
Kalawati and Sucheta
6.
Kriplani Hospital
7.
Institute of Liver and Billiary Diseases
Nephrology, Urology etc
103
104
2
TOTAL
NO. OF
BEDS
3
4
TOTAL
5
PAID
6
7
8
9
10
FREE
IPD ATTENDANT
FREE %AGE TOTAL PAID
TOTAL OPD ATTENDANT
NO. OF
FREE
BEDS
11
%AGE
12


14
NO. OF
PATIENT
REFERRED
BY GOVT.
HOSPITALS

15
OBSERVATI REMARKS
ON GIVEN
BY
HOSPITAL, IF
ANY

13
NO. OF IN- NO. OF IN
PATEINT PATEINTS
DAYS
( FREE)
(PAID)

S.NO.





AnnExure 10: Quarterly report format
16
AnnExure 11: Newspaper clippings
105