Thursday, October 6, 2022

Private Cannot be Public

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Health care at well-equipped, corporatized hospitals is strictly the prerogative of those who can afford it. The poor are not encouraged to seek treatment at such facilities

By Ajith Pillai

How difficult is it for patients to get admission in a private hospital in the event of an emergency? If they have the financial muscle, then it couldn’t be easier. If not, then it could turn out to be much more than an uphill task. That is the bald truth as it stands. Money is the bottom line that inspires almost all swank hospitals. It is the language that their managements understand.

Of course, if you formally put the question to any private hospital. it will point out that the commitment to serve any patient in an emergency, whatever his/her financial situation is its paramount priority and in keeping with its altruistic philosophy. It will however also be underlined that there is no legal obligation for private sector hospitals to treat economically challenged patients although there have been some court orders to the contrary.

For example, in Delhi, a high court ruling of March 2007 set down that 10 percent beds and 25 percent treatment in outpatient departments (OPDs) should be kept aside for indigent/poor patients. The guidelines drawn up following the court ruling made it explicit that poor patients should not be charged for “admission, bed, medication, treatment, surgery facility, nursing facility, consumables and non-consumables etc.” But this has been challenged on various counts, leaving the question of whether private hospitals are obliged to offer their services to the poor, open ended.

A view of RML Hospital as dengue desese incries in the capital on Wednesday-
 Patients outside a government hospital. It sometimes takes days for a bed to be free

But despite that, since the guidelines are in place one would think that it would operate in any public emergency, like the recent outbreak of dengue in the national capital. That it did not is a clear indication that the laws are being brazenly flouted.
What brought the issue of private hospitals and their callous response to public emergencies was the death of a seven-year-old boy who was refused admission by five private hospitals. He finally succumbed to dengue, more due to medical apathy and negligence. His distraught parents later committed suicide by jumping off the fourth floor of the building they lived in.

The incident sparked off reactions at several levels. The Delhi government ordered a ministerial inquiry. Chief Minister Arvind Kejriwal told the media that he was considering calling a special session of the assembly to pass a law that would hand severe punishments to private hospitals that turn away patients. On September 21, a division bench of the Delhi High Court, while admitting a PIL, reportedly observed that “all hospitals—both private and public—should be directed not to refuse any patients on account of monetary conditions or any other reason and in case of misconduct of hospitals or refusal to admit patients, heavy penalty must be imposed.”

So, despite the recent dengue controversy and bad press, one can safely conclude from the court’s observations that the problem of private hospitals and their response to public emergencies and treatment of poor patients still needs to be adequately addressed.

Last year I was down with dengue and following a respiratory complication was rushed to a private hospital. But before being allowed entry into the hallowed and antiseptic portals of its ICU a deposit of Rs75,000 was demanded. It was unstated but was made amply clear that the money was a prerequisite for any treatment to kick in. Luckily, plastic money came to the rescue late in the night. Two days of intensive care and a battery of tests (many of them a doctor friend later told me were uncalled for) saw me out of the woods.

My insistence that I be discharged at the earliest obviously was persuasive and convincing enough but I was, nevertheless, left with a bill that broke the Rs 1 lakh barrier. One entry in it under the head “consultation fee” was a bit of a bother though. A family friend, who works in the same hospital, had called on me during visiting hours to enquire if I needed books or magazines to cheer me up. His was purely a social call but he was listed among the doctors I had apparently consulted and would have to pay for.
Very few would go to court over such a small lapse. Most patients like me are thankful that they are alive and well to bicker over details. But I am told that milking money from patients and their relatives is the name of the game in several private hospitals. And why should anyone expect more from them? In the main, many of these institutions, whatever their pretensions, are healing shops where profit margins matter. Any bed thus allotted to a free patient would reflect poorly in the balance books. This explains why there is great reluctance to admit anyone under the 10 percent free quota.

Most doctors do not like to talk about the inner workings of private concerns that pay members of the profession handsomely. But there have been forthright voices. Dr Samiran Nundy is a noted gastrointestinal surgeon and medical academic. He articulated in an interview to The Times of India last year the predicament that doctors find themselves in when they sign up with the corporate healthcare sector:

“If you are paid more than you think you are worth, you are in big trouble. Working in the corporate sector is a nightmare. They offer crores of rupees as salary. But the small print in the contract says the salary will be reviewed in six months to see if the doctor is able to bring in the money expected. I have heard of people whose salaries went down by 30 per cent after such reviews and some were even forced to leave because they could not deliver the profits expected. They have financial experts who ask doctors to justify the salaries they are being paid, especially if the revenue they have generated for the hospital from investigations and operations falls short of the targets set for them. There are even places where one-third of the doctor’s salary is taken away for marketing and they are forced to give talks to GPs and canvass them to send patients.”

Doctor friends have told me about how most private establishments formulate a bed-to-patient ratio. This is a ballpark calculation on when occupancy of a bed becomes profitable. Very often patients are kept in ICUs long after they can be shifted out so that the bed that they are occupying yields returns. They are apparently kept in the “recovering yet serious” category. Similarly, patients are kept on life support systems endlessly when chances of their survival are in medical terms, zero. What drives such unprofessional decisions are cold financial calculations that have to be adhered to by the doctors.
Dr Nundy was candid when he said in his interview that most doctors have to dance to the tune of the managements. “It is all very well for an established practitioner like me to pontificate. I am established and I was privileged as I came to the private sector after 21 years in AIIMS. What about young doctors who are starting out? What can they do? The corporate hospitals are the dominant employers. This is happening in top hospitals. No doctor likes this, but they have no choice.”

Last year, when David Berger, an Australian doctor, wrote in the British Medical Journal (BMJ) about his experience of working in a private hospital in India and the rampant corruption that plagues the healthcare system in this country, it drew two extreme reactions. One was that there were of course a few bad eggs but in the main all was well. The other was that large-scale exploitation of patients was a reality which the government as well doctors must accept.
Some of Dr Berger’s observations were quite revealing. He pointed out that the Indian healthcare system was an inequitable one and amongst the most privatised in the world. He says this was thanks to the World Bank backed policy introduced in the 1990s which reduced public financing for healthcare so
as to encourage the private sector.

As a result, he noted, you now have a situation where latest procedures and equipment were available for the rich while the overworked government health system was what serves the vast majority.

That government-run public hospitals are poorly equipped, unhygienic and over-crowded has been over the years the focus of much media attention. Nothing much has been done to improve the conditions in such establishments which are the only ones the poor can turn to. The government inaction is therefore inexplicable and needs to be corrected.

But what of private hospitals? It is time that the healing shops are recognized for what they are. Strong regulation and reservation of beds for the underclass can only work if there is persistent audit and monitoring. In the absence of that, most poor patients who are rushed in an emergency to a swank five star hospital will be turned back unless they have political or bureaucratic backing. That is the reality. Rather than depend on the private sector it is time that the government strengthens public health care. As for dengue it would require a civic clean-up drive to contain mosquitoes more than medical intervention alone. But then dengue is not the only health problem that confronts us.

I will conclude with this shocking but rather odd and revealing incident. A few years ago a young photographer colleague was troubled by a burning sensation in the chest. His family panicked and rushed him to a private hospital in East Delhi where he was kept under observation. A surgery, he was told, may have to be conducted to rectify a cardiac condition he was possibly suffering from. Luckily, he had the presence of mind to seek a second opinion from a government doctor who prescribed him an antacid tablet for his chest pain!

I am happy to report that he is alive and well and so far has had no reason to consult a cardiologist.

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