Free Treatment in the Private Sector: Myth or Reality?

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 B-45, 2nd Floor, Main Road Shivalik, Malviya Nagar New Delhi- 110017 Ph. No.: 011-65637632, 26692730 E-mail: sama.womenshealth@gmail.com Cover : Dhananjay Printed by: Impulsive Creations 8455, Sector C, Pocket8, Vasant Kunj New Delhi-110070

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) Centre s Exp as % of GDP Total Exp (Centre+ States) as % of GDP 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 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 Minister, Health and Family Welfare Directorate of Health Services Delhi Govt Hospital Autonomous Bodies Local Bodies IHBAS Delhi AIDS Society Directorate of Food Adulteration C.A.T.S Drug Controller Other National programmes MCD NDMC Cantonment Board Other Govt and Non Govt Healthcare organisations 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. Qureshi 1 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 2009 2. 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 2. Pushpawati Singhania Research Institute, Sheikh Sarai, Phase-II, Saket, New Delhi-110017 3. National Heart Institute, 49, Community Centre, East of Kailash, New Delhi-110065 4. Mai Kamli Wali Chari Hospital, Plot No. 12, J-Block, Community Centre, Rajouri Garden, Delhi-110027 14 11 5 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 17.* Sir Ganga Ram Hospital, Hospital Marg, Rajinder Nager, Delhi-110060 18. National Chest Institute, A-133, Niti Bagh, Gautam Nagar, Delhi-110092 2 68 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 22.* Rockland Hospital, B-33,34, Qutab Institutional Area, New Delhi-110016 23. Bensups Hospital, A Unit of B R Dhawan Medical Charitable Trust, Bensups Avenue, Sector-12, Dwarka, Delhi-110075 24. Flt Lt Rajan Dhall Hospital, Sector-B, Pocket-I, Aruna Asaf Ali Marg, Vasant Kunj, New Delhi-110070 25. Dr B L Kapoor Memorial Hospital, Pusa Road, New Delhi-110005 7 11 3 11 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 Name and Address of the Hospitals Free Beds Available 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, 3 Delhi-110085 30. Max Balaji and Diagnostic Research Centre, 108-A, 15 IP Extension, Patparganj, Delhi-110092 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, 26 Delhi-110025 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 TOTAL NUMBER OF BEDS 171 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) Key Informants Hospital 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 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 Medical Research Centre Tie up between private Health Care chain and a Memorial Foundation to manage and operate the hospital 4 DH4 Multi-speciality Established as a Charitable trust, now a 100% subsidiary of International Health Care Chain 5 DH5 Multi-speciality Teaching Institute and Research Centre Run by a Research Foundation 6 DH6 Super-speciality Charitable Society 7 DH7 Super -speciality Private Hospital 20