Onus Of Compensation On Hospitals

Maharashtra’s public health department has asked all hospitals and healthcare centres performing sterilisation operations to give an undertaking that the owner will be liable to pay compensation in case of death, incapacitation and complications. Falaknaaz Syed reports

Hospitals and nursing homes have been asked to give an undertaking on stamp paper of Rs 100 and submit it to the Directorate General of Health Services. (See box for text of the undertaking)

The medical fraternity allege that by issuing such an instruction, the State is shifting the responsibility of compensating victims to the hospitals.

"Nowhere in the interim order is it mentioned that individual gynaecologists performing sterilisation operation will have to pay compensation" - Dr P K Shah, Deputy Secretary General, FOGSI

The resolution comes in the wake of the Supreme Court’s interim order last March, admonishing State governments on lack of quality care and infrastructure in nursing homes and sterilisation camps resulting in a high number of deaths, failures and post-operative complications after sterilisation operations. The Supreme Court issued instructions on the experience of doctors, infrastructure and compensation regarding tubal ligation. (See box for the details of SC order)

“Nowhere in the interim order is it mentioned that individual gynaecologists performing sterilisation operation will have to pay compensation. We have no objection to following the Ministry Guidelines of 1999 on sterilisation operations, as these will improve the quality of care. Budgetary provision is made by the Union Health Ministry for compensations in every State, then why is the government passing the responsibility of compensating to individual gynaecologists?” asks Dr PK Shah, Deputy Secretary General of Federation of Obstetrics and Gynaecological Society of India (FOGSI), a body of 18,000 gynaecologists in the country.

Shruti Pandey, lawyer for Health Watch, the NGO that fought the case in the SC to implement quality care stresses, “The SC has asked the State Governments to pay and not individual doctors.”

Compensation As Per Order

The SC has asked State Governments to pay Rs one lakh ex-gratia assistance to the legal heirs of every death attributable to sterilisation operation. Of this, Rs 10,000 will be paid in cash and the rest in the form of National Savings Certificates.

Similarly an ex-gratia payment of Rs 30,000 is to be given to the patient if she is incapacitated or handicapped due to a sterilisation operation. In case of complications, the expenditure incurred by the patient on laboratory investigations and medicines will be reimbursed up to Rs 20,000. This compensation will be given after an assessment and confirmation by the State-appointed divisional quality assurance committee.

One aspect of the undertaking not acceptable to private doctors is that inspection will be done by State Level and Divisional Level Quality Assurance Committees (SLQAC) to decide whether the doctor has been negligent if a patient dies during the sterilisation operation.

“SLQAC is a state committee and may be pressurised into finding some sort of a lapse in the doctor, staff or infrastructure to make doctors pay compensation. It will be against the private practitioners. The purpose of the SLQAC is to improve quality of care. It has no business to penalise the doctors or institution,” says a gynaecologist who performs sterilisation operations in his centre.

Dr PP Doke, Director General Health Services differs, “This undertaking includes even government hospitals. If SLQAC finds that a government doctor has committed negligence, we cancel his registration, terminate his services, his increment is stopped and Medical Council of India will even debar him from practising. In private hospitals we can’t penalise so we ask them to pay compensation. Our main aim is patient safety and we need their cooperation.”

Another point worth mentioning is that the SLQAC constituted for inspection by the state has only one gynaecologist; the rest are pathologists, anaesthesiologists, urologists and other specialists. Dr Shah says, “When formulating such resolutions, the government should have representation from FOGSI.” About the SLQAC being a government committee, Dr Doke argues, “The new SLQAC committee has representation of experts from private medical colleges too.”

Ground Reality

“Doctors will stop performing tubal ligation, thereby adversely affecting the family planning programme. In a private setup, the doctor may not do or dissuade the woman from undergoing tubal ligation due to the fear of paying compensation. So comprehensive healthcare will not be provided.

MTP with laparoscopic tubal ligation is safe across the world. This resolution will affect targets,” says Dr Shah. Doctors allege that the order banning MTP with TL together brought out a sharp decline in tubal ligation and the target rate for population control has fallen drastically.

Dr Doke differs, “This allegation is baseless. In one or two centres there may have been a drop in targets but we didn’t find any drop at other centres. Also in June ‘05, we passed an order rectifying the previous order of ‘04, which states that those centres which have a blood bank, anaesthesiologist and a 24-hour doctor can still do MTP with TL together.”

Until recently, doctors and patients found it convenient cost-wise and time-wise to have both medical termination of pregnancy (MTP) and Laparoscopic Tubal Ligation (LTL) performed together in the first trimester of the pregnancy. LTL is minimally invasive and sutureless, hence preferred by women. But as these were two major operations, the rate of mortality was high when combined and performed in places where infrastructure, skilled doctors and facilities were lacking. Therefore in 2004, the Maharashtra government issued guidelines banning MTP and LTL done together.

So now, after an MTP, the woman is asked to return after a gap of six weeks for undergoing LTL. Rarely does she return, thereby increasing the chance of an unwanted pregnancy, say experts. However MTP can be done with Minilaparoscopic Tubal Ligation, which is with sutures. But here too as per the Maharashtra State Guidelines, the woman has to be in hospital for seven days post operation.

Improve Rural Quality Of Care

In rural areas, most Family Planning Centres and Primary Health Centres (PHCs) lack the infrastructure to perform sterilisation operations.

One gynaecologist accuses, “Centres that are government-aided have only one laparoscope which is sterilised and reused. Most of the deaths occur in rural Maharashtra. The government should improve infrastructure and care rather than pass such resolutions.” Dr Shah agrees, “The Maternal Mortality Rate (MMR) in India is 480 per one lakh live births due to pregnancy-related complications compared to deaths due to MTP and Tubal Ligation.” Says Dr Doke, “There are 1800 PHCs in Maharashtra of which only 1000 that have the infrastructure are permitted to do sterilisation operation.”

Time wasted

Dr Asha Dalal, Head of Department, Gynaecology, Nair Hospital says, “I agree that a lot of applications for recognising MTP centres are still pending but DGHS intends to speed up the registration process in six months time.” She feels that doctors are unnecessarily being apprehensive of the Government resolution, as the intent is patient safety. “If the centre conducting MTP and TL is registered and a death occurs during TL, then the government pays an ex-gratia amount of Rs 50,000. But if the centre is not registered then the owner has to pay. If the doctor is found negligent by SLQAC, then he pays. But all doctors have indemnity insurance, so the insurance companies will pay.”