It's Free, But Is It Fair?

The High Court-appointed committee's report on free medical treatment in charitable hospitals is out. But the report has pleased neither the petitioner nor trust hospitals, reports Jayata Sharma

The cat is out of the bag. The Bombay High Court-appointed expert committee has finally submitted the much-awaited report on free treatment norms to be followed by charitable trust hospitals in Mumbai.

The committee has recommended that 10 per cent of the beds in such hospitals should be for indigent patients and another 10 per cent for weaker sections. Two per cent of the total income earned by trust hospitals has to be credited to a specially created fund, which will be screened by a monitoring committee every month. Also, it mentions guidelines for services to be provided absolutely free, how hospitals can verify patients' financial status, and the protocol for an emergency.

Why The High Court Probe?

The report is a fall-out of a public interest litigation (PIL) filed by Advocate Sanjeev Punalekar in December 2004. Punalekar had alleged that charity hospitals were not providing free treatment to weaker sections, despite enjoying several concessions and exemptions from the Government. He filed the PIL after a charitable hospital denied free treatment to his father Gunjan Punalekar.

The High Court suggested formation of a committee to probe the matter and come up with uniform guidelines. The committee was constituted in October last year, under the Chairmanship of SB Dhumal, former Charity Commissioner of Maharashtra, by a division bench comprising the then Chief Justice Dalveer Bhandari and Justice SA Bobde.

The New Face

The report was compiled after garnering feedback from 319 charitable hospitals (including remote and tribal ones) in Maharashtra, based on questionnaires sent by the committee. Suggestions by various expert committee members were also taken into account. To know more, let us look at the highlights and various views surrounding the report.

Reservations

The report says that centres termed as state-aided are obliged to reserve 10 per cent of the total operational beds for indigent patients, free. Another 10 per cent of operational beds are to be reserved for weaker sections of the populace at a concession of 50 per cent of the bill, which is to be calculated on lowest class rates.

"Charitable hospitals were allotted land, and as a part of lease agreement with the Government, these hospitals have to provide 15 plus 15 per cent (higher than 10 plus 10 per cent) reservation. But the distinction between 10 and 15 per cent is not highlighted in the report," Punalekar points out. However, Brig Joe Curian, President, Association of Hospitals (AoH), counters, "The Government has not provided equal concessions to all the charitable hospitals. So, how can they ask for obligations that are the same for all?"

Hospitals Free To Verify

According to the report, charitable hospitals can verify the economic status of patients by appointing a Medical Social Worker, who will scrutinise the ration card of the patients, or a certificate from the tahsildar . "This is not enough, it leaves room for fake documents. A Government agency must also give out certificates regarding patients' financial position," avers Dr Lalit Kapoor, Chairman of Medico Legal Cell, Association of Medical Consultants.

Experts point out that verifying authenticity would prove to be difficult. A lesser evil would be a centralised public controlled system, which would be bureaucratic but accountable, unlike the private sector. According to sources, non-hospital committee members had resisted this clause during discussion, but eventually gave in.

Creating A Fund

The report directs hospitals to create a separate fund called Poor Patients Fund (PPF), and credit two per cent of their gross billing of patients (other than indigent and weaker) to this fund without any deductions. All donations from individuals or other charitable trusts towards providing medical treatment to poor patients must be credited to the PPF account. This amount will be at the disposal of the hospital, but will only be used for medical treatment of the poorer classes. "The formula of a cap on expenses for poor patients (two per cent) may result in dilution of even the 10 per cent cap," feels Punalekar. Health Activist and former CEHAT Co-ordinator Ravi Duggal vehemently opposes the PPF, saying, "The Government has created a white elephant for itself. It is problematic as the whole attention would then shift to monitoring those funds."

What Is Totally Free

As per the report, the following services provided by hospitals should be totally free to both indigent and weaker section patients: bed, RMO services, nursing care, food, linen, water, electricity, routine diagnostics by general specialists, and housekeeping services.

This clause has displeased non-hospital experts. "Exclusion of medicines and non-routine diagnostics in free treatment is against the law of what is free. The Justice Qureshi Committee Report on Delhi's Trust and Corporate hospitals has very clearly defined what is free care and one should go by that definition," Duggal suggests.

The Age-Old Tussle

This is not the first time that trust hospitals have come under the Government scanner. Earlier, the State Government had noticed that some hospitals registered under the BPT Act were not abiding by the rules.

They were not providing free/concessional medicare to the poorer sections, even when they were raking in huge profits. To ensure the poorer classes get benefits of the medical facilities, the Act was amended by inserting Section 41 AA in August 1985. This empowered the Charity Commissioner and the State Government to issue appropriate directions to hospitals.

Section 41 AA defines an indigent person as one whose total annual income does not exceed Rs 25,000 or any such limit the State Government may specify from time to time. A person belonging to the weaker section of the society is one who is not indigent, but whose income does not exceed Rs 50,000 annually. These limits can be altered as and when the State Government feels the need.

The Recent Clash

The report has failed to appeal to anyone. The petitioner feels the report is pro-trust hospitals, while the AoH, an umbrella body of over 40 charitable hospitals in Mumbai, dismisses this report and demands another one.

Trust hospitals are enraged by the Government's insistence on free treatment, when over the years the State Government and the BMC have withdrawn certain concessions mentioned in the BPT Act. The situation persists even after hospital associations have filed petitions for restoring a few benefits.

"Over the years, the cost of setting up high-end hospitals and the cost of medical equipment and other technology has gone up. This makes it impossible for hospitals to remain viable, yet provide costly services free," maintains Brig Curian, also the CEO of SL Raheja Hospital.

Another crucial point raised by trust hospitals is how they can be expected to offer free services to needy patients when doctors operate on 'fee for service'. "It may not be possible for hospitals to deal with this issue unless the law states that doctors should offer free and subsidised treatment," adds Brig Curian.

Close to 75 per cent of healthcare is provided by the private sector in India. Of this, almost 70 per cent is from charitable hospitals. In Mumbai, out of total 42,000 beds available, 29,000 beds are provided by private sector. Of these, around 50 per cent are provided by charitable hospitals. "We have been doing charity sincerely for a long time and will continue to do so. Why are our functions being disturbed now? The Government should attend to Government hospitals, as they are the ones which need guidelines more than we do," states Col M Masand, Director General, Jaslok Hospital. Some experts point out that even hospitals providing free treatment to the poor are coming under the scanner as they fail to maintain records. A spokesperson from Breach Candy Hospital said, "We have been doing charity work from a long time, even before the BPT Act came into existence. We are providing free treatments to a much larger number of patients than the report mentions."

However, people on the other side of the debate feel that after assessment of concessions enjoyed by trust hospitals under the BPT Act, the Government needs to move ahead. "The Government needs to monitor trust hospitals enjoying tax concessions under section 35 (1) (ii) of the Income Tax Act because of being registered as research centres. This status needs to be reviewed as one has not seen any significant research from these hospitals who enjoy so many tax rebates," opines Duggal.

According to Punalekar, the BPT amendment of 1985 is meant for those who were not bound by any rules. "This does not mean that those who were previously governed by higher percentage (15+15) can now reduce it. If they fail, they are liable to lose their lands. The report ought to have been more assertive on this aspect," states Punalekar.

Eyebrows have also been raised about the composition of the committee which drafted the report. "The Committee is headed by the Charity Commissioner and consists of only representatives from the Government and the hospital association. It excludes consumer groups, health activists and civil society, the very people who filed the PIL. Further, the thrust of the enquiry mandated by the High Court was implementation of Section 41 AA of the BPT Act. The Charity Commissioners' office is responsible for implementing that Act. So, how can members of the Charity Commission sit on a committee that is enquiring into its own (mal) functioning?" asks Duggal.

Interestingly,though AoH's name features in the report, the Director of Cumbala Hill Hospital Dr KR Shetty, a representative from AoH, resigned from the committee because of AoH's exclusion from a crucial part of report formation. AoH is also disenchanted with the functioning of the Charity Commissioner, who was supposed to study each hospital and consider its size and facilities available. "It's 28 years now, and still this has not been implemented," rues Brig Curian.

In Conclusion

With the report receiving flak and experts complaining of being excluded, various groups are expected to put forth their views before the High Court in the second hearing. Whether the changes will be incorporated, and whether the report will regularise the private healthcare industry, will depend on how various experts work in tandem.

jayata@expresshealthcaremgmt.com