Last month, the Delhi High Court pulled up the Indraprastha Apollo Hospital for not honouring a commitment it made to get land from the government at a discount.
The hospital in south Delhi promised to reserve one-third of its beds for patients from economically weaker sections, who would be treated for free.
A monitoring committee appointed by the high court found that another 22 of the 38 hospitals that got land on concession have also failed to keep similar promises they made.
The court’s observation may have been guided by intentions to make healthcare more accessible and affordable to the poor, but it has also brought to fore the flaws in the policy and approach of the government.
“In a country that is exploring public-private partnership to drive growth and development, the failure of these private hospitals to treat the poor after taking land on concession sets a very poor example,” said Ashok Aggarwal, a lawyer who brought the issue before the Delhi High Court.
The problem lies in the assumption that private hospitals — many of which are enterprises listed on the stock exchange — would forego profit for charity. The agreements they sign at the time of taking land on concession are so ambiguous that they can renege on the contract.
“There is nothing ‘social’ about this social contract as the private hospitals know they can get away without treating the poor and the government doesn’t have effective laws to enforce free treatment,” said Aggarwal. “In Apollo’s case it wasn’t clear whether the hospital was supposed to bear the cost of medicines and consumables while treating the poor. Twelve years were lost in trying to clear this ambiguity.”
Across India, state governments have given land on concession to private hospitals with a promise they would treat a required number of poor patients for free. But compliance has been poor.
In their defence, private hospitals in Delhi say they don’t end up treating the required number of patients because they don’t get enough poor patients.
“The government hospitals or the Delhi government is supposed to refer poor patients to us but the referral system isn’t efficient,” said Pervez Ahmed, chairman, Max Healthcare. “It also becomes difficult to determine who exactly is poor — one with a recommendation from a government hospital, one who claims to be very poor or one with a below poverty line (BPL) card.”
The Apollo Hospital says it attends to all patients referred to it by the 14 designated Delhi government hospitals or from the government. “At any given time we have 60 poor patients in our hospital,” said the hospital’s spokesperson.
The hospital, however, is supposed to set aside 200 beds for the poor.
“The referral system needs to improve, and for effective implementation more caveats are needed in the policy that requires private hospitals to treat the poor for free,” said J.P. Singh, health secretary, Delhi government.
Clearly, the plan for providing free treatment to poor patients isn’t working. Caught between overcrowded government hospitals and expensive private healthcare, the poor patient in India has nowhere to go.
“There is immense burden on both private and government hospitals,” said Singh.
The All India Institute of Medical Sciences, for instance, gets more than 8,000 patients a day.
“We need to improve systems such as primary health centres (PHCs) that are already in place,” said Singh.
Each PHC is supposed to cover 100,000 people and provide basic facilities such as an operation theatre, four to six beds, an ambulance and 14 paramedic staff including doctors, and take care of the basic health needs of poor patients in both urban and rural areas.
There are more than 23,000 PHCs across India — 200 in Delhi alone. However, they are often ill-equipped and understaffed.
“If these health centres functioned efficiently, poor patients wouldn’t have to visit either AIIMS or Apollo for simple ailments,” said Singh.
One of the tools that can make access to healthcare easier for the poor is state-sponsored health insurance, which some states have successfully experimented with.
In Karnataka, more than 3 million farmers have benefited from the Yeshasvini Co-operative Farmer’s Health Care Scheme, the brainchild
of Devi Shetty of Narayana Hrudayalaya, Bangalore. For Rs 120 a year poor people can get cover for 1,600 surgeries under this micro-insurance scheme.
In April 2007, the Andhra Pradesh government launched ‘Rajiv Arogyasri’, a health insurance scheme for which the more than 20 million ration-card holders below the poverty line are eligible. The scheme provides a cover of Rs 2 lakh per annum per individual for treating major ailments. Since January this year, approximately 1,100 surgeries and procedures, costing Rs 3.5 crore in all, are being done every day.
Replicating the Andhra model could help fill a big gap in providing poor families with access to healthcare, but there is no escaping the need to train more doctors, build more government hospitals and revamp the existing primary healthcare network, said Singh.
“What we need is to make the system we have work.”