Charity on paper

IN August, the Comptroller and Auditor General (CAG) of India conducted an audit of 11 top private charitable hospitals in Mumbai run by trusts for the years 2012-15. Its scrutiny of records exposed a system that misused the special facilities that such hospitals were meant to offer to the indigent and those below the poverty (BPL) line.

The Bombay Public Trusts Act (BPTA), 1950, states: “The Charitable Trust Hospital shall be under legal obligation to reserve and earmark 10 per cent of the total number of operational beds for indigent patients and provide medical treatment to the indigent patients free of cost and reserve and earmark 10 per cent of the total number of operational beds at concessional rate to the weaker section patients as per the provisions of section 41AA of the BPT Act. The Charitable Hospitals shall physically transfer 2 per cent of the total patients’ billing (excluding the bill of indigent and weaker section patients) in each month to IPF [Indigent Patients Fund] Account.”

In exchange, the hospitals were offered a variety of concessions—such as lower rates of import for medical equipment, land on long lease at low rates, subsidies in utility bills and income tax waivers. Some were even granted additional Floor Space Index (FSI) if they allocated 20 per cent of the total operational beds to BPL patients.

The CAG report found that seven of the 11 hospitals had not reserved the stipulated number of beds for impoverished patients, billed them and demanded deposits at the time of admission. Most of the hospitals had availed themselves of the FSI concession but failed to allocate the extra 10 per cent beds for the poor. And most of them did not offer the 10 per cent reservation for outpatient services as set out in the scheme. The CAG recommended that the concessions given to these hospitals be reviewed. In response the State government set up a committee to examine each case.

Violations galore

The violations are by no means new. In 2015, a panel of doctors and bureaucrats appointed to carry out surprise checks found that four top private charitable hospitals in the city had violated the law. In one hospital the panel found that although there was a special ward for poor patients, it did not have the requisite number of beds and even the existing ones meant for free patients were given to patients who could pay. In another major hospital, the panel found that although the correct number of beds had been reserved, there was only one poor patient admitted; the others were either regular patients who paid or relatives of staff members. The story was the same in a suburban hospital where patients who paid were put in beds supposedly reserved for the poor.

Hospitals say that they follow all the regulations and even send their patient status to the office of the Charity Commissioner under whose jurisdiction they come. A senior bureaucrat told Frontline that the severely understaffed office of the Charity Commissioner was incapable of following up on cases. With approximately three staff members to see to more than 50 private charitable hospitals, the Charity Commissioner’s office is “bound to find this a difficult task”. The bureaucrat also said that most often only about 4 to 7 per cent of the beds were reserved for the poor instead of the mandatory 20 per cent. Ravi Duggal of the People’s Health Movement in India says that if these hospitals wholeheartedly did what they had signed up to do then “Mumbai would have at least 2,000 more hospital beds for the poor”.

Glaring differences

The glaring differences between the mandate of the hospitals and the reality faced by poor patients came to the fore in April 2012 when a pregnant Reena Kutekar was hit by a car. Her husband, a casual labourer, took her first to Nanavati Hospital in suburban Mumbai but was refused admission because he was unable to pay Rs.25,000 as deposit.

Denied immediate medical help by two other hospitals, Reena was finally admitted to a government hospital in the city, but the delay in treatment resulted in her death three days later. Nanavati Hospital is a charitable hospital and Kutekar should have been admitted there without a deposit.

Significantly, nothing seems to make the hospitals accountable to anyone. When Duggal was a part of the Medico Friends Circle, he was one of the petitioners in a 1990 case against the violations of charitable hospitals. He says the case is probably not yet closed but is not sure of its status anymore.

Various hospitals at various times have attempted to delink themselves from the scheme under the BPTA. In 2012, four of the city’s big hospitals told the Charity Commissioner’s office that the financial burdens of treating the poor for free were too much for them to bear. This complaint was debunked when the State government exposed the fact that the hospitals were violating the stipulations of the scheme anyway.

The hospitals also tried the legal route to escape the scheme but were unsuccessful there too. The hospitals did not give up and their target was the Rajiv Gandhi Jeevandayee Arogya Yojana (RGJAY). The insurance-based scheme backed by government money has been operational in Maharashtra since 1997. Under this scheme, public hospitals can send poor patients to private charitable hospitals for surgeries, including those relating to diseases of the heart, brain and kidney. Poor patients are also eligible for treatment for cancer and cancer-related surgery.

The hospitals said they could not implement both the BPTA scheme and the RGJAY. However, the point is that the RGJAY is not a charity scheme. The hospital bears no financial burden at all for it since the Maharashtra government has undertaken the fiscal responsibility through an insurance provider.

Enforcing the BPTA scheme is necessary for poor patients to get medical aid. Hospitals have benefitted greatly from the scheme and are legally bound to carry out their part of the deal. But what is more important is for the State to enhance budgetary allocations for public health infrastructure.