Public Health: Delhi

In poor health

Print edition : April 14, 2017

At the outpatient department of Guru Gobind Singh Hospital in Delhi as dengue cases increased, in September 2015. Photo: Shiv Kumar Pushpakar

Government health establishments in the national capital lack infrastructure and facilities and the private ones are unaffordable.

IT is a warm afternoon in late March and chamber number 483 on the Delhi High Court premises is brimming with visitors. Inside, Senior Advocate Ashok Agarwal, seated across the table from this correspondent, is weighing in on the recently announced National Health Policy (NHP). Far from being impressed by the seemingly well-drafted text, Agarwal emphasises the subtext of the policy and calls it “jugglery”.

Explaining why he is not impressed by the policy, Agarwal points out that the government has not made public health a “fundamental right backed by a national law” without which patients, especially the poor for whom access to health services is often uncertain, are relegated to the status of “beggars”. This is because government health establishments are often overcrowded and private ones are unaffordable.

Besides, the policy’s strong dependence on private and non-profit sectors to make up for “gaps” left by government institutions in delivering health care seems unrealistic given the fact that hospitals in the private sector are often unaffordable and their commitment to delivering health care to the poor has been patchy. Agarwal said: “If everyone in this country was a crorepati, then it [dependence on private hospitals and services] would have been fine. But 70 per cent of Indians will not be able to afford it.” In this context, the policy’s stated goal of ensuring “universal access to good-quality health care services without anyone having to face financial hardship as a consequence” seems less than convincing.

Private sector in Delhi

Consecutive state economic surveys have noted that “Delhi has the highest private sector participation in health sector”. One metric of this is the proportion of total hospital beds in the city. According to the latest survey, 48.39 per cent of the hospital beds in Delhi are in the private sector. Typically, patients, for multiple reasons, including overcrowding at public hospitals, prefer private health service providers. But when it comes to accessing free or affordable health care in the private sector, the experience of the poor has been grim.

Agarwal’s observations are rooted in Delhi’s experience with the private health sector in recent decades. The best known example of this is the issue of provision of free beds and treatment for the poor in big private hospitals that received subsidised land from the government in the 1980s and 1990s against the condition of providing free health care for poor patients (25 per cent outpatients and 10 per cent inpatients). Agarwal has played an exceptional role in highlighting the issue and facilitating its implementation. A writ petition filed in the Delhi High Court in 2002 by a lawyers’ collective named Social Jurist set up by Agarwal exposed how the hospitals had not kept their end of the bargain. Initially, many of the hospitals denied any responsibility for the treatment of poor patients, but in March 2007, the court asked them to comply with the conditions. At least four hospitals appealed against this decision in the Supreme Court, but it upheld the High Court order. It was after sustained follow-up and pressure from courts, the media and activists that several private hospitals began complying with the conditions.

A High Court-appointed monitoring committee to ensure that beds are provided to the poor has Agarwal as member apart from government officials. There are at least 43 such hospitals with 636 free beds for poor patients who belong to the economically weaker sections (EWS). While things have improved from the past, many hospitals continue to implement the conditions only half-heartedly. On a visit to Fortis Escorts Heart Institute in the Okhla locality, this correspondent found an empty white board at the entrance of the outpatient department, which had unfilled columns against the following headings: total number of free beds in hospital, number of beds occupied by BPL (below poverty line)/EWS patients, and number of beds lying vacant for BPL/EWS patients. It was well past 5: 30 p.m. and the receptionist said the designated official looking after EWS patients had left for the day. “She works from 9 am to 5: 30 p.m.,” said the hospital staff. It was a similar scene, minus the board, at the inpatient section of the hospital.

While private hospitals may not be too enthusiastic about serving the poor, the Delhi government also appears to have lost its initial momentum in improving the quality of services provided by private hospitals. In early 2015, months after it came to power, the Arvind Kejriwal government started a special scheme to increase the occupancy of beds under the EWS arrangement in private hospitals. In 2016, the government also ordered a recovery of at least Rs.600 crore from five private hospitals for allegedly making “unwarranted profit” by not providing the agreed extent of free services ever since they were established.

While litigation over it has dragged on and its follow-up suffered partly because of the government’s war over jurisdiction with the Centre, the scheme in 2015 had made some headway in increasing occupancy of beds for patients from the EWS category. However, it is hard to quantify the actual extent of compliance by private hospitals today. That is because the supposed mechanism of online and real-time monitoring of availability of free beds is not properly functional.

A senior official from the Health Department admitted as much while speaking with Frontline. “The numbers of beds available are actually updated once or twice a day online. They are not real time. Besides, we do not have fully authentic figures about daily compliance by private hospitals to the condition of catering to EWS patients as mandated by the courts,” he said. This official attributed the unavailability of real-time data to the discontinuation of a government agency from the job of managing data about availability of beds and the lackadaisical attitude of Health Department employees. Significantly, raw data accessed by this correspondent showed that some hospitals had claimed that they provided much more than their mandated share of beds or treatment to patients—something that officials themselves doubted.

Another problem concerns the changing and unclear guidelines for deciding who belongs to the EWS category. For a long time, income certificates or BPL cards sufficed to prove this, but it was changed to PR-S ration cards. A recent advisory to hospitals states that self-declarations should suffice. Hem Prakash, Additional Director (EWS) in the Health Department, conceded that “EWS guidelines are not clear and they need to be reframed”.

While issues regarding EWS category patients’ access to health care in private hospitals await proper resolution, advocacy groups are increasingly articulating the need to improve and increase state capacity in the public sector, which is overburdened with patients and underserved in infrastructure and facilities. “Private hospitals have a limitation. Just 636 free beds won’t suffice to cater to the increasing number of people, many of them poor, coming from all over India to Delhi to seek good-quality treatment. So, eventually, the government system will have to be improved,” said Agarwal, whose chamber is by now brimming with patients who have come to seek his help with getting a hospital bed or some other health-related assistance. Intermittently chatting with his guests, he underlined an important idea that policymakers need to pay heed to: “Health and education are not private assets. They are a public good.”

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