One-sided deal: Hospitals get but don’t give back


Hospital, Bandra

Hospital, Bandra (Photo credit: Wikipedia)

Grants, concessions and exemptions given to the hospitals far exceed the cost of free treatment they are asked to carry out

Jyoti Shelar and Lata Mishra, in Mumbaimirror

Posted On Thursday, April 26, 2012

The death of accident victim Reena Kutekar, whose husband Ram desperately hunted for a hospital that would save her life, has brought into focus how badly poor patients are treated in private medical facilities across the city.

Reena was first taken to Vile Parle’s Nanavati Hospital, where the authorities refused to take her into the ICU because Ram could not furnish the Rs 25,000 required for admission.

The story in most other hospitals in the city is alarmingly similar: though they are required by law to treat a certain number of economically backward patients, most people come away empty handed in their time of need.

The contention of the hospitals – from Jaslok to Breach Candy, from Lilavati to Hinduja – is that taking care of poor patients is a huge burden on them, and that they are asked to provide free treatment for nothing in return.

What these hospitals fail to reveal, however, is that the grants and concessions they are given by the government far exceed the cost of free treatment they are being asked to carry out. Running as charitable public trusts, their list of unaccounted-for exemptions is staggering:

1. Cheap land

If any charitable trust wants government land to build a hospital, it is charged only one-tenth of the market value in the island city, and one-twentieth of the market value in the suburbs. If the land is on lease, the price can be as low as Re 1 per square foot per year.

“Several facilities, such as Jaslok, Hinduja and Bombay Hospital, are on government land given to them on a Re 1 lease. Now they’re earning crores annually but still make excuses when it comes to treating poor patients,” said advocate Sanjeev Punalekar, who had filed a PIL on the issue in 2004.

2. Extra FSI

While the rest of the city’s commercial establishments have to make do with an Floor Space Index of 1.33 to 2, public trust hospitals get an additional FSI of up to 5.32 in the island city and up to 5 in the suburbs.

The FSI determines the height of the structure, which in turn translates into more room for patients, and more business. But the taller hospitals have hardly been of help to poor patients.

“The additional FSI and all other rebates come from the government. The rest of the money comes from patients. Ultimately, it is the government and public money that adds up to the surplus funds of hospitals,” said health activist Leni Chaudhary. “Then why not ensure that poor patients get treated?”

When contacted, Dr Pramod Lele, the CEO of the Mahim’s Hinduja Hospital, admitted that additional FSI proved beneficial in increasing the hospital’s “bed- strength”, but contented that they were asked to pay a premium for it. Not the best argument considering the demand-supply ratio of hospital rooms guarantees that this money is easily recovered.

3. Income Tax rebate

The exact rate of exemption varies from hospital to hospital, depending on how much money it makes. On average, however, 85 per cent of a public trust hospital’s income is exempt from tax. Even the remaining 15 per cent can be set aside as a corpus fund, ensuring that most hospitals have to pay no tax at all. The only catch is that anything accumulated above this 15 per cent in their account is taxable. Hospitals registered as research institutes are given similar concessions.

4. No Octroi

While Octroi rates in Maharashtra are inordinately high, hospitals are exempted from any additional tax for transporting equipment and machinery. In 2003, the BMC withdrew Octroi exemption from a few hospitals for not doing enough charity work. When contacted, a senior doctor from Lilavati hospital agreed that there had been several complaints made to the Charity Commissioner about norms being flouted, which had resulted in some rebates being pulled back for certain hospitals.

5. Duty free

All public trust hospitals are exempted from customs duty on imported machinery and medical equipment, as opposed to 10 per cent for all non-public-trust hospitals. When contacted, Customs officials said machinery and medicines from abroad were one of the most common items brought into the country. “As per the law, we clear them immediately,” an officer said.

6. Cheap Medicines

Hospitals procure generic drugs at nominal costs, and several medicines which are made available by the government under various programmes such as Tuberculosis and Malaria eradication are given to them at a fraction of the cost. However, health experts point out, that these drugs are then sold to patients at the market rate.

7. Low water and electricity rates

Despite being commercial establishments, hospitals are charged residential tariffs for water and electricity, which in itself is a huge benefit. The Residential rate for water per 1,000 litres, for example, is Rs 2.25 as opposed to Rs 38 for commercial use.

 What hospitals are supposed to do 

According to a Supreme Court judgment, charitable hospitals must admit a patient brought in an emergency and provide “essential medical facilities” until stabilisation. Transportation to a public hospital should be arranged, if necessary, and no deposit should be asked for.

Each hospital has to transfer 2 per cent of its income to an Indigent Patients Fund (IPF). The hospital has to reserve 10% of its beds for indigent patients (annual income less than Rs 25,000) who should be given free treatment.

A further 10% of its should be reserved for economically weak patients (annual income less than Rs 50,000) who should be treated at concessional rates. At the time of admission, all a patient has to provide is a certificate from the Tehsildar or a ration card or BPL card.

“I ran with my dying wife from Nanavati to Cooper to KEM to JJ “


I ran with my dying wife from Nanavati to Cooper to KEM to JJ

A poor man’s damning testimony of our emergency services

Lata Mishra and Jyoti Shelar

Cover story Mumbai Mirror

This newspaper has run a series of stories on the hit and run accident that led to the death of the wife and unborn child of a construction labour in Juhu.

The circumstances that led to the accident; the police’s hunt for the mystery man who dropped Ram and a bleeding Reena Kutekar to the hospital but fled soon after; and finally, his surrender ten days later at the insistence of his family after they had read about it in Mumbai Mirror.

But there is a larger story that still remains to be told.

Ram Kutekar’s desperate hunt for a doctor and hospital that would save his wife’s life, and his frantic 16-hour journey from Nanavati to Cooper to KEM to JJ Hospital across Mumbai puts the spotlight on everything that is wrong with emergency medical services in the city. And why its poor can never bank on them.

• First, Nanavati Hospital refused Reena the operation she so urgently needed because her husband, a daily wage worker, couldn’t put together a deposit of Rs 25,000 (He was falling Rs 10,000 short, which he promised to raise as soon as he could).

• At Cooper Hospital, the next stop, there was no CT scan facility which meant Reena had to be taken to a private clinic close by leading to precious loss of time. The results showed Reena had suffered serious head injuries and needed urgent surgery.

• But Cooper had no neurosurgeons on call at the time, so Ram was asked to take his wife, battling for her life, to KEM Hospital in Parel.

• At KEM, there were no beds available in the ICU. Ram was told to head to JJ Hospital.

• By the time Reena was put on a ventilator at JJ, it was 11 pm. The neurosurgeon that operated on her told Mumbai Mirror she was in critical condition when she was brought in – “her brain was swollen, her blood pressure had dropped alarmingly”.

Reena – five months pregnant – died three days later. The baby inside her, doctors said, had died one day before her.

“It’s not just that young man who killed my wife,” says Ram Kutekar sitting in a cramped room in a Vile Parle chawl. “The doctors are equally responsible.”

In the Hipporcatic Oath which all doctors have to swear by before their passing out, there’s a line that reads so: “I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person’s family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick.”

There is also a Supreme Court directive that says emergency patients must enjoy all the rights of a consumer even before they pay any money to hospital. Nanavati management, however, insists the hospital flouted no norms, as it was only at the second level of treatment that they asked for the deposit. “We admitted the patient, thoroughly examined her, and concluded she needed ICU care,” Dr Ashok Hatolkar, Medical Superintendent at the hospital, said. “Our policy clearly states that a deposit of Rs 25,000 has to be paid upfront for an ICU admission.”

The distinction between the first and second line of treatment is specious. Reena Kutekar was examined merely physically. There were no tests run to gauge the extent of her concussion. Tests she needed urgently and which, as later events proved, could have saved her time.

“I remember waiting nervously at the reception as Reena was taken for a preliminary examination. Then the doctors told me she would have to be shifted to the ICU. This was at around 8.30 am… the nurse came around and asked for a deposit of Rs 25,000.”

Ram had around Rs 200 on him, and Siddharth Pandya – the man who had been behind the wheel, and who had dropped them to the hospital – was his only hope. He spent 20 minutes looking for him… in the car park, in the washrooms. By this time, Ram was joined by his brother Sachin, and sister-in-law, who he had asked to rush to the hospital with as much cash as they could manage. “We were still falling short by over Rs 10,000,” he says, “I pleaded with the doctors to not stop the treatment, while I arranged for the money.”

Instead, Nanavati provided Ram with an ambulance – for which he paid Rs 600 – to take them to Cooper Hospital. “By the time we got there at noon, my wife’s condition was deteriorating, I was told that she was bleeding internally, and that the injuries to the head could prove fatal.”

Following the CT scan at a private clinic, which cost Rs 3000, Reena was put on a ventilator and Ram was asked to wait. At around 4 pm, the Cooper authorities said no neurosurgeon was available, and suggested Ram take his wife to KEM Hospital in Parel. “All this time, I kept telling myself that the doctors knew best; that my wife was in safe hands and that she would be alright. I followed their instructions, ran from Nanavati to Cooper to KEM. I told the doctors that they were like gods, and that they had the power to save my wife and our unborn child. They kept saying, ‘don’t worry, just take her to so-and-so hospital’,” he says.

By the time the couple reached KEM, more than eight hours had passed since the accident, and here they encountered the most common problem poor patients face in Mumbai: No beds. “I was told there was a long waiting list, that the ICU was packed beyond capacity. The authorities asked me to try my luck at JJ Hospital,” he says. Yes, the words emergency medical services and luck are closely linked in this city, and unfortunately, the Kutekars had none.

While Reena was operated upon at JJ, she passed away three days later. When Mumbai Mirror spoke to neurosurgeon Velu Varnan, he said she had been brought there in “extremely critical condition”.

Nanavati Hospital authorities say they “sympathised” with the victim’s family, but add that they were “helpless” under the circumstances. Medical Superintendent (Nanavati Hospital) Dr Ashok Hatolkar said, “We never flouted any directive. From our end, we did everything we could to help the victim. We only asked for the deposit at stage two, which is ICU treatment and surgery. It is unfair to blame the hospital for the death. We treat poor patients who ahve requisite documents but can’t treat everybody as we don’t get funds from the government.”

Ram, who earns around Rs 4,000 a month working as a daily labourer, says Reena supplemented the family’s income by working as maid. “Just a few days before the accident, I had told her to stop working as she was more than five months pregnant. In a matter of hours, my family was gone.”

On paper there are several schemes to enable the poor patients to take treatment at the private hospitals. The newest of them all is the Rajiv Gandhi Jeevan Dayi Yojna that promises free treatment for over 972 ailments. The problem is, none of the private hospitals want any part of it. These hospitals feel that the price list offered by the government is extremely low and they want a better price to be a part of the scheme. Medical superintendent of south Mumbai’s Jaslok Hospital, SK Mohanty, says, “We had agreed to be a part of the scheme assuming that the rates would be fair if not at par with our charges. But the rates are so low that we would have to bear huge losses if we agreed to be a part of this scheme.”

For instance, the state has set the cost for a bypass surgery at Rs 1.30 lakhs while packages at most hospitals are above Rs 1.65 lakhs. For an angioplasty, the state has set the cost to Rs 50,000 while the actual packages range from Rs 1 lakh and above depending on the make of the stent.

“We need a viable policy or else we won’t be able to run our hospitals with the new scheme. Also, the government should not force us to be a part of this scheme and it should be left to us to sign the agreement or not,” says president of Association of Hospital (AOH), Dr Pramod Lele.

The hospitals say that they already need to keep 10% of their beds reserved under the Bombay Public Trust Act (1950) for the poor. In addition to this, they have to set aside 2% of their revenue as an Indigent Patients Fund (IPF) for subsidising treatment for poor patients. If they are asked to be a part of this new scheme as well, they will not be left with any profits.

The IPF is yet another scheme aimed at benefiting those below poverty line which has hit a roadblock, again due to the negative response from these hospitals.

In this case, private hospitals claim that they were not properly explained the details of the scheme. “We were under the impression that the state will pay us some minimum amount under the scheme for the two per cent indigent patients that we already treat as per the charity commissioner’s rule. However it turned out that we were expected to treat yet more poor patients,” says a senior doctor attached to a private hospital on condition of anonymity. “We will suffer losses running into crores of rupees if we start doing charity this way,” he adds.

The government on the other hand had already collected a database of over 2 crore people across the state who will be benefited under the scheme. While earlier, the state had made it optional for the private hospitals to join the scheme, recently they announced a compulsory reservation of beds under the scheme. Early this month, health minister Suresh Shetty requested the chief minister to consider withdrawing the compulsion.

Last year, more than 14,000 people were benefited under the scheme and the state spent over Rs 110 crores. However, the scheme covered only four diseases and several hospitals complained about delay in payments.

(With inputs from Santosh Andhale)

Most pregnancy-related deaths occur in transit’


A map of the world showing country-level mater...

A map of the world showing country-level maternal mortality rates. (Photo credit: Wikipedia)

AARTI DHAR, The Hindu

Maternal Death Reviews reveals many facilities show mothers the door soon after delivery

According to a study conducted on pregnancy-related deaths, a large number of women die during transit to a health facility or returning home after a delivery. ‘Maternal Death Reviews — Implications for Quality of Care,’ (MDR) a review of maternal deaths done by the Federation of Obstetric and Gynaecological Societies of India (FOGSI) in Jhunjhunu and Sikar districts of Rajasthan between November 2010 and March 2012 has revealed that 90 per cent of these deaths had occurred during transit to a higher health centre.

The study, conducted on 819 deaths of a total of 1,065 probably maternal deaths reported in Madhya Pradesh between April 2011 and January 2012, suggests 132 women died on their way home or to a health facility. A similar analysis done in 69 health facilities in Karnataka has revealed that 20 per cent women die during transit.

Experts believe such deaths could possibly have increased because of an emphasis on institutional deliveries and a lack of corresponding clinical infrastructure — the Janani Suraksha Yojana gives women financial incentives for delivering at a health facility, but are often taken to the health facility as a mere formality and often asked to go home immediately after delivery because of lack of infrastructure to deal with the heavy patient load, which puts the life of the child and mother at huge risk.

This reality came across during a daylong conference to mark the Safe Motherhood Day last week, where participants from several States shared their experiences and progress on maternal death reviews.

The MDR was rolled out in 2010 under the Reproductive and Child Health programme as an important strategy to improve the quality of obstetric care and to reduce maternal mortality and morbidity.

It provides detailed information on various factors at the facility, district, community, regional and national levels that need to be addressed to reduce maternal deaths. Analysis of these deaths can identify the delays that contribute to maternal deaths at various levels and the information can be used to adopt measures to fill the gaps in service.

While haemorrhage, sepsis, abortion, obstructed labour and hypertensive disorders are the major medical causes of maternal deaths in the country, delay in initiating treatment, substandard care in hospital, lack of blood, equipment and drugs in hospitals coupled with lack of staff at health facility are other factors that often lead to the death of a young woman.

At the community level, absence of ante-natal check ups, delay in seeking care, referral, getting transport, mobilising funds and not reaching the appropriate facility in time are some other factors of maternal deaths, besides prevailing beliefs and customs that prevent women from going to a health facility at the appropriate time.

In a presentation on maternal death reviews in Madhya Pradesh, Apurva Chaturvedi, State Consultant, National Rural Health Mission, and Archana Mishra, Deputy Director (NRHM), explained that 32 per cent of the reviewed deaths had occurred in district hospitals, 25 per cent in maternity centres, 13 per cent in sub-centres and 6 per cent in private facilities. “Only 17.7 per cent of the expected maternal deaths are being reported and analysed while the remaining go unreported. Worse, in 37 per cent of the cases the cause of maternal deaths is registered as ‘other’,” they said.

“Maternal death review is a good thing and not some kind of a blame game. It aims to look into where and how maternal deaths are happening and how these cane be prevented,” says Aparajita Gogoi of the White Ribbon Alliance, working in the field of maternal health and rights.

“The government has given cash incentives to promote institutional deliveries but the communities should also be able to identify signs of emergency and understand the importance of regular ante-natal and post-natal check-ups for safe delivery. The focus should also be on the quality of care,” she said.

According to T.P. Jayanthi, Department of Community Medicine at Kilpauk Medical College (Chennai), in addition to medical causes, maternal death reviews also help us to identify the various contributory factors leading to maternal deaths. It is an important quality indicator to identify our system gaps and community barriers, including some problems that are area specific.

In her analysis of maternal death review process in 10 States between April and December 2011, Himachal Pradesh had reviewed 92 per cent of the reported maternal deaths, Uttar Pradesh 90 per cent, Orissa (79 per cent), Rajasthan (69 per cent), Assam (56 per cent), Uttarakhand (53 per cent), Bihar (38 per cent), Madhya Pradesh (39 per cent) and Chhattisgarh only 18 per cent.

In Tamil Nadu, all the 18 government medical college hospitals are being reviewed under the facility-based MDR programme. The review is being conducted by the Mission Director, State Health society through videoconferencing on the fourth Thursday of every month.

The MDR, even deaths occurring in other departments like Medicine, and Intensive Care Unit which would come under the criteria of maternal deaths are discussed along with the concerned specialist.

 


  • Communities should identify signs of emergency to make use of State incentives: NRHM official
  • MDR came out in 2010 to improve quality of obstetric care, reduce maternal mortality, morbidity

Poem for Mehdi Hassan by Gulzar


King of Ghazls Mehdi Hassan

King of Ghazls Mehdi Hassan

aankhon ko visa nahi lagta
sapnon ki sarhad hoti nahi
band aakhon se roz main sarhad paar chala jaata hoon
milne ”Mehdi Hassan” se

sunta hoon unki avaaz ko chot lagi hai
ab kehte hain
sookh gaye hain phool kitaabon mein
yaar ‘Faraz’ bhi bichad gaye hain
shayad milein woh khawaabon mein
band aakhon se aksar sarhad paar chala jata hoon
milne Mehdi Hasan se…
aankhon ko visa nahi lagta
sapnon ki sarhad koi nahi…

Listen to Gulzar recite the poem

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