ISSN (Print) - 0012-9976 | ISSN (Online) - 2349-8846
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EWS Beds in Delhi

Private Profiteering on Public Sufferings

Siddheshwar Shukla (siddheshwar.shukla@gmail.com) is a senior journalist based in New Delhi.

In 2007, the Delhi High Court ordered all private hospitals in Delhi having the free treatment condition for economically weaker section patients in their lease deed to provide free treatment to 10% poor inpatients and 25% poor outpatients. This article analyses the monthly reports of “percentage bed occupancy” of the ews beds in 34 private hospitals from 2012–13 to 2015–16. The bed occupancy of 41% hospitals was below 10% and only two hospitals featured more than 30%. A number of loopholes need to be plugged by the custodian of the public properties, which is the state in this case, to ensure that the public partners who are the poor patients are welcomed and provided non-discriminatory health services without any fee.

The state, in pursuance of its social responsibilities bestowed on it by the Constitution,1 has been providing various concessions, including highly subsidised land at prime locations to the entrepreneurs and voluntary organisations to construct and operate hospitals in different parts of the country. This public–private partnership (PPP) to provide quality health services has existed since decades and the private partners have been claiming to extend the benefits to the economically weaker section (EWS) patients through charity. In 1973, the Land and Development Office (L&DO) of the Delhi administration2 allotted land to a trust for a 100-bed hospital in the posh Chanakyapuri area. The agreement called for providing free treatment to the EWS patients and it was inserted as a precondition and enforceable clause in lieu of the concessional land. The hospital management promised to reserve 70% of its beds completely free for the EWS category patients while the government approved reasonable rates were to be charged for the remaining 30% beds. Thereafter, the L&DO and the Delhi Development Authority (DDA) allotted concessional land to several trusts and non-governmental organisations (NGOs), and the clause of providing free treatment to the EWS patients were inserted in their lease deeds. The percentage of free treatment in the inpatient department (IPD) and outpatient department (OPD) categories, however, differed from hospital to hospital since there was no uniform policy. But none of the hospitals which signed such agreements met the requirement, and some of them even shut their doors for the poor and ran their hospitals as private business ventures.

However, as per their lease deeds, the landowning agencies (DDA and L&DO) were empowered to cancel the allotment and take over the hospital but these hospitals were part of a strong lobby that thwarted all attempts by the enforcement agencies to get them to implement the relevant clause. The Delhi administration even constituted a committee under Justice Qureshi3 to sort out the issue. After wide consultations, the committee recommended that, irrespective of their agreement, each hospital should provide 10% of its IPD and 25% of OPD facilities completely free to EWS patients. The hospitals refused to implement the recommendations. In 2002, the Social Jurist4 challenged 20 such private hospitals5 in the Delhi High Court through a public interest litigation (PIL) for not implementing the clause of free treatment for EWS patients in their lease deed and prayed that the high court order the Delhi government to implement the Qureshi Committee’s recommendations.

The Delhi High Court in 2007 ordered6 all the 20 hospitals to implement the recommendations of the committee and directed the Delhi government to form a committee to monitor the implementation. Additionally, it also asked the government to constitute a high-level committee to impose fines on the hospitals which earned undue profits by not providing free health services to the poor prior to the judgment too. All the hospitals challenged the Delhi High Court order in the Supreme Court but the apex court upheld the high court’s ruling. Five7 hospitals are still fighting a legal battle in the Supreme Court to be exempted from the liability net.

This article makes an effort to present a quantitative evaluation of the free health services being provided by these hospitals in pursuance of the above order of the Delhi High Court. The data provided by these hospitals to the Directorate General of Health Services (Dte gHS), the National Capital Territory (NCT) of Delhi (Delhi Government) has been used for quantitative evaluation besides the data and information obtained by the EWS Monitoring Committee (set up in accordance with the high court’s ruling) during its surprise inspections were also obtained for the study. As the hospitals are required to provide free treatment facilities to EWS patients without any discrimination, a survey was also conducted to present a qualitative analysis of the free health services to the poor. The data obtained from Right to Information (RTI) queries, the EWS beds online system, reports of the EWS Monitoring Committee, judgments of the Delhi High Court, and the National Health Policy, 2015, have also been used in the study.

An analysis of various PPP models in the hospital sector has also been presented.

EWS Scheme in Delhi

The first private hospital to get concessional land from the government was the Veeranwali International Hospital which was allotted two acres of prime land in Chanakyapuri, the diplomatic enclaves area in New Delhi on 6 August 1973 by the L&DO of the area. The second hospital to get concessional land from the same government agency on the same conditions was the Vimhans PrimaMed Super Speciality Hospital in Nehru Nagar which was allotted 3.5 acres of land on 2 June 1984. The remaining 18 hospitals mentioned in the original PIL were allotted concessional land by the DDA on the condition of providing around one-third beds and free OPD services to the EWS category patients besides reasonable charges for the general patients. The Delhi High Court had ordered all the 20 hospitals and other identically situated private hospitals to provide free treatment to this8 category of patients as per the recommendations of the Qureshi Committee, and also directed the Delhi government to constitute a three-member inspection committee with jurist Ashok Agarwal as member; having powers to inspect these private hospitals regarding compliance and report to the court for revival of the petition in case of violations. In pursuance of the order, the Delhi government constituted the EWS Monitoring Committee with director, Delhi Health Services (DHS) as its chairperson and the medical superintendent, DHS, jurist Ashok Agarwal and the medical superintendent of the private hospital under inspection as its members.

The court also directed the Delhi government to constitute a special committee, within six months of the judgment, comprising the chief secretary of the Delhi government, finance secretary of the DHS, and the medical superintendent of the general public hospital of the concerned area. The committee would be responsible for appointing accountants for inspection of records to estimate undue profits accumulated by the private hospitals by not providing free EWS health services in the past. The amount thus recovered would be deposited in the central corpus/pool under the DHS and utilised to grant aid and/or upliftment of health standards of the poorer section of the society in Delhi.

After the judgment, 22 more hospitals were included in the scheme by 2010 either voluntarily or in pursuance of the directions from the court. At the time of the study, there were around 640 EWS beds available in the private hospitals where EWS category patients could avail totally free health facilities at par with the patients who pay as per market rates. The government started an online system to provide information related to real-time availability of EWS beds,9 and also an online monitoring system besides deployment of patient welfare officers (PWOs)10 to assist the EWS patients.

The importance of the PPP in hospital sector has been asserted in various policy documents like the Twelfth Five Year Plan11 and the National Urban Health Mission (NUHM)12 to attract social entrepreneurs. These policy documents, however, did not recommend any PPP model for the construction and operation of hospitals but left it to the government agencies to devise the model or even proceed without any distinct model of sharing investment and shouldering responsibilities.

In developed countries, different PPP models (James et al 2013) are used in the hospital sector based on the degree to which the services and responsibilities are fixed in the agreement. The accommodation-only model is popular in the United Kingdom (UK), Italy, France, Spain, Portugal, Sweden, Canada and Australia. This model is also known as the design, build, finance, operate (DBFO) or build, own, operate, transfer (BOOT), wherein public bodies enter into a contract pertaining to hard facilities like building and maintenance besides some soft facilities like cleaning, catering and non-clinical services.

Another model which is considered an extension of the accommodation-only model aims to create a special purpose vehicle (SPV)—InfroCo, responsible for development and management of buildings while ClinCo, takes care of clinical services. This model is popular in Portugal wherein government agencies sign agreements with different companies to construct/maintain and operate the clinical facilities. In Germany, the government agencies sell their financially strained hospitals to private agencies which run the facility under a franchise from the states. The full-service provision model is implemented in Ribera Salud, Spain wherein a private body takes up the responsibility to build and operate the hospital for a geographic area from its own facilities, and regulatory and payment mechanisms maintain quality. A holistic study of the agreements signed by various government agencies with private hospitals along with the recommendations of the Qureshi Committee and the judgment of Delhi High Court can create a new PPP model for hospital construction and operation which could be an ideal one for Delhi and the rest of the country as also for other developing countries. Its merit is that it does not require any monetary investment from the public partner but only efficient monitoring after the hospital becomes operational. Furthermore, the public partner is free to define the EWS category as per regional variations and requirements. In 2010, the DDA allotted land to two new hospitals, the VPS Rockland Hospital, Dwarka and Max Super-specialty, Shalimar Bagh. The condition-free treatment to EWS patients was inserted as a pre-auction clause and also in the lease deed agreements. The new model could be along these lines:

(i) The public partner would provide concessional land or free land on lease for a specific period to the private body/charitable trust.

(ii) Both partners can either sign an agreement to provide 10% IPD and 25% OPD services completely free to EWS patients or calculate the monetary value of the land and fix the percentage of free treatment to EWS patients on a pro rata basis. As per their requirement, the clause of health services on reasonable price could also be included for the patients of a certain geographical area, or government employees. This will also help in adopting an inclusive approach at a time when farmers/small landowners feel alienated due to land acquisition.

(iii) The private body will be fully responsible for construction and operation of the hospital, including all the clinical and non-clinical services. The condition of free health facilities will be applicable as soon as the hospital starts operation and extends free health services without any discrimination.

(iv) The landowning government agency (public partner) will sign the agreement on behalf of public (potential beneficiaries). After the hospital is partially/full operation, the government agency shall be responsible for execution and monitoring of the free services to ensure benefit goes to the public partner (potential beneficiaries on behalf of whom the agreement was signed). The government agency can also impose cost on the private partner if they use the beds/facilities of public partner for paid customers. The money collected in this way should be used in patient welfare activities increase shares in the hospital/investing in new hospitals/purchase new instruments.

(v) In the case of repeated violation, the public partner shall have the right to cancel the lease deed and engage the new management to run the hospital. The maximum permissible limits of violations must be recorded in the lease deed. The facilities in these private hospitals could also be used to decongest nearby government hospital with a well-established referral system.

Implementation

In compliance with the Delhi High Court’s order, the Dte GHS, Delhi government appointed a medical superintendent13 level official as in charge of the EWS cell and also constituted the EWS Monitoring Committee. The hospitals were required to submit reports on the number of IPD and OPD patients treated by them and percentage of EWS beds in their hospitals. These reports were earlier highly irregular but the Aam Aadmi Party (AAP) government has launched an online management information system (MIS) where all the information regarding patients is available on a daily basis besides percentage availability of free EWS beds for any specific period. The new dispensation also relaunched an online portal called “real-time availability of free beds”14 for better information and coordination. The reporting of EWS OPD services was still being done through the old system of manual reporting at the time of the study.

The implementation of the scheme has been evaluated on two aspects, namely quantitative and qualitative. In the quantitative evaluation, four years data of percentage occupancy of EWS beds in the private hospitals obtained from MIS are analysed. As the AAP government often reiterates its commitment to ensure rights of the poor people in EWS beds scheme, the data of the financial year 2015–16 has been analysed for each quarter. A sample survey of hospitals was also conducted to evaluate the quality of the services they were providing to the EWS patients (see Appendix, p 57).

The Reality

The first quarter of the financial year 2016–17 was chosen for the survey and at that time there were 42 private hospitals in the scheme out of which seven were providing services voluntarily. The government had authority to enforce the free treatment scheme in only 34 hospitals which were liable for free EWS treatment as per their lease deed so were considered to be “universe.” Based on the annual “percentage occupancy of EWS beds” in these hospitals for the period of study, they were classified into three groups: having bed occupancy below 10%, hospitals with bed occupancy of more than 10% and hospitals with bed occupancy of 10%. The stratified proportionate random sampling method was used and nine hospitals were selected for the survey. Among the selected hospitals, three were in East Delhi, three in South Delhi, two in Dwarka and one in New Delhi while the size of the sample was 26.47% of the universe.

In each hospital 10 OPD and 10 IPD patients were selected. Besides, separate interview schedules were also used for the liaison officer deployed by the government in these hospitals for assisting the EWS patients. The senior government officers involved in the implementation of the scheme and nodal officers of the hospitals for the EWS were also interviewed besidesmembers of the EWS Monitoring Committee with the help of an interview guide. The findings of the survey can be summarised as follows.

IPD facility: Eighty percent of the patients admitted in the IPD of these hospitals accepted that they were not charged any fee and all the medical tests, consultancy, consumables and medicines were being provided free of cost while 20% patients complained about some charges. The liaison officers and nodal officers argued that the patients are charged for a few diagnostic services/consumables which are outsourced by the hospital. The complaints of being charged were confined to 22% of the hospitals. The major complaint by the liaison officers was rather long dates for surgery given to the EWS patients, which force them to either wait/go back to government or charitable hospitals or approach less costly private hospitals. The average waiting time for surgery of EWS patients in these hospitals was four to six months while the intensive care unit (ICU) beds of the EWS category were lying vacant. The waiting period for surgeries of some patients was between nine months and a year. There was no such waiting time for paid category patients. Forty-four percent of the hospitals gave dates for surgery while 33.3% did not do so but called the patients as and when a surgeon and EWS ICU beds were available. The liaison officers of 22.2% hospitals complained that the concerned hospitals had not conducted a single surgery and had forced patients to go back to the government hospitals from where they were referred. A total of 77.8% hospitals were found running separate EWS wards—general and ICU. In 11.1% of the hospitals, huge discrimination was found between EWS and paid wards. The latter were air conditioned while the EWS wards had fans, less staff, less hygienic facilities, insufficient toilets, and fewer attendants.

In 66.7% of the hospitals, the total beds earmarked as EWS ones were less than the required 10% of the official bed strength of the hospital. The nodal officers of 44.4% of such hospitals said that if the EWS wards were filled they adjusted the EWS patients in the “paid wards” to meet minimum requirements, while 33% of the hospitals replied that they are partially functional and EWS bed strength is 10% of the total functional beds. The liaison officers attributed the long wait list of surgery patients to less number of EWS ICU beds in these hospitals and their reluctance to admit critical patients considering the high cost of treatment in such cases.

OPD facility: Nearly 55.6% of the hospitals have separate OPD facility for EWS patients. These are run at an isolated space/counter away from the OPD for paid patients. Here too, 92.5% of the patients accepted that they were not charged money but 56.3% were not satisfied with the treatment and alleged discrimination. However, the government has directed hospitals to admit poor patients on the basis of “self-declaration of income” forms but the hospitals neither provide such forms nor do they accept them. All the liaison officers admitted that the hospitals accept only below the poverty line (BPL) cards and income certificate not older than six months to extend free treatment facilities under the EWS category.

Discrimination against EWS patients: Nearly 61% of the patients reported discrimination in these private hospitals with 77.8% OPD and 44.4% IPD patients saying so. The major forms of discrimination was mistreatment by doctors, long wait for being attended, being forced to visit the hospital several times because the concerned specialist was “not available,” delay of surgery, limited number of medicines and pathological tests being available, etc. The liaison officers and their senior officers also admitted receiving regular complaints against such hospitals which were dealt with on a case-to-case basis.

Little Profit, Big Loss

The Indraprastha Apollo Hospital, a joint venture of the Apollo group and Delhi government is operated by a SPV—namely the Indraprastha Medical Corporation Ltd (IMCL). It provides free health facilities minus medicines and consumables to the EWS and government or member of the legislative assembly recommended patients. But, this case is entirely different from that of the other hospitals in three aspects—the land was provided completely free, government invested money in this project, it was specifically established to provide free treatment to poor patients and deemed to act as subsidiary to the public health system.

In 1986, the Delhi administration invited expression of interest in running a multidisciplinary super-specialty hospital in the unoccupied Players’ Building, presently the Delhi Secretariat building, on a “no-profit, no-loss” basis. In the advertisement it was clearly mentioned that the operator of the hospital would provide free health facilities to one-third of its IPD and 40% OPD patients without any discrimination. There were 25 applicants. Pratap C Reddy, Chairman of Apollo Hospitals Group submitted a separate proposal in which he put down his terms and conditions. These were: the hospital after completion would treat 10,000 IPD and 30,000 OPD patients every year, one-third of the free IPD was further divided into three parts—free of cost health facilities to 10% patients, 10% patients to pay for medicines and consumables and the remaining 10% to pay subsidised rates. This was accepted and the Apollo group was permitted to run the 600-bed hospital.

As the building was required by the government, the Apollo group was provided 15 acres of land on a lease of ₹1 for 30 years at a prime location in Jasola in 1997, where it is presently situated. It was also given ₹14.83 crore through an interest-bearing account for construction of the building. The government also pumped in ₹23.83 crore to constitute a SPV called the IMCL, to construct and operate the hospital but with a rider that the free facility would be provided only after the hospital became fully functional—the average bed occupancy remains at 65% for minimum six months. Thus the government invested 15 acres of land plus ₹38.66 crore in the hospital in 1997. The hospital allocated 26% share to the government for its investments. The hospital was dragged to the Delhi High Court by Social Jurist for not extending its facilities to the poor patients. The hospital administration which also comprises the Delhi Chief Secretary and Health Secretary, argued in court that the hospital is liable to provide free treatment to the poor only after it is fully functional which means minimum 65% bed occupancy continuously for a minimum six months. The hospital also argued that the government does not have the right to demand free treatment for the poor as it is only an investment partner like other partners. But the high court15 on 22 September 2009 ordered the hospital to provide free health facilities to one-third IPD and 40% OPD patients. The case is pending in the Supreme Court. However, the hospital partially implements the decision but has been accused of denying admission to poor patients (Millennium Post 2016a; The Caravan 2015). The Delhi government annually receives a pittance for its investment in the hospital. The hospital does not release data on the poor patients it treats for free (Millennium Post 2015).

Conclusions

Martin Luther King Jr16 has said, “Of all the forms of inequality, injustice in health care is the most shocking and inhumane.” The above study reveals that the private partners (trusts or NGOs) which approach government agencies with laudable promise of charity and manage lands at prime locations either free on lease or on highly subsidised price, have a hidden business agenda. The sufferers are the EWS patients who are the potential beneficiaries of the scheme for whom the government agencies had signed agreements with private bodies to construct and operate hospitals in the first place. The agreements even have a clause that says that in case the hospital fails to provide or denies free treatment, the government agencies would have the power to cancel the lease deed and take/hand over the hospital to a new management. In all the agreements, the EWS patients were shown as public partner on behalf of whom the custodian of the public properties, that is, the government agencies had signed the agreements. The private partner never welcomed the public partner in the PPP model and indulged in undue profiteering. The government agencies deserve appreciation for signing agreements which became the legal ground to nail the private partners. But they have not been successful in enforcement and monitoring.

The government agencies need to design effective monitoring strategy and implement it with a vision that the private partner is not providing “free health facilities” to EWS but paying back dividends for the investment it had received in the form of free/concessional land from the custodian of the public that is the concerned government agency. Thus, the private partner was paid in advance to provide cashless health service to the public partner, that is, the EWS category patients. In response to an RTI query, several state governments like that of Uttarakhand, Gujarat, Odisha, Chandigarh and Uttar Pradesh admitted that they neither have any policy to provide land to private parties to set up hospitals nor any provision to provide free treatment to the EWS category patients. The Mizoram17 government admitted that it does not provide any concession of any type to set up private hospitals nor is there any scheme for the EWS.

Notes

1 The Article 47, Directive Principles of States Policy, Constitution of India states—“Duty of the State to raise the level of nutrition and the standard of living and to improve public health.”

2 Before 1993, Delhi was Union Territory so referred as Delhi administration. Now its Government of National Capital Territory (NCT) Delhi (Delhi government). Hereafter, Delhi government.

3 Delhi government wide Notification No F.13/36/99-DHS/NH/pet.File/340 dated 12 June 2000 constituted a committee headed by Justice A S Qureshi (Retd). The committee recommended that the private hospitals which obtained free/ concessional land shall provide completely free treatment to 10% IPD and 25% OPD services to EWS category patients. It also recommended the government to cancel the lease deed in case of persistent violation of these norms and allot it to new management.

4 Social Jurist, an NGO led by Delhi-based lawyer Ashok Agarwal.

5 These hospitals are multi-specialty corporate hospitals and run by big players in hospital sector like Max Super-speciality, Fortis, Escorts, Apollo but referred as private hospitals as used in government documents.

6 Delhi High Court/ WP (C) 2866/2002.

7 RTI ID No 2015130 dated 1 April 2015. Mool Chand Khairti Lal Hospital, St Stephens Hospital, Sita Ram Bhartia Institute of Research Science, VPS Rockland Hospital in Qutab Institutional Area, Rajiv Gandhi Cancer Institute and Research Centre.

8 As per the order, a family having income below ₹5,000 per month were made eligible for free health benefits under the EWS category. Later on Delhi government linked it with the minimum wages for unskilled labour in the city which are revised from time to time. Besides, below the poverty line (BPL) cardholder families are also entitled for the benefits. The minimum income for EWS category is presently ₹9,540 per month.

9 See “Availability of Free Beds,” http://dshm.delhi.gov.in/mis/(S(c0zdupc4ccbuln35qynvba2v))/Private/frmViewMapinBlock.aspx.

10 See “List of Nodal Officers with Telephone Number of Private Hospitals,” http://www.delhi.gov.in/wps/wcm/connect/doit_health/Health/Related+Links/Information+Regarding+Fee+Treatment+in+Private+Hospitals/. The new government has replaced doctors with nursing staff and claims to have improved the services.

11 See Twelfth Five Year Plan (2012–17), Social Sectors, Part III, Health, Twelfth Plan Strategy, pp 8–10.

12 See NUHM 2013, Para 5.2 and Para 6.0.2.

13 The new government under the Aam Aadmi Party has appointed additional director-level officer to head the EWS cell. The cell is responsible for assisting EWS patients, addressing their grievances, collecting reports from hospitals and conducing surprise inspections.

14 The webpage for free beds existed before the AAP government. See “Free Treatment of EWS People in Private Hospitals in NCR Delhi” at http://pib.nic.in/newsite/PrintRelease.aspx?relid=113446.

15 WP (C) No 5410/1997.

16 Delhi High Court, WP (C) 7279/2013.

17 RTI No D 28019/70/2015-DHME/ESST/Vol- II dated 21 October 2015.

References

Down to Earth (2014): “Delhi Hospitals Freed of Poor,” 3 May, http://www.downtoearth.org.in/coverage/delhi-hospitals-freed-of-poor-44376.

Hindustan Times (2015): “Dengue Sting, Deaths Spur Delhi Govt into Action,” 16 September, http://www.hindustantimes.com/delhi/dengue-sting-deaths-spur-delhi-govt-into-action/story-egyrEMWOn55TuJP1Md3efL.html.

James, Barlow, Roehrich Jens and Wrigt Steve (2013): “Europe Sees Mixed Results from Public–Private Partnerships for Building and Managing Health Care Facilities and Services,” Health Affairs, January, pp 146–54.

Millennium Post (2014): “Hippocratic Loath! How Top Delhi Hospitals Keep Out the Poor,” 14 August, http://www.millenniumpost.in/NewsContent.aspx?NID=65727.

— (2015): “Apollo a Profit Making Venture for Delhi Govt: RTI,” 20 November, http://millenniumpost.in/NewsContent.aspx?NID=167192.

— (2016a): “Pvt Hospitals Conceal Actual Bed—Strength to Deny EWS Patients,” 21 June, http://www.millenniumpost.in/NewsContent.aspx?NID=304281.

— (2016b): “Pvt Hospitals Deny Surgery to EWS Patients, Cite Fewer ICU Beds,” 20 June, http://www.millenniumpost.in/NewsContent.aspx?NID=304181.

The Caravan (2015): “How a Private Hospital in Delhi May Be Keeping Families Below the Poverty Line from Availing Free Healthcare,” 14 September, http://www.caravanmagazine.in/vantage/private-hospital-apollo-bpl-families-free-healthcare.

Times of India (2016): “Five City Hospitals ‘Fined’ Rs 600 Crore for Spurning the Poor,” New Delhi, 12 June, p 1.

Appendix

The hospitals under free EWS treatment scheme: In its historic judgment1 in 2007, Delhi High Court had initially ordered 20 private hospitals to provide 10% IPD beds and 25% OPD completely free for EWS category patients. The condition of free treatment was clearly mentioned in their “lease deed” of the land transferred to them. They are (1) Gujarmalmal Modi Hospital and Research Center (Max Smart Super-specialty), Saket, (2) Amar Jyoti Charitable Trust, Karkardooma, (3) Indian Spinal Injuries Center, Vasant Kunj, (4) Deepak Memorial Hospital, Karkardooma, (5) Saroj Hospital, Rohini, (6) Kottakkal Arya Vaidya Sala, Karkardooma, (7) Venu Eye Hospital, Saket, (8) Pushpawati Singhania Research Institute, Saket, (9) Dharamshila Cancer Hospital and Research Center, Vasundhara Enclave, (10) Fortis Escorts Heart Institute and Research Center, Okhla, (11) Max Super-specialty (Devki Devi) Hospital, Saket, (12) Max Balaji Hospital, I P Extension, (13) Jaipur Golden Hospital, Rohini, (14) Shanti Mukund Hospital, Vihar Marg, (15) National Heart Institute, East of Kailash, (16) Bhagwati Hospital, Rohini, (17) Mai Kamli Wali Ch Hospital, Rajouri Garden, (18) Bimla Devi Hospital, Mayur Vihar, (19) Dr Vidya Sagar Kaushalya Devi Memorial Health Center (VIMHANS), Nehru Nagar, (20) Primus Super-specialty Hospital, Chanakayapuri. After the judgment, DHS, Delhi Government with Social Jurist scrutinised land allotment letters and lease documents of several hospitals and added five more hospitals in the list in the same year 2007, (21) Sri Balaji Action Medical Institute, Paschim Vihar, (22) Batra Hospital and Medical Research Center, Tughlaqabad, (23) Delhi ENT Hospital and Research Center, Jasola, (24) Bhagwan Mahavir Hspital, Rohini, (25) Jeevan Anmol Hospital, Mayur Vihar. Further scrutiny of land records of private hospitals identified seven more hospitals which had received land on concessional price and were added in the list after 2010, (26) Maharaja Agrasen Hospital, Punjabi Bagh, (27) MGS Super-specialty Hospital, Punjabi Bagh, (28) Vinayak Hospital, Model Town, (29) Guru Harkrishan Hospital, Gurudwara Bala Sahib, (30) Jivodaya Hospital, Ashok Vihar Phase–I, (31) RLKC Metro Hospital, Pandav Nagar, Naraina Road, (32) Jankidas Kapoor Memorial Hospital, Pandav Nagar, Nariana Road. The government included free EWS beds and OPD conditions as pre-auction clause while allotting lands for two new hospitals, (33) VPS Rockland Hospital, Dwarka, (34) Max Super-specialty, Shalimar Bagh.

In its judgment on 28 April 2014, a double bench of the Delhi High Court excluded four (Down to Earth 2014) hospitals, namely St Stephan’s Hospital, Tis Hazari, Mool Chand Medicity, Lajpat Nagar, Sitaram Bhartia Institute of Science and Research, and VPS Rockland Hospital, Qutab Institutional Area from the liability of providing EWS facility on the grounds that there were no such conditions in their land allotment letters or lease documents. The Rajiv Gandhi Cancer Institute and Research Centre pointed out that there was “no condition of free treatment” in their lease deed. Meanwhile, 11 private hospitals which do not have the condition of free treatment in their lease deed (non-conditional) were also voluntarily included in the scheme but three others, the Dr B L Kapoor Memorial Hospital, Pusa Road, R B Seth Jessa Ram, Karolbagh and National Chest Institute, Niti Bagh opted out when the government mounted pressure to meet the minimum criteria, free treatment and non-discriminatory services. The Red Cross Maternity and Child Hospital, Dilshad Garden also joined the scheme but was not submitting monthly reports to the Delhi government at the time of the study.

EWS bed strength: In the course of study of EWS beds in the private hospitals the researcher stumbled upon some crucial facts which are sufficient to reveal that how these private hospitals tactically devised a strategy to ensure minimum expenditure on EWS beds by allocating maximum beds for non-critical patients. First, several hospitals were found showing lesser bed strength (Millennium Post 2016a) so that they are required to allocate fewer beds for EWS patients. Second, the classification of the beds is done in such a way that minimum beds or no beds fall in “critical” category (Millennium Post 2016b) and the arguments of non-availability of critical beds are used to deny treatment for serious or surgical patients. These hospitals have classified their beds into two categories—General Ward and Intensive Care Units (ICU) but they have divided the EWS beds into three categories—Non-critical, Critical without Ventilator (CRWV) and Critical with Ventilator (CRV).

As per the order of Delhi High Court, these hospitals are required to dedicate 10% of their beds for EWS category commonly known as EWS beds. In concurrence with government officers they further earmark 90% of total beds as non-critical. The 10% of the remaining 10% beds are allocated under CRV while rest is CRWV. This division leaves only 1% of seats for critical and high-risk surgery patients. These hospitals themselves use around 30% of their total beds as ICU beds, for instance, Batra Hospital had 382 beds underpaid category out of which 113 beds were in ICU wards.

The result of this is that out of the total 640 EWS beds available in the “free treatment scheme” only 3.9% of the beds belong to CRV category and 9.06% beds are in CRWV category. Out of the 34 hospitals which have the “condition of free treatment in their land deed” (conditional), seven hospitals do not have any ICU beds for EWS patients. There are 486 EWS beds in “conditional” hospitals out of which 2.48% are CRV, 10.58% are CRWV while 86.93% beds are non-CR category. The percent of CRV beds in “non-conditional” hospitals is 8.44% and CRWV is 4.6%. Khosla Medical Institute (five EWS beds) of “non-conditional” category and Kottakkal Arya Vaidya Sala (four EWS beds) of “conditional” category are Ayurvedic hospitals and do not have any ICU beds. Interestingly, in their monthly “EWS Beds occupancy” reports, these hospitals do not give separate data for CRV, CRWV and non-CR category but an aggregate one. The 14 conditional hospitals which consecutively have “EWS bed occupancy” below 10% in 2012–13, 2013–14 and 2014–15 had collectively 0.68% beds under CRV while 9.58% beds under CRWV. The non-availability of CRV/CRWV beds are major reason to turn away or refer serious or surgical patients or force them to shift on paid category beds forcing the relatives to sell out their valuables and immovable properties.

(i) Occupancy of EWS beds: The EWS beds occupancy of 14 “conditional” hospitals is below 10% from 2012–13 to 2015–16. Out of these 14 hospitals 11 had bed occupancy below 5% in 2015–16. The number of such hospitals having bed occupancy below 5% was 10 in 2014–15, nine in 2013–14 and 13 in 2012–13 (Table 1). In the case of “non-conditional” hospitals only two have bed occupancy below 5% since 2012–13 (Table 2). The remaining five hospitals have improved their EWS bed occupancy in 2015–16. The EWS bed occupancy improved in already performing hospitals but dipped to zero in poor performers. In the entire period only one hospital (Venue Eye) had bed occupancy above 30% while two hospitals (Venue Eye and Bhagwan Mahavir) had occupancy above 30% in 2015–16.

In aggregate these 41 private hospitals admitted 37,761 patients on their EWS beds in 2015–16 and provided health facilities out of which 7,760 patients were from Venue Eye Institute, an exclusive eye hospital. The EWS bed occupancy of this eye hospital is all-time high and was 106.01% in 2015–16. It does not have even a single critical (ICU) bed but all the 20 beds are in non-critical category. The officials of EWS cell admitted that this hospital and several other hospitals include their “free health check-up camps” in EWS bed scheme which is violation of the guidelines but they do not take any action as such health campus also benefit poor patients in Delhi and other parts of the country.

In 2015–16, the maximum 10,100 patients were admitted in these private hospitals in third quarter (Q3) (October–November) followed by 9,552 patients in second quarter (Q2). In the first quarter (Q1) this figure was 8,781 patient and 8,964 patients were admitted in Q4 of 2015–16. The increase in number of patients in Q3 and Q4 were due to dengue epidemic in the city and government had allowed all the hospital to increase (Hindustan Times 2015) their bed strength by 10% and increased vigil as the issue came into limelight of media. A month-wise analysis of the data further reinforces the arguments as maximum 3,774 patients were admitted in these hospitals in the month of September closely followed by 3,396 patients in October. It is also clear that the vigil was only for dengue patients as even in this month seven private hospitals had bed occupancy of zero while EWS beds occupancy of another eight hospitals was below 8%. The positive aspect, however, was that the bed occupancy of 38 private hospitals improved significantly as out of eight hospitals which fall within 1%–10% bracket only three were below 5%. The number of patients treated under EWS category beds in the private hospitals in 2014–15 was 36,153 which were 34,725 in 2013–14. In 2012–13, the total number of patients admitted on EWS beds was only 27,146 (Table 3). In a report, the EWS Monitoring Committee had revealed several malicious designs like denying medicines and consumables, including their staff in EWS category to fudge data, over staying non serious patients, etc; adopted by these hospitals to fudge data and turn away/discriminate genuine EWS patients (Millennium Post 2014).

In compliance of the court order, DHS issued an order to the five private hospitals to deposit “unwarranted profits” of over ₹600 crore (Times of India 2016) they had earned by denying free health facility to EWS patients.

(ii) Free treatment to EWS OPD patients: The reporting of free treatment to EWS patients in OPD category is manually furnished by these hospitals. As per the reports with DHS over 6.89 lakh patients were provided free OPD services in private hospitals in 2015–16. A monthly analysis shows that only a few hospitals are meeting the minimum standard for free OPD (Table 4). The availability of physicians and medical experts in these private hospitals could have been used to minimise load of patients in government hospitals and provide them better health facilities through effective monitoring.

1  Delhi High Court/ WP (C) 2866/2002.

Updated On : 4th May, 2018

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