Governmental action only after catastrophy has struck

A patient died in a reputed private allopathic hospital in Mumbai due to a wrong blood type administered during transfusion by an homeopathic doctor. This death led to a Public Interest Litigation (PIL) being filed in the Bombay High Court raising issues with regard to the quality of care provided by private hospitals, the type of staff employed, regulation and monitoring systems and the role of regulating bodies.

Private hospitals neither monitored nor regulated

Till recently only the states of Maharashtra and Delhi had an act for monitoring private hospitals. Due to the pressure brought by various consumer organisations, the states of Tamil Nadu and Bihar are in the process of enacting a legislation. There is opposition by hospital owners and medical associations of the particular states to the proposed legisration (See item 21 in Vox Populi).

It is a sad fact that where legislation is already in place, it is not being implemented. It took a PIL to awaken the authorities to implement the provision of the act. The chief justice of the Bombay High Court remarked: “The writ petition has served the purpose of activising the concerned authorities who seem to have woken up and taken certain steps in the direction of implementation of the various provisions of the law.”

The Bombay Nursing Home Act of 1949 is quite inadequate in its various provisions. The act is only meant for registration of the private hospital. It does not cover minimum standards to be maintained with regard to space, facilities, staff employed, sanitary conditions, equipment and other supportive services. It is quite surprising and disgraceful that after fifty years of independence, private hospitals and nursing homes are functioning practically unregulated and, when regulation is being brought in, it is being opposed by vested interests who do not want to be accountable.

This unregulated and unaccountable nature of private hospitals has led to various problems in the delivery of health care. The quality of care provided varies wildly from one such hospital to another. In many cases, there is a lot to be desired.

Statistics on private hospitals not available

The Government of India and those in the states do not have reliable information on the number of private hospitals functioning in the country. According to Health Information of India, 1992, brought out by the Central Bureau of Health Intelligence, Ministry of Health, Government of India, there were only 1,319 private hospitals in Maharashtra. But the Bombay Municipal Corporation, alone, declared the presence of 907 private hospitals in Mumbai when questioned by the court during the PIL referred to above. Even this figure from Mumbai is an underestimate.

If one was to seek from authorities information on hospitals by sizes (small nursing homes, medium sized nursing homes, small hospitals, large hospitals, private teaching hospitals); details on staff and equipment in each; types of cases treated; diagnosis; type of treatment provided; outcome of treatment; mortality figures and statistical analysis of medical data from each hospital one would face incredulous, blank visages. Such data is just not available. Worse, since no records are maintained by many of these hospitals, there is no way anyone can ever get such information!

Only in the recent past have attempts been made by researchers and the media to study various aspects of the functioning of private hospitals. These studies have shown a variety of unpleasant facts on the functioning of private hospitals.

Some perturbing findings

A large majoritv of the private hospitals in the country have less than thirty beds and most of them are run by individual proprietors. The number of hospitals which are run by entrepreneurs and corporate houses who appoint doctors and other staff to run the hospital is relatively small.

There is a misconception being perpetuated that private hospitals provide care of good quality. This is not supported by facts. The findings of the various studies conducted on private hospitals show that the condition of many of the private hospitals and the quality of care provided leave a lot to be desired. This is a consequence of the fact that they are not regulated and monitored.

In the premier city of Mumbai, a study showed that 62.5% of the hospitals were located in residential premises and 12.5% were in sheds which had roofs of asbestos or tin. Of the twenty-two hospitals that were supposed to have operation theatre facilities, only fifteen had a designated area for this purpose. In seven hospitals the operation theatre was also used as the labour room. In many hospitals, the operation theatres were located in the kitchen of the flat, with leakages through their roofs and paint peeling off their walls. In one instance, the operation theatre was located below a toilet block and fluid from the toilet was leaking through the roof into the area where operations were being performed! Seventy-five percent of the hospitals did not have separate scrubbing and sterilising rooms. Many hospitals were not equipped to handle emergencies and did not have supportive services such as generators.

Most private hospitals function with unqualified and inadequate staff. In another study thirty-nine percent of the hospitals were functioning without either a full-time doctor or a visiting consultant. 29.6 % of hospitals were run by non-allopaths but these doctors prescribed allopathic drugs. In 10% of cases, these doctors functioned in isolation. Patients in intensive cardiac units are left to the mercies of homeopaths or ayurveds. In one case a non-allopathic doctor also performed surgical operations using allopathic techniques and drugs.

Only three qualified nurses could be found in the entire sample of fifty hospitals studied. Many doctors boast of the fact that they have trained the ‘nurses’ who were also assisting them in the operation theatres. When asked why these nurses are not certified by the Nursing Council to ensure adequate training, these doctors remain silent.

With regard to equipment and instruments, too, private hospitals were found to cut corners. An oxygen cylinder was available in only half of hospitals claiming to be providing obstetric and gynaecology services. A labour table was available in only three-fourths, and a suction machine in eight out of ten of them.

With regard to surgical services, only a third of the hospitals studied had an X-ray machine, half had an oxygen cylinder and a third possessed an electrocautery unit. None of the hospitals had a Boyle’s apparatus for conducting general anaesthesia.

The sanitary conditions in private hospitals are also appalling. In both the studies quoted above, the hospitals were seen to be congested, lacking adequate space, with narrow and crowded passages and entrances, dirty beds, sheets, pillows, insufficient lights and ventilation and lack of privacy for the patients. Catering to a patient who suddenly took a turn for the worse was impossible under these conditions for there was no space around the patient’s bed for any intervention and there was no way such a patient could be shifted out immediately for transfer to an intensive care area. The number of toilets and bathrooms were not in adequate proportion to the number of beds provided.

In nearly all the hospitals it was found that the waste disposal was shocking. Most deposited it into the common garbage dump of the locality. There was no segregation of gauze and dressings soaked by blood or exudates. Sharps were not destroyed before disposal.

If these are the findings in the city of Mumbai and in an average district of Maharashtra, can you imagine the condition of private hospitals in states such as Bihar, Uttar Pradesh, Rajasthan, Orissa and Madhya Pradesh?

Doctors in private hospitals tend to ask for many more tests than are required on clinical grounds and perform unnecessary operations. The Kerala Shashtra Sahitya Parishad study revealed that of the total number of Caesarean deliveries conducted, seventy percent were performed in private hospitals. Tests and cross-consultations are often recommended because of the kickbacks received rather than for the actual diagnosis.

When, however, patients in private hospitals develop complications, they are promptly referred to public hospitals so that the doctors under whom these complications developed are not liable when death follows and their images remain untarnished. Most private hospitals refuse admission to accident cases (even if the accident occurs next to the hospital) and those involving medico-legal work even when the patient is in a serious state.

Fees

Another major problem related to private hospitals is with regard to the fees charged. There are no restrictions on what is to be charged and no fixed basis for levying such charges. There are no guidelines on fees charged by private hospitals. Fees are often irrationally exorbitant.

Public scrutiny

What, then, needs to be done if these private hospitals are to be forced to attain and maintain an uniformly high standard?

First of all, we need national, enforceable guidelines categorising private hospitals, by size and laying down the minimum requirements to be fulfilled by each hospital in each category. These guidelines must encompass standards on location, layout, environment, approaches, architecture, equipment and staff. Stringent guidelines are necessary to ensure that whilst a fair financial return is ensured to the person(s) running the hospital, fees are charged on the rational basis of a nationally and regionally accepted formula.

Private hospitals from the humblest nursing home upwards must be compelled to publish their balance sheets and statistics on patients treated during each financial year.

Given the dismal. state of our body politic, such steps are unlikely to be taken for quite some time. Can anything be done in the meantime?

All aspects of the functioning of private hospitals must attract a closer look by consumers. Citizens must make their demand for regulation of private hospitals in the country heard by those in power.