What Karnataka’s pitched battle between private doctors and public health activists is all about

The Karnataka government will try to pass an amendment to the Karnataka Private Medical Establishments Act, 2007 in the assembly session that begins this week in Belagavi.

However, doctors with private medical establishments have been strongly opposed to some of the proposed amendments. The Indian Medical Association in Karnataka has called for doctors to march to Belagavi on Monday to register their protest. Out-patient services in private hospitals across the state may be affected as thousands of doctors are expected to join the March. Private hospitals across the state had closed their out-patient departments on November 3 in a similar protest.

“We are not opposed to the entire Act,” said Dr Ravindra HN, president-elect Indian Medical Association. “But the health minister is trying to pass an amendment which is draconian in nature.”

The Karnataka Private Medical Establishments Act, 2007 was passed with the aim of regulating private sector medical establishments. The Act mandates registration of all private medical establishments, charts out the obligations like maintaining records, prescribes minimum standards of facilities and services provided in the private medical establishment and mandates displaying rates of various procedures. But the Act has no teeth, say health activists. The government is now trying to strengthen the law to include prices caps for medical treatments and procedures and to strengthen grievance redressal systems.

Public health activists in the state have welcomed these changes.

“We need some control mechanism that can take action against those who violate patients rights or medical ethics,” said Narsimha Murthy from Slum Janandolana Karnataka that works for the rights of slum dwellers.

Murthy recalled a case from 2016, when his organisation tried to help file a case against a nursing home in Tumkur for inflated bills. The nursing home treating a man who had consumed poison told his family that we had to be kept on ventilator for two days but then kept him on the ventilator for 10 days instead.

“We tried to file a police complaint,” said Murthy. “After first agreeing to file a complaint, the police later tried to file a complaint against the patient and harassed them.”

Murthy said that Slum Janandolana Karnataka had seen many such complaints where the private medical facilities have harassed poor patients who had no legal recourse. This despite Karnataka having a statewide law to regulate private medical establishments.

The Slum Janandolana Karnataka is among the 16 organisations of health activists, labour rights organisations, sex workers, and women’s rights groups that have pushed for the amendments to the Act, which they believe is pro-people.

Karnataka passed the Karnataka Private Medical Establishments Act three years before the union government passed its Clinical Establishments Act – a law to regulate all health establishments in the country – in 2010. But only 11 states and union territories adopted the Clinical Establishments Act so far.

Yet, Karnataka has not been able to implement the Karnataka Private Medical Establishments Act, properly. For instance, several private medical establishments are still not registered by district authorities.

“We agree that the implementation has not been good,” said Kumar. “We feel the amendment will help us implement the Act better.”

While some news reports suggest that Karnataka Chief Minister Siddaramaiah will review the The Karnataka Private Medical Establishments (Amendment) Bill, 2017, the Health Minister Ramesh Kumar maintained that the Bill will be passed in its current form.

“We are going ahead with the Amendment Bill,” said Kumar. “We believe these private medical establishments need to be regulated. There is a large information asymmetry between the medical establishments and the patients. The establishments know a lot while the patients know too little.”

Taking note of the protests against the amendments, the state government made some concessions by tweaking the Bill earlier this month. One of the changes is addition of a provision that says no court can take cognisance of a complaint against a private medical establishment unless the district authority that registers such establishments submits a complaint to the court in writing. But these changes have not appeased protesting doctors.

No legal framework for patients’ rights violations

The Amendment Bill makes a significant change by drawing up a patients’ charter that talks about the right of the patient to receive care irrespective of caste, social status, and gender. The Bill emphasises the importance of informed consent with patients being given complete information including about costs procedures, risks and benefits before the treatment is started.

The Bill also proposes the creation of district grievance redressal committees that can look into complaints, especially about violations of patients rights. This, the Indian Medical Association says, is unnecessary.

“We have the legal framework to handle such complaints,” said Ravindra. “We have the Consumer Protection Act, or [a patient can] lodge a complaint with the Karnataka Medical Council. If it fits, [a patient] can also file criminal cases in the court.”

However, the current laws do not work to protect patients’ rights, said Akhila Vasan who works with the health right movement Karnataka Janaarogya Chaluvali. Vasan cited the cases from 2015, when private hospitals in Kalburgi district were reported to have performed thousands of unnecessary hysterectomies on women just to be able to charge for the procedures. During an enquiry by district health authorities, many hospitals refused to part with their documents. In 2016, the people running these errant private establishments could only be booked for non maintenance of records under the Karnataka Private Medical Establishments Act, relevant sections of Pre Conception and Pre Natal Diagnostic Techniques Act, 1995 and the Bio Medical Waste (Management and Handling) Rules, 1998.

“In cases of gross violation of rights of the patients, the [current] Karnataka Private Medical Establishments Act is inadequate,” said Vasan.

The Amendment Bill extends the section on penalties. In the 2007 Act, only people who ran medical establishments could be penalised. These penalties were for running medical establishments without registration (a maximum jail term of seven years and a fine) and not maintaining clinical records (six months in jail and fine). The amendment proposes penalising doctors for not displaying rates for treatments on the premises of their establishments.

Price caps

The clause that doctors are most worried about is the one that proposed capping prices for medical procedures and treatments.

Ravindra said that the government has no right to fix rates for treatment and procedure. “They can only fix rates for state health insurance schemes,” he said.

Dr BS Ajaikumar, president of the Association of Healthcare Providers India, said for years the private sector cross-subsidising healthcare, charging rich patients more while charging poorer patients at concession rates. “If the price is fixed, many nursing homes in the rural areas will shut down (because they will not be able to cope with prices),” he said. “We cannot have the same price for a procedure from Bengaluru to Belur (a town in Hassan district of Karnataka).”

Vasan said that there is no basis to the statement that smaller establishments will shut down because of price caps.

Other public health experts pointed out that the private healthcare sector has found ways around price cap before. “When the price of stents were capped, the private sector decided to increase the rates of procedures and doctors fees,” said Dr Abhay Shukla, who works with the health rights organisation Saathi in Pune. “We have to understand that health care is essential services. Nobody wants to buy hospitalisation care. People spend on health care under duress.”

He said that the government can consider differential pricing for rural and urban areas.

Why not include public hospitals?

The IMA also also said that the Bill was discriminatory because it does not bring public sector hospitals into its ambit. “The private sector covers 80% of the health sector, and are filling in for the government,” said Ajaikumar. “They do not mind lower standards for public sector, whereas higher standards for us.”

Health Minister Kumar said that the government already works under a framework under the Directorate of Health Services that keeps their establishments accountable. Besides, the standards for the hospitals are already set by the central government under the Indian Public Health Standards.

Shukla disagrees on this count and believes that public health facilities, which have additional responsibilities of providing free immunisation, carrying out disease surveillance and handling epidemics, can also be held to the same standards as private facilities. “While we can agree public medical facilities need to have standards and should be regulated, we should perhaps have a caveat that they cannot shut down if the standards are not met,” he said. “The drop in standards should be treated as an emergency and should be improved.”

Other activists agree that there should be better standards for government hospitals too, but since more people access private hospitals, they need to be more transparent.

“We direct people who ask for our help to the public sector, but often the private hospitals are nearby,” said Gauri from Mahila Munnade, a women’s rights organisation. “Many women have complained that they have been given exorbitant bills. We have not been able to get any help for them. We need the government to have some control over them.”

Said Vasan, “If [private medical establishments] provide 80% care in the health sector, then you should also be regulated democratically accountable.”