Insurance is no replacement to building strong national health Infrastructure
Corona crisis has brought into lime light the issue of medical ethics apart from the absolute failures of the government to protect people suffering from other diseases. There is no doubt that this is a dangerous virus yet we always believed that human spirit and science will always overcome whatever evils these viruses have but what we have seen is a painful reminder of how human being behaved absolutely unethically. At many places the doctors and other front line warriors were targeted as their localities, which were either posh areas of the cities or middle class localities, for bringing the risk of Corona. The behavior of people with the rural poor was reflection of already disconnected social structure which bothers about its own self.
While we all appreciated and expressed our gratitude towards the doctors and health workers dedicated their lives to protect us but it is also a fact that with growing privatization of these services profit remain the sole motive of them. Can the hospitals really deny patients their right to get treatment? It is also important for the government to fix the amount that should be charged for such treatment as in the absence of a clear guidelines, hospitals are charging beyond limit and when life become more painful than death as after recovering people will only be paying huge debt because of their expensive treatment.
Exorbitant charging by private hospitals
With politicians already embracing the ‘private’ cooperation ( actually corporation) to ‘assist’ our national fight against Corona, they have started charging exorbitantly. Even the southern states which were supposed to be more pro people policies allowed such horrific commercialization of the medical resources. A report published Sunday Guardian says,’
‘Of the around 2,000 private hospitals in Hyderabad, only 30 to 40 are eligible to take Covid cases under the ICMR guidelines. In most private hospitals, the starting packages range from Rs 10 lakh per two weeks’ stay, but some high-end hospitals charge up to Rs 12 lakh for the period. This is in addition to the treatment costs of other ailments (co-morbidity conditions) of the patient. If the stay exceeds two weeks, the patients will have to cough up to Rs 50,000 per day, according to sources from various Hyderabad hospitals. A Covid patient who has been unofficially taking treatment in a corporate hospital in Jubilee Hills in the city since 27 April has been billed for Rs 41 lakh, including costs of other ailments and he is expected to be discharged by Sunday, according to reliable sources in the hospital. Patients like him now can officially get admitted to private hospitals from now[i]’.
Another report published by Sunday Express provide horrific tale of a family who were forced to pay over four lakh rupees by the Max hospital in Delhi. Surendra Gaur said, “They had charged us Rs 70,900 just for PPE kits… They also charged a hefty fee on per day visit of a specialised doctor who hardly visited seven times, whereas in the bill it shows 22 times. Per day charge was said to be Rs 30,000 and the two days he was admitted to the private ward we were charged Rs 55,000. The senior doctor whose scheduled visit has been mentioned in the bill never showed up. The total bill was Rs 4.08 lakh[ii]”.
It is difficult for an average family to get treatment at the hospital as people may not know the exact bill in the beginning. The hospitals are charging hugely for ICU, ventilators, doctors consultation as well as PPE. As the number is increasing those who have mediclaims or medical facilities are using them. This has also put the insurance companies into a rethinking mode as it would become difficult for them to clear everything if the hospital continues to ‘overcharge’. In fact, many of them go bankrupt if the government doesn’t step in. It will also bring a disastrous impact on the uninsured patient. A report from The Mint gives details of how things are moving.
“According to data from the General Insurance Council (GIC), as on 11 May, 1,520 covid-19 claims were reported. Of this, 920 were settled by various general and stand-alone health insurers. The total cost of claims came to ₹12.47 crore. Compare this with data as on 28 March when the insurers settled just five claims amounting close to ₹11 lakh. This was an average claim size of a little over ₹2 lakh. Now with more claims coming to insurers the average size has shrunk to about ₹1.35 lakh”[iii].
In Chennai which is considered to be a far better counterpart than any other metropolitan city in terms of health care Corona has brought ‘insensitivity’ in the private hospital and they have been charging patients overwhelmingly. With no guidelines and instructions from either Central or state government or ICMR, private hospitals will kill more people with their hefty bills or denial to treat persons if they don’t have the money.
‘A medical staff in Chennai says, “If the patient needs to be admitted to the isolation Intensive Care Unit, the room charge per day is ₹10,000. The cost of COVID-19 testing is ₹6,000. The other heads are doctors’ fees and nursing charges. The patient has to pay for the PPE used by doctors every day — one set costs ₹4,000 to ₹5,000. So, till the laboratory test result arrives, a minimum of ₹60,000 will be charged a day, At a leading hospital, patients are being charged ₹70,000 on the first day of treatment, as they have to undergo screening, including a CT scan and a COVID-19 test. “The charges depend on the condition of the patient. If he/she is a diabetic, or has renal diseases, they will require longer hospitalisation, and [their] recovery will take time. Some may need ventilator support. The bill could be around ₹3 lakh-₹4 lakh or ₹12 lakh-₹14 lakh, or more, depending on their condition,” a hospital staff member said. The family of an elderly patient, who was admitted to this hospital, was charged around ₹17 lakh”[iv].
No emergency treatment even for the colleagues
Disturbing news came from many places where even the physicians were not treated and left to die. In the absence of proper guidelines in many of the hospitals, fear has taken over medical ethics. A physician in Chembur died because he did not get a bed for nearly five hours which deteriorated his health ultimately taking his life. According to his wife, the physician suspected Corona like symptoms and decided to give his swab test on May 14th. The test results could not come before May 15th but his condition started deteriorating as was having severe breathing issues. “ According to his wife, the couple struggled from 3pm to 8pm to get him admitted. The BMC-run helpline (1916) was of no help. “First, they said there was one bed in Nair Hospital. When I agreed to admit him there, another attendant informed us there was no bed. They couldn’t give us any bed in Mumbai,” said his wife. The couple also inquired with private hospitals, but to no avail. Ultimately, another doctor arranged for a bed in SRV Hospital. The next obstacle was finding an ambulance, which wasn’t immediately available. “It was a horrible experience. Despite being a doctor, I never thought that I would face this situation. I had read about unavailability of beds in hospitals but until you experience it, you don’t understand that it is real,” said his wife. When they were finally able to admit the GP on May 15, he was rushed to the intensive care unit. He succumbed to the infection on Thursday, at around 7.30pm”. [v]
The point is who is responsible for the death of the doctors. Why has the situation come at this level that we have completely lost our sensitivity? If a doctor cant receive treatment then who will get it ? Can we expect that poor will be treated this way. Frankly, nobody is bothered about the poor. A story recently came in the Indian Express of how a Corona patient was found dead near a bus stop, a kilometer away from his home though the patient was being treated for Corona in the famous Ahmedabad Civil hospital. How is it possible that the patient could be allowed to leave the hospital or did he go himself. The man was found dead on the road.
In fact, alarmed over the growing death at the Ahmedabad Civil hospital, the Gujarat High Court slammed the government as well as the hospital authorities on a petition taken suo moto by the court. More than 570 deaths have been recorded in the Ahmedabad in which more than 370 alone died in civil hospital of the city. The court termed the situation at the hospital as distressing and appointed a committee to look into the affair. The judges also said that they might make a surprise visit to the hospital.[vi]
Punishment for demanding PPE
It is not that all the doctors have turned unethical. The problem is that the governments are still not keen to strengthen the public health services. They still feel that privatization is the key. Even today, at many places health workers have not got their protection gears. If they speak up for these protection gears, they face penalization. An doctor, who also happened to be a Dalit was suspended by the Andhra Pradesh government just because he demanded PPEs. The doctor was a senior with twenty years of service record and was mentally under deep distress due to this.
Dr Sudhakar was kicked and beaten up by the police on the road when he ‘abused’ chief minister Jagan Reddy. Media reported that the doctor was heavily drunk and has psychological disorder. They published his details which was actually unethical as all the patients have the right to privacy about their ailments. The doctor was humiliated publically by the police. All this, when the prime minister and the central government has been speaking of ‘respecting’ the doctors but then caste also come into picture.
“Trauma of the doctor began when he asked: “Where are sufficient PPE kits, where are masks for doctors to treat coronavirus patients? We are putting our lives at risk here. We are asked to use the same mask for 15 days and a fresh mask will be provided only twice a month.” He alleged that the government was giving N95 masks and PPEs meant for doctors to politicians and the police. The Government Civil Surgeon (anaesthetist) with 20 years of experience in Narsipatnam Government Hospital in Visakhapatnam district, Dr Sudhakar was immediately suspended from service.[vii]
Later, Andhra Pradesh high court took serious note of it and ordered a CBI inquiry into it though Andhra government is filing a case in the supreme Court against the said order. It clearly indicate how the state government is rattled with the order and there seems to be an issue of prestige for the top leadership of the state.
Ironically, India ordered 15 million PPE[viii] kits from China and according to reports in the first week of April. In fact, it suggested that nearly 1.5 million had already arrived in India and others would have arrived by second week but despite that the reality is the hospitals are still in short of that. It is the shortage of the PPE kits which has actually created a human crisis. As the number of doctors getting affected is growing, they are worried about their lives.
A 46 year old nurse Ambika P K died a few days back in Delhi due to Corona at the Safdarjang Hospital. She hailed from Kerala. Her colleagues said while the doctors were being provided new PPEs, the nurses were asked to ‘reuse’ them which is medically unethical. While the bosses of the Kalara hospital where she worked for over 10 years denied this, her son Akhil, who was living in Kerala, said, “ My mother’s condition deteriorated so rapidly… I couldn’t understand how to get here sooner. Over a week ago, she mentioned that the hospital was making her reuse PPE and charging money for masks. I got agitated and told her to just stay at home, but she didn’t listen to me. She continued working, and now she is dead[ix].” What is important here to note is that while doctors and health workers had been protesting for lack of PPEs in March and April when there was shortage of it but why is this happening in May now when the government claims it has no issue related to PPEs.
Denying patient a right to treatment
What has been more disturbing during the Covid 19 crisis is absolute anarchy on parts of the hospitals as they completely abdicated their duty to treat patients. There is no denial of fact that we are amidst a huge crisis and definitely medical fraternity need protection. None deny all these things but merely hospitals cant be blamed for the crisis and central government’s ordinances, notifications also added to confusion. When the hospitals were asked to prepare for Corona patients, it would also have been kept in mind that the existing treatment cant exists to cease away. Unfortunately, the private hospitals have got a pretense to keep the patient away. How can a serious patient be turned away without treatment. I give a first-hand story heard from my dear friend Ehtesham Shahid who is based in Dubai and yet could not come to India due to lock down to be with his father. It is such a difficult time when sons, daughters, parents are unable to meet each other during the crisis.
Ehtesham’s father Mr Shahid Ahmad Yahya was about 76 years of age who had spent almost all his life in his village in Darbhanga, Bihar. He became a schoolteacher at age 21 but continued his studies (MA in Urdu and Persian). For 14 years, he served at the school and a nearby college (for free) and moved to the college (JN College, Nehra, Darbhanga) when it became constituent. He retired as the principal of the college. Alongside his teaching career, he looked after our ancestral property and was loved being a farmer at the same time. After his retirement and his wife’s death he continued to look after farm properties and used to spent time with his daughters in Kolkata and Mumbai and his son in Dubai. He was suffering from the old age ailments and was being treated at a private nursing home in Darbhanga, Bihar.
‘Shahid Ahmad Yahya, a resident of Darbhanga, was brought to Kolkata on May 9 for admission to the Apollo Gleneagles Hospitals on the recommendation of the doctor who used to treat him. He was in the ICU of a hospital in Darbhanga, to be shifted here for better treatment. They brought him to Kolkata in an ambulance after completing all the necessary requirement and went straight forward to Apollo Gleneagles Hospitals, They were made to wait for several hours and the doctor informed them that he was a Covid suspect and should be taken to another hospital specifically meant for Covid 19. They took him to another private hospital which denied him admission. Finally, he was admitted at M R Bangur hospital run by the state government and is a Covid 19 special hospital on May 9 and he died on May 11 around 4.15 am, Ironically, his medical report came negative for Covid 19 and his death certificate mentioned cardiorespiratory failure in a case of sepsis with chronic kidney disease and stage 3 diabetic Mellitus and hypertension as the cause of his death[x].
Now the question is should not the hospitals be punished for such gross irresponsible behavior. A patient who is being referred by another hospital for serious ailment is not treated because the doctor suspected he is covid positive. How can the doctors be so brutal? Even if they were doing test for him, can’t he be given a bed in the hospital?
The problem with the private hospitals is that they are using these pretexts not to avoid patients. The government hospitals discourage people. It is difficult for people who are not Covid to go to hospitals or even private nursing homes for the treatment. What is going to happen is that every time any one visit to these hospitals for any treatment, the private doctors will force them to first go for a ‘Covid 19’ test and extract lot of money. Already, people are dying in the streets without any treatment and we are sure, to avoid the crowded government hospitals people will go to private doctors but it will difficult. Some protocol in this regard should be prepared.
The biggest villain in the entire exercise is government of India which has done very little to these hospitals. It should have actually taken over the private hospitals for the Covid 19 treatment but should have allowed others to operate as usual. You can’t shut all the facilities for the purpose of treating one disease. It is bound to create much bigger crisis. There are no guidelines as why should those suffering from serious ailments or under the observations be required to go through the same tiring process as a new patient. And then these hospitals become ruthless in extracting money. Can you imagine when the insurance companies are feeling the heat of the inflated bills by the hospitals what would happen to common men?
Rather than thinking of investing a huge amount in our health sector and improving our health care facilities at the district and municipality level, the government continue to be under the impression that ‘Insurance’ is the best way. This is a big lie and fraud on people and continuation of privatization process. World over, the countries which have spent money on public health care performed well in dealing with the current crisis and those who dominated with ‘privatisation’ and ‘insurance’ discourse actually failed miserably. Look at how USA with over one lakh deaths, UK with over forty thousand deaths, Italy, Spain with equal number of deaths reflected the failed and crumbling health infrastructure while responses from Vietnam, Taiwan, South Korea, Norway, Sweden, and Singapore have been far superior in handling the Covid crisis as these countries have well-established health infrastructure and government took care of everything. Even a country like UK, where conservatives were out and out rejecting the National Health Services earlier, are, now proud of it for the extraordinary work they did. Why is government of India shying away from thinking of creating a National Health Services on the line of Indian Civil Services?
Now the matter regarding private hospitals super charging have come to the notice of the Supreme Court. Actually, when the government decided an amount of Rs 4,500/- to be charged for testing of Covid 19, the Supreme Court initially ordered that all testing should be free of cost but the government resented the order and ultimately the court made an amendment in its order. The government claimed that over 107 million families or 500 million people were already covered by Ayushman Bharat yojana and don’t need to pay anything[xi]. The court then ordered that all those who are not covered under the scheme or are middle Income Group should be charged with ICMR fixed 4,500/-. This was in April but now the Supreme Court is hearing a Public Interest Litigation, where issue of excessive charging by the private hospitals on Covid patients have been brought to its notice. Will the government react positively or it will continue to with the rhetoric of Ayushman Bharat. It is important to understand that given the nature of pandemic and as experts are now suggesting that there will be routine to hear such catastrophe, shouldn’t our government and state governments seriously ponder over to build a strong public health policy. How long will we keep conspicuous silence on the issues and build up alternative narrative through ‘manustream’ media about ‘Ayushman Bharat’ or ‘Arogyasetu’. These may be good for certain things as well as tracing but definitely not the solution. The solution of lies in building health infrastructure and developing not only national health services but also encouraging state to develop state services and Panchayats to develop a Panchayat health cadre. A tiny country like Cuba should be a big role model for all of us as how it sends a large number of health professionals to other countries. Cuban health system is still considered one of the best in the world. The government can’t shy away from its national responsibility but will it really be interested when all it is looking is converting this ‘crisis’ into an ‘opportunity’ for privatizing our national services. We know the corporate sponsored ‘experts’ will give their ‘advise’ to go for vigorous privatization. It is time for state chief ministers, expert groups, ICMR as well as opposition parties to speak about National Health Services and build a long term plan for the betterment of the health of the nation.
Vidya Bhushan Rawat is a social activist