State govt wants to keep tabs on healthcare services
K Yatish Rajawat MUMBAI

    MAHARASHTRA may set its foot where almost no state government has
ventured so far and where even the Centre fears to tread. The state
government has decided hospitals need to be registered, regulated and
monitored for service standards. To this effect, a draft bill called the
Bombay Nursing Home Registration Act (BMNHRA) '06 is awaiting legislature
clearance.

    The move has been fiercely opposed by the entire medical community and
battlelines have been drawn up even before the bill comes under discussion.
Healthcare is a state subject, and barring Karnataka which has introduced a
similar legislation, no state has attempted to regulate the sector.

    Though the need for regulating healthcare services extends much beyond
the state borders, the central government does not have any guidelines for
it.

    Over the years, healthcare in India has passed out of the hands of the
public sector into the hands of doctor entrepreneurs. The recent 60th round
of the National Sample Survey shows that the proportion of patients treated
at government hospitals has declined from 60% in 1986-87 to 43% in 1995-96
and to 39% in '04-05 in urban areas. The corresponding figures for rural
areas are 60%, 44% and 42%. Current estimates indicate that at least 60-70%
of healthcare services in India are provided by the private sector.

    Small and medium private sector healthcare has mushroomed across the
country. Lack of regulations, high profit margins, huge demand for
healthcare services has led to every doctor becoming an entrepreneur and
businessman.

    A large part of the private healthcare sector is in the hands of a
husband-wife team running a clinic. Today, a doctor can open a clinic
whenever and wherever he wants to. A corporate house can do just the same,
thanks to the lack of regulations, control or standards for hospitals in the
country. Medical fraternity opposes govt control in healthcare

    THE state government has been toying with the idea of regulating
healthcare services, but nothing has been done so far. The main stumbling
block being opposition from the medical community. However, associations
like the Centre for Enquiry into Health & Allied Themes (Cehat) have been
spearheading the movement to bring in some control, standards and regulation
in healthcare.

    Padma Devasthali, co-ordinator at Cehat says, "We have been trying for
years to get some legislation at the state level for minimum level of
standards in public and private hospitals in the state. The problem is so
endemic to the system across public and private sector and yet it is largely
ignored by the state government." However, it is not that the powers to be
are ignorant about health per se. The problems arise because there are
stringent norms regarding selling of food in the country as it affects the
health of citizens. Sample this. To make ice cream in India, you need 15
licences and 25 clearances to open a restaurant.

    These clearances/licences come from various state and local bodies like
the state health department, municipal corporation and even the police. The
state health department issues a licence after inspecting the premises for
cleanliness and safety. The restaurant licence has to be renewed every year
and needs a fresh inspection every year. The impact of this rapid
unregulated growth is that there is no assurance of quality standards for
treating patients in the country

    Chennai-based Mohan Rao, a surgeon for 40 years, says, "Over the years,
developments have made healthcare unnecessarily and wastefully expensive.
When profit is the motive, lots of unnecessary tests are done, gadgets are
used, expensive medicines given, five-star facilities provided and the
patient is pampered to his delight. Provided of course someone else is
footing the bill, either the insurance company or expense account of a
company or black money." he adds

    YK Sapru, founder, Cancer Patients Aid Association (CPAA), says, "There
is absolutely no control or regulation in the healthcare industry. The
outcome of any patient's treatment, in any hospital, is more a matter of
luck than processes or standards followed. While the facilities may be of a
five-star hotel, it does not mean the healthcare provided in the hospital is
also of high standards. There are no standards for healthcare in the
country, which means there is no difference between a public hospital or a
private hospital in the country." Therefore, while the state government may
be giving it a shot, there is some direction and standardisation needed even
at the central level. Narrottam Puri, executive director (medical services),
Max Healthcare says, "There is a huge demand for quality healthcare in the
country. Healthcare is important and quality is not regulated in our
country, there is certainly a need for standards to ensure better care in
the country. As it's a state subject and I don't think states are paying any
attention to it, there is a need for central regulation at least."

    While some think government regulation is a good idea, there are others
who oppose it as well. Joe Curian, president, Association of Hospitals (AOH)
in Mumbai, is against any form of government control. Mr Curian claims the
AOH is working on its own standards for its member hospitals and the market
will decide what is good or bad. "Let the market decide, statutory
regulation from the government for healthcare will not work. We don't want
to bring the licence raj into the healthcare industry," Mr Curian says.

    While the BNHRA lays down the registration and regulation of hospitals
in the state, it does not cover the crucial area of standards. The draft
bill says a committee comprising all the stakeholders will be formed to
draft the standards of what constitutes a 10-bed hospital, an ICU or any
other description of a healthcare service provider.

    Mr Puri feels there is a need for some kind of standards and regulations
to ensure that the service provided is up to par. "In the US, there is a
certification and accreditation process to be followed by anyone trying to
open a hospital. We are trying to develop our own standards and
accreditation as some of the international standards cannot be applied to
India. " The bill states that for minimum standards, "The state Nursing Home
Registration Board will appoint committees with relevant experts to decide
on minimum standards regarding physical space, human resources,
infrastructure, clinical standards and facilities for 30-bed, 50-bed,
100-bed, single- and multiple-speciality hospitals."

    These standards, once notified, will become part of the Annexure to the
Act and will be used to determine registration.

    The Act has defined some standards for 10-bed general, surgical and
maternity hospitals, but has left the field open for other healthcare
service providers.

Measures proposed under BMNHRA 2006

Measure: Regulatory structure will be created at the state and district
level. Healthcare providers will be registered with either the District
Nursing Home Registration Board or the State Nursing Home Registration
Board. Impact: All 'mom-n-pop' clinics masquerading as hospitals will have
to be compulsorily registered. Else, they will not be allowed to offer their
services. A new level of bureaucracy is being created by the state to
monitor healthcare services in the state. Measure: Minimum standards for
different kind of healthcare providers will be laid down by the state.
Impact: While applying for registration a nursing home will have to specify
the kind of treatment it plans to offer its patients and its facilities will
have to match. For instance, if a nursing home says it can provide emergency
cardiac care it will need to have a wellfurnished ICU unity.

Facilities needed for even routinelyoffered services will be defined. Measure: The
state health registration board will come out with specific standards for
the facilities which are necessary for healthcare. The standardisation of
facilities will improve the general level of services offered across service
providers. Impact: A committee will be formed with relevant experts to
decide on minimum standards regarding physical space, human resources,
infrastructure, clinical standards and facilities for 30-bed, 50-bed,
100-bed and single- and multiple-speciality hospitals. These standards will
be incorporated as rules in the Annexure to Act and will be mandatory for
registration. Measure: All emergency patients at a nursing home, must be
attended to primarily to save the life without considering the financial
capability of the patient, and then, may be referred with relevant medical
reports about the ailments, as early as possible to the nearest suitable
referral unit. No advance payment may be demanded for such emergency care.

It is also the responsibility of the patient or his/her party to pay all the
dues to the nursing home. Non-payment of dues cannot become ground for
refusal of emergency care for that person or for future cases. Impact:
Patients will have the right to demand healthcare and deaths due to
hospitals rejecting patients in serious condition will go down.


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