Battle lines

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

Proposed amendments to the Karnataka Private Medical Establishment Act lead to strong opposition from private doctors.

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.”

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Swara Bhasker: Sharp objects has to be on the radar of every woman who is tired of being “nice”

The actress weighs in on what she loves about the show.

This article has been written by award-winning actor Swara Bhasker.

All women growing up in India, South Asia, or anywhere in the world frankly; will remember in some form or the other that gentle girlhood admonishing, “Nice girls don’t do that.” I kept recalling that gently reasoned reproach as I watched Sharp Objects (you can catch it on Hotstar Premium). Adapted from the author of Gone Girl, Gillian Flynn’s debut novel Sharp Objects has been directed by Jean-Marc Vallée, who has my heart since he gave us Big Little Lies. It stars the multiple-Oscar nominee Amy Adams, who delivers a searing performance as Camille Preaker; and Patricia Clarkson, who is magnetic as the dominating and dark Adora Crellin. As an actress myself, it felt great to watch a show driven by its female performers.

The series is woven around a troubled, alcohol-dependent, self-harming, female journalist Camille (single and in her thirties incidentally) who returns to the small town of her birth and childhood, Wind Gap, Missouri, to report on two similarly gruesome murders of teenage girls. While the series is a murder mystery, it equally delves into the psychology, not just of the principal characters, but also of the town, and thus a culture as a whole.

There is a lot that impresses in Sharp Objects — the manner in which the storytelling gently unwraps a plot that is dark, disturbing and shocking, the stellar and crafty control that Jean-Marc Vallée exercises on his narrative, the cinematography that is fluid and still manages to suggest that something sinister lurks within Wind Gap, the editing which keeps this narrative languid yet sharp and consistently evokes a haunting sensation.

Sharp Objects is also liberating (apart from its positive performance on Bechdel parameters) as content — for female actors and for audiences in giving us female centric and female driven shows that do not bear the burden of providing either role-models or even uplifting messages. 

Instead, it presents a world where women are dangerous and dysfunctional but very real — a world where women are neither pure victims, nor pure aggressors. A world where they occupy the grey areas, complex and contradictory as agents in a power play, in which they control some reigns too.

But to me personally, and perhaps to many young women viewers across the world, what makes Sharp Objects particularly impactful, perhaps almost poignant, is the manner in which it unravels the whole idea, the culture, the entire psychology of that childhood admonishment “Nice girls don’t do that.” Sharp Objects explores the sinister and dark possibilities of what the corollary of that thinking could be.

“Nice girls don’t do that.”

“Who does?”

“Bad girls.”

“So I’m a bad girl.”

“You shouldn’t be a bad girl.”

“Why not?”

“Bad girls get in trouble.”

“What trouble? What happens to bad girls?”

“Bad things.”

“What bad things?”

“Very bad things.”

“How bad?”

“Terrible!!!”

“Like what?”

“Like….”

A point the show makes early on is that both the victims of the introductory brutal murders were not your typically nice girly-girls. Camille, the traumatised protagonist carrying a burden from her past was herself not a nice girl. Amma, her deceptive half-sister manipulates the nice girl act to defy her controlling mother. But perhaps the most incisive critique on the whole ‘Be a nice girl’ culture, in fact the whole ‘nice’ culture — nice folks, nice manners, nice homes, nice towns — comes in the form of Adora’s character and the manner in which beneath the whole veneer of nice, a whole town is complicit in damning secrets and not-so-nice acts. At one point early on in the show, Adora tells her firstborn Camille, with whom she has a strained relationship (to put it mildly), “I just want things to be nice with us but maybe I don’t know how..” Interestingly it is this very notion of ‘nice’ that becomes the most oppressive and deceptive experience of young Camille, and later Amma’s growing years.

This ‘Culture of Nice’ is in fact the pervasive ‘Culture of Silence’ that women all over the world, particularly in India, are all too familiar with. 

It takes different forms, but always towards the same goal — to silence the not-so-nice details of what the experiences; sometimes intimate experiences of women might be. This Culture of Silence is propagated from the child’s earliest experience of being parented by society in general. Amongst the values that girls receive in our early years — apart from those of being obedient, dutiful, respectful, homely — we also receive the twin headed Chimera in the form of shame and guilt.

“Have some shame!”

“Oh for shame!”

“Shameless!”

“Shameful!”

“Ashamed.”

“Do not bring shame upon…”

Different phrases in different languages, but always with the same implication. Shameful things happen to girls who are not nice and that brings ‘shame’ on the family or everyone associated with the girl. And nice folks do not talk about these things. Nice folks go on as if nothing has happened.

It is this culture of silence that women across the world today, are calling out in many different ways. Whether it is the #MeToo movement or a show like Sharp Objects; or on a lighter and happier note, even a film like Veere Di Wedding punctures this culture of silence, quite simply by refusing to be silenced and saying the not-nice things, or depicting the so called ‘unspeakable’ things that could happen to girls. By talking about the unspeakable, you rob it of the power to shame you; you disallow the ‘Culture of Nice’ to erase your experience. You stand up for yourself and you build your own identity.

And this to me is the most liberating aspect of being an actor, and even just a girl at a time when shows like Sharp Objects and Big Little Lies (another great show on Hotstar Premium), and films like Veere Di Wedding and Anaarkali Of Aarah are being made.

The next time I hear someone say, “Nice girls don’t do that!”, I know what I’m going to say — I don’t give a shit about nice. I’m just a girl! And that’s okay!

Swara is a an award winning actor of the Hindi film industry. Her last few films, including Veere Di Wedding, Anaarkali of Aaraah and Nil Battey Sannata have earned her both critical and commercial success. Swara is an occasional writer of articles and opinion pieces. The occasions are frequent :).

Watch the trailer of Sharp Objects here:

Play

This article was published by the Scroll marketing team with Swara Bhasker on behalf of Hotstar Premium and not by the Scroll editorial team.