One of the big health debates that will continue in 2019 is the the protection of patients in India’s poorly regulated medical sector. One move that can help strengthen such protections is the adoption and implementation of the Charter for Patient’s Rights.
The National Human Rights Commission prepared the draft and adopted it in August following which the health ministry released the document for public comments. The Ministry of Health and Family Welfare is still in the process of finalising the draft Charter of Patients Rights. The comprehensive document enumerates the rights of patients as well as protection and redressal mechanisms in cases of violations by doctors and hospitals to be made enforceable through existing regulatory frameworks across the country.
The charter comes after two high profile cases of alleged medical negligence and over-billing at Medanta Hospital in Delhi and Fortis Hospital in Gurugram triggered a national conversation about widespread malpractices at both government and private hospitals.
The discussion around the draft charter has highlighted the fault lines between patients’ rights activists and medical doctors, especially those working in the private sector, with the former seeking even stronger protections of patients and the latter insisting on emphasis on patient’s responsibilities.
In its present form, the draft charter details 17 rights of patients, including right to adequate and relevant information about their illness and treatment, right to emergency medical care without any conditions, right to informed consent before any test or treatment, right to confidentiality as well and human dignity and privacy, right to a second opinion, right to transparency in rates, right to non-discrimination and right to redressal in case of complaints against a doctor or hospital.
“The National Human Rights Commission has proposed that this charter be implemented through all regulatory frameworks,” said Dr Abhay Shukla, member of the commission’s core group on health and convener of the Jan Swasthya Abhiyan. “Once it becomes part of a standard set of rules, then it is like any other standard. Just as a hospital is supposed to keep a certain number of square feet for a bed or have certain facilities, it will also have to observe patients rights. If they do not observe patients rights, there will be penalties.”
Shukla said that especially with the massive national health insurance programme, the Pradhan Mantri Jan Swasthya Abhiyan, being rolled out with extensive participation of private hospitals, it was imperative to ensure patient protections.
“How can we hand over thousands of crores to private hospitals without expecting them to observe patients rights?” he asked.
Doctors demand their own protections
Bodies like the Indian Medical Association and the Federation of Indian Chambers of Commerce and Industry have suggested changes to the health ministry to reflect their view that doctors and medical establishments also need to be given protection.
One provision that FICCI has contested is the right of a patient to choose the source for obtaining medicines or tests, arguing that this can only be applied to out-patients.
“In an in-patient setting it can not only be deleterious, it can be fatal,” said Dr Narottam Puri, advisor to the FICCI Health Services Committee, former chairman of the National Accreditation Board for Hospitals and Healthcare Providers and and ENT specialist at Fortis Hospital in Delhi.
“Suppose, someone is admitted in the Intensive Care Unit and the relative looking after him says that he does not want the injection or antibiotic given at the hospital because is costs Rs 20 more than outside. What happens if there is an adverse reaction to this medicine brought from outside? If it takes the caregiver two hours to go and bring the medicine and the patient’s condition deteriorates in that time, who is responsible? If you want to allow this for in-patients then you should indemnify the doctor and the hospital and don’t sue them.”
The charter also provides for the right to obtain discharge or for the body of a deceased to be released without delay on procedural grounds, that is, discharge or release of a body cannot be withheld if a bill is not paid or payment is contested.
Dr Ramendra Tandon, secretary general of the Indian Medical Association, said that this provision is incomplete if the document does not also emphasise patients’ obligations to pay their bills.
“Someone should take the responsibility to make payment,” he said. “Not discharging patients or releasing a dead body is not acceptable but someone has to take the responsibility to make the payment. That should be made clear and it cannot be open-ended.”
Puri and Tandon were quick to bring up protections for doctors and medical establishments, given the number of reports of violence against them across the country in recent years.
“There is no mention at all about violence against doctors,” said Puri. “You are making every law to give rights to patients but where is the law to protect caregivers?”
At least 19 states have enacted laws prohibiting violence against medical practitioners and damage of medical establishments but the doctors claim that these are poorly implemented. The draft charter also lists five responsibilities of patients, including that patients and caregivers should not resort to violence in any form. The doctors’ bodies want a longer, more comprehensive list of responsibilities.
Several public health activists have argued that the charter should have not have patients’ responsibilities slipped in because these may be used as excuses for hospitals not to ensure the enumerated rights.
“Not only do private hospitals have money and muscle power but doctors themselves are extremely privileged,” said Akhila Vasan, an activist with the Karnataka Janaarogya Chaaluvali. “They are hegemonically much more powerful in terms of class, caste and knowledge backgrounds. This is an extremely unequal situation. The section on patients’ responsibilities that has been slipped in must be contested.”
Question of implementation
The charter recommends that all states and union territories adopt the charter in the entire range of existing and emerging regulatory frameworks for healthcare. States like Rajasthan, Uttar Pradesh, Bihar and Jharkhand that have adopted the central Clinical Establishments Act must include the rights enumerated in the charter into the law as should states like West Bengal and Karnataka that have enacted their own versions of the central law.
“Even in states that do not have the Clinical Establishments Act, they can start displaying the hospital in government hospitals and private hospitals that receive state subsidies in any form or charitable hospitals,” said Shukla. “In that way patients will start seeing it, it will become part of the discourse and hospitals will have to ensure these rights.”
Further, the charter recommends that central and state governments ensure grievance redressal mechanisms for patients. The first step is an internal grievance officer within every clinical establishment. If this officer fails to resolve the problem, it can be escalated to the district registering authority, failing which a patient can approach the state councils and expect resolution within 30 days.
An analysis from the University of Toronto in 2012 of patients rights charters in 39 countries showed that such documents have been largely ineffective in ensuring protections unless patients have a cheap, accessible and independent complaints process. Many countries have appointed independent ombudsmen or commissioners to look into patient complaints.
“One of the thing that was demanded under the Karnataka Private Medical Establishments Act amendment was to have a tribunal that will hear cases of patients’ right violations that will be heard by a district judge at the district level and a high court judge at the high court level,” said Vasan. “A tribunal will provide a lot more space in terms of enforcement rather than consumer protections forums.”