Friday, July 16, 2010
Problems of Public Health System in India
Core problems of public health system
Indian public health system and overall health care system’s failure is characterized by following things:
• High out-of pocket expenditure
• Failure of Primary Health System
• Collapse of Secondary Level System
• Overloaded Tertiary Level System
• Regional inequality in terms of Health Indicators
• Unregulated Private Health Sector
HIGH OUT-OF POCKET EXPENDITURE
Public health expenditure is shared between centre and state governments. The state or local governments incur about three-fourth of the expenditure on public health and the remaining one-fourth of the total expenditure is spent by the central government.
The government (state, local or central) provides publicly financed and managed curative and preventive health services from primary to tertiary level, throughout the country and free of cost or highly subsidized rates to the consumer. These account for about 17.8% of the overall health spending and 0.9% of the GDP. However, a fee-levying private sector that plays a dominant role in the provision of individual curative care through ambulatory services accounts for about 82% of the overall health expenditure. It has been found that private health services are directed mainly at providing primary health care and financed from private resources, which could place a disproportionate burden on the poor
As compared to the rest of the world, Indian health system is one of the least publicly funded health systems. It is also one of the highest privatized, unregulated and characterized by very high out of pocket expenditure. Comparable countries with India in these dimensions are- Cambodia, Georgia, Myanmar and Afghanistan. According to UNDP Human Development Report, 2002 and The World Health Report of 2000; India’s per capita health expenditure ranking (in $ terms) was 133 and corresponding Health DALE Ranking was 134.In all developed countries, public expenditure on health as a share of GDP is very high compared to India where only 0.9% of GDP is publicly spend on health.
Country Public health expenditure Private health expenditure
as share of GDP as share of GDP
Norway 6.5 1.1
Sweden 6.2 1.8
Japan 5.9 1.8
United Kingdom 5.9 1.4
United States 5.8 7.3
Egypt 1.8 2.3
Sri Lanka 1.8 1.9
India 0.9 4.3
Even this short amount of 0.9% of GDP spent on public health does not benefit poor people in adequate extent. Public expenditure on curative services favors rich. According to the study - ‘PROPORTION OF PUBLIC EXPENDITURE ON CURATIVE SERVICES, BY INCOME QUINTILE, ALL INDIA, Year 1995-96’: “for every Re.1 spent on poorest 20% population, Re.3 spent on the richest quintile.” This denotes high disparity in public health service delivery.
Hospitalized Indians spend 58% of their total annual expenditure on health care.
Over 40% of hospitalized Indians borrow heavily or sell assets to cover expenses.
Over 25% of hospitalized Indians fall below poverty line because of hospital expenses.
This emphasizes great need of providing security net for poor and protecting them from financial ruin out of high hospital expenses. Also there is urgent need to decrease dependence on private health sector by strengthening of public health system with better delivery mechanism. There is also need of proper allocations of this meager amount of resources. Right now, only 3% of public health budget is spend on capital expenditure while 97% goes to consumption expenditure. While 60% amount goes to paying salaries, only 35% is spent on material and equipments while Indian public health system has insufficient health infra structure. Public curative services where we spend 60% amount, are not showing good results on other hand 26% amount is spent on public health and family welfare. We need to improve budget allocation along with keeping its cost-effective analysis in mind.
Public and Private sector use for Patient care-All India distribution:
OUT PATIENT CARE RURAL URBAN
Public sector 20% 19%
Private sector 80% 81%
IN PATIENT CARE RURAL URBAN
Public sector 45.2% 43.1%
Private sector 54.7% 56.9%
(Source: David.H.Peters, Abdo.S.Yazbeck, Rashmi R. Sharma, G.N.V. Ramana, Lant H. Pritchett, Adam Wagstaff, Better Health System For India’s Poor -Findings Analysis and Options, The World Bank, 2002, Washington. p.5)
Reason for this high dependence upon private health care despite of its very high cost is failure of public primary health care system. This situation is compounded by total collapse of secondary health care system that in turn leads to overloaded tertiary health care system.
PRIMARY HEALTH CARE SYSTEM
Primary health care system in India is suffering from following main problems:
ACCESSIBILITY:
Primary health service in many parts of country especially in rural India is inaccessible for some vulnerable sections of society due to discrimination on basis of gender, caste and class etc. women and children, people from scheduled castes and scheduled tribes with overall poorest section of society can not get proper benefits of public health system.
ABSENTEEISM AND RETENTION OF DOCTORS IN RURAL AREA:
It is very grave problem. Doctors are not willing to into rural areas and even if they go, it is characterized by chronic absenteeism.
Reasons:
• Though we have adequate buildings for PHCs in rural area; they lack facilities like toilet, water supply, and electricity.
• There is lack of good schools for children of doctors, Para medical staff. Also, there is lack of appropriate transport and communication facilities.
• It is also found that doctors serving in rural areas get relatively less salary in comparison to their urban counterparts, if we take into the consideration, less availabilities of facilities in rural areas.
• There is less control and monitoring of doctors serving in rural areas.
• There is less personal growth in terms of positions held, monetary increments in government health services. There is high difference in income of private practioners and public doctors, resulting in less availability of doctors for government services especially for difficult postings in rural areas.
• In this phase of Globalization, lots of opportunities for personal growth are available. Just compare income levels of private medical practioner, Public health doctor, engineers, and management persons. A doctor with high intelligence will be always attracted towards lucrative private practice rather than serving for government for meager amount of money, that too in rural area.
POOR QUALITY OF CARE
There is lack of interest on the part of doctors and absenteeism leading to- development of similar kind of attitude in paramedical staff. It leads to docility, irregularity and neglect towards duty in all staff members. It is found that many times pharmacists attend OPDs instead of doctors. This along with irregularity leads to poor delivery of health care to the people.
LACK OF CREDIBILITY
Today this is biggest problem of public health system. This is a barrier, which should be overcome for better delivery of primary health services. In fact, better delivery and regularity in service provision can remove this hurdle.
INADEQUATE AND UNDER-UTILIZATION OF INFRASTRUCTURE
Already there is inadequate health infrastructure in rural areas but due to above mention factors it leads to under-utilization of this infrastructure.
SECONDARY AND TERTIARY PUBLIC HEALCARE SYSTEM
There is total collapse of secondary level system and because of this tertiary level system is overloaded.
Reasons -• Less number of functional secondary hospitals
• Lack of sufficient equipments, drugs
• Most importantly, lack specialists for these hospitals due to very less pay scale. Averagely at all India level, there are about 90% shortfalls of specialists.
• Tertiary hospitals are over loaded along with there is poor up gradation of equipments, lack of sufficient allocation for functioning tertiary hospitals.
• Though population increased exponentially, number of tertiary hospitals is quite stagnant leading to further overload of patients. This leads to poor quality of services.
Tuesday, July 13, 2010
CHARTER OF PATIENTS’ RIGHTS AND RESPONSIBILITIES
Charter of
PATIENTS’ RIGHTS AND RESPONSIBILITIES
(Jointly prepared by Rugna Hakka Samiti-Pune, Jan Aarogya Abhiyan, Indian Medical Association-Pune(IMA) and Federation of Obsteric and Gynaecological Societies of India-FOGSI)
Doctor-patient relations have to be healthy if patients are to get good care and doctors are to work satisfactorily. For this to happen doctors should respect patients’ rights and patients should observe their responsibilities.
Doctor-patient relations are not merely that of seller and buyer. Secondly the specificities of medicine, of medical service have to be borne in mind and a system needs to be created to ensure observance of patients’ rights and responsibilities. Representatives of patients (e.g. Rugna Hakka Samiti-Pune, Jan Aarogya Abhiyan) and doctor’s representatives (Indian Medical Association (IMA), Pune and Federation of Obstetricians and Gynecologists (FOGSI)) have decided to work towards this end. This brochure is part of that joint endeavor.
Firstly, specificities of medical science and technology make medical profession a distinct one. Unlike physical sciences and engineering where things are reasonably certain, unexpected medical complications cannot be predicted. Sometimes the doctors may not be able to avoid such complications. But they need to be detected in time, treated promptly and good communication needs to be established with the patients/relatives. If the doctor-patient relations are healthy, a good rapport can be established in such delicate situations.
Any professional is some kind of expert. But doctors are not just experts. The patient’s immediate need is relief from pain, illness. He /she may be in hurry to become fit and join work at the earliest. Doctors fulfill this delicate, immediate need. Secondly, the process of opening up one’s body and mind to the doctor, so necessary for proper diagnosis and treatment, inevitably leads to doctors having a kind of authority. Medical ethics demands that doctors should always use this ‘medical power’ for patient’s benefit. That is why medicine is regarded as a ‘noble profession’. After receiving a service, a customer merely thanks the service provider whereas the patient remains indebted to the doctor. Patients’ rights have to be respected keeping in mind this inherent vulnerability of patients vis a vis doctors. Patients too should follow their responsibilities so that doctors can do their work satisfactorily.
Keeping in mind above-mentioned characteristics of medical profession and doctor-patient relationship, let us see what doctors, patients ought to do. Let us first understand patient’s rights as a human being without any discrimination on the basis of income, gender, caste, religion, location etc.
PATIENTS’ RIGHTS
1) Right to Emergency Medical Care –
All doctors are duty bound to provide basic Emergency Medical Care and injured persons have a right to get Emergency Medical Care. It includes any of the essential measures like removing obstruction in the respiratory tract, stopping blood loss, intravenous fluids, analgesic medicines as per requirement, stabilising patient’s vital parameters (by using life saving medicines when necessary), preparation for referral to appropriate hospital if required etc. Only after providing this emergency care, hospitals can demand fees or can inform police.
2. Right to information-
All patients should be given the adequate relevant information about the nature, severity and likely outcome of the present illness; provisional diagnosis or confirmed diagnosis; relevant information about the proposed care, the expected results, risks and advantages/disadvantages of various alternative procedures, treatment options and the possible effects of the non-use of medical treatment should be communicated. It should be noted that sometimes-precise diagnosis might not be initially possible. Secondly, there are no set standards about how much information is to be given. Hence what minimum information is to be provided has to be based on practical experience. In case of further doubts, patients/relatives should ask doctors about these. Doctors may take help of informative booklets written in simple language comprehensible to patients, or any educational material, or take help of assistant doctor to provide such information. Any queries beyond this should be asked to concerned main doctor.
Patients/person authorised by patient should be informed about the likely cost of the treatment. Patients and family should be informed about the financial implications when there is a change in the patient’s condition or line of treatment. (Doctor would communicate, in this regard, to one person authorised by patient. It is difficult for the doctor to communicate with a number of different persons.)
Patient or person authorised by patient has a right to have an access to his / her indoor case paper’s photocopy (during admission-within 24 hours and after discharge-within 72 hours) after paying appropriate fees for photocopying.
Hospital should provide Indicative Rates (like daily visit fee, bed charges, main diagnostic tests charges) to each patient. Some of these Indicative Rates should be displayed prominently on the board in the hospital. Secondly, rates of concerned services relevant to the patient like - relevant rates for a woman coming for delivery, specialist’s fee for each visit should be provided to each patient. This will help the patients to figure out the likely expenditure from all these displayed charges. On request, the hospital should provide written expenditure estimation to patients according to his/her illness. Patient/person authorised by the patient should be informed about the financial implications when there is a change in the patient condition or treatment setting.
At the time of discharge, patient should get a discharge card, which should contain: condition of patient at time of admission; important clinical findings; summarized results of laboratory tests; diagnosis and, treatment during hospitalisation; condition of patient at discharge; date of follow-up visit if required; medicines and precautions to be taken after discharge, medicines to be avoided,(especially in case of any allergy to any medicines). Clear instructions should be given in cases where medicines that should not be stopped without doctor’s consultation (e.g. medicines for hypertension, diabetes) and instructions should be given regarding emergency situations. This follow up advice should be written in a language and manner, which can be easily understood by a common person.
In case of death of the patient, the death summary should be provided to deceased’s relatives. It should include all-important medical points, ranging from condition of patient at time of admission to the cause of death.
3. Right to informed consent
In case of any potentially hazardous treatment (like surgery, blood transfusion, potentially hazardous tests etc.), patient should get adequate information (in a manner comprehensible to common person) related to the treatment or operation to be undergone, including the associated risks and discomforts, side effects and alternatives. Patients have a right to give written consent to the treatment and have a right to refuse treatment. If patient refuses the treatment or invasive investigation, consequences of such refusal are patient’s responsibility.
In the case of an unconscious patient or when a patient is not able to take decision, then the written consent of a relative/ patient authorised person should be taken.
(In case of surgery or similarly potentially hazardous treatment (e.g. Chemotherapy for cancer), consent should not be taken immediately before the surgery or potentially hazardous treatment. It should be taken when decision of such treatment is finalised.)
4. Right to confidentiality
All the data and information related to an individual’s state of health, and concerning the medical/surgical treatments to which he or she is subjected, must be stored and used in such a manner to maintain the anonymity of the patient/informant. This is especially necessary in cases of conditions, which carry a stigma. (There are some exceptions to this - If a person has HIV infection, then it is a human right of his/her partner to know this. Similarly in case of some communicable diseases, such information needs to be provided to public health authorities. Information must be provided if any court demands it. Barring such exceptions, patient’s identity, condition, disease, diagnosis etc. should be limited to doctors and medical staff.)
5. Right to second opinion
Patients/persons authorised by patients have the right to seek a second opinion from an expert in the concerned field by inviting him/her in the same hospital. All medical information must be made available to the second doctor; whereas the latter should meet the first doctor.
(Of course, patient would pay the second doctor’s fees. Secondly, patient and the first doctor has a right to get the opinion, including due rationale, from the second doctor in writing so that second opinion would not be given irresponsibly or with ulterior intentions. The second doctor’s opinion will not be binding on first doctor. If the second doctor gives a different opinion about diagnosis, treatment and if patient wants that treatment, then patient should take treatment from second doctor on his/her own responsibility. The first hospital has responsibility to continue the ongoing treatment till the patient is transferred out. It is not responsibility of first hospital to take care of the patient while transporting him/her to second hospital. Such a discharge would be ‘discharge against medical advice’ (AMA) and it would be noted as such on the discharge card. From all this, it becomes clear that patient’s responsibility increases while seeking second opinion. e.g. if delays occur, due to the process of seeking second opinion, in getting tests done or receiving treatment then, the first doctor is not responsible . Despite of all this, patients have a right to seek second opinion.)
6. Right to respect human dignity and privacy of the patient
Keeping in mind the patient’s vulnerability, doctors and hospital staff should respect his/her human dignity. Each patient has the right to receive respectful care and communication at all times and under all circumstances, as recognition of his/her personal dignity.
During physical examination of female patients, a female caregiver or female staff member must be present.
7. Non-discrimination on the basis of HIV status –
No person suffering from HIV may be denied care on the basis of the HIV status if the hospital can provide necessary services. E.g. HIV positive pregnant women seeking hospital delivery care should receive delivery care. Treatments of other illnesses (diabetes, high blood pressure, malaria etc.) of HIV positive patients do not require special knowledge, skills. Special knowledge, skills are required only for the treatment of AIDS patients.
8. Right to choose alternative treatment if options are available
The patient has the right to choose alternative line of treatment if such options are available. Doctors should inform about all benefits and risks of such options, preferably in written form. However, consequences of choosing a particular alternative become patient’s responsibility. In the case of an unconscious patient or when patient is not able to take decision, then written consent of a relative/ patient authorised person should be taken.
9. Right to make suggestions/complaints and to seek redressal-
Patients have the right to complain/make suggestions about any aspect of hospital service or non-adherence to any patient’s rights. Every hospital should display information prominently in the hospital about the existence of grievance redressal system along with the name, address and telephone number of persons to be contacted.
In order to avoid unnecessary court cases, conflicts and tensions in hospital premises it is desirable that a committee or body independent of the hospital management would organise periodical dialogue between the hospital and patients/citizens with the objective to informally address patient’s complaints.
According to section (7) of ‘Maharashtra Medicare Service Persons and Medicare Service Institutions (Prevention of Violence and Damage or Loss of Property) Act, 2009’, Maharashtra state government shall establish Authority to hear grievances of victims of medical negligence or mismanagement and to aid and advice such victims to take recourse to an appropriate forum for suitable relief.
10. Compliance with ICMR guidelines for clinical trials on patients-
In case of conducting Clinical trials involving patients, documented policies and procedures should guide all research activities in compliance with ICMR guidelines. Some important points, in this context, are as below:
a) Adequate information about the research should be given in a simple and easily understandable unambiguous language about the nature, duration and purpose of study, procedures to be followed, benefits to participant, foreseeable risks and discomforts, availability of medical treatment for injuries or side effects, compensation, alternative treatments if available etc.
b) The investigator must obtain the informed consent of the participant. Patient has right to deny participation at any stage during the clinical trial.
c) Re-consent should be taken when there is change in treatment modality, procedures and site visits.
d) Compensation should be provided to the patient if there is economic loss of the patient as a result of the inconvenience and time spent.
e) As a general rule, pregnant or nursing women should not be participants of any clinical trial except if there is special requirement to do so.
11. Free beds in Trust Hospital for poor patients-
As per the Mumbai High Court directive, Trust Hospitals should reserve 10% beds for free treatment to poor patients and another 10% beds for economically weaker sections at concessional rates.
_______________________________________
PATIENTS’ RESPONSIBILITIES
Patients should follow their responsibilities so that doctors can perform their work satisfactorily.
1) The patient should provide his/her health related information to the doctor and should provide full information in response to doctor’s questions without concealing any relevant information so that diagnosis of the disease and treatment can be done properly. (Patients/relatives should read carefully, informative pamphlets, brochures given by doctors. Patients need not insist that all information should be given by main doctor only. If further clarification is needed then before going to doctor, patients may write down all points/queries for their own convenience. This will help in asking precise questions.)
2) The patient should cooperate with the doctors during examination, diagnostic tests and treatment, and should follow doctor’s advice. Doctors can deny treatment to the patient if patient is not taking treatment as per doctor’s advice.
3) Patients should follow all instructions regarding appointment time, cooperate with hospital staff and fellow patients, observing silence and maintaining hygiene in the hospital.
4) Patients should not expect free services in private hospitals (with exception of particular categories of patients in Trust hospitals). Patients should pay doctor’s agreed fees, hospital charges in time.
5) Patients should respect the dignity of the doctor and other hospital staff as human beings and as professionals. Patients should remember that doctors need rest, private life like any other human being. Doctors should fulfill their responsibility towards patients once consulted. However, keeping in mind above factors, at certain time doctors may decline to consult any new patients. However this denial should not be a discrimination against any patient (e.g. people living with HIV)
6) Whatever the grievance may be, patient/accompanying persons should not resort to violence (verbal or physical). Violence against hospital and healthcare personnel is a cognizable and non-bailable offence. Offenders may be punished with imprisonment up to 3 years and fine up to Rs. 50,000/- and liable for compensation twice the amount of damage or loss to the property.
PATIENTS’ RIGHTS AND RESPONSIBILITIES
(Jointly prepared by Rugna Hakka Samiti-Pune, Jan Aarogya Abhiyan, Indian Medical Association-Pune(IMA) and Federation of Obsteric and Gynaecological Societies of India-FOGSI)
Doctor-patient relations have to be healthy if patients are to get good care and doctors are to work satisfactorily. For this to happen doctors should respect patients’ rights and patients should observe their responsibilities.
Doctor-patient relations are not merely that of seller and buyer. Secondly the specificities of medicine, of medical service have to be borne in mind and a system needs to be created to ensure observance of patients’ rights and responsibilities. Representatives of patients (e.g. Rugna Hakka Samiti-Pune, Jan Aarogya Abhiyan) and doctor’s representatives (Indian Medical Association (IMA), Pune and Federation of Obstetricians and Gynecologists (FOGSI)) have decided to work towards this end. This brochure is part of that joint endeavor.
Firstly, specificities of medical science and technology make medical profession a distinct one. Unlike physical sciences and engineering where things are reasonably certain, unexpected medical complications cannot be predicted. Sometimes the doctors may not be able to avoid such complications. But they need to be detected in time, treated promptly and good communication needs to be established with the patients/relatives. If the doctor-patient relations are healthy, a good rapport can be established in such delicate situations.
Any professional is some kind of expert. But doctors are not just experts. The patient’s immediate need is relief from pain, illness. He /she may be in hurry to become fit and join work at the earliest. Doctors fulfill this delicate, immediate need. Secondly, the process of opening up one’s body and mind to the doctor, so necessary for proper diagnosis and treatment, inevitably leads to doctors having a kind of authority. Medical ethics demands that doctors should always use this ‘medical power’ for patient’s benefit. That is why medicine is regarded as a ‘noble profession’. After receiving a service, a customer merely thanks the service provider whereas the patient remains indebted to the doctor. Patients’ rights have to be respected keeping in mind this inherent vulnerability of patients vis a vis doctors. Patients too should follow their responsibilities so that doctors can do their work satisfactorily.
Keeping in mind above-mentioned characteristics of medical profession and doctor-patient relationship, let us see what doctors, patients ought to do. Let us first understand patient’s rights as a human being without any discrimination on the basis of income, gender, caste, religion, location etc.
PATIENTS’ RIGHTS
1) Right to Emergency Medical Care –
All doctors are duty bound to provide basic Emergency Medical Care and injured persons have a right to get Emergency Medical Care. It includes any of the essential measures like removing obstruction in the respiratory tract, stopping blood loss, intravenous fluids, analgesic medicines as per requirement, stabilising patient’s vital parameters (by using life saving medicines when necessary), preparation for referral to appropriate hospital if required etc. Only after providing this emergency care, hospitals can demand fees or can inform police.
2. Right to information-
All patients should be given the adequate relevant information about the nature, severity and likely outcome of the present illness; provisional diagnosis or confirmed diagnosis; relevant information about the proposed care, the expected results, risks and advantages/disadvantages of various alternative procedures, treatment options and the possible effects of the non-use of medical treatment should be communicated. It should be noted that sometimes-precise diagnosis might not be initially possible. Secondly, there are no set standards about how much information is to be given. Hence what minimum information is to be provided has to be based on practical experience. In case of further doubts, patients/relatives should ask doctors about these. Doctors may take help of informative booklets written in simple language comprehensible to patients, or any educational material, or take help of assistant doctor to provide such information. Any queries beyond this should be asked to concerned main doctor.
Patients/person authorised by patient should be informed about the likely cost of the treatment. Patients and family should be informed about the financial implications when there is a change in the patient’s condition or line of treatment. (Doctor would communicate, in this regard, to one person authorised by patient. It is difficult for the doctor to communicate with a number of different persons.)
Patient or person authorised by patient has a right to have an access to his / her indoor case paper’s photocopy (during admission-within 24 hours and after discharge-within 72 hours) after paying appropriate fees for photocopying.
Hospital should provide Indicative Rates (like daily visit fee, bed charges, main diagnostic tests charges) to each patient. Some of these Indicative Rates should be displayed prominently on the board in the hospital. Secondly, rates of concerned services relevant to the patient like - relevant rates for a woman coming for delivery, specialist’s fee for each visit should be provided to each patient. This will help the patients to figure out the likely expenditure from all these displayed charges. On request, the hospital should provide written expenditure estimation to patients according to his/her illness. Patient/person authorised by the patient should be informed about the financial implications when there is a change in the patient condition or treatment setting.
At the time of discharge, patient should get a discharge card, which should contain: condition of patient at time of admission; important clinical findings; summarized results of laboratory tests; diagnosis and, treatment during hospitalisation; condition of patient at discharge; date of follow-up visit if required; medicines and precautions to be taken after discharge, medicines to be avoided,(especially in case of any allergy to any medicines). Clear instructions should be given in cases where medicines that should not be stopped without doctor’s consultation (e.g. medicines for hypertension, diabetes) and instructions should be given regarding emergency situations. This follow up advice should be written in a language and manner, which can be easily understood by a common person.
In case of death of the patient, the death summary should be provided to deceased’s relatives. It should include all-important medical points, ranging from condition of patient at time of admission to the cause of death.
3. Right to informed consent
In case of any potentially hazardous treatment (like surgery, blood transfusion, potentially hazardous tests etc.), patient should get adequate information (in a manner comprehensible to common person) related to the treatment or operation to be undergone, including the associated risks and discomforts, side effects and alternatives. Patients have a right to give written consent to the treatment and have a right to refuse treatment. If patient refuses the treatment or invasive investigation, consequences of such refusal are patient’s responsibility.
In the case of an unconscious patient or when a patient is not able to take decision, then the written consent of a relative/ patient authorised person should be taken.
(In case of surgery or similarly potentially hazardous treatment (e.g. Chemotherapy for cancer), consent should not be taken immediately before the surgery or potentially hazardous treatment. It should be taken when decision of such treatment is finalised.)
4. Right to confidentiality
All the data and information related to an individual’s state of health, and concerning the medical/surgical treatments to which he or she is subjected, must be stored and used in such a manner to maintain the anonymity of the patient/informant. This is especially necessary in cases of conditions, which carry a stigma. (There are some exceptions to this - If a person has HIV infection, then it is a human right of his/her partner to know this. Similarly in case of some communicable diseases, such information needs to be provided to public health authorities. Information must be provided if any court demands it. Barring such exceptions, patient’s identity, condition, disease, diagnosis etc. should be limited to doctors and medical staff.)
5. Right to second opinion
Patients/persons authorised by patients have the right to seek a second opinion from an expert in the concerned field by inviting him/her in the same hospital. All medical information must be made available to the second doctor; whereas the latter should meet the first doctor.
(Of course, patient would pay the second doctor’s fees. Secondly, patient and the first doctor has a right to get the opinion, including due rationale, from the second doctor in writing so that second opinion would not be given irresponsibly or with ulterior intentions. The second doctor’s opinion will not be binding on first doctor. If the second doctor gives a different opinion about diagnosis, treatment and if patient wants that treatment, then patient should take treatment from second doctor on his/her own responsibility. The first hospital has responsibility to continue the ongoing treatment till the patient is transferred out. It is not responsibility of first hospital to take care of the patient while transporting him/her to second hospital. Such a discharge would be ‘discharge against medical advice’ (AMA) and it would be noted as such on the discharge card. From all this, it becomes clear that patient’s responsibility increases while seeking second opinion. e.g. if delays occur, due to the process of seeking second opinion, in getting tests done or receiving treatment then, the first doctor is not responsible . Despite of all this, patients have a right to seek second opinion.)
6. Right to respect human dignity and privacy of the patient
Keeping in mind the patient’s vulnerability, doctors and hospital staff should respect his/her human dignity. Each patient has the right to receive respectful care and communication at all times and under all circumstances, as recognition of his/her personal dignity.
During physical examination of female patients, a female caregiver or female staff member must be present.
7. Non-discrimination on the basis of HIV status –
No person suffering from HIV may be denied care on the basis of the HIV status if the hospital can provide necessary services. E.g. HIV positive pregnant women seeking hospital delivery care should receive delivery care. Treatments of other illnesses (diabetes, high blood pressure, malaria etc.) of HIV positive patients do not require special knowledge, skills. Special knowledge, skills are required only for the treatment of AIDS patients.
8. Right to choose alternative treatment if options are available
The patient has the right to choose alternative line of treatment if such options are available. Doctors should inform about all benefits and risks of such options, preferably in written form. However, consequences of choosing a particular alternative become patient’s responsibility. In the case of an unconscious patient or when patient is not able to take decision, then written consent of a relative/ patient authorised person should be taken.
9. Right to make suggestions/complaints and to seek redressal-
Patients have the right to complain/make suggestions about any aspect of hospital service or non-adherence to any patient’s rights. Every hospital should display information prominently in the hospital about the existence of grievance redressal system along with the name, address and telephone number of persons to be contacted.
In order to avoid unnecessary court cases, conflicts and tensions in hospital premises it is desirable that a committee or body independent of the hospital management would organise periodical dialogue between the hospital and patients/citizens with the objective to informally address patient’s complaints.
According to section (7) of ‘Maharashtra Medicare Service Persons and Medicare Service Institutions (Prevention of Violence and Damage or Loss of Property) Act, 2009’, Maharashtra state government shall establish Authority to hear grievances of victims of medical negligence or mismanagement and to aid and advice such victims to take recourse to an appropriate forum for suitable relief.
10. Compliance with ICMR guidelines for clinical trials on patients-
In case of conducting Clinical trials involving patients, documented policies and procedures should guide all research activities in compliance with ICMR guidelines. Some important points, in this context, are as below:
a) Adequate information about the research should be given in a simple and easily understandable unambiguous language about the nature, duration and purpose of study, procedures to be followed, benefits to participant, foreseeable risks and discomforts, availability of medical treatment for injuries or side effects, compensation, alternative treatments if available etc.
b) The investigator must obtain the informed consent of the participant. Patient has right to deny participation at any stage during the clinical trial.
c) Re-consent should be taken when there is change in treatment modality, procedures and site visits.
d) Compensation should be provided to the patient if there is economic loss of the patient as a result of the inconvenience and time spent.
e) As a general rule, pregnant or nursing women should not be participants of any clinical trial except if there is special requirement to do so.
11. Free beds in Trust Hospital for poor patients-
As per the Mumbai High Court directive, Trust Hospitals should reserve 10% beds for free treatment to poor patients and another 10% beds for economically weaker sections at concessional rates.
_______________________________________
PATIENTS’ RESPONSIBILITIES
Patients should follow their responsibilities so that doctors can perform their work satisfactorily.
1) The patient should provide his/her health related information to the doctor and should provide full information in response to doctor’s questions without concealing any relevant information so that diagnosis of the disease and treatment can be done properly. (Patients/relatives should read carefully, informative pamphlets, brochures given by doctors. Patients need not insist that all information should be given by main doctor only. If further clarification is needed then before going to doctor, patients may write down all points/queries for their own convenience. This will help in asking precise questions.)
2) The patient should cooperate with the doctors during examination, diagnostic tests and treatment, and should follow doctor’s advice. Doctors can deny treatment to the patient if patient is not taking treatment as per doctor’s advice.
3) Patients should follow all instructions regarding appointment time, cooperate with hospital staff and fellow patients, observing silence and maintaining hygiene in the hospital.
4) Patients should not expect free services in private hospitals (with exception of particular categories of patients in Trust hospitals). Patients should pay doctor’s agreed fees, hospital charges in time.
5) Patients should respect the dignity of the doctor and other hospital staff as human beings and as professionals. Patients should remember that doctors need rest, private life like any other human being. Doctors should fulfill their responsibility towards patients once consulted. However, keeping in mind above factors, at certain time doctors may decline to consult any new patients. However this denial should not be a discrimination against any patient (e.g. people living with HIV)
6) Whatever the grievance may be, patient/accompanying persons should not resort to violence (verbal or physical). Violence against hospital and healthcare personnel is a cognizable and non-bailable offence. Offenders may be punished with imprisonment up to 3 years and fine up to Rs. 50,000/- and liable for compensation twice the amount of damage or loss to the property.
7) Patients’ relatives, friends etc should not bring any undue pressure on doctors by invoking any other identity based on caste, politics. religion, language, community or any such factor
All citizens should help to create greater awareness about Patient’s Rights and Responsibilities in society.
All citizens should help to create greater awareness about Patient’s Rights and Responsibilities in society.
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