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JOURNAL OF COMMUNITY MEDICINE |
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INDIAN ASSOCIATION OF PREVENTIVE AND SOCIAL MEDICINE ORISSA CHAPTER |
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*Lecturer Department of Community Medicine, MKCG Medical College, Brahmapur |
D.Shobha Malini |
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Introduction
The background behind implementation of user fee charges is to raise funds for public health services in order to improve financial sustainability. Other common reasons are improving the quality of services and improving access to health services. The positive impact of user charges depends to a large extent on how well the system is implemented. Most of the states in our country have introduced user fee charges in public hospitals through government orders or notifications issued by the government under the authority of the minister concerned. It is also possible to have an Act on the subject for greater political acceptability and performance, but acts are more difficult to pass and amend.
Indian Scenario Many states have created Hospital Management societies (different names in different states) to increase hospital autonomy and to manage user charges free of government procedures. These societies differ in terms of structure, responsibilities and power but in common they serve as a forum for management of a system of user charges. In Orissa, societies are formed around the entire district named ZSS (Zilla Swasthy Samiti)1, in others they are created around hospitals. In Rajasthan Medicare Relief Societies (MRS)2 was established in 1995-96 in each tertiary and secondary level hospitals with 100 beds or more. In Andhra Pradesh3, Quasi officiary advisory committees are attached to al health institutions from subcentres to district hospitals with hospital development societies attached to the tertiary and teach hospitals. In M.P., Rogi kalian Samiti4 collects user charges from tertiary hospitals to PHC level. Generally the management is headed by the District Collector or an elected official.
The cost of delivering a health service may be an important factor in deciding how much the patients are going to be charged. Two things should be kept in mind. The willingness to pay and the affordability survey should be done about how much they are willing to pay and what patients actually pay for health services in private sector and to what extent they can afford to pay. A study carried out in Karnataka5 found that households are willing to pay for health services provided that the quality of services is improved. As perceived the quality includes factors such as
Availability and hospitality of staff Facility cleanliness and hygiene Availability of drugs and surgical material Diagnosis equipments, consumables available Reasonable level of charges Round the clock services
Similar things have come out in Rajasthan2; consumers are willing to pay user charges provided there is improvement in service quality. Regarding the quality of services, the Himachal Pradesh4 government has ordered the establishment of “Quality circles” in each hospital where user charges are being implemented. Quality circles and development of the culture of quality need a great deal of initial work by technically competent persons or group.
Services for charge ▪ Most states have user charges for ▪ OPD registration ▪ Paying/private ward and food ▪ Diagnostic and investigations ▪ Ambulance services Non-patient services-certificate of medical fitness, certificates of medical leave
Users fee charges in public hospital Malini applications, license fees for food vendors/food handlers, registration of births and deaths.
The Uttar Pradesh government has laid down rates for surgical procedures.
User Fee Revenue Almost all states have some amount of revenue collection through user charges. However in many states charges are not uniformly collected across districts or facilities. One of the main reasons for this is lack of follow up by both hospital authorities and district officials. In most states at least part of fee revenue is retained and used for the maintenance of buildings and equipments and to purchase necessary consumables. This varies from state to state. In Harayana6 100% of the fees collected must be deposited in the treasury whereas in Orissa1, 100% can be retained at the collecting facility. Good quality records are essential for any system to function effectively as well as being necessary for any case regarding claims and prosecutions. A transparent system of income and expenditure, exemptions granted etc is also necessary for continuing public support. Computerization at the larger hospitals is advisable.
In order to ensure that fee revenue is additional state government should not reduce allocations to hospitals because they have enough revenues. States currently follow one of the two systems described below for the retention of charges by the hospital
The Hospital or its attached society directly retains the collection. The state government or the district level society takes all the collection and reallocates all or part of it to the hospitals under its control.
Exemptions from user charges Exemptions for patients categorized as “below poverty line” (BPL) are almost universal across India. The operational problem lies in identifying BPL patients correctly. Andhra Pradesh has a high coverage of population by civil supplies ration cards and BPL cards are a separate category. In Delhi persons carrying jhuggi-jhopri (slum cluster) ration cards are exempted from user charges. Orissa gives the Hospital Superintendent the discretion to decide on exemptions. Other criteria that can be used for exempting patients include a mixture of service or patient characteristics.
o Preventive/promotive services o Children under 5 yrs o Pregnant women o Poor geographical areas o Certain hazardous occupations o Senior citizens o Disabled persons o Prisoners o Emergency care
Legal Issues Adopting user charges (other than nominal outpatient registration charges) would according to the current interpretation of the law make a charging hospital subject to the provisions of the Consumer Protection Act (CPA)7. The liability of CPA remains even if every patient is not charged. In due course it may also become necessary to provide legal help and insurance cover against suits for malpractice, negligence etc. The first defence against any claim under the consumer Protection Act, under the general law or torts of prosecution under the criminal law is proper documentation of medical treatment and surgical procedures. The second defence is an efficient consumer grievances redressal mechanism, which can prove before the court that the grievance was receive and attended to promptly and to the best ability of the institution.
Conclusion The message is that the impact of user charges depends to a large on how well they are implemented. They can make the things worse but can also make things better. This refers both to the implementation.
Users fee charges in public hospitals Malini and communication of an exemption policy, transparency in the collection and use of funds and the involvement of patients in important decisions.
Reference 1. User fee charges in Orissa – evaluation study of user charges in government hospitals in Orissa, September 1999, Institute of Management in Government, Thiruvananthapuram. 2. Sharma, S. and Hotchkiss D.R. “Developing financial autonomy in Public Hospitals in India: Rajasthan’s model”. Health Policy, vol. 55. 2001. 3. DFID Impact and Expenditure Review, health Sector, Andhra Pradesh (Phase I) Public Expenditure Analysis, March 2001. 4. IHMR Policy briefs No. 3 October 1998. 5. Report on determinants of willingness to pay for health care services in government hospitals, sponsored by the Karnataka health Systems Development Project, Centre for environmental and social concerns, Bangalore. 6. The Benefit incidence analysis of public health spending in India, by NCAER on behalf of the World Bank and the MoHFW. 7. Crease, A. and Kurzin, J., 1995 lessons from cost recovery in health, Forum on Health sector Reforms, World Health Organisation, Geneva. |
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Policies and Issue in Implementation of Fee Charges in Public Hospitals |
