The hospital is situated in the heart of mill area. It draws poor and middle class people despite the fact that the mills have become defunct during last two decades. During last quarter of century, the health problems have kept pace with advance in medical diagnosis and treatment. Lately, awareness of the patients’ right and the maltreatment had reached the minds of a common man. The prices of the drugs have sky rocketed. All these factors contribute towards pushing the satisfactory treatment of any illness beyond the reach of an average patient. After 2nd world war, the British introduced the National Health Scheme and U.S.A started state hospitals. These schemes ease the burden of an ordinary man who could expect the best of the treatment at the least expenses. Similarly introduction of health insurance in India was expected to improve the patients lot.

We already have 40 years of experience in treating private patients in clinical practice as well as free public hospitals. Introduction of health insurance, which started more than 5 decades ago (E.S.I.S) for labour class, did not make much impact on improvement in patients’ suffering because it was done in hospitals specially designed for the insured persons. Only in last 10 years, private parties are entering this field by way of MediClaim policies and enlightened middle class patients are taking benefit of health insurance. We analyzed our records of indoor patients and cost of the hospital treatment both for insured as well as non-insured patients.

Our hospital is an institution open for any qualified medical specialists (including those who practice on premises). The 25 beds are occupied from paediatric to geriatric patients who suffer from acute to chronic illnesses. Thus, nearly 1500 patients are admitted every year for emergency as well as elective treatment. The patient has to pay a deposit on admission to the hospital. This is adjusted against the final bill when the patient is discharged. He replaces medicines and other material used for his treatment. The doctor’s professional charges and other charges (operation charges, theatre charges, anaesthetist’s charges) depends on patients choice of accommodation (i.e. general ward, special room). Even the insured person follows the same procedure and collects his expenses from the insurance company later. Many patients declare that they are covered by insurance scheme while making the final payment with the hope that the hospital will not charge them exorbitant fees. Cashless treatment is a very recent phenomenon.

Our gross findings about the patients with health insurance are as follows:

• People take insurance cover for a chronic illness when treatment becomes expensive or a sudden illness befalls on them, requiring major expenses. Not many people take health insurance by choice or as a prophylaxis. The doctors treating such patients are sure of reimbursement hence they manipulate history, clinical findings and treatment to get maximum benefits from the insurance company. The laws of insurance company are very strict but can be easily bypassed.
• The insurance company perhaps due to the past bitter experiences treats all claims with suspicion and raises hurdles after hurdles even in genuine claims and earns distrust of society in general. The tie–ups between the insuring companies and five star hospitals have broken up because the insurer refuses to reimburse the hospital after the treatment is over and the patient has left the hospital. The attitude of the insured which forces him to get more from insurer (than what he has paid) ultimately defeats the health insurance scheme. This has happened in U.K as well as U.S.A.
• The Consumer Protection Act (C.P.A) which is now extended to medical practice has worsened the health insurance scheme. Doctors want to protect themselves from the wrath of patients. They practice ‘defensive medicine’ and indulge in over investigating patients and cross references. Finally, the burden falls on the insurance company.

The present constitution of health insurance does not permit proper implementation of the scheme for the benefit of deserving patients. If the ‘Health For All’ movement (2020) is to succeed, health care will have to be grouped region wise as well as system wise. Also, if the burden of funding is distributed over many agencies it will not break the “camel’s back”.

We suggest a breakup as:

1. Primary health care in villages will have primary health centre for a group of 10-15 villages depending upon the total population. With preventive medicine, vaccination must be for everybody of all age groups. For curative purposes, qualified doctors, trained assistants, trained nurses and non medical staff for acute and chronic illnesses, coordination with the consultants is necessary. No indoor facility except for acute dehydration and poisoning only. Minor surgical facilities without admission should be made available.
2. Secondary health care restricted to Talukas and Districts where towns and minor cities are present. At taluka level, OPD facilities, I.P.D facilities should be provided depending on the population based on age and sex consideration. Here the intermediate operative facilities with stop gap emergency facilities should be made available. At district level, major operative facilities, full emergency intensive facilities should be made available.
3. Tertiary health care in metros and in big cities-anything under the sun should be made available.

Health givers (e.g. doctors, trained nurses) should get maximum payment at primary health centre, a little less at Taluka level,a little less at District and metro levels

System of Medicine should only include allopathy, homoeopathy, ayurveda and unani in combination or alone. But pathies like Naturopathy, Urine therapy and other pathies should be left to the patient to enjoy at his risk and consequences.

Funds Provision as G.D.P is to be made 3%. The provision I suggest is as follows:

1. Central Government contribution should be 0.5%
2. State government contribution should be 0.5%
3. Insurance companies contribution 2%
4. NGOs, WHO, donations from international bodies as and when.
   

Last But Very Important

• Continuous training programme for everybody concerned and of everything.
• Definition of each and every thing for example insuring person, category, facility available, duties of medical and non-medical administrative people, etc should be made crystal clear.
• Making the use of instrumentation (mechanization) wherever and whenever possible.
• Punishment: Human error should be omitted at all levels, defaulters should be heavily penalized after a legitimate and immediate inquiry e.g. should be out of system throughout the country throughout life.