User Charges in AIIMS:

Pushing Poor Patients Out of Health Care

At the fag end of the last year, charges of various services were introduced at the country’s premier hospital, All India Institute of Medical Sciences, New Delhi. Srikant discusses the implications of this move with Dr. Anoop Saraya, a Professor of Gastroenterology at the AIIMS, who is actively involved in democratic and civil and human rights struggles.

Q : Prior to the recent hikes in various charges, medical care at AIIMS was by and large affordable and hence accessible to the poor and lower middle classes. Now, after these massive hikes do you think that this strata could still be able to access medical care of AIIMS? What impact will the hike have on overall health care services for the economically weaker sections?
Dr. AS:
Whatever the Govern-ment may claim, the problem is that wherever user charges have been introduced, the experience is the same world over. The accessibility to health care for the poor goes down. They will simply not be able to access the facilities at AIIMS if they don’t have money.
The annual budgetary allocation for AIIMS is over Rs.300 crores, and through user charges the Institute will generate at the most Rs.10-12 crores. Those who will contribute to the kitty of Rs.10-12 crore through the new user charges will monopolise the benefit of the entire budget. And the poor will be out of the ambit of health care at the AIIMS.
Right to health is a basic human right directly connected to the Right to life which has been recognized by the international community in numerous international instruments. Article 25(i) of Universal Declaration of Human Rights (UDHR) affirms that everyone has a right to a “standard of living adequate for health for himself and his family including food, clothing, housing and medical care and necessary social services.” The International Covenant on Economic, Social and Cultural Rights (1966) provides for the right of everyone to the enjoyment of the highest attainable standard of physical and mental health. The Constitution of India also guarantees the fundamental right to life, which essentially means a right to live a healthy life - which is possible only by making quality health care accessible to everyone.
In a country like India where the burden of disease is very high and income of the masses low, the budgetary allocation for health is less than 1% of the GDP. Whereas in many developed countries, where the burden of disease is quite low and income high, the expenditure on health care is 6 to 8 % of their GDP and in some countries even up to 12 %. So, keeping in mind the extreme vulnerability of poor people even to easily curable diseases due to inaccessibility to quality healthcare, it is all the more obligatory for the Indian State to greatly increase the budgetary allocation for health, rather than generating funds through packages and user charges.
The present UPA Govt. supported by the Left, promised in its Common Minimum Programme to increase the budgetary allocation on health to 3-4 %. However, the recent move to generate resources through user charges is a U-turn from the declared intention.
Q: What were the basic aims and objectives behind creating this premier Institute and are these hikes violating them? Were there alternatives for generating resources?
Dr. AS:
All India Institute of Medical Sciences (AIIMS) was established in 1956 by an Act of Parliament with the objective of making it a centre of excellence in the field of medical education and research with emphasis on training quality health manpower for the country and making the country self-sufficient in postgraduate medical education, specially training teachers for medical colleges. It was expected to serve as a model for similar institutions not only in India but also the entire third-world countries. During the Parliament debate Rajkumari Amrit Kaur, the first Union Health Minister, had made it clear that the central government would bear the entire funding, which obviously is the taxpayers’ money.
Unfortunately, neither the local administration nor the Union government is considering this as an institute. The attempt is to reduce it to a five-star super-specialty hospital meant for those who can pay. The very character of this Institute will change. Teaching and research will take a back seat.
Q : For the past few years a process had already begun to levy user charges in various forms and there has been a gradual shifting of the burden of medical expenses on the patient, such as procuring even emergency medication, gloves, syringes, cannulas, etc. Was this move towards gradual privatization ever resisted by the medical fraternity of AIIMS?
Dr. AS:
Attempts were made repeatedly in the past by the AIIMS Administration to introduce packages for various procedures and user charges, specially in few super-speciality departments and centers like the cardio-thoracic and neuro-sciences (CN Centre). This began in 1990s with the adoption of the new economic policies. This attempt was opposed by the faculty, resident doctors, and various sections of the AIIMS community. A move was floated for the first time in 1997 to introduce an ‘incentive’ scheme to the health providers from the money collected through user charges. But we opposed it because we didn’t want a share from the loot of hapless patients. The Faculty opposed it and we made it absolutely clear to the then Minister that we are not averse to incentives, but that incentive should come from the government and not from the poor man’s pocket. So due to stiff opposition from the faculty, this idea was dropped.
Then again in 1999, fresh attempts were made to introduce user charges and various packages in CN Centre as well as in the main Hospital. Again, this was met with stiff opposition from the faculty due to which it could not be implemented in the main Hospital, but in the CN Centre, which was then headed by the present Director, the user-charges and packages got implemented. So, they have been collecting money for quite some time now. But despite user charges and packages one thing is very clear, that the quality of patient care or the level of patient satisfaction has hardly improved. Therefore, one thing is certain now, that you simply cannot enhance quality by levying user charges. Only the composition of the patients coming to the Institute will change.
Regarding the medicines and consumables, what has happened in the meanwhile, is that the costs of these have gone up tremendously while the budget has narrowed down. So, the stocks get exhausted quickly and therefore patients are asked to bring certain things when it is not in the stores.
Q : But isn’t the record of the CN Centre regarding quality and patient satisfaction better in comparison to the main Hospital?
Dr. AS :
You can find out by making a simple visit to the two places. The plight of the patients is same at both places. You will find equally long queues at the CN Centre with bewildered patients not knowing when will they get admission. They are facing the same problem, which the patients in the main Hospital face. Besides, there is no addition of necessary new facilities. So, even after paying user charges there the plight of the patients is the same.
Q. : How is the medical fraternity of AIIMS reacting to this hike? Is there any hope of these hikes being reversed?
Dr. AS:
Most of the Faculty members have opposed the user charges. The fact that more than two hundred senior faculty members have signed a memorandum to the Prime Minister expressing their opposition and demanding immediate withdrawal shows that they are quite against it. It is unfortunate that the parliamentary political forces have not reacted against this anti-people move. It seems that there is a consensus amongst the ruling classes on economic policies of commercialising health and education.
We are very hopeful that the people will rise against such anti-people, anti-poor policies.
In the end I would like to say that a movement for free health care from various social groups and political forces to increase the budgetary allocation on health is the need of the hour.