Doctors participating in a protest rally against Rajasthan’s Right to Health Bill in April | Photo Credit: PTI
The Rajasthan Right to Health (RTH) Bill, which became an Act in April, had sparked a bitter controversy, after which the state government agreed to some exclusions. Many doctors termed the Act as draconian, while public health activists are largely in favor of it. But there are aspects of the Act that have received little discussion, making it unsuitable as a role model for other states.
Repetitions, Before and After
A comparison of the two iterations of the RTH Bill, one before and after the Select Committee review, is a good starting point for the review. The primary iteration was sent for select committee review in 2022, and the amended bill was passed on March 21, 2023, fueling protests. Even a cursory review reveals how the revised edition, which sparked controversy, was itself a highly restrained version strongly attuned to the interests of the medical community.
After amendments by the Select Committee, some definitions (accidental emergency, emergency care and first aid) were added to the Bill. In addition, the term ‘specified health care centre’ was introduced, and a reimbursement clause for unpaid emergency care was added. This addition is commendable. However, most of the other changes in the amended bill were not so good, at least as far as protecting the public health interest is concerned.
This shows, first of all, in the revamped structure of state and district health authorities. For the State Health Authority, the initial iteration included three representatives each from Ayurveda, Homeopathy and Unani as ex-officio members. Instead, the amended bill had provision for only one representative from alternative medical systems, with medical education representatives filling in for the remaining two. What is even more shocking is that the amended bill has swapped public health/hospital management experts for nominated members of the Indian Medical Association (IMA). This leaves these officers with little or no representation from the public health fraternity and most importantly the community for which the Act is aimed.
Further, the powers of the administrative organs were significantly circumscribed in the amended Bill. The grievance redressal mechanism proposed in the initial iteration was also significantly changed in the amended Bill. Initially proposed to be redressed through web portal, helpline centers and concerned authorities within 24 hours, now patient complaints will be handled by the concerned health care institution within three days. This introduces specific conflicts of interest. Furthermore, it stands to increase the administrative burden of hospitals. It predisposes patient complaints to be handled slowly or inattentively, and more often than not, to be dealt with informally.
Health law includes not only curative medical care but also important social determinants such as health promotion, disease prevention and nutrition, which have a greater impact on health than medical care. The current RTH Act, lacking in public health representation, is ill-equipped to achieve these goals or serve as a template for other state or all-India legislation. Now coming to the MoU which made the Bill somewhat palatable for the doctors associations. The state government has assured that private multispeciality hospitals with less than 50 beds and those that have not taken concessional land/building from the government will be kept out of the purview of the law, even if temporarily. This effectively excludes the plethora of small and medium hospitals that are dominant in the health care landscape, especially outside urban agglomerations. Contrast this with the Emergency Medical Treatment and Labor Act (EMTALA) – the US law ensuring public access to emergency care – which covers 98% of hospitals.
prognosis
Despite being a liberal bill, some of the objections seeking outright repeal are too frivolous, for example, to vague definitions of certain words such as ’emergency’. Medico-legal definitions are always given to ambiguity, and even widely accepted definitions are generally vague and full of ambiguities. Rather than seeking outright repeal of a bill with far-reaching implications for public health beyond just emergency care, such matters require all parties to work together to arrive at the best detail. Again, the EMTALA example shows that some residual ambiguities are irreconcilable and are routinely navigated using risk-benefit and reasonable belief principles.
The most important lesson for the state is that such legal pronouncements must be carefully crafted to prevent opposition from arising in the first place. Second, for any true health law to exist, the government must avoid being swayed solely by organized medical interests. The common theme of most medical protests has been that private medical practice should be laissez faire As possible, which is inconsistent with equitable, universal health care. Governments and the medical community must sensitize themselves to the wider social dimensions of health and health law. Last, but not least, governments must realize that undertaking such radical pieces of legislation without a threshold level of adequate financial preparedness can be counterproductive, as it is the state’s obligation to provide health care, not health itself. By ignoring care providers. own livelihood.
Dr. Soham D. Bhaduri, health policy and leadership expert, is editor-in-chief of The Indian Practitioner